OBJECTIVE:To evaluate treatment trends and compare outcomes following fenestrated-branched endovascular aortic repair (FB-EVAR) versus open surgical repair (OSR) of thoracoabdominal aortic aneurysms (TAAA). BACKGROUND:FB-EVAR has been increasingly utilized as a less invasive alternative to OSR for treatment of TAAAs. METHODS:We studied patients who underwent elective FB-EVAR or OSR of TAAAs (2008-2020), since the initiation of an Advanced Endovascular Aortic Program. Primary endpoints were early major adverse events (MAE) and early and late all-cause mortality. Propensity score overlap weighting analysis was performed to adjust for measured confounders between groups. RESULTS:There were 357 (70.8%) patients treated by FB-EVAR and 147 (29.2%) with OSR. The use of FB-EVAR increased from 16.7% in 2008 to >80% since 2017 (P<0.001). Incidences of early MAEs were 25.8% and 49.0%, respectively; early mortality rates for FB-EVAR and OSR were 2.5% and 6.8%, respectively. In the weighted cohort, FB-EVAR patients had decreased early MAEs (weight-adjusted odds ratio [aOR], 0.28; 95% confidence interval [CI], 0.18-0.41; P<0.001) and mortality (aOR, 0.35; 95% CI, 0.17-0.73; P=0.005) versus OSR patients. Five-year survival estimates were 52.2% (95% CI, 45.2-60.4%) and 78.0% (95% CI, 70.6-86.2%), respectively. In the weighted cohort, there was no significant difference in late survival between groups (weight-adjusted hazard ratio, 1.33; 95% CI, 0.74-2.39; P=0.34). CONCLUSIONS:This study confirmed the change in practice from OSR to FB-EVAR for treatment of TAAAs over the past decade. Incidences of early MAEs and mortality were lower with FB-EVAR, with no significant difference in late survival in the weighted cohort.

OBJECTIVE:The most common complications of open thoracoabdominal aortic repair (OTAAR) are respiratory in nature. The aim of this study was to analyze the impact of intraoperative diaphragm management on prolonged postoperative ventilation, pulmonary complications, and overall outcomes in patients undergoing OTAAR. METHODS:We conducted a retrospective single-institutional review of patients who underwent extent I to V OTAAR between 2013 and 2024. Patients who did not require diaphragm division were excluded. Outcomes were analyzed in two groups based on full circumferential division (FCD) or partial circumferential division (PD). The primary outcome was prolonged ventilation, defined as postoperative ventilator support for >48 hours. Secondary outcomes included early respiratory morbidity, in-hospital mortality, major adverse events, and length of intensive care unit (ICU) and hospital stays. Univariate followed by multivariable analyses were used to evaluate the association of extent of diaphragm division with the primary and secondary outcomes. RESULTS:Among 135 patients who underwent OTAAR during the study period, 110 patients met the inclusion criteria and were included in the analysis. The average patient age was 54 ±14 years, and 77 patients (70%) were male. Most repairs were done for postdissection aneurysms (n = 83 [76%]) requiring extent II thoracoabdominal aortic repair (n = 88 [80%]). Demographics, comorbidities, and preoperative variables were similar between the two groups. FCD was performed in 60 patients (54%), and 50 patients (46%) underwent PD. Prolonged ventilation occurred in 25 patients (24%). On univariate analysis, patients who underwent FCD were more likely to have prolonged ventilation as compared with those who underwent PD (32% [n = 18] vs 15% [n = 7]; P = .037). This association persisted on multivariable analysis (odds ratio, 4.0; 95% confidence interval, 1.4-11.8; P = .01). Patients who underwent FCD demonstrated a trend toward higher rates of postoperative pneumonia (35% vs 25%), need for reintubation (16% vs 8%), and ICU readmission (20% vs 10%). No significant differences were seen when comparing in-hospital mortality, length of ICU and hospital stays, cerebrovascular accident, myocardial infarction, or renal failure requiring dialysis. CONCLUSIONS:PD of the diaphragm is associated with a shorter duration of postoperative mechanical ventilation without any significant impact on mortality or major adverse events. PD should be considered for OTAARs.

Objective:The aim of this study is to determine perioperative outcomes and the patency of interposition conduits for visceral arterial reconstruction in this setting.Background:Visceral arterial encasement in locally advanced pancreatic cancer was historically a contraindication for surgery. With modern, effective neoadjuvant strategies, our recent experience has made advanced vascular resection and reconstruction feasible in selected patients.Methods:A retrospective review was performed of patients undergoing pancreatic tumor resection with en bloc arterial resection and interposition revascularization between June 2002 and October 2022. Endpoints included graft patency, vascular-related complications, reinterventions, morbidity, and mortality.Results:Visceral arterial reconstruction with interposition grafting was performed in 111 patients undergoing en bloc arterial resections for pancreatic cancer. Graft types included autologous arterial conduits (n=66, 58 superficial femoral arteries (SFA) and 8 splenic arteries), cryopreserved arterial allografts (n=24), autologous saphenous veins (n=12), synthetic conduits (n=8), and composite autologous artery and synthetic (n=1). Perioperative 90-day mortality decreased significantly over time to 5% in the last 6 years. Vascular complications related to arterial reconstruction occurred in 11% (n=12) and included pseudoaneurysm (n=6), graft thrombus (n=2), stenosis requiring reintervention (n=2), hepatic failure (n=1), and hepatic and intestinal ischemia (n=1). Nine (8%) patients underwent vascular-related reinterventions. After a median follow-up of 17 months, primary patency was 81% for the entire cohort and was highest in the SFA group (95%). The donor limb/harvest site complication rate was 8% with 100% primary patency.Conclusion:Visceral arterial resection with interposition reconstruction for locally advanced pancreatic cancer can be performed with acceptable vascular morbidity and durable patency. Autologous SFA was the most suitable conduit for reconstructions in our experience, with the highest primary patency.

OBJECTIVE:To describe early and late outcomes of segmental resection and graft replacement of the inferior vena cava (IVC) for malignant disease over three decades. METHODS:All patients who had IVC resection with graft replacement from 1990 to 2024 at a single institution were retrospectively reviewed. Patients with tangential excision and primary or patch venorrhaphy were excluded. End points were early (<30 days) mortality, major adverse events, graft-related complications, primary patency, overall survival, and freedom from local recurrence. RESULTS:One hundred sixty-seven patients (54% female; mean age at operation 55 ±14 years) had IVC resection and graft replacement. Primary IVC leiomyosarcoma occurred in 69 patients (41%) and other secondary malignancies in 97 (58%). Preoperative performance status (Eastern Cooperative Oncology Group) was good or excellent in 153 patients (92%). Resection of multiple IVC segments was required in 94 patients (56%), 41 who needed renal vein reconstruction or implantation (25%) and 6 (3.6%) who had hepatic vein implantation. Graft replacement was with ringed polytetrafluoroethylene in 163 patients (98%). Two patients died of intraoperative hemorrhage. Six others died within 4 months; three were procedure-related. One or more major adverse events occurred in 28 patients (17%). Intra-abdominal hemorrhage requiring transfusion was the most common complication, occurring in 10 patients (5.9%). Only one patient developed permanent renal or liver failure. Two patients (1.2%) had asymptomatic subsegmental pulmonary emboli. Over a mean follow-up of 5.5 ± 5.8 years (median 3.2 [1.2, 7.5] years), 10 patients experienced graft occlusion (5.9%). Two occlusions were within 1 month of graft placement, two were within 1 year, and 6 were over 1 year, with one at 23 years postoperatively. Four patients had stents placed to treat asymptomatic high-grade stenoses, one early and three late. There were four graft infections, all related to small bowel leaks. The median overall survival was 52% and 36% at 5 and 10 years, respectively (range, 0-27 years). Freedom from local recurrence was 85%, 71%, and 54% at 1, 5, and 10 years, respectively. Kaplan-Meier estimates of IVC graft primary patency were 96%, 95%, and 88% at 1, 5, and 10 years, respectively. CONCLUSIONS:IVC resection and graft replacement for malignant disease are safe and durable, and provide excellent local control of the tumor, offering a chance for long-term survival in select patients.

The majority of tumors which involve the inferior vena cava (IVC) or iliac veins are malignant. IVC and iliac vein tumors are divided into two types: primary and secondary. Some surgeons arbitrarily call the region around the renal vein–caval confluence the pararenal IVC segment. The most common location of primary venous leiomyosarcoma (PVL) is the IVC, with the suprarenal segment involved most often. PVL is hard to distinguish from other retroperitoneal sarcomas if it is large and invades through the IVC wall. Retroperitoneal sarcoma is the most common secondary tumor to extrinsically compress and invade the infrarenal IVC or iliac veins. Patients with IVC or iliac vein malignancies present with symptoms and signs related to the tumor or its metastases, but rarely due to venous obstruction. Symptomatic IVC obstruction occurs from acute thrombosis when venous collaterals are poorly developed or when the venous hypertension caused by progressive IVC or iliac vein obstruction exceeds the capacity of the collaterals.

A 73-year-old woman presented with severe postprandial abdominal, weight loss, hypertension, and claudication. Computed tomography angiography (CTA) showed diffuse, bulky atheroma in the thoracic and abdominal aorta, involving the superior mesenteric artery (SMA) and left renal artery (LRA)/right renal artery origins. The celiac artery was occluded. The ascending aorta was free of disease (Fig 1). She presented subacutely with lower extremity neurologic deficits and worsening abdominal and leg pain. Her symptoms improved with hydration and CTA showed no acute arterial occlusions. She underwent expeditious cardiopulmonary evaluation. Arterial reconstruction was performed through a median sternotomy and laparotomy. Left medial visceral rotation was used to isolate the SMA, LRA, and both external iliac arteries. The right kidney was small, and its artery was unreconstructable. An ascending aortobilateral external iliac arteries bypass was performed using composite straight and bifurcated grafts. The SMA and LRA were separately bypassed (Fig 2). The aortic and visceral grafts were wrapped with omentum. The operation proceeded uneventfully, and she awoke neurologically intact. However, she sustained a small right hemispheric stroke with left hemiparesis 12 hours after surgery. She required a temporary tracheostomy and had transient acute kidney injury without dialysis. Her neurologic symptoms markedly improved during hospitalization. She required physical therapy in a rehabilitation facility after hospital dismissal. At 5 months postoperatively, she was eating well, her blood pressure was well-controlled, and she had minimal left lower extremity weakness. CTA demonstrated patent aortic and visceral grafts. However, there was a large asymptomatic, late-filling ascending aortic pseudoaneurysm from a small aortic defect proximal to the ascending graft origin. The pseudoaneurysm was successfully treated with an Amplatzer plug (Abbott Vascular, Santa Rosa, CA). At 2 years of follow-up, she was doing well. The ascending aorta can be used for inflow in select patients with diffuse thoracic and abdominal aortic disease. Preoperative assessment of cardiopulmonary function is important in these circumstances.Fig 2Intraoperative photograph demonstrating ascending aortic to bilateral external iliac artery bypass with grafts to the superior mesenteric artery (SMA) and left renal artery (LRA). LRV, Left renal vein.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Objective: Aberrant subclavian arteries (aSCAs), with or without aortic pathology, are uncommon. The purpose of the present study was to review our experience with the surgical management of aSCA. Methods: We performed a retrospective review of patients who had undergone surgery for an aSCA between 1996 and 2020. Symptomatic and asymptomatic patients were included. The primary end points were <= 30-day and late mortality. The secondary end points were <= 30-day complications, graft patency, and reinterventions. Results: A total of 46 symptomatic and 3 asymptomatic patients with aSCA had undergone surgery (31 females [62%]; median age, 45 years). An aberrant right subclavian artery was present in 38 (78%) and an aberrant left subclavian artery in 11 patients (22%). Of the 49 patients, 41 (84%) had had a Kommerell diverticulum (KD) and 11 (22%) had had a concomitant distal arch or proximal descending thoracic aortic aneurysm. Symptoms included dysphagia (56%), dyspnea (27%), odynophagia (20%), and upper extremity exertional fatigue (16%). Five patients (10%) had required emergency surgery. The aSCA had been treated by transposition in 32, a carotid to subclavian bypass in 11, and an ascending aorta to subclavian bypass in 6. The KD was treated by resection and oversewing in 19 patients (39%). Fifteen patients (31%) had required distal arch or proximal descending thoracic aortic replacement for concomitant aortic disease and/or KD treatment. Thoracic endovascular aortic repair was used to exclude the KD in six patients (12%). Seven patients (14%) had undergone only bypass or transposition. The 30-day complications included one death from pulseless electrical activity arrest secondary to massive pulmonary embolism. The 30-day major complications (14%) included acute respiratory failure in three, early mortality in one, stroke in one, noneST-elevation myocardial infarction in one, and temporary dialysis in one patient. The other complications included chylothorax/lymphocele (n = 5; 10%), acute kidney injury (n = 2; 4%), pneumonia (n = 2; 4%), wound infection (n = 2; 4%), atrial fibrillation (n = 2; 4%), Horner syndrome (n = 2; 4%), lower extremity acute limb ischemia (n = 1; 2%), and left recurrent laryngeal nerve injury (n = 1; 2%). At a median follow-up of 53 months (range, 1-230 months), 40 patients (82%) had had complete symptom relief and 9 (18%) had experienced improvement. Six patients had died at a median of 157 months; the deaths were not procedure or aortic related. The primary patency was 98%. Reintervention at <= 30 days had been required for two patients (4%) for ligation of lymphatic vessels and bilateral lower extremity fasciotomy after proximal descending thoracic aorta replacement. One patient had required late explantation of an infected and occluded carotid to subclavian bypass graft, which was treated by cryopreserved allograft replacement. Conclusions: Surgical treatment of the aSCA can be accomplished with low major morbidity and mortality with excellent primary patency and symptom relief.

Objective: Elevated troponin (TnT) levels after open or endovascular surgical procedures have been previously shown to correlate with significantly higher postoperative and short-term mortality. The incidence of asymptomatic myocardial injury after vascular surgical procedures has also been shown to be high. The aim of the present study was to evaluate the utility of routine postoperative TnT screening and long-term outcomes for patients with postoperative TnT elevation. Methods: Data from consecutive patients who had undergone open or endovascular surgery on an emergent or elective basis with routine postoperative TnT testing from January 2010 to December 2012 were retrospectively analyzed. Elevated postoperative TnT was considered >0.01 ng/mL. Patients with no documented postoperative TnT levels, those who had denied research authorization, and those with elevated TnT levels secondary to renal insufficiency alone were excluded. Patients were also excluded if they had required a dialysis access procedure, varicose vein procedure, or any procedure performed on an outpatient basis, because these were considered nonmajor surgeries. The end points were all-cause mortality at 30 days and 1, 2, 4, and 8 years postoperatively. Mortality data were retrieved from the electronic medical records and the Social Security Death Index and Accurint Death database. Results: During the 3-year study period, 1632 patients with postoperative TnT levels available had met the inclusion criteria (70% men; 30% women; mean age, 69.7 years). Postoperatively, 410 patients (25.1%) had had elevated TnT levels (TnT+) and 1222 (74.9%) had had nonelevated TnT levels (TnT-). Of the 410 TnT+ patients, 261 had undergone open, 143 had undergone endovascular, and 6 had undergone hybrid procedures. These included 180 aortic, 128 infrainguinal, 22 cerebrovascular, and 80 upper extremity or miscellaneous procedures. Of the 410 TnT+ patients, 168 had experienced asymptomatic myocardial injury. The 30-day mortality was significantly higher for the TnT+ patients than for the TnT-patients (3.9% vs 0.8%; P < .001). The cumulative probability of death for the TnT+ patients remained significantly higher than that for the TnT-patients at 1 (13% vs 3.2%), 2 (17.8% vs 4.8%), 4 (43% vs 18.5%), and 8 (81.4% vs 48.6%) years (P < .0001). The difference held true even for the 168 asymptomatic TnT+ patients compared with the TnT-patients at 30 days (2.4% vs 0.8%) and 1 (7.6% vs 3.2%), 2 (13.3% vs 4.8%), 4 (43.6 vs 18.5%) and 8 (80.8 vs 48.6%) years (P < .0001). Conclusions: In the present study, patients with elevated TnT levels after vascular surgery had had significantly higher early and late all-cause mortality compared with those with normal postoperative TnT levels. This was true even for patients with asymptomatic TnT elevation, suggesting a role might exist for routine postoperative TnT screening to allow for long-term risk stratification and targeted medical management. (J Vasc Surg 2023;77:1216-23.)

Objective: Primary venous leiomyosarcomas (PVL) are rare and pose challenges in surgical management. This study evaluates the clinical outcomes and identifies predictors of survival in our surgical series of PVL. Methods: A retrospective review was performed of patients who had resection of PVL at three centers between 1990 and 2018. Patient demographics, comorbidities, intraoperative data, survival, and graft-related outcomes were recorded. Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards regression. Results: Seventy patients with a diagnosis of PVL were identified between 1990 and 2018. Fifty-four patients (77%) had PVL of the inferior vena cava (IVC) and 16 (23%) had peripheral PVL. The mean follow-up for the series was 55.0 months (range, 1-217 months). Fifty-one patients (96%) with IVC-PVL needed caval reconstruction and 3 (4%) had resection only. There were no deaths within 30 days of surgery. Five patients (9%) required early reintervention including one (2%) IVC stent. Sixteen peripheral PVL were identified. Eight patients (50%) had venous reconstructions performed and 8 (50%) had the vein resected without reconstruction. There were no deaths within 30 days. Five-year survival was 57.5% for IVC-PVL and 70.0% for peripheral PVL. Kaplan-Meier survival analysis for IVC and peripheral PVL revealed no difference in overall survival (P = .624) at 5 years. Conclusions: PVL is a rare and aggressive disease even with surgical resection. We found no difference in survival between IVC and peripheral lesions, suggesting that aggressive management is warranted for PVL of any origin. Management of PVL requires a multidisciplinary approach to provide patients with the best long-term outcomes.

Objective: Arterial thoracic outlet syndrome (ATOS) is rare. We present our 30-year experience with the management of ATOS at a high-volume referral center. Methods: A retrospective review of all patients who had undergone primary operative treatment for ATOS from 1988 to 2018 was performed. ATOS was defined as subclavian artery pathology caused by extrinsic compression from a bony abnormality within the thoracic outlet. Results: A total of 41 patients (45 limbs) underwent surgery for ATOS at a median age of 46 years (interquartile range [IQR], 34-58 years). Chronic symptoms (>6 weeks) were present in 31 limbs (69%). Of the 45 limbs, 13 (29%) presented with acute limb ischemia (ALI), requiring urgent brachial artery thromboembolectomy (BAT) in 9 and catheter-directed thrombolysis and thrombectomy (CDT) in 4. All patients underwent thoracic outlet decompression. 31 limbs (69%) required subclavian artery reconstruction. No perioperative deaths and only one major adverse limb event occurred. Patients with ALI underwent staged thoracic outlet decompression after initial BAT or CDT at a median of 23 days (IQR, 11-140 days). Of the 13 limbs with an initial presentation of ALI, 8 (62%) had recurrent thromboembolic events before thoracic outlet decompression subsequently requiring 10 additional BATs and 1 CDT. The cumulative probability of recurrent embolization at 14, 30, and 90 days was 8.33% (95% confidence interval [CI], 1.28%-54.42%), 16.67% (95% CI, 4.70%-59.06%), and 33.33% (95% CI, 14.98-74.20%), respectively. The median follow-up for 32 patients (35 limbs) was 13 months (IQR, 5-36 months). Subclavian artery/graft primary and secondary patency was 87% and 90%, respectively, at 5 years by Kaplan-Meier analysis. Of the 35 limbs, 5 (14%) had chronic upper extremity pain and 5 (14%) had persistent weakness. Preoperative forearm or hand pain and brachial artery occlusion were associated with chronic pain (P = .04 and P = .03) and weakness (P = .03 and P = .02). Of the 13 limbs that presented with ALI, 11 had a median follow-up after thoracic outlet decompression of 6 months (IQR, 5-14 months), including 9 (82%) with oral anticoagulation therapy. Anti-coagulation therapy had no effect on subclavian artery patency (P = 1.0) or the presence of chronic symptoms (P = .93). Conclusions: The presentation of ATOS is diverse, and the diagnosis can be delayed. Preoperative upper extremity pain and brachial artery occlusion in the setting of ALI were associated with chronic pain and weakness after thoracic outlet decompression. Delayed thoracic outlet decompression was associated with an increased risk of recurrent thromboembolic events for patients who presented with ALI. An early and accurate diagnosis of ATOS is necessary to reduce morbidity and optimize outcomes.

Objective: Aneurysms of the superior mesenteric artery (SMA) and its branches are rare and account for only 6% to 15% of all visceral artery aneurysms. In the present report, we have described our 30-year experience with the management of aneurysms of the SMA and its branches at a high-volume referral center. Methods: A retrospective review of all patients with a diagnosis of an aneurysm of the SMA or one of its branches from 1988 to 2018 was performed. Pseudoaneurysms and mycotic aneurysms were excluded. The clinical presentation, etiology, aneurysm shape and size, treatment modalities, and outcomes were analyzed. The growth rate of the aneurysms was estimated using linear regression. Results: A total of 131 patients with 144 aneurysms were reviewed. The patients were primarily men (64%), with a median age of 60 years. Of the 144 aneurysms, 57 were fusiform, 30 were saccular, and 57 were dissection-associated aneurysms. Of the 131 patients, 41 had had an isolated SMA branch aneurysm. Degenerative aneurysms were the most common etiology (66%). A total of 35 patients (27%) were symptomatic at presentation. Of the 144 aneurysms, 111 had multiple computed tomography angiograms available, with a median follow-up of 43.6 months (interquartile range, 10.6- 87.2 months). Only 18 aneurysms (16%) had had an estimated growth rate of mm/y. The initial aneurysm size was significantly associated with the growth rate for the fusiform aneurysms (odds ratio [OR],1.13; 95% confidence interval [CI], 1.0-1.3]; P= .02) but not for the saccular (OR, 0.91; 95% CI, 0.76-1.1; P= 1.1) or dissection-associated (OR, 1.2; 95% CI, 0.91-1.5; P= .20) aneurysms. Acute abdominal pain (OR, 5.9; 95% CI,1.6-22; P= .01) and chronic abdominal pain (OR, 3.7; 95% CI,1.1-13; P= .04) were associated with aneurysm growth. Only two patients had a ruptured aneurysm, both of whom presented with rupture with no prior imaging studies. These two patients had a diagnosis of fibromuscular dysplasia and systemic lupus erythematosus, respectively. Of the 131 patients, 46 (34%) had undergone operative repair, including 36 open revascu larizations and 8 endovascular procedures. The average aneurysm size for these 46 patients was 24.0 +/- 8.6 mm. One patient died perioperatively, and nine patients experienced perioperative complications (25%). Of the 144 aneurysms, 91 were <20 mm, with an average size of 13.4 +/- 3.1 mm. These 91 aneurysms had been followed up for a median of 120.8 months (interquartile range, 30.5-232.2 months), with no ruptures within this cohort during the follow-up period. Conclusions: The present study represents one of the largest series on aneurysms of the SMA and its branches. Our results showed that aneurysms of the SMA are relatively stable. Patients with symptomatic and fusiform aneurysms had a greater risk of growth. Aneurysms <20 mm with a degenerative etiology can be safely monitored without treatment.

A healthy 21-year-old man presented with a right neck palpable mass and calcifications diagnosed during a Panorex odontologic study. Computed tomography angiography imaging of the neck demonstrated a right common and internal carotid artery (ICA) pseudoaneurysm with irregular thrombus and calcifications causing severe right ICA stenosis (A, B). An elongated styloid process was identified adjacent to the pseudoaneurysm associated with ossification of the stylohyoid ligaments (C/Cover). A diagnosis of stylocarotid artery syndrome, a subtype of Eagle's syndrome, was considered and operative treatment recommended, given the pseudoaneurysm appearance with large thrombus and stenosis of the ICA.

OBJECTIVES:To assess the ability of the current classification system for popliteal entrapment syndrome to accurately capture all patients, and if not, to design an all-inclusive new classification.METHODS:Retrospective review of all interventions performed for popliteal entrapment syndrome between 1994 and 2013 at our institution was performed. Preoperative imaging and intraoperative findings were used to establish the compressive morphology of popliteal entrapment syndrome. Patients were categorized, when possible, into six types of the current classification system (Rich classification, modified by Levien) and into seven types of a new classification.RESULTS:Sixty-seven limbs of 49 patients were operated on for unilateral (31) or bilateral (18) popliteal entrapment syndrome. The current classification system captured the anatomy of only 43 (64%) of 67 limbs with popliteal entrapment syndrome. Compressive morphologies without a defined class included aberrant insertion of the lateral head of gastrocnemius muscle, muscle slip originating from the lateral head of gastrocnemius or hamstrings, hypertrophied hamstring muscle, abnormal fibrous bands, perivascular connective tissue, and prominent lateral femoral condyle. The new classification captured 100% of the limbs with popliteal entrapment syndrome.CONCLUSIONS:Current classification of popliteal entrapment syndrome is inadequate as more than one-third of the cases reviewed fell outside of the standard classification system. Consideration of a more inclusive new anatomic classification system is warranted.

CI], 1.004-1.040),female gender (OR, 1.393; 95% CI, 1.012-1.916),glomular filtration rate (GFR) <30 (OR, 5.068; 95% CI, 3.255-7.891),current smoking (OR, 1.942; 95% CI, 1.067-3.535),chronic obstructive pulmonary disease (COPD) (OR, 1.402; 95% CI, 1.066-1.843),max abdominal aortic aneuryms (AAA) diameter (OR, 1.018; 95% CI, 1.006-1.029),and presence of iliac aneurysm (OR, 1.352; 95% CI, 1.007-1.816)were associated with increased odds of CA-AKI.The Fig depicts the final classification tree.Using the VQI dataset (n ¼ 18,380), we found that GFR <30 (OR, 6.55; 95% CI, 5.25-8.17),female gender (OR, 1.42; 95% CI, 1.22-1.64),and maximum AAA diameter >6.9 cm (OR, 2.90; 95% CI, 2.53-3.33)were associated with increased risk of CA-AKI after EVAR.Conclusions: Herein, we present a simple and novel risk calculator to identify patients at risk of CA-AKI after EVAR (Fig) .Patients with a GFR <30, maximum AAA diameter >6.9 cm, and females who are undergoing EVAR may benefit from preoperative hydration or use of non-iodinated contrast agents.Prospective studies are needed to determine the efficacy of our model and pre-hydration protocol.

A 48-year-old woman presented with a 4-year history of right lower extremity claudication in the anterior thigh, while running or cycling at a high intensity. Physical examination and lab work were unrevealing. Physiologic testing showed a drop in her exercise ankle-brachial index on the right side from 1.02 to 0.24. Conventional arteriography performed with hip flexion maneuvers (A) and computed tomography angiography were normal. Subsequently, Duplex ultrasound was performed at rest and after exercise (B/Cover). Resting images were normal. After the patient exercised on a treadmill for 10 minutes at 10% incline, the right external iliac artery showed focal wall thickening and severe stenosis. The peak systolic velocity increased from 170 cm/s to greater than 600 cm/s, and the luminal diameter decreased from 6 mm to 2 mm. The patient was diagnosed with exercise-induced arterial vasospasm of the right external iliac artery and was surgically treated with bovine pericardial patch angioplasty.

Objective: Significant debate exists among providers who perform endovascular abdominal aortic aneurysm repair (EVAR) regarding the renal function change between suprarenal (SuF) and infrarenal (InF) fixation devices. The purpose of this study is to review our institution's experience using these devices in terms of renal function. Methods: This is a retrospective review of all elective EVARs performed within a three-site health system(Florida, Minnesota, and Arizona) during the period of 2000 to 2018. The primary outcome was renal function decline on long-term follow-up depending on the anatomical fixation of the device (SuF vs InF). Secondary outcomes were length of hospitalization (LOH) and progression to hemodialysis. Multivariable regression analysis was performed to test for associations affecting LOH. Results: There were 1130 elective EVARs included in our review. Of those, 670 (59.3%) had SuF and 460 (40.7%) InF. Long-term follow-up was 4.8 +/- 3.7 years, and the rate of change in creatinine and estimated glomerular filtration rate (eGFR) were not statistically significant among groups (SuF vs InF). LOH was higher in those individuals with a SuF device (3.4 +/- 2.2 vs 2.3 +/- 1.0 days; P <.001). Ten patients with chronic kidney disease progressed to hemodialysis at 6.7 +/- 3.8 years from EVAR. On Kaplan-Meier analysis, patients with chronic kidney disease with SuF were more likely to progress to hemodialysis ( P =.039). On multivariable regression, female sex (Coef, 2.4; 95% confidence interval [CI], 0.17-0.41; P =.02), SuF (Coef, 9.5; 95% CI, 0.11-1.11; P <.0001), and intraoperative blood loss of greater than 150 mL (Coef, 15.4; 95% CI, 0.11-1.76; P <.0001) were predictors of prolonged LOH. Conclusions: Our three-site, single-institution data indicate that, although the starting eGFR was statistically lower in those individuals undergoing elective EVAR with InF, device fixation type did not affect the creatinine and eGFR on longterm follow-up. However, caution should be exercised at the time of abdominal aortic aneurysm repair in those individuals who already presented with renal dysfunction.