Background: Major vascular involvement is often considered a contraindication to resection of malignant tumors, but in highly selected patients, it can be performed safely, with results that are highly dependent upon the tumor biology. Resection of both the aorta and inferior vena cava (IVC) is a rare undertaking, requiring both favorable tumor biology and a patient fit for a substan-tial surgical insult; nevertheless, it provides the possibility of a cure. Methods: Patients requiring resection and reconstruction of both the aorta and IVC from 2009 through 2019 at 2 university medical centers were included. Patient characteristics, operative technique, and outcomes were retrospectively collected.Results: We identified 9 patients, all with infrarenal reconstruction or repair of the aorta and IVC. All cases were performed with systemic heparinization and required simultaneous aortic and caval cross-clamping for tumor resection. No temporary venous or arterial bypass was used. Since arterial reperfusion with the IVC clamped was poorly tolerated in 1 patient, venous reconstruction was typically completed first. Primary repair was performed in 1 patient, while 8 required replacements. In 2 patients, aortic homograft was used for replacement of both the aor-toiliac and iliocaval segments in contaminated surgical fields. In the remaining 6, Dacron was used for arterial replacement; either Dacron (n = 2) or polytetrafluoroethylene (n = 4) were used for venous replacement. Patients were discharged after a median stay of 8 days (range: 5-16). At median follow-up of 17 months (range 3-79 months), 2 patients with paraganglioma and 1 patient with Leydig cell carcinoma had cancer recurrences. Venous reconstructions occluded in 3 patients (38%), although symptoms were minimal. One patient presented acutely with a thrombosed iliac artery limb and bilateral common iliac artery anastomotic stenoses, treated successfully with thrombolysis and stenting.Conclusions: Patients with tumor involving both the aorta and IVC can be successfully treated with resection and reconstruction. En bloc tumor resection, restoration of venous return before arterial reconstruction, and most importantly, careful patient selection, all contribute to positive outcomes in this otherwise incurable population.

Abstract: Based on a presentation at the American Philosophical Society's Member Meeting in April 2019, this essay tackles the lingering question of whether Abraham Lincoln suffered from Marfan Syndrome. The author—an eminent vascular surgeon with experience studying and treating Marfan Syndrome—describes the syndrome in detail, provides an overview of the arguments and evidence of those who have previously speculated on the topic, and ultimately concludes that Lincoln lacked the cardinal manifestations of Marfan Syndrome.

Operative expenses compose one-third of the rising health care costs in the United States. Therefore, novel strategies for mitigating cost in the vascular surgery space are warranted. Our institution implemented a cost reduction strategy in 2017 by simply showing surgeons the costs of their implants and disposable supplies at the end of each case in order to increase surgeon financial awareness and reduce costs. We performed a retrospective analysis of recorded supply and implant costs for vascular procedures from 2015 to 2018 at a single institution. Total operative cost was defined as the accumulated implant and supply cost during a procedure. We assessed total implant and disposable supply cost, supply cost alone, and cost per time. Cost was analyzed over two periods: the 24 months prior (PRE) to the tool implementation and 24 months following (POST) with a 1-month washout. Medians and interquartile ranges were calculated for each parameter and compared using the Mann-Whitney U test. We analyzed a total of 1372 procedures performed over the time period studied. Total supply and implant cost (–17.5%; P = .008), supply cost (–1.99%; P = .049) and cost per minute (–28.24%; P = .015) all saw significant reductions across the composite of open procedures from the PRE to POST time point (Table). Largest supply cost reductions were seen in common femoral artery endarterectomy (–42%; P < .001). The total operative cost/time was most significantly reduced for carotid endarterectomy (–8.89%; P = .001), abdominal aortic aneurysm repair (–16.21; P = .019), carotid-subclavian bypass (–9.94%; P = .032), and common femoral endarterectomy (–41.16%; P = .06), with nonsignificant cost reductions in arteriovenous grafting and rib resection. Relative price increases of 31%, 8%, and 3% were calculated for temporal artery biopsy, vein transposition, and distal bypass, respectively. The composite of all endovascular procedures saw large implant cost increases with minimal change in supply cost. We demonstrate that a low-cost, highly implemenTable cost sheet is effective at reducing cost in vascular surgery. Further investigations should assess how and why surgeons choose supplies and implants in order to target further intraoperative cost savings.TableCost trends before and after implementation of a cost sheet across multiple vascular surgery proceduresProcedureTotal operative cost (supply + implant), $Supply cost, $Total cost/time (supply + implant), $/minutePREPOST% ΔP valuePREPOST% ΔP valuePREPOST% ΔP valueCarotid endarterectomy504.3 (411.5-664)452.6 (409.5-525.7)–10.25.012250.3 (238.5-277)249.1 (235-276.1)–0.45.35344.86 (4.05-6.09)4.43 (3.77-5.25)–8.89.001AAA repair1686 (1268-2041)1399 (1257-1717)–17.01.037542.5 (432-602.5)536.8 (456.6-621.8)–1.052.81857.59 (5.67-9.49)6.36 (1.65-8.13)–16.21.019Carotid-subclavian bypass681 (609.1-805.4)682.6 (641-771.6)0.23.953272.3 (245.8-385.7)259.9 (245.1-290)–4.54.36155.49 (4.52-6.36)4.85 (1.39-5.76)–9.94.032Common femoral endarterectomy3102 (1107-5232)971.3 (532.5-4309)–68.69.0107662.4 (441.3-886.1)382.8 (237.8-566.8)–42.21<.000114.35 (6.32-14.35)8.45 (3.81-8.45)–41.16.061Arteriovenous graft181.8 (130.8-189.2)183.3 (123.8-223.1)0.822.5425113.8 (108.3-132.4)112.5 (106.7-125.9)1.0865.54112.07 (1.39-10.57)1.70 (1.48-2.67)–17.65.14Rib resection119.7 (115.8-124.6)116.6 (112.2-149.2)–2.577.8662120.3 (117.8-123)114.6 (109.7-138.3)–4.738.05621.46 (1.25-2.06)1.39 (1.02-2.11)–4.46.56Temporal artery biopsy45.25 ( 34.41-73.4)90.26 (47.84-121.4)99.49.000345.25 (34.41-73.4)90.55 (48.17-121.4)100.01.00041.38 (0.79-1.79)1.81 (1.25-3.05)30.92.0099Upper extremity vein transposition181.9 (125.1-249)187.7 (132.2-269.2)3.16.5116127.2 (113-145.7)114.9 (101.3-121.1)–9.669.00081.89 (1.02-2.84)2.05 (1.39-2.56)8.68.53Distal bypass831.7 (491.8-2315)767.6 (480-2987)–7.69.8428308.8 (244.9-382.6)377.9 (242.4-572)22.36.08172.64 (1.87-7.98)2.72 (1.59-8.29)3.26.94All endovascular (EVAR + TEVAR)17653 (12890-24376)22524 (15366-29092)27.59.00022031 (1581-2588)2022 (1559-2597)0.437.8103180.3 (11.4-262.1)163.2 (97.84-271.4)–9.48.6396All open549 (275.1-1115)452.7 (209.3-782.4)–17.54.0078250.3 (141.1-411.1)245.3 (121.5-343.2)1.99.04935.237 (2.039-11.03)3.758 (1.86-7.241)–28.24.015AAA, Abdominal aortic aneurysm; EVAR, endovascular aneurysm repair; POST, the 24 months following tool implementation; PRE, The 24 months prior to the tool implementation; TEVAR, thoracic endovascular aneurysm repair.Values are median (interquartile range). Open table in a new tab

During pancreatic head resection (Whipple procedure), the portal vein (PV) and mesenteric veins must often be resected or repaired. Grafts or patches for mesenteric venous reconstruction—homograft, internal jugular vein, or bovine pericardium—can take time to thaw or to be harvested. Therefore, temporary procedural shunting of the mesenteric venous circulation during reconstruction can mitigate bowel edema and ischemia resulting from procedural venous occlusion (Fig). Patient health information was harvested retrospectively from a prospectively maintained database. Data were summarized using standard statistical techniques. Twenty-one patients, 12 women and 9 men, underwent temporary PV shunting during oncologic resection and PV reconstruction from 2010 to 2020. Average age was 64 years. All patients had either pancreatic cancer (95%) or cholangiocarcinoma (5%) and underwent Whipple procedure (81%) or pancreatectomy and splenectomy (19%). Reconstructions consisted of interposition grafting (52% cadaveric aortic homograft and 5% internal jugular vein) or patch angioplasty (38% bovine pericardium and 5% internal jugular vein). No. 12 and No. 14 Argyle shunts were used. In all but two patients, the shunt was easily placed into the superior mesenteric vein (SMV) caudally and the PV cranially. One patient was shunted caudally into the splenic vein as his SMV had chronic nonocclusive thrombus that precluded shunt placement. The other patient lacked sufficient length of the SMV stump to clamp around the shunt, so only the second anastomosis (on the liver side) was performed with the shunt in place. Technical success of the PV reconstruction was 100%, and no intraoperative complications resulted from shunt placement. Postoperatively, one PV reconstruction thrombosed before discharge on day 7, which was managed nonoperatively with anticoagulation. During a mean follow-up of 13.6 months (range, 0.2-112 months), three additional reconstructions occluded (two early at 0.5 month and 1.5 months in patients with aggressive recurrent cancer and one late at 28 months after adjuvant radiation therapy). No other complications, including pseudoaneurysm or graft infection, were noted. Shunting is a well-established technique with which most vascular surgeons are comfortable in practice. Applying it as an adjunct in a novel context for PV reconstruction is safe, is technically straightforward, and may mitigate the deleterious effects of temporary mesenteric venous occlusion required for mesenteric venous reconstruction during oncologic resection.

Introduction: True pancreaticoduodenal artery aneurysms (PDAAs) are rare, and prior reports often fail to distinguish true aneurysms from pseudoaneuryms. We sought to characterize all patients who presented to our health system from 2004 to 2019 with true PDAAs, with a focus on risk factors, interventions, and patient outcomes. Methods: Patients were identified by querying a single health system picture archiving and communication system database for radiographic reports noting a PDAA. A retrospective chart review was performed on all identified patients. Patients with pseudoaneurysm, identified as those with a history of pancreatitis, abdominal malignancy, hepatopancreaticobiliary surgery, or abdominal trauma, were excluded. Continuous variables were compared using t-tests, and categorical variables were compared using Fisher's exact tests. Results: A total of 59 true PDAAs were identified. Forty aneurysms (68%) were intact (iPDAAs) and 19 (32%) were ruptured (rPDAAs) at presentation. The mean size of rPDAAs was 16.4 mm (median size, 14.0 mm; range, 10-42 mm), and the mean size of iPDAAs was 19.4 mm (median size, 17.5 mm; range, 8-88 mm); this difference was not statistically significant ( P = .95). Significant celiac disease (occlusion or >70% stenosis) was noted in 39 aneurysms (66%). Those with rupture were less likely to have significant celiac disease (42% vs 78%; P = .017) and less likely to have aneurysmal wall calcifications (6% vs 53%; P = .002). Thirty-seven patients underwent intervention (63%), with eight (22%) undergoing concomitant hepatic revascularization (two stents and six bypasses) due to the presence of celiac disease. Eighteen patients with occluded celiac arteries underwent aneurysm intervention; of those, 11 were performed without hepatic revascularization (61.1%). Those with rPDAAs experienced an aneurysm-related mortality of 10.5%, whereas those with iPDAAs experienced a rate of 5.6%. One patient with celiac occlusion and PDA rupture who did not undergo hepatic artery bypass expired post-operatively from hepatic ischemia. rPDAAs showed a trend toward the increased need for aneurysm-related endovascular or open reintervention, but this was not statistically significant (47% vs 28%; P = .13). Conclusions: These findings support previous reports that the rupture risk of PDAAs is independent of size, their development is often associated with significant celiac stenosis or occlusion, and rupture risk appears decreased in patients with concomitant celiac disease or aneurysm wall calcifications. Endovascular intervention is the preferred initial treatment for both iPDAAs and rPDAAs, but reintervention rates are high in both groups. The role for hepatic revascularization remains uncertain, but it does not appear to be mandatory in all patients with complete celiac occlusion who undergo PDAA interventions.

Introduction: Current evidence suggests that dual antiplatelet therapy (DAPT) reduces perioperative stroke, but increases bleeding after carotid endarterectomy (CEA). The long term effects of antiplatelet therapy after CEA have yet to be studied. Methods: A retrospective review of patients undergoing CEA in the national Vascular Quality Initiative database (2003-2018) was performed. Based on antiplatelet regimen at discharge, patients were propensity score matched on aspirin monotherapy vs. DAPT. Multivariable logistic regression and Kaplan-Meier analyses were used to investigate the long term effects of antiplatelet regimen on mortality and stroke/TIA. Results: Of the 72,122 patients undergoing CEA, 64.6% were discharged on aspirin, and 35.4% on DAPT. The DAPT group had higher frequencies of comorbidities (COPD, HTN, CHF, smoking, diabetes) as well as atherosclerotic diseases (PAD, CAD, prior PCI, prior CABG). After propensity score matching, two groups of 8,722 patients with comparable comorbidities were formed. While unmatched Kaplan-Meier analysis showed the DAPT cohort to have higher mortality (p=0.001), this difference dissipated after matching. The resultant matched DAPT cohort did not differ from the aspirin group in one year stroke/TIA (1.7% vs. 1.6%, p=0.70), or mortality (3.1% vs. 3.3%, p=0.55). At 5 years, however, patients treated with DAPT did exhibit a mortality benefit (6.4% vs. 7.3%, p=0.02) with multivariable logistic regression identifying DAPT as an independent predictor of reduced mortality (OR 0.94, 95% CI 0.88-0.99, p=0.04). Conclusions: Patients discharged on DAPT after CEA represent a significantly different cohort than those discharged on aspirin monotherapy. After propensity score matching, there was no difference at one year stroke/TIA or mortality outcomes, but DAPT was found to be protective against long-term mortality. Further study is warranted to investigate this finding.

Current guidelines recommend dual antiplatelet therapy (DAPT) for at least one month after Carotid Artery Stenting (CAS). The effects of maintained dual antiplatelet therapy after CAS have yet to be examined.

BACKGROUND:The characteristics of and indications for open abdominal aortic aneurysm (AAA) repair have evolved over time. We evaluated these trends through the experience at a tertiary care academic center. METHODS:A retrospective review was conducted for patients undergoing open AAA repair (inclusive of type IV thoracoabdominal aortic aneurysms) from 2005 to 2018 at an academic institution. Trends over time were evaluated using the Spearman test; Cox regression was used to determine predictors of mortality and to generate adjusted survival curves. RESULTS:There were 628 patients (71.5% male; 88.2% white) with a mean age of 70.5 ± 9.4 years who underwent open AAA repair with a mean aneurysm diameter of 6.2 ± 1.5 cm. The median length of stay was 10 days, and the median intensive care unit length of stay was 3 days. Urgent repair was undertaken in 21.1%; 22.3% were type IV thoracoabdominal aortic aneurysm repairs, and 9.9% were performed for explantation. Our series favored a retroperitoneal approach in the majority of cases (82.5%). The proximal clamp sites were supraceliac (46.1%), suprarenal (29.1%), and infrarenal (24.8%), with approximately a third requiring renal artery reimplantation. The average cross-clamp time was 25.5 ± 14.9 minutes; the mean renal ischemia time for supraceliac and suprarenal clamp sites was 28.4 ± 12.3 minutes and 23.5 ± 12.7 minutes, respectively. Postoperative renal dysfunction occurred in 19.6% of the overall cohort, with 6.2% requiring hemodialysis. Of those requiring postoperative hemodialysis, the majority (75%) received an urgent repair. The in-hospital mortality was 2.3% for elective cases vs 20.9% for urgent repair, and 29.8% of patients were discharged to rehabilitation, with an overall 30-day readmission rate of 7.9%. Over time, there were trends of increased aneurysm repair complexity, with decreasing infrarenal clamp sites, increasing supraceliac clamp sites, increasing proportion of explantations, and increasing need for bifurcated grafts. The acuity of aneurysm repair likewise changed, with the proportion of urgent repairs increasing over time, largely attributable to the rise in explantations. Clamp site influenced the frequency of perioperative complications. Urgent repairs and age at operation were associated with mortality, whereas mortality was not associated with need for explantation and clamp location. CONCLUSIONS:Aneurysm repair reflected increasing complexity over time, with the need for explantation among urgent repairs significantly on the rise. Urgency and clamp location independently predicted long-term mortality, even after adjustment for age. These findings underscore the changing landscape of open AAA repair in the current era.

Background: Definitive treatment of Paget-Schroetter syndrome (PSS) involves first rib resection (FRR), division of the anterior scalene muscle, and resection of the subclavius muscle. This is a single-institution experience with PSS, according to a treatment algorithm of preoperative venogram (accompanied by lysis and percutaneous mechanical thrombectomy as needed) followed by transaxillary FRR. In the later period of this experience, patients have often been discharged on aspirin only, with no plan for anticoagulation postoperatively. We sought to evaluate outcomes in light of this experience and these practice patterns. Methods: Between 2007 and 2018, 125 transaxillary FRRs were performed in 123 patients. All patients presented with documented venous thrombosis, underwent diagnostic venography and-if indicated-lysis and percutaneous mechanical thrombectomy (VPT) before FRR. The patient was not offered FRR if the vein could not be crossed with a wire and patency was not re-established during percutaneous treatment. The experience was divided into early (before 2012, n = 50) and late (n = 75) periods. Results: Mean patient age was 28.4 (12-64 years) years. Of the cohort, 33 were high-level competitive athletes, 13 presented with documented pulmonary embolism in addition to local symptoms, and 3 had a cervical rib fused to the first rib. Patients underwent FRR a median of 50 (4 days to 18 years) days after their initial symptoms, and a median of 22 (1 day to 9 months) days after their percutaneous intervention. Postoperative VPT was required in 23 patients and performed a median of 5 (1-137 days) days postoperatively; in 19 of these patients, postoperative VPT was required for postoperative re-thrombosis, whereas in 4 patients, postoperative VPT was planned before FRR due to vein stenosis or residual thrombus. All these patients were prescribed postoperative anticoagulation. No operative venous reconstruction or bypass was performed. Median follow-up time after FRR was 242 days; at last follow-up, 98.4% (123/125) of axillosubclavian veins were patent by duplex ultrasound (and all those patients were asymptomatic). Postoperative anticoagulation was less frequently prescribed in the late experience, with no difference in the rate of early re-thrombosis or follow-up patency. Conclusions: This experience demonstrates 98.4% patency at last follow-up with standard preoperative percutaneous venography and intervention, transaxillary FRR, and postoperative endovascular re-intervention only in cases with persistent symptoms, stenosis, or re-thrombosis. Patients presenting with both acute and chronic PSS did not require surgical venous reconstruction. In the later experience, patients frequently have not been anticoagulated postoperatively. Advantages of this algorithm include the following: (1) the cosmetic benefits of the transaxillary approach, (2) the preoperative assessment of the ability to recanalize the vein to determine which patients will benefit from surgery, (3) the capacity to use thrombolysis preoperatively, and (4) potential elimination of the risk and inconvenience of postoperative anticoagulation.

Improvements in chemoradiotherapy have rendered complex pancreatic cancers involving the portal vein (PV) amenable to resection. PV reconstruction (PVR) is an essential component. Various conduits have been proposed; however, the optimal choice remains unknown. Fourteen patients underwent PVR with a cadaveric descending thoracic aortic homograft from 2014 to 2020. The primary diagnosis was pancreatic cancer. The splenic vein was ligated in seven patients (50%). The 30-day and 3-, 12-, and 24-month primary patency rates were 100%, 86%, 76%, and 76%, respectively. We found a cadaveric descending thoracic aortic homograft is an excellent conduit for PVR, given the optimal size, rapidly availability, favorable risk profile, and absence of harvest site complications.

Treatment of Paget-Schroetter syndrome (PSS) involves first rib resection and division of the anterior scalene muscle (FRR). This is a single-institution experience with PSS, according to a treatment algorithm of preoperative venogram and lysis, percutaneous mechanical thrombectomy, and angioplasty (henceforth, venography, and percutaneous treatment [VPT]), followed by transaxillary FRR. In the later period of this experience, patients have often been discharged on aspirin only, with no plan for anticoagulation postoperatively. Between 2007 and 2018, 125 transaxillary FRRs were performed in 123 patients. All patients underwent VPT before FRR; if the vein could not be crossed and opened during VPT then the patient was not offered FRR. The experience was divided into early (before 2012, n = 50) and late periods. Mean patient age was 28 years (range, 12-68 years). Of the cohort, 33 were high-level competitive athletes, 13 presented with pulmonary embolism in addition to local symptoms, and 3 had a cervical rib. Patients underwent FRR between 4 days and 18 years after their initial symptoms (median, 50 days), and between 1 day and 9 months (median, 22 days) after VPT. Postoperative VPT was required in 23 patients, and performed 1 to 137 days postoperatively (median, 5 days); in 19 of these patients, postoperative VPT was required for postoperative rethrombosis, whereas in 4 patients postoperative VPT was planned before FRR owing to vein stenosis or residual thrombus. No operative venous reconstruction or bypass was performed. Last follow-up was at 1 to 89 months (median, 8 months) after FRR; at that time, 123 of 125 axillosubclavian veins were patent by duplex ultrasound examination (98.4%) and all those patients were asymptomatic with respect to symptoms of PSS. Postoperative anticoagulation was less frequently prescribed in the late experience, with no difference in the rate of early rethrombosis or follow-up patency, as summarized in the Table. This large experience demonstrates excellent Results with standard preoperative VPT, transaxillary FRR, and postoperative endovascular reintervention only in cases with persistent symptoms, stenosis, or rethrombosis. Patients presenting with both acute and chronic PSS did equally well; surgical venous reconstruction was never used. In the later experience, patients have frequently not been anticoagulated postoperatively. Advantages of this algorithm include (1) the cosmetic benefits of the transaxillary approach, (2) the preoperative assessment of the ability to recanalize the vein to determine which patients will benefit from surgery, (3) the capacity to use thrombolysis preoperatively, and (4) elimination of the risk and inconvenience of postoperative anticoagulation.TableEarly rethrombosis and follow-up patencyNo.Postoperative anticoagulationEarly rethrombosisClinical and duplex vein patency at last follow-upOverall experience12586 (69)19 (15)123 (98.4)Early experience5047 (94)9 (18)49 (98)Late experience7539 (52)a10 (13)b74 (98.7)cValues are number (%) unless otherwise indicated.aP < .005 comparing use of postoperative anticoagulation during early and late experiences, by Fisher Exact test.bP = .32 comparing rate of early rethrombosis during early and late experiences, by Fisher Exact test (one tailed).cNot significant comparing vein patency at last follow-up during early and late experiences, by Fisher exact test. Open table in a new tab

Objective: Intravascular ultrasound (IVUS) examination is an integral technique used for treating type B aortic dissection (TBAD) because it verifies true lumen access. The purpose of this study was to evaluate the use of IVUS, to determine factors associated with IVUS use, and to investigate the potential survival benefit associated with IVUS in the treatment of TBAD. Methods: A retrospective review of TEVARs performed for TBAD in the national Vascular Quality Initiative was performed from January 2010 to August 2018. Data collected included demographics, intraoperative and postoperative variables, and long-term mortality. Multivariable logistic regression evaluated variables associated with IVUS the use and mortality, and Cox regression was performed for adjusted survival analysis. Results: In this study of 2686 patients, the average age was 60.4 years, 69.3% were male, and IVUS examination was used in 74.6% of cases. IVUS patients were younger (60.0 years vs 61.7 years; P = .004), more often male (72.1% vs 61.3%; P < .001), exhibited less coronary disease, but had higher preoperative creatinine (1.27 +/- 0.89 mg/dL vs 1.14 +/- 0.68 mg/dL; P < .001) and were more often treated in the acute setting (55.2% vs 49.7%; P = .03). Interestingly, there were no differences in contrast use (117.4 +/- 77.6 mL vs 123.0 +/- 81.90.1 mL; P = .11) or fluoroscopy time (20.3 +/- 16.5 minutes vs 19.0 +/- 22.1 minutes; P = .10). However, IVUS cases had a greater number of devices implanted (1.84 vs 1.65; P < .001), higher rates of Zone 0 to 2 proximal seal (43.9% vs 30.7%; P < .001), higher rates of distal seal zones beyond the diaphragm (53.9% vs 37.4%; P = .001), and larger proximal and distal graft diameters, with no differences in postoperative renal function. IVUS patients notably also had higher rates of follow-up imaging (61.3% vs 54.8%; P = .003), larger maximum aortic diameters at follow-up, and more reinterventions over time. The number of aortic devices (odds ratio [OR] 1.56; 95% confidence interval [CI], 1.24-1.97; P < .001), malperfusion indication (OR, 1.68; 95% CI, 1.17-2.42; P = .005) and distal seal zone beyond the diaphragm (OR, 1.64; 95% CI, 1.30-2.07; P < .001) were independently associated with IVUS use, whereas female gender showed a trend towards less IVUS use (OR, 0.79; 95% CI, 0.62-1.01; P = .063). Even after controlling for age, preoperative comorbidities, and postoperative complications like spinal cord ischemia, IVUS was associated with a 61% decrease in the odds of mortality (OR, 0.39; 95% CI, 0.20-0.78; P = .008), with a clear survival advantage shown in adjusted survival curves. Conclusions: IVUS examination was used in the majority of TBAD, although not universally. IVUS examination was used more often in acute TBAD and more complex aortic repairs, and was independently associated with improved long-term survival. Further study is needed to understand these patterns.

We present the management of a 62-year-old man with symptomatic stenosis after suboptimal carotid stent placement. The stent was successfully explanted and the carotid replaced with an interposition vein graft. His symptoms have resolved and his bypass remains free of stenosis. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJhOTY5MTg1NGRlYTE1MDY5NDI1ZTJkNTQ3NWVkMDE0MCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4NjkxNDYyfQ.pFH1iA-gXYFCYpnhpYFVnA2nbKJSzwKZAFWLledI3FqVSPxmUbM3ukKtPFlpDTR8u2rrbJSwcZW0wByYIncUUXWbj_Ov5OYEQuFYPAF-D7PF9HFTe-EPZ1i4pr_a-Q6HnUNwIpO1GtfEGWSLFGKrjz2asDqsDCeEWDWCPuWjnl9YiJjEggoc30E63QeBr937bnUtCbZDlP-7gNMNr1Tcy3zZOdQ20xKcxQyhHvYd-d9tTr504zFjxGxjWPpjqs9FfSFFgmpB_NQdqbFTFIEXd0gH4KW5m7ksdBHsHirQQP_KX136o-u3PtuOqQRDg0T-kVffhtDywZ3ecz3EyWQghA Download .mp4 (124.94 MB) Help with .mp4 files Video

The aim of this study was to evaluate patterns of inferior vena cava (IVC) filter insertion and retrieval in a granular, national data set. A review of all IVC filter procedures entered into the national Vascular Quality Initiative registry between January 2012 and August 2018 was performed. Data collected included demographics, venous thromboembolism risk factors, indications for filter placement, and presence and timing of retrieval. Trend analysis and multivariable logistic regression were performed to evaluate factors associated with failure to retrieve the filter. During the study period, 8050 IVC filters were inserted. The mean age was 62.6 ± 16.7 years, and 52.2% were male; 59.5% were placed for major indications, 14.8% were placed for relative indications, and 25.7% were placed for prophylaxis. The overall filter retrieval rate was 34.5%. The clinically relevant retrieval rate (excluding those filters placed with permanent intent or patients who died before follow-up) was 57.1%. Trends in filter placement and retrieval are represented in the Fig. The total number of filter placements and retrievals increased from 2013 to 2015. However, beginning in 2015, there was a significant decline in filter placement (P = .009), whereas the number of filter retrievals remained relatively stable (P = .243). Importantly, the clinically relevant filter retrieval rate significantly increased throughout the years of the study from 36.2% in 2013 to 78.4% in 2018 (P = .004). The average time to filter retrieval also decreased from 138.5 ± 126.7 days in 2015 to 90.9 ± 50.9 days in 2018 (P < .001). The independent predictors for failure to retrieve the filter are represented in the Table. In addition to age and baseline medical comorbidities (congestive heart failure, chronic obstructive pulmonary disease, diabetes, malignant disease, smoking), recent trauma (odds ratio [OR], 2.41; 95% confidence interval [CI], 1.62-3.58), new follow-up deep venous thrombosis (OR, 2.34; 95% CI, 1.67-3.28), and long-term filter complications (OR, 2.30; 95% CI, 1.62-3.27) all predicted failure to retrieve the filter. Factors found to be protective from filter nonretrieval were discharge home after filter placement (OR, 0.50; 95% CI, 0.42-0.59), use of anticoagulation at follow-up (OR, 0.60; 95% CI, 0.52-0.69), and relative (OR, 0.81; 95% CI, 0.68-0.98) or prophylactic indication for filter placement (OR, 0.53; 95% CI, 0.30-0.94). These results show a decline in overall IVC filter placement in 2015 with a steady and significant rise in clinically relevant filter retrieval rate from 2013 to 2018. These data reflect a change in practice nationally with a more conservative stance toward filter placement and more aggressive approach for filter retrieval.TableMultivariate logistic regression analysis predicting failure to retrieve filterOR (95% CI)P valueRecent trauma2.41 (1.62-3.58)<.001Follow-up DVT2.34 (1.67-3.28)<.001Long-term filter complication2.30 (1.62-3.27)<.001CHF1.35 (1.04-1.76).024Malignant disease1.29 (1.08-1.54).004COPD1.28 (1.06-1.55).01Diabetes1.20 (1.01-1.42).038Smoking1.18 (1.03-1.35).019Age1.01 (1.01-1.02)<.001Relative indication (compared with major indication)0.81 (0.68-0.98).026Follow-up anticoagulant use0.60 (0.52-0.69)<.001Prophylactic indication (compared with major indication)0.53 (0.30-0.94).029Discharge home after filter placement0.50 (0.42-0.59)<.001CHF, Congestive heart failure; CI, confidence interval; COPD, chronic obstructive pulmonary disease; DVT, deep venous thrombosis; OR, odds ratio. Open table in a new tab

Major vascular involvement is often considered a contraindication to resection of malignant tumors, but in highly selected patients, it can be performed with mixed oncologic results that are highly dependent on the tumor’s biology. Resection of both the aorta and inferior vena cava (IVC) is a rare undertaking, requiring both favorable tumor biology and a patient fit for a substantial surgical insult; nevertheless, it provides the possibility of a cure. Patients requiring resection and reconstruction of both the aorta and IVC from 2009 through 2018 at a single university medical center were included. Patients’ characteristics, operative technique, and outcomes were retrospectively collected. We identified seven patients, all with infrarenal reconstruction or repair of the aorta and IVC. Patients’ characteristics are detailed in the Table. All cases were performed with systemic heparinization and required simultaneous aortic and caval cross-clamping for tumor resection. No temporary venous or arterial bypass was used. Because arterial reperfusion with the IVC clamped was poorly tolerated in one patient, venous reconstruction was typically completed first. Primary repair was performed in one patient, whereas six required replacement. In two patients, aortic homograft was used for replacement of both the aortoiliac and iliocaval segments in contaminated surgical fields. In the remaining four, Dacron was used for arterial replacement; either Dacron (n = 2) or polytetrafluoroethylene (n = 2) was used for venous replacement. Patients were discharged after a median stay of 8 days (range, 6-16 days). At median follow-up of 16 months (range, 1-79 months), there were no deaths. Two patients with paraganglioma had cancer recurrences. Venous reconstructions occluded in three patients (50%), although symptoms were minimal. One patient presented acutely with a thrombosed iliac artery limb and bilateral common iliac artery anastomotic stenoses, treated successfully with thrombolysis and stenting. Patients with tumor involving both the aorta and IVC can be successfully treated with resection and reconstruction. En bloc tumor resection, restoration of venous return before arterial reconstruction, and most important, careful selection of patients contribute to positive outcomes in this otherwise incurable population.TablePatients’ characteristics and oncologic outcomePatient’s age, years, and sexDiagnosisVenous involvementVenous reconstructionArterial involvementArterial reconstructionEBL, LAntithrombotic therapyRecurrence1. 28 FParagangliomaIVC, obliterated left CIVIVC only (Dacron)Aortic bifurcationAortoiliac (Dacron)2.5WarfarinNone2. 51 FParagangliomaIVCIVC only (ringed PTFE)AortaAortic tube graft (Dacron)3NoneNone3. 50 MParagangliomaIVCPrimary repairAortaPrimary repair1.8Aspirin 325 mgSpine4. 71 FParagangliomaIVC, bilateral CIVsIliocaval (ringed PTFE)Aorta, bilateral CIAsAortoiliac (Dacron)6Aspirin 81mgSpine, LNs5. 26 MMixed germ cell tumorThrombosed IVCIVC only (thoracic aorta homograft)Aortic bifurcationAortoiliac (aortoiliac homograft)3.5Aspirin 81 mgNone6. 36 MMixed germ cell tumorIVC, bilateral CIVsIliocaval (aortoiliac homograft)Aorta, bilateral CIAsAortoiliac (aortoiliac homograft)3Aspirin 81 mgNone7. 21 MMixed germ cell tumorIVC, thrombosed bilateral CIVsIliocaval (Dacron)Aortic bifurcationAortoiliac (Dacron)5RivaroxabanNoneCIAs, Common iliac arteries; CIVs, common iliac veins; EBL, estimated blood loss; IVC, inferior vena cava; LNs, lymph nodes; PTFE, polytetrafluoroethylene. Open table in a new tab

OBJECTIVE:The aim of this study was to examine practice patterns of inferior vena cava (IVC) filter insertion and retrieval at a tertiary care institution. METHODS:A retrospective review of all IVC filter procedures performed at the University of Pennsylvania and entered into the Penn cohort of the Vascular Quality Initiative registry between January 2013 and September 2017 was performed. Data collected included demographics, venous thromboembolism risk factors, indications for filter placement, and presence and timing of retrieval. Trend analysis and multivariable logistic regression were performed to evaluate factors associated with failure to retrieve the filter. RESULTS:During the study period, 627 IVC filters were inserted. The mean age was 52.8 ± 16.9 years, and 49.3% were male; 39.2% were placed for a major indication, whereas 58.1% were placed for prophylaxis. There was a significant decline in overall frequency of filter placement during the period observed, with a 33% decrease from 2015 to 2016 and a 26% decrease from 2016 to 2017 (P < .001), with an overall retrieval rate of 44.9%. In contrast, there was a corresponding increase in filter retrieval, with a 20% increase in 2015 and a 68% increase in 2016 (P = .02). In evaluating trends separated by indication, there was a significant decline in prophylactic filter placement (P < .001) and a trend toward an increase in retrieval of prophylactic filters (P = .09). Whereas there was not a significant change in number of filter insertions for major indication (P = .06), filter retrievals for major indication filters increased (P = .01). Multivariable regression analysis revealed that longer time to follow-up (odds ratio [OR], 1.08; P < .001) and discharge to rehabilitation facility (OR, 6.14; P < .001) were predictive of failure to retrieve the filter. In contrast, filter placement at a later date within our study period (OR, 0.90; P < .001) and prophylactic indication for filter placement (OR, 0.36; P < .001) were protective from filter nonretrieval. CONCLUSIONS:These results show both a decline in overall IVC filter placement and an increase in overall IVC filter retrieval at our institution. These trends are predominantly due to a decrease in prophylactic filter placement as well as an overall increase in filter retrieval. Further study should be dedicated to increasing the retrieval rate in this population of patients.

Objective: Fenestrated endografting for juxtarenal and pararenal abdominal aortic aneurysms affords the ability to seal stent grafts in normal aorta at and above the renal arteries. The Zenith fenestrated graft (ZFEN; Cook Medical, Bloomington, Ind) is custom-made to surgeon specifications, subject to certain manufacturing limitations. The most common configuration in the pivotal trial and in commercial use after approval has been as a scallop for the superior mesenteric artery (SMA) and two small fenestrations for the renal arteries (configuration A). An alternative configuration to maximize the seal zone length, consisting of a large fenestration for the SMA and two small fenestrations for the renal arteries (configuration B) has been routinely adopted at our institutions to potentially prevent type IA endoleak. Methods: The present retrospective cohort study examined 100 consecutive ZFEN grafts designed for patients at two university centers from 2012 through 2019. The proximal seal length, measured from the top of the graft to the beginning of the aneurysm, was determined from the preoperative computed tomography angiograms. Alternative configurations were evaluated to determine whether they would have provided a longer proximal seal length. Results: The two most common configurations were B (n = 45) and A (n = 38). For the cases in which A had been chosen but B could have been built, 5.8 +/- 1.9 mm of seal zone length was lost. For the cases in which B was chosen but A could have been built, 5.8 +/- 2.8 mm of seal zone length was gained. Owing, in part, to the increased proximal seal length with configuration B, this configuration has been used more frequently in the past 4 years of the present study compared with the first four (53% vs 25%; P = .004). Of 95 patients who had completed surgery and follow-up, type IA endoleaks were observed in 12 (13%) on completion angiography, all of which had resolved on follow-up imaging without intervention. No SMA was compromised by misalignment of the large fenestration in configuration B. Conclusions: A significantly longer proximal seal length can be obtained using a ZFEN with a large fenestration for the SMA and two small fenestrations for the renal arteries. Whenever possible, surgeons should consider this configuration to maximize the proximal seal length and potentially reduce the risk of proximal endoleak. An additional advantage of this approach is that stenting of the SMA to prevent shuttering will be unnecessary or impossible, making the procedure more technically facile.

Purpose: The majority of type 2 endoleaks (T2EL) are identified on computed tomography angiography (CTA) both on arterial and venous phase. There is a subset of T2EL that are demonstrated only on venous phase CTA. This study was done to report the outcomes of T2EL detected only on venous phase CTA. Materials and methods: A total of 261 consecutive T2EL treated via embolization were reviewed for the presence of endoleak demonstrated only on venous phase CTA. A group of 16 patients (12 men, 4 women; mean age, 80.1 years) was identified who had pre-embolization venous phase T2EL. Patients were evaluated for presence of T2EL after embolization, change in aneurysm diameter, and need for further intervention. Results: The prevalence of venous phase T2EL was 6.1% (16/261; 95% CI: 3.2%-9.0%). On post-embolization CTA, the rate of successful embolization at 6 months was 2/12 (17%; 95% CI: 0%-38%). At 6-month follow-up, mean change in aneurysm diameter was +2.3 mm (n = 12; 95% CI: -0.5 mm to + 5.0 mm). In total, 4/16 (25%; 95% CI: 4%-46%) underwent re-embolization and 4/16 (25%, 95% CI: 4%-46%) underwent conversion to open repair. There was one aneurysm rupture, which was successfully treated surgically. Conclusion: These results suggest that venous phase T2EL are not as responsive to embolization as standard T2EL and emphasize the need to follow patients with venous phase T2EL closely. (C) 2017 Editions francaises de radiologie. Published by Elsevier Masson SAS. All rights reserved.

Objective: Acute limb ischemia (ALI) is the cause of significant morbidity and mortality. Although ALI after cardiac surgery is associated with high rates of morbidity and mortality, there are no robust, controlled analyses of the risk factors and outcomes of ALI in this setting. We aimed to identify risk factors for and to delineate outcomes after ALI in patients undergoing cardiac surgery. Methods: We performed a retrospective review of prospectively collected data on patients undergoing cardiac surgery at our institution between 2002 and 2012. Results: Between 2002 and 2012, there were 11,343 patients who underwent major open cardiac surgery, with 156 cases of ALI for an incidence of 1.4%. In amultivariable model, significant risk factors for ALI included body surface area (odds ratio [OR], 0.41; 95% confidence interval [CI], 0.18-0.92), current smoking status (OR, 2.2; 95% CI, 1.3-3.7), peripheral arterial disease (OR, 2.5; 95% CI, 1.6-3.7), nonelective operative status (OR, 1.9-5.0; 95% CI, 1.2-19.7), use of extracorporeal membrane oxygenation (OR, 5.6; 95% CI, 2.5-11.6) or intra-aortic balloon pump (OR, 4.7; 95% CI, 2.9-7.5), and valve operation (OR, 2.1; 95% CI, 1.1-4.0). There were 105 (67%) patients who developed ALI who required an operation, and 27 (17%) required an amputation on the index admission. ALI was associated with a significant reduction in long-term survival (hazard ratio, 3.72; 95% CI, 2.97-4.65; P < .0001). Conclusions: ALI is associated with significant morbidity and mortality, and it is also associated with reduced long-term survival. Those patients with the risk factors described require extra vigilance to limit the risk of ALI and should be managed in accordance with the patient's overall clinical condition and goals of care.