Objective The COVID-19 pandemic has drastically altered the medical landscape. Various strategies have been employed to preserve hospital beds, personal protective equipment, and other resources to accommodate the surges of COVID-19 positive patients, hospital overcapacities, and staffing shortages. This has had a dramatic effect on vascular surgical practice. The objective of this study is to analyze the impact of the COVID-19 pandemic on surgical delays and adverse outcomes for patients with chronic venous disease scheduled to undergo elective operations. Methods The Vascular Surgery COVID-19 Collaborative (VASCC) was founded in March 2020 to evaluate the outcomes of patients with vascular disease whose operations were delayed. Modules were developed by vascular surgeon working groups and tested before implementation. A data analysis of outcomes of patients with chronic venous disease whose surgeries were postponed during the COVID-19 pandemic from March 2020 through February 2021 was performed for this study. Results A total of 150 patients from 12 institutions in the United States were included in the study. Indications for venous intervention were: 85.3% varicose veins, 10.7% varicose veins with venous ulceration, and 4.0% lipodermatosclerosis. One hundred two surgeries had successfully been completed at the time of data entry. The average length of the delay was 91 days, with a median of 78 days. Delays for venous ulceration procedures ranged from 38 to 208 days. No patients required an emergent intervention due to their venous disease, and no patients experienced major adverse events following their delayed surgeries. Conclusions Interventions may be safely delayed for patients with venous disease requiring elective surgical intervention during the COVID-19 pandemic. This finding supports the American College of Surgeons’ recommendations for the management of elective vascular surgical procedures. Office-based labs may be safe locations for continued treatment when resources are limited. Although the interventions can be safely postponed, the negative impact on quality of life warrants further investigation.

Background: To measure the impact of the COVID-19 pandemic on the management of pa-tients with carotid artery stenosis.Methods: We prospectively collected data from 25 centers (19 centers in the United States and 6 centers internationally) on postponed carotid artery operations between March 2020 and January 2022. We describe the characteristics of these patients and their planned operations, along with outcomes including mortality and neurological deterioration during the period of oper-ative delay due to the COVID-19 pandemic.Results: A total of 1,220 vascular operations were postponed during the pandemic, of them 96 patients presented with significant carotid stenosis (median stenosis of 71%; interquartile range; 70e80) and 80% of them were planned for carotid endarterectomy. Most patients were asymp-tomatic (69%), and 31% of patients were symptomatic (16% of patients had a stroke, 15% of patients had a transient ischemic attack, and 1% of patients experienced amaurosis fugax). The median length of surgical delay was 71 days (interquartile range: 45.5, 115.5). At the data entry time, 62% of patients had their carotid operations postponed and successfully completed. Most postponements (72%) were due to institutional policies aimed at resource con-servation. During the delay, no patient decompensated or required an urgent operation. A total of 5 patients (5%) with carotid stenosis died while awaiting operations due to COVID-19. Conclusions: Our study of a cohort of patients with carotid artery stenosis who underwent a median delay of 71 days during the COVID-19 pandemic showed a disparate operation delay between US regions and internationally, most postponements were due to hospital policy, and none of the patients deteriorated or required an emergency surgery during the delay.

Vascular research questions can be answered using various study designs. Observational studies are used frequently to address a wide range of clinical questions when randomized clinical trials are not feasible or practical. One of the powerful vascular research tools is the cohort study. The cohort study is a reliable observational study design in which individuals who share a common characteristic (a cohort) are followed over time and their outcomes are assessed at various intervals. This review focuses on the essential characteristics, design, implementation, bias, validity, and clinical significance of cohort studies and provides illustrative examples. A cohort study can be either a prospective or a retrospective study, depending on whether the outcome occurred before or after the enrollment of the cohort. Each type has its advantages and disadvantages. Confounding, selection, and information biases can all occur in cohort studies. Applications of the cohort study design include studying the natural history of a disease, describing a condition's frequency, and investigating multiple outcomes simultaneously.

Acute limb ischemia (ALI) is one of the most catastrophic thrombotic manifestations of COVID-19 resulting in limb loss if not promptly treated. Our goal is to evaluate revascularization outcomes of ALI in patients with COVID-19 who underwent either open or endovascular treatment. The Vascular Surgery COVID-19 Collaborative started in March 2020 to assess hematological changes of COVID-19. We performed an interim data analysis on 46 patients with COVID-19 associated ALI submitted to the ALI module of the Vascular Surgery COVID-19 Collaborative REDcap database from 10 institutions in the United States. Among the 46 patients included in the analysis, the mean age was 62.2 (standard deviation [SD]: 9.51) years. The majority of patients were male (73.9%). A total of 67.4% were White, 13% were Hispanic, and 4.3% were Black. In total, 93.5% of patients met Rutherford’s criteria of ALI class 2 or 3. On average, patients developed ALI 12.2 (SD: 13.5) days after a positive COVID test. Revascularization was attempted using open thrombectomy in 50.0%, endovascular lysis or thrombectomy in 23.9%, and bypass in 2.2%, and revascularization was not attempted in 23.9% of the patients (Table). Revascularization was successful in 41.3% with symptom resolution and 15.2% with limb salvage but persistent symptoms; 2.2% had minor amputation, 4.3% ultimately had a major amputation, 4.3% required reoperation, and revascularization was unsuccessful in 10.9% of patients. The average length of hospital stay was 13.2 (SD: 13.3) days, the average intensive care unit (ICU) length of stay was 4.66 (SD: 6.85) days, and the average ventilation days was 12.3 (SD: 10.8) days. Overall, in-hospital mortality was 21.7%, 8.7% had major amputation, 8.7% had stroke, 6.5% required major limb intervention, and 2.2% had sepsis. Successful revascularization rate was 62.5% in the 24 patients who underwent open surgery vs 36.4% in the 11 patients who underwent endovascular repair. The average length of stay in the ICU was shorter in the open group (mean = 3.24 days) than in the endovascular group (mean = 8.60 days). Of the 11 patients who had no revascularization attempt, 36.4% died, 18.2% had a major amputation, 9.1% had a pulmonary embolism, and 9.1% had a stroke. COVID-19-associated ALI carries a high mortality. Patients with COVID-19 who develop ALI can be managed successfully with open surgery or endovascular intervention. In our cohort, open revascularization resulted in reduced ICU stay and reduced ventilation days with improved limb salvage than the endovascular group. Further data are needed to develop management algorithms for ALI in patients with COVID-19.TableRevascularization outcomesEndovascular (N = 11)Open (N = 24)None (N = 11)Overall (N = 46)Age, mean (SD)65.1 (6.17)60.8 (8.59)62.2 (13.6)62.2 (9.51)Diabetes mellitus4 (36.4)9 (37.5)5 (45.5)18 (39.1)Rutherford ALI scale I0 (0)0 (0)3 (27.3)3 (6.5) IIa4 (36.4)9 (37.5)2 (18.2)15 (32.6) IIb5 (45.5)14 (58.3)2 (18.2)21 (45.7) III2 (18.2)1 (4.2)4 (36.4)7 (15.2)No preoperative anticoagulation medication use6 (54.5)22 (91.7)22 (91.7)37 (80.4)No preoperative antiplatelet medication use3 (27.3)13 (54.2)7 (63.6)23 (50.0)Preoperative aspirin use18 (39.1)9 (37.5)4 (36.4)18 (39.1)Successful revascularization with symptom resolution4 (36.4)15 (62.5)0 (0)19 (41.3)Major amputation1 (9.1)1 (4.2)1 (9.1)4 (8.7)Ventilation in days, mean (SD)17.7 (9.61)10.6 (13.0)8.50 (7.78)12.3 (10.8)Average length of stay in ICU, days, mean (SD)8.60 (9.86)3.24 (4.96)3.29 (5.19)4.66 (6.85)Average length of stay in hospital, days, mean (SD)11.9 (10.5)12.8 (14.3)11.9 (10.5)13.2 (13.3)Death, in hospital3 (27.3)3 (6.5)4 (36.4)10 (21.7)Death, within 30 days1 (9.1)1 (4.2)0 (0)3 (6.5)ICU, Intensive care unit; SD, standard deviation.Data are presented as number (%) unless otherwise indicated. Open table in a new tab

The objective of this study was to determine if preoperative vein mapping (PVM) was associated with increased use of autogenous venous conduits in a real-world registry of lower extremity infra inguinal bypass (IIB).

Background: The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented challenges for health care systems globally. We designed and administered a global survey to examine the effects of COVID-19 on vascular surgeons and explore the COVID-19-related stressors faced, coping strategies used, and support structures available. Methods: The Pandemic Practice, Anxiety, Coping, and Support Survey for Vascular Surgeons was an anonymous cross-sectional survey sponsored by the Society for Vascular Surgery Wellness Task Force. The survey analysis evaluated the effects of COVID-19-related stressors on vascular surgeons measured using the Generalized Anxiety Disorder 7-item scale. The 28-item Brief Coping Orientation to Problems Experienced inventory was used to assess the active and avoidant coping strategies. Survey data were collected using REDCap (Research Electronic Data Capture) from April 14, 2020 to April 24, 2020 inclusive. Additional qualitative data were collected using open-ended questions. Univariable and multi-variable analyses of the factors associated with the anxiety levels and qualitative analysis were performed. Results: A total of 1609 survey responses (70.5% male; 82.5% vascular surgeons in practice) from 58 countries (43.4% from United States; 43.4% from Brazil) were eligible for analysis. Some degree of anxiety was reported by 54.5% of the respondents, and 23.3% reported moderate or severe anxiety. Most respondents (similar to 60%) reported using active coping strategies and the avoidant coping strategy of "self-distraction," and 20% used other avoidant coping strategies. Multi-variable analysis identified the following factors as significantly associated with increased self-reported anxiety levels: staying in a separate room at home or staying at the hospital or a hotel after work (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.08-1.79), donning and doffing personal protective equipment (OR, 1.81; 95% CI, 1.41-2.33), worry about potential adverse patient outcomes due to care delay (OR, 1.47; 95% CI, 1.16-1.87), and financial concerns (OR, 1.90; 95% CI, 1.49-2.42). The factors significantly associated with decreased self-reported anxiety levels were hospital support (OR, 0.83; 95% CI, 0.76-0.91) and the use of positive reframing as an active coping strategy (OR, 0.88; 95% CI, 0.81-0.95). Conclusions: Vascular surgeons globally have been experiencing multiple COVID-19-related stressors during this devastating crisis. These findings have highlighted the continued need for hospital systems to support their vascular surgeons and the importance of national societies to continue to invest in peer-support programs as paramount to promoting the well-being of vascular surgeons during and after the COVID-19 pandemic.

secondary outcomes included 12-month primary patency, freedom from target lesion revascularization, and amputation-free survival.Random-effect model was used to pool the odds ratios (ORs) and related 95% confidence intervals (CIs).Results: Our systematic review included three randomized controlled trials and five cohort studies.A total of 4262 patients treated with DES and 9259 patients with DCB were analyzed.All included cohort studies were high-quality with Newcastle-Ottawa scores from 7 to 8. The pooled results suggested that no significant difference in 12-month all-cause mortality was found between the DES and DCB groups, without significant heterogeneity (OR, 1.02; 95% CI, 0.92-1.14;P ¼ .69;I 2 ¼ 0%, P heterogeneity ¼ .80)(Fig 1).No significant difference was observed between the two groups in terms of primary patency (OR, 1.27; 95% CI, 0.75-2.15;P ¼ .36;I 2 ¼ 55%; P heterogeneity ¼ .06)(Fig 2 ) and freedom from target lesion revascularization (OR, 0.94; 95% CI, 0.64-1.40;P ¼ .77;I 2 ¼ 0%; P heterogeneity ¼ .72).Conclusions: This systematic review and meta-analysis suggest that primary patency and freedom from target lesion revascularization were comparable between DES and DCB for treatment of lower extremity peripheral arterial disease.There is no significant difference in terms of 12month all-cause mortality between the DES and DCB groups.The choice of DES or DCB could be decided individually based on the features, complexity and site of target lesions.

Objective: The goal of the VASCC (vascular surgery COVID-19 [coronavirus disease 2019] collaborative) study was to determine the influential characteristics of a population with severe peripheral artery disease (PAD) and/or chronic limb threatening ischemia (CLTI) during the COVID-19 pandemic for whom postponement of scheduled procedures could have affected the outcomes.Methods: VASCC, founded in March 2020, is an international multicenter observational study of a subset of PAD/CLTI patients for whom planned interventions were postponed during the COVID-19 pandemic surge.The following interim data were collected for 165 patients in the United States: demographics, comorbidities, wound ischemia foot infection (WIfI) stage, indication and planned surgery, location of surgery, time delay, change in surgical plan, and adverse events.Descriptive statistics were used for the interim data.

This is a retrospective review of a pilot program to provide in home vascular testing to patients during the COVID-19 Pandemic. Results: Eighty-four patients underwent a total of 105 vascular imaging tests as part of the program. Two patients required hospitalization secondary to imaging findings. A description of the program, the results of the testing and patient experience with in-home vascular testing is discussed.

Simulation is becoming an important tool in surgical education. Surgical faculty have been forced to modify how they teach technical skills. Instead of a complete reliance on teaching in the operating room, a structured curriculum and dedicated time in the simulation center are being used in many centers. Some of the advantages of this approach include the ability to learn and practice new procedures in a safe and nurturing environment. The disadvantages include the significant cost of virtual reality simulators and the competition, between various training programs, to gain access to simulation.

Background The COVID-19 pandemic has made a significant impact on all spheres of society. The objective of this study was to examine the impact of COVID-19 on the practices, finances, and social aspects of Brazilian vascular surgeons’ lives. Methods This is a descriptive analysis of the responses from Brazilian vascular surgeons to the cross-sectional anonymous Society for Vascular Surgery Wellness Task Force Pandemic Practice, Anxiety, Coping, and Support Survey for Vascular Surgeons disseminated 14–24 April 2020. Survey dissemination in Brazil occurred mainly via the Brazilian Society of Angiology and Vascular Surgery (SBACV) and social media. The survey evaluated the impact of the COVID-19 pandemic on vascular surgeons’ lives by assessing COVID-19-related stressors, anxiety using theGeneral Anxiety Disorder (GAD)-7 scale, and coping strategies using the Brief Coping Orientation to Problems Experienced (Brief-COPE) inventory. Results A total of 452 responses were recorded from Brazil, with 335 (74%) respondents completing the entire survey. The majority of respondents were males ( N = 301, 67%) and practiced in an urban hospitals. The majority of respondents considered themselves at high risk to be infected with COVID-19 ( N = 251, 55.8%), and just over half the respondents noted that they had adequate PPE at their primary hospital ( N = 171, 54%). One hundred and nine (35%) surgeons confirmed that their hospitals followed professional surgical society guidelines for prioritizing surgeries during the pandemic. At the time of the survey, only 33 (10%) surgeons stated they have pre-operative testing of patients for COVID-19 available at their hospital. Academic vascular surgeons reported being redeployed more often to help with other non-vascular duties compared to community-based or solo practitioners (43% vs. 30% vs. 21% respectively, P = .01). Severe anxiety due to pandemic-related financial concerns was similar in those surgeons practicing solo compared to those in community- or academic-based/group practice (46% vs. 38% vs. 22%; P = .54). The respondents reported their anxiety levels as mild based on the stressors investigated instead of moderate-severe (54% vs. 46%; P = .04). Social media was utilized heavily during the pandemic, with video gatherings being the most commonly used tool (76%). Self-distraction (60%) and situational acceptance (81%) were the most frequently reported coping mechanisms used among Brazilian vascular surgeons. Conclusion The COVID pandemic has greatly affected healthcare providers around the world. At the time of this survey, Brazilian vascular surgeons are reporting low anxiety levels during this time and are using mostly active coping mechanisms.

COVID-19 has had an unprecedented effect on the global delivery of vascular surgical services. The international Vascular Surgery COVID-19 Collaborative (VASCC) registry prospectively recruited patients to evaluate the impact of surgical delay and subsequent natural history of patients awaiting scheduled aortic operations. The VASCC registry identified 127 patients with aortic disease whose operations were postponed during the 2020 COVID-19 pandemic. This interim analysis was conducted approximately 10 months after commencement of the registry based on data from centers in the United States. Data was collected on 127 planned aortic cases with a mean age of 70.7 years (standard deviation, 11.3 years), and 68.5% were male. The range of procedures delayed consisted of 100 for aneurysm repair (78.7%), 7 acute aortic syndromes (5.5%) (penetrating aortic ulcer, intramural hematoma, and subacute or chronic Type B dissection), and 18 endoleak procedures (14.2%) (Fig 1). As of this analysis, 89 (70%) of patients had completed surgeries with a median delay of 63 days (interquartile range, 42-98 days), with one patient undergoing unsuccessful emergency repair for aneurysm rupture. Eighteen patients (14.2%) were still waiting for surgery at the time of completion of the case report form, consisting of 17 aneurysms and one endoleak. Thirteen patients (10.2%) had their procedure permanently cancelled. Including the aforementioned rupture, another 5 patients (3.9%) were reported as having died after postponement of their aneurysm surgery (Fig 2). Mortality among aneurysm patients alone was 6% during the 10-month analysis period. At the time of analysis, 70% of postponed aortic procedures were completed with a median delay of 63 days. Nevertheless, six patients died as a result of postponed surgery, including one aneurysm rupture. Overall mortality of 6 patients (4.7%) over 10 months from COVID-19-related health service disruption underscores the wider impacts of this pandemic, and the importance of resource and contingency planning for future epidemics and natural disasters.Fig 2Outcome of delay.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Abdominal aortic aneurysm is a pathologic dilation of the aorta defined as 50% greater than normal diameter. The etiology of this condition has been shown to be associated with medial weakening of the vessel wall through smooth muscle cell dysfunction and structural weaknesses related to connective tissues. Correct access technique is essential to EVAR as it is the portal for all subsequent endovascular surgical equipment in the procedure. If a lesion responds to suction thrombectomy, exclusion using a covered stent may be attempted, or open cutdown and open thrombectomy when appropriate. If this yield success, it can be an option to see if the endoleak channel is able to be directly accessed to allow for placement of embolization coils, glue, dimethyl sulfoxideethylene vinyl alcohol solution. Additionally, it may be possible to access the IMA via collateral vessels such as the superior mesenteric artery via the marginal artery of Drummond or Arc of Riolan or the lumbar arteries through iliolumbar branches.

Background/Objective The unprecedented pandemic spread of the novel coronavirus has severely impacted the delivery of healthcare services in the United States and around the world, and has exposed a variety of inefficiencies in healthcare infrastructure. Some states have been disproportionately affected such as New York and Michigan. In fact, Detroit and its surrounding areas have been named as the initial Midwest epicenter where over 106,000 cases have been confirmed in April 2020. Method, Results and Conclusions Facilities in Southeast Michigan have served as the frontline of the pandemic in the Midwest and in order to cope with the surge, rapid, and in some cases, complete restructuring of care was mandatory to effect change and attempt to deal with the emerging crisis. We describe the initial experience and response of 4 large vascular surgery health systems in Michigan to COVID-19.

Objective: During the COVID-19 pandemic, central venous access line teams were implemented at many hospitals throughout the world to provide access for critically ill patients. The objective of this study was to describe the structure, practice patterns, and outcomes of these vascular access teams during the COVID-19 pandemic. Methods: We conducted a cross-sectional, self-reported study of central venous access line teams in hospitals afflicted with the COVID-19 pandemic. To participate in the study, hospitals were required to meet one of the following criteria: development of a formal plan for a central venous access line team during the pandemic; implementation of a central venous access line team during the pandemic; placement of central venous access by a designated practice group during the pandemic as part of routine clinical practice; or management of an iatrogenic complication related to central venous access in a patient with COVID-19. Results: Participants from 60 hospitals in 13 countries contributed data to the study. Central venous line teams were most commonly composed of vascular surgery and general surgery attending physicians and trainees. Twenty sites had 2657 lines placed by their central venous access line team or designated practice group. During that time, there were 11 (0.4%) iatrogenic complications associated with central venous access procedures performed by the line team or group at those 20 sites. Triple lumen catheters, Cordis (Santa Clara, Calif) catheters, and nontunneled hemodialysis catheters were the most common types of central venous lines placed by the teams. Eight (14%) sites reported experience in placing central venous lines in prone, ventilated patients with COVID-19. A dedicated line cart was used by 35 (59%) of the hospitals. Less than 50% (24 [41%]) of the participating sites reported managing thrombosed central lines in COVID-19 patients. Twenty-three of the sites managed 48 iatrogenic complications in patients with COVID-19 (including complications caused by providers outside of the line team or designated practice group). Conclusions: Implementation of a dedicated central venous access line team during a pandemic or other health care crisis is a way by which physicians trained in central venous access can contribute their expertise to a stressed health care system. A line team composed of physicians with vascular skill sets provides relief to resource-constrained intensive care unit, ward, and emergency medicine teams with a low rate of iatrogenic complications relative to historical reports. We recommend that a plan for central venous access line team implementation be in place for future health care crises.

Background: The coronavirus disease 2019 (COVID-19) pandemic has led to widespread postponement and cancelation of elective surgeries in the United States. We designed and administered a global survey to examine the impact of COVID-19 on vascular surgeons. We describe the impact of the pandemic on the practices of vascular surgeons in the United States. Methods: The Pandemic Practice, Anxiety, Coping, and Support Survey for Vascular Surgeons is an anonymous cross-sectional survey sponsored by the Society for Vascular Surgery Wellness Task Force disseminated April 14 to 24, 2020. This analysis focuses on pattern changes in vascular surgery practices in the United States including the inpatient setting, ambulatory, and vascular laboratory setting. Specific questions regarding occupational exposure to COVID-19, adequacy of personal protective equipment, elective surgical practice, changes in call schedule, and redeployment to nonvascular surgery duties were also included in the survey. Regional variation was assessed. The survey data were collected using REDCap and analyzed using descriptive statistics. Results: A total of 535 vascular surgeons responded to the survey from 45 states. Most of the respondents were male (73.1%), white (70.7%), practiced in urban settings (81.7%), and in teaching hospitals (66.8%). Almost one-half were in hospitals with more than 400 beds (46.4%). There was no regional variation in the presence of preoperative COVID-19 testing, COVID-19 OR protocols, adherence to national surgical standards, or the availability of personal protective equipment. The overwhelming majority of respondents (91.7%) noted elective surgery cancellation, with the Northeast and Southeast regions having the most case cancellations 94.2% and 95.8%, respectively. The Northeast region reported the highest percentage of operations or procedures on patients with COVID-19, which was either identified at the time of the surgery or later in the hospital course (82.7%). Ambulatory visits were performed via telehealth (81.3%), with 71.1% having restricted hours. More than one-half of office-based laboratories (OBL5) were closed, although there was regional variation with more than 80% in the Midwest being closed. Cases performed in OBL5 focused on critical limb ischemia (42.9%) and dialysis access maintenance (39.9%). Call schedules modifications were common, although the number of call days remained the same (45.8%). Conclusions: Vascular surgeons in the United States report substantial impact on their practices during the COVID-19 pandemic, and regional variations are demonstrated, particularly in OBL use, intensive care bed availability, and COVID-19 exposure at work.

Objective: Adverse outcomes observed late in the Nellix EndoVascular Aneurysm Sealing (EVAS) System (Endologix, Inc, Irvine, Calif) investigational device exemption trial prompted refinement of the anatomic instructions for use (IFU). This study aimed to investigate the association of procedural factors during Nellix endograft deployment and patient outcomes. Methods: We retrospectively reviewed 1-month imaging of 333 patients enrolled in the prospective, multicenter EVAS investigational device exemption trial between January 2014 and September 2016. Initial observations of those patients who met revised anatomic IFU yet still experienced late adverse events suggested that inadequate seal and low graft placement were common among these patients. Key procedural variables identified from a univariate analysis were applied to construct four cohorts stratified by procedural technical performance (technically adequate [P+] or technically inadequate [P-]) and the revised anatomic indications for use (anatomically within IFU [A+] or anatomically outside of IFU [A-]) and to compare them for aneurysm-related outcomes. A logistic regression analysis was performed to identify significant predictors of sac expansion or migration. Results: Proximal and distal seal zones and low graft placement were identified by logistic regression analysis as significant predictors of sac expansion or migration. Accordingly, acquisition of 10-mm proximal and distal seal zones and the position of the lowest stent within 10 mm of the lowest renal artery were clinically justified as thresholds for a technically adequate procedure. Patients who did not achieve these parameters were deemed to have a technically inadequate procedure. By use of the proposed procedural adequacy criteria and established anatomic criteria, patients were stratified into four cohorts: A+/P+ (n = 77), A+/P- (n = 54), A-/P+ (n = 71), and A-/P- (n =131). Three-year estimates of freedom from migration of 10 mm were 98.6% in A+/P+, 95.9% in A+/P-, 85.8% in A-/P+, and 80.1% in A-/P-; freedom from type IA endoleak estimates were 98.6% in A+/P+, 100% in A+/P-, 96.4% in A-/P+, and 90.3% in A-/P- cohorts. Freedom from sac expansion and secondary intervention were 96.9% and 90.6% in A+/P+, 86.0% and 93.6% in A+/P-, 87.1% and 83.1% in A-/P+, and 80.5% and 79.8% in A-/P- groups, respectively. Two early deaths (aneurysm-related mortality) on days 4 and 12 postoperatively were reported within the A+/P- group. Kaplan-Meier estimates of freedom from all-cause mortality and aneurysm-related mortality at 3 years were similar between cohorts. Conclusions: This post hoc analysis suggests that achieving a 10-mm proximal and distal seal with adequate positioning of the endog raft with respect to the renal arteries is associated with improved patient outcomes.

Extracranial internal carotid artery (EICA) aneurysms make up 1% of peripheral aneurysms and less than 1% of patients who have relapsing polychondritis develop aneurysms. A 39-year-old man with relapsing polychondritis presented with right neck pain. Initial computed tomography angiography demonstrated a 16-mm right EICA aneurysm with growth to 25 mm after 2 months. A right EICA aneurysmectomy, external carotid artery to ICA transposition, and internal jugular vein patch of the common carotid artery was performed with symptom resolution. The inflammatory nature of the underlying disease, aggressive expansion, and symptomatic state warranted open repair and we recommend life-long monitoring given the rarity of this case.

Background: A previously repaired right popliteal artery aneurysm via a medial approach with proximal and distal ligation and interval bypass re-presented 7 years after the initial repair with a ruptured 9 x 25.5 cm right popliteal aneurysm. Methods: Surgical repair was complex due to the large size of the aneurysm. Technique and management of popliteal aneurysm repair are discussed, along with a review of the current literature. Results: A 58-year-old male with a 3.5 cm popliteal artery aneurysm was initially treated with end-to-end prosthetic bypass and proximal/distal aneurysm ligation from a medial-approach without complication. Seven years later, he presented with a 9-cm popliteal aneurysm rupture. Posterior approach endoaneurysmorrhaphy repair was far more complicated than expected with massive blood loss. Despite this, he was discharged without complication POD #5, but on POD #19 presented with cellulitis and underwent incision and drainage of retained hematoma with cultures positive for Strep dysgalactiae. With appropriate treatment, he was healed in 3 months. Conclusions: Surgical repair of large popliteal aneurysms can be challenging, but continued aneurysmal degeneration is a potential consequence if the sac continues to be pressurized from patent geniculate arteries. Surgical repair of large popliteal artery aneurysms is complex and requires adjunctive techniques to maximize success. A posterior approach is described and the literature reviewed to support recommendations for primary popliteal artery aneurysm repair and repair of large degenerated popliteal artery aneurysms. We recommend primary popliteal artery aneurysm repair from a posterior approach with endoaneurysmorrhaphy and an interposition bypass. For ruptured large popliteal artery aneurysms, there is a high risk of hemorrhage and wound complications. Therefore, we recommend the use of a tourniquet, surgical drain and to consider the collection of intraoperative cultures to guide potential antibiotic management.