Vascular surgery has evolved to include a large proportion of minimally invasive endovascular procedures. These procedures are better tolerated by patients, but can be taxing for the operator with less than adequate ergonomics and high effective radiation doses. Lead aprons do not protect the entire body and cause significant strain on the spine. Traditional lead shields are difficult to adequately position to optimize visualization and operator protection. Novel radiation protection systems provide stable protection for the entire team. Here we present a case using a novel protection system allowing the entire team to operate without traditional lead apron shielding.

OBJECTIVE:There is limited data demonstrating the benefit of artificial intelligence (AI) technology for the diagnosis and triage of pulmonary embolism (PE). This study aimed to demonstrate improved time to diagnosis of PE and subsequent anticoagulation and intervention, with the goal of reducing in-hospital mortality. We hypothesized that implementation of AI-assisted computed tomography pulmonary angiogram (CTPA) detection would reduce time to diagnosis, anticoagulation, and intervention compared with the standard radiology-based workflow. METHODS:A single institution retrospective review from July 2018 to March 2025 was performed to identify patients diagnosed with PE who underwent pulmonary angiogram with mechanical thrombectomy and/or thrombolytics. Patients were divided into a pre-AI cohort (July 2018-2022) and a post-AI cohort (2022-March 2025) corresponding to the institutional implementation of Viz.ai PE (Viz.ai), a Food and Drug Administration-cleared, Health Insurance Portability and Accountability Act-compliant AI platform for automated PE detection on CTPA. Time to diagnosis was defined as the interval from CTPA scan completion to AI-generated alert (post-AI cohort) or to the final radiology report issuance (pre-AI cohort). Time to anticoagulation and intervention was measured from the time of confirmed PE diagnosis. In-hospital mortality was also evaluated. RESULTS:From July 2018 to March 2025, a total of 148 patients were diagnosed with PE and underwent endovascular intervention. Twenty-four patients were excluded. Forty-two patients were diagnosed in the pre-AI era and 82 in the post-AI era. The median age was 65 [interquartile range (IQR), 53-73] and 65.5 (IQR, 52-73.5) years, respectively. Time to diagnosis improved significantly from 72.5 (IQR, 44.5-93.3) to 40 (IQR, 28-68.2) minutes (P = .00005). Time to anticoagulation was 76 (IQR, 48.3-99.8) vs 61.5 (IQR, 46.8-110) minutes (P = .824, not significant). Time to intervention improved from 1360 (IQR, 1075.5-1790.2) to 1224 (IQR, 601.6-1563) minutes (P = .036). Two in-hospital deaths occurred, both in the pre-AI cohort. CONCLUSIONS:Implementation of AI-assisted CTPA detection using Viz.ai PE significantly improved time to diagnosis and intervention in patients with acute PE requiring catheter-directed therapy. Time to anticoagulation was not significantly different between groups; this was study was insufficiently powered to detect differences in clinical outcomes including mortality.

Objective For patients with outflow obstructions secondary to thrombotic disease, including acute deep venous thrombosis (aDVT), post-thrombotic stenoses (PTS), and nonthrombotic iliac vein lesions (NIVLs), venous stenting is the treatment of choice. Prior studies highlight good long-term patency rates and improved quality of life with iliofemoral venous stenting in industry-sponsored trials. The purpose of this study is to evaluate this institution's experience with iliofemoral venous stenting for aDVT, PTS, and NIVLs. Methods This is a retrospective review from January 2016 to March 2021 of 123 patients who underwent iliofemoral venous stenting for NIVLs and thrombotic disease. The primary end points were stent patency at 3 years and major adverse events (MAEs) at 30 days. Secondary end points included primary assisted and secondary assisted patency at 3 years, MAEs at 1 year, stent fracture, and change in Venous Clinical Severity Scores (VCSS) 6 months after stenting. Results Of 123 patients who underwent iliofemoral venous stenting, 73 patients had follow-up imaging at 3 years. Stent patency at 3 years was 97.3% (P= .248) for all patients, 93.5% for aDVT, 100% for PTS, and 100% for NIVLs. Rate of MAEs at 30 days was 11% (P= .453) for all patients, 16.1% for aDVT, 10% for PTS, and 6.3% for NIVLs. Of the 73 patients, 16 required reinterventions with a primary assisted patency rate of 90% and a secondary patency rate of 87.5%. The rate of MAEs at 1 year was 5.5% (P= .192) for all patients, 9.7% for aDVT, 10% for PTS, and 0% for NIVLs. There was no evidence of stent fracture at 3 years. The median change in VCSS scores was 8 for all patients, 8 for aDVT, 13 for PTS, and 8 for NIVLs. Conclusions Patients with venous outflow obstructions secondary to aDVT, PTS, and NIVLs have been successfully treated with iliofemoral venous stenting with high patency rates at 3 years. Primary assisted and secondary patency rates were high as well. There were low rates of MAEs at 30 days and 1 year, with a decrease in VCSS scores, making this a safe and effective procedure for treating iliofemoral venous outflow obstructions.

Objective: To report the midterm clinical outcomes from the GORE (R) EXCLUDER (R) Conformable AAA Endoprosthesis system (EXCC) pivotal regulatory trial in the United States (U.S.). Methods: This is a prospective, multicenter, investigational device exemption clinical trial at 31 U S. sites with Core Laboratory assessment of imaging and independent adjudication of safety. The study enrolled patients with abdominal aortic aneurysms (AAA) with a minimum proximal landing zone >= 10 mm and proximal neck angulation of <= 60 degrees between December 2017 and February 2019 as part of a larger study to gain indications of the EXCC device. Endpoints included patient survival, freedom from secondary interventions, and stent-graft related outcomes. Results: There were 80 patients enrolled (88.8% male, mean 73.5 +/- 8.14 years-old). Mean maximum aortic diameter was 57.7 +/- 8.0 mm (range, 42.5-82.7). There was 100% freedom from type I and III endoleak and aneurysm-related mortality at 36-months. Freedom from secondary intervention was 91.9 +/- (0.83, 0.96, 95% C.I.) at 36-months. There were no device fractures, migrations (>= 10 mm), or aneurysm ruptures. At 36 months, thirteen patients (26.5%) had type 2 endoleak, 32 patients (58.2%) had AAA sac regression, 17 (30.9%) had no change in diameter, and 6 (10.9%) had sac enlargement. Seven patients (8.8%) through 36 months underwent reintervention. Conclusions: The 3-year outcomes have continued to show an adequate safety and efficacy profile of the EXCC device with no aneurysm related mortality or Type I/III endoleak. These results demonstrate durability for an EVAR device in US regulatory trials. (J Vasc Surg 2025;81:105-15.)

BACKGROUND CONTEXT:Fluoroscopy and radiation exposure occur during anterior lumbar interbody fusion (ALIF). Image enhancement technology is available that can potentially reduce radiation exposure. PURPOSE:The purpose of this study is to evaluate radiation exposure and fluoroscopy times comparing standard fluoroscopy (FL) with a low dose image enhancement platform (LD). STUDY DESIGN:Retrospective review of prospectively maintained database. PATIENT SAMPLE:Consecutive patients undergoing ALIF with either standard fluoroscopy or low dose image enhancement technology. OUTCOME MEASURES:Radiation dispersion and fluoroscopy times in ALIF patients with standard fluoroscopy and low dose image enhancement technology. METHODS:A retrospective review of a prospective database on consecutive patients who have undergone ALIF, stratified into 2 groups: subjects with standard fluoroscopy (FL), and low dose fluoroscopy with image enhancement technology (LD). RESULTS:A total of 487 ALIF patients were included (FL: 372 vs LD: 115). LD patients were significantly older (66 vs 60 years), with more deformity cases (28% vs 12%), and less degenerative cases (71% vs 87%), all p<.05; no differences in sex, BMI, or the number of levels operated on between groups. Fluoroscopy time (sec) was significantly higher in LD (51.4 vs 45.5), with a statistically significant reduction in radiation (mGy) compared to FL (23.3 vs 48.2), both p<.05. Furthermore, the results showed that radiation dispersion is increasingly reduced as fluoroscopy time increases in LD compared to FL (12%, 56%, and 65% reduction in radiation dispersion for fluoroscopy time <30 sec, between 30 to 60 sec, and >60 sec, respectively). CONCLUSIONS:The use of low dose fluoroscopy with image enhancement technology significantly reduces the cumulative dose of radiation during ALIF compared to standard dose fluoroscopy. Also, radiation dispersion increasingly decreases as fluoroscopy time increases using low dose image enhancement technology. Low dose image enhancement technology improves the safety profile of ALIF for patients and operating room staff.

Objectives For patients with outflow obstructions secondary to thrombotic disease including acute Deep Venous Thrombosis (aDVT), Post Thrombotic Stenoses (PTS) and Non-thrombotic iliac vein lesions (NIVLs), venous stenting is the treatment of choice. Prior studies highlight good long term patency rates and improved quality of life with iliofemoral venous stenting in industry sponsored trials. The purpose of this study is to evaluate this institution’s experience with iliofemoral venous stenting for aDVT, PTS, and NIVLs. Methods This is a retrospective review from January 2016 to March 2021 of 123 patients who underwent iliofemoral venous stenting for NIVLs and thrombotic disease. The primary end points were stent patency at 3 years and major adverse events (MAEs) at 30 days. Secondary end points included primary assisted and secondary assisted patency at 3 years, MAEs at 1 year, stent fracture, and change in VCSS scores 6 months after stenting. Results Of 123 patients who underwent iliofemoral venous stenting, 73 patients had follow up imaging at 3 years. Stent patency at 3 years was 97.3% (p=0.248) for all patients, 93.5% for aDVT, 100% for PTS, and 100% for NIVLs. Rate of MAEs at 30 days was 11% (p=0.453) for all patients, 16.1% for aDVT, 10% for PTS, and 6.3% for NIVLs. Of the 73 patients, 16 required reinterventions with a primary assisted patency rate of 90%, and a secondary patency rate of 87.5%. The rate of MAEs at 1 year was 5.5% (p=0.192) for all patients, 9.7% for aDVT, 10% for PTS, and 0% for NIVLs. There was no evidence of stent fracture at 3 years. The median change in VCSS scores was 8 for all patients, 8 for aDVT, 13 for PTS, and 8 for NIVL. Conclusion Patients with venous outflow obstructions secondary to aDVT, PTS, and NIVLs have been successfully treated with iliofemoral venous stenting with high patency rates at 3 years. Primary assisted and secondary patency rates were high as well. There were low rates of MAEs at 30 days and 1 year with a decrease in VCSS scores making this a safe and effective procedure for treating iliofemoral venous outflow obstructions.

Objective Lower extremity acute limb ischemia (LE-ALI) is associated with high morbidity and mortality rates, and a burden on patient quality of life (QoL). There is limited medium- to long-term evidence on mechanical aspiration thrombectomy (MT) in patients with LE-ALI. The STRIDE study was designed to assess safety and efficacy of MT using the Indigo Aspiration System in patients with LE-ALI. Thirty-day primary and secondary endpoints and additional outcomes were previously published. Here, we report 365-day secondary endpoints and QoL data from STRIDE. Methods STRIDE was a multicenter, prospective, single-arm, observational cohort study that enrolled 119 patients across 16 sites in the United States and Europe. Patients were treated first-line with MT using the Indigo Aspiration System (Penumbra, Inc). The study completed follow-up in October 2023. Secondary endpoints at 365 days included target limb salvage and mortality. Additionally, the VascuQoL-6 questionnaire, developed for evaluating patient-centered QoL outcomes for peripheral arterial disease, was assessed at baseline and follow-up through 365 days. Results Seventy-three percent of patients (87/119) were available for 365-day follow-up. Mean age of these patients was 65.0 ± 13.3 years, and 44.8% were female. Baseline ischemic severity was classified as Rutherford I in 12.6%, Rutherford IIa in 51.7%, and Rutherford IIb in 35.6%. In general, baseline and disease characteristics (demographics, medical history, comorbidities, target thrombus) of these patients are similar to the enrolled cohort of 119 patients. The secondary endpoints at 365 days for target limb salvage was 88.5% (77/87) and mortality rate was 12.0% (12/100). VascuQoL-6 improved across all domains, with a median total score improvement from 12.0 (interquartile range, 9.0-15.0) at baseline to 19.0 (interquartile range, 16.0-22.0) at 365 days. Conclusions These 365-day results from STRIDE demonstrate that first-line MT with the Indigo Aspiration System for LE-ALI portray continued high target limb salvage rates and improved patient-reported QoL. These findings indicate Indigo as a safe and effective therapeutic option for LE-ALI.

Endovascular procedures are minimally invasive approaches to treat conditions affecting blood vessels without the need for large incisions. The benefits are less blood loss and faster recovery. One condition commonly treated endovascularly is aortic aneurysmal disease often secondary to atherosclerosis or chronic hypertension. As endovascular aneurysm repair becomes increasingly complex and sophisticated, the intraoperative organization and management of wires from multiple access sites becomes paramount. Often, the physician selects visceral or great vessels for delivery of stent grafts to maintain vessel patency. Loss of wire in critical target vessels and wire contamination pose significant patient risks. WireWatch (BioTex Inc. Houston, Texas, USA) is a novel device designed for intraoperative wire management to improve surgical field organization, provide wire stabilization, and prevent dropped wires. This case describes its use in a 73-year-old female undergoing a fenestrated endovascular aneurysm repair of 5.6 cm types IV thoracoabdominal aortic aneurysm.

Pulmonary embolism (PE) is a serious and potentially life-threatening condition. A streamlined PE workflow with timely assessment and initiation of treatment may improve a patient's chance of survival. Artificial intelligence (AI) has been increasingly used in health care to improve clinical efficiency. In October 2022, our institution implemented an AI-powered parallel workflow tool designed to automatically detect and triage patients with suspected PE. The aim of this study was to evaluate the clinical impact of AI software on time to assessment, time to anticoagulation, and patient outcomes at our institution.

Stenting has become the first line of treatment for symptomatic chronic iliofemoral venous obstruction in patients with quality-of-life impairing clinical manifestations who have failed conservative therapy. Patient selection for such intervention is however dependant on clear identification of relevant clinical manifestations and subsequent testing to confirm the diagnosis. In this regard the physician engaged in management of such patients need to be well aware of symptoms and signs of chronic iliofemoral venous obstruction (CIVO), instruments used to grade chronic venous insufficiency (CVI) and determine quality of life in addition to diagnostic tests available and their individual roles. This review serves to provide an overview of the diagnosis of CIVO and patient selection for stenting.

The presentation of pulmonary embolism (PE) varies from asymptomatic to life-threatening, and management involves multiple specialists. Timely diagnosis of PE is based on clinical presentation, D-dimer testing, and computed tomography pulmonary angiogram (CTPA), and assessment by a Pulmonary Embolism Response Team (PERT) is critical to management. Artificial intelligence (AI) technology plays a key role in the PE workflow with automated detection and flagging of suspected PE in CTPA imaging. HIPAA-compliant communication features of mobile and web-based applications may facilitate PERT workflow with immediate access to imaging, team activation, and real-time information sharing and collaboration. In this review, we describe contemporary diagnostic tools, specifically AI, that are important in the triage and diagnosis of PE.

Percutaneous revascularization is the primary strategy for treating lower extremity venous and arterial disease. Angiography is limited by its ability to accurately size vessels, precisely determine the degree of stenosis and length of lesions, characterize lesion morphology, or correctly diagnose postintervention complications. These limitations are overcome with use of intravascular ultrasound (IVUS). IVUS has demonstrated the ability to improve outcomes following percutaneous coronary intervention, and there is increasing evidence to support its benefits in the setting of peripheral vascular intervention. At this stage in its evolution, there remains a need to standardize the use and approach to peripheral vascular IVUS imaging. This manuscript represents considerations and consensus perspectives that emerged from a roundtable discussion including 15 physicians with expertise in interventional cardiology, interventional radiology, and vascular surgery, representing 6 cardiovascular specialty societies, held on February 3, 2023. The roundtable’s aims were to assess the current state of lower extremity revascularization, identify knowledge gaps and need for evidence, and determine how IVUS can improve care and outcomes for patients with peripheral arterial and deep venous pathology.