Prior Vascular Intervention Research Articles

Is there an association between arteriovenous fistulas and axillary artery aneurysms? A report of two cases

IntroductionAxillary artery aneurysms are rare vascular conditions that can present with various clinical manifestations, including neurological deficits and vascular compromise. While the underlying pathophysiology remains complex and multifactorial, potential associations with trauma, arteriovenous fistula formation, and atherosclerosis have been reported.Presentation Of Case.Two male patients, aged 33 and 38, with a history of kidney transplantation and previous arteriovenous fistula (AVF) presented with symptoms of upper limb ischemia and neurological compromise. Imaging revealed large axillary artery aneurysms. Open surgical repair was performed for both cases. Two weeks after discharge, one patient showed good pronation and supination with mildly limited extension. The other patient's wrist drop gradually improved with physiotherapy. DiscussionMultifactorial pathophysiology encompassed altered blood flow dynamics, inflammation, and the underlying vascular pathology. Chief complaints and prior vascular interventions contributed. Open surgical repair was preferred to endovascular approaches, achieving favorable outcomes. ConclusionAxillary artery aneurysms in patients with a history of AVF are rare but potentially serious complications. The cases highlight the complexity of axillary artery aneurysms and the need for careful evaluation and surgical intervention This strategy is crucial to prevent potential complications and optimize patient outcomes. Further research is needed to elucidate the precise pathophysiology and the potential association between AVF and the subsequent development of axillary artery aneurysms. Increasing awareness among surgeons could enable earlier detection of aneurysms, thereby reducing the risk of complications.

Midterm Outcomes and Predictors of Failure of Lower Extremity Bypass to Para-Malleolar and Pedal Targets

ObjectivesThe frequency of distal lower extremity bypass (LEB) for infra-popliteal critical limb threatening ischemia (IP-CLTI) has significantly decreased. Our goal was to analyze the contemporary outcomes and factors associated with failure of LEB to para-malleolar and pedal targets. MethodsWe queried the VQI infra-inguinal database from 2003-2021 to identify LEB to para-malleolar or pedal/plantar targets. Primary outcomes were graft patency, major adverse limb events [vascular re-intervention, above ankle amputation] (MALE), and amputation-free survival at 2 years. Standard statistical methods were utilized. ResultsWe identified 2331 LEB procedures (1265 anterior tibial at ankle/dorsalis pedis, 783 posterior tibial at ankle, 283 tarsal/plantar). The prevalence of LEB bypasses to distal targets has significantly decreased from 13.37% of all LEB procedures in 2003 to 3.51% in 2021 (p<0.001). The majority of cases presented with tissue loss (81.25. Common post-operative complications included major adverse cardiac events (8.9%) and surgical site infections (3.6%). Major amputations occurred in 16.8% of patients at 1 year. Post-operative mortality at 1 year was 10%.On unadjusted Kaplan-Meier survival analysis at 2 years, primary patency was 50.56%±3.6%, MALE was 63.49%±3.27%, and amputation-free survival was 71.71%±0.98%. In adjusted analyses [adjusted for comorbidities, indication, conduit type, urgency, prior vascular interventions, graft inflow vessel (femoral/popliteal), concomitant inflow procedures, surgeon and center volume] conduits other than GSV (p<0.001) were associated with loss of primary patency and increased MALE. High center volume (>5 procedures/year) was associated with improved primary patency (p=0.015), and lower MALE (p=0.021) at 2 years. ConclusionsDespite decreased utilization, open surgical bypass to distal targets at the ankle remains a viable option for treatment of IP-CLTI with acceptable patency and amputation-free survival rates at 2 years. Bypasses to distal targets should be performed at high volume centers to optimize graft patency and limb salvage and minimize re-interventions.

Analysis of Early Death after Elective Open Abdominal Aortic Aneurysm Repair

Mortality after open abdominal aortic aneurysm repair is a quality measure and early death may represent a technical complication or poor patient selection. Our objective was to analyze patients who died in the hospital within postoperative day (POD) 0-2 after elective abdominal aortic aneurysm repair. The Vascular Quality Initiative was queried from 2003-2019 for elective open abdominal aortic aneurysm repairs. Operations were categorized as in-hospital death on POD 0-2 (POD 0-2 Death), in-hospital death beyond POD 2 (POD ≥3 Death), and those alive at discharge. Univariable and multivariable analyses were performed. There were 7,592 elective open abdominal aortic aneurysm repairs with 61 (0.8%) POD 0-2 Death, 156 (2.1%) POD ≥3 Death, and 7,375 (97.1%) alive at discharge. Overall, median age was 70years and 73.6% were male. Iliac aneurysm repair and surgical approach (anterior/retroperitoneal) were similar among groups. POD 0-2 Death, compared to POD ≥3 Death and those alive at discharge, had the longest renal/visceral ischemia time, more commonly had proximal clamp placement above both renal arteries, an aortic distal anastomosis, longest operative time, and largest estimated blood loss (all P<0.05). Postoperative vasopressor usage, myocardial infarction, stroke, and return to the operating room were most frequent in POD 0-2 Death and extubation in the operating room was least frequent (all P<0.001). Postoperative bowel ischemia and renal failure occurred most commonly among POD ≥3 Death (allP<0.001).On multivariable analysis, POD 0-2 Death was associated with congestive heart failure, prior peripheral vascular intervention, female sex, preoperative aspirin use, lower center volume quartile, renal/visceral ischemia time, estimated blood loss, and older age (all P<0.05). POD 0-2 Death was associated with comorbidities, center volume, renal/visceral ischemia time, and estimated blood loss. Referral to high-volume aortic centers could improve outcomes.

Variability in Antithrombotic Therapy after Infrainguinal Lower Extremity Bypass

Antiplatelet monotherapy is recommended after infrainguinal lower extremity bypass (LEB). However, there is a paucity of high-quality data to guide therapy, and antiplatelet therapy is often prescribed in combination with anticoagulation. We therefore aimed to assess the variability in the use of antithrombotic therapy after infrainguinal LEB. The Vascular Quality Initiative dataset (2015-2021) was retrospectively reviewed to determine discharge patterns of antithrombotic therapy for all patients undergoing infrainguinal LEB. Monotherapy on discharge was defined as either single antiplatelet therapy (SAPT) or single anticoagulant (SAC). Combination therapy was dual antiplatelet therapy (DAPT), anticoagulant+antiplatelet (ACAP), or triple therapy. Hierarchical multivariable logistic regression with random effects for physician and center was used to identify predictors of combination therapy. Median odds ratios (MOR) were derived to quantify degree of variability in antithrombotic therapy. There were 29,507 patients undergoing infrainguinal LEB (monotherapy=10,634 vs. combination therapy=18,873). SAPT (90.6%) was the most common form of monotherapy, while DAPT (57.7%) and ACAP (34.6%) were the most common combination therapies. Patients undergoing LEB to popliteal targets were more likely to be prescribed monotherapy (SAC or SAPT) than to infra-popliteal targets (60.6% vs. 56.6%, P<0.001). Combination therapy (DAPT, ACAP, or triple therapy) was more often used in patients with tibial or plantar arteries as the bypass target. Patients undergoing bypass using autogenous vein were more likely to receive monotherapy compared with those receiving other conduits (64.8% vs. 52.9%, P<0.001), while patients with prosthetic grafts were more likely to receive combination therapy (37.9% vs. 28.2%, P<0.001). There were no significant differences in postoperative bleeding (P=0.491) or 30-day mortality (P=0.302) between the two groups. Prior peripheral vascular interventions (PVI) (odds ratio [OR]: 1.89, 95% confidence interval [CI]: 1.79-1.99), concomitant PVI (OR: 1.83, 95% CI: 1.66-2.02), prosthetic graft use (OR: 1.74, 95% CI: 1.64-1.85), prior percutaneous coronary intervention (OR: 1.53, 95% CI: 1.43-1.65), plantar distal target (OR: 1.46, 95% CI: 1.29-1.65), alternative conduits (OR: 1.39, 95% CI: 1.25-1.53), and tibial distal targets (OR: 1.36, 95% CI: 1.28-1.44) were independent predictors of combination therapy in a multivariable regression model. Upon adjusting for patient-level factors, there was significant physician-level (MOR: 1.65, 95% CI 1.61-1.67) and center-level (MOR: 1.64, 95% CI 1.57-1.69) variability in the selection of antithrombotic therapy. Significant physician- and center-level variability in the use of antithrombotic regimens after infrainguinal bypass reflects the paucity of available evidence to guide therapy. Pragmatic trials are needed to assess antithrombotic strategies and guide recommendations aimed at optimizing cardiovascular and graft-specific outcomes after LEB.

Alternative autologous and biologic conduits have worse outcomes than prosthetic grafts for infrainguinal bypass in patients with chronic limb-threatening ischemia

ObjectiveSingle segment great saphenous vein (GSV) is the preferred conduit in infrainguinal bypass. Alternative autologous conduits (AAC) and nonautologous biologic conduits (NABC) are thought to be a better alternative to traditional prosthetic conduits (PC) in the absence of GSV. In this study we analyzed the outcomes of these alternative conduits in lower extremity bypasses (LEB) in patients with chronic limb-threatening ischemia. MethodsThe Vascular Quality Initiative LEB database from 2003 to 2020 was queried for this study, to identify LEB in patients with chronic limb-threatening ischemia. Primary outcomes were graft patency, major adverse limb events (MALE), and MALE-free survival at 1 year. Standard statistical methods were used as appropriate. ResultsWe identified 22,671 LEB procedures (12,810 GSV, 6002 PC, 1907 AAC, and 1952 NABC). Compared with the GSV group, the other conduit patients were significantly older, had more comorbidities, had an increased rate of prior lower extremity interventions, had a higher rate of infrageniculate bypass targets, and were less ambulatory at baseline. The PC, AAC, and NABC groups had significantly higher rates of postoperative morbidity compared with the GSV group. The PC group had a higher 30-day mortality compared with the GSV, AAC, and NABC groups (3% PC vs 2% GSV, 2% AAC, 2% NABC; P = .049). Both PC and NABC had higher 1-year mortality compared with GSV and AAC (13% PC and 13% NABC vs 10% GSV, 10% AAC; P = .02). In an adjusted Cox regression model (stratified by infrageniculate target and adjusted for age, comorbidities, and prior vascular interventions) PC was not significantly different from GSV, but AAC (hazard ratio [HR], 1.41; 95% confidence interval [CI], 1.19-1.67; P < .001) and NABC (HR, 1.9; 95% CI, 1.61-2.25; P < .001) were associated with an increased risk of loss of primary patency. A similar association with MALE was observed: both AAC (HR, 1.35; 95% CI, 1.15-1.58; P < .001) and NABC (HR, 1.8; 95% CI, 1.53-2.11; P < .001) were associated with an increased risk of MALE compared with GSV; PC was not significantly different from GSV. ConclusionsIn the absence of GSV, alternative conduits (autologous or nonautologous biologic) do not confer a benefit with regard to graft patency or MALE compared with PCs. Increased operating time or costs associated with the use of these conduits is not justified based on this study.

Alternative Conduits Have Worse Outcomes Than Prosthetic Grafts for Infrainguinal Bypass

Single-segment great saphenous vein (ssGSV) is the preferred conduit for infrainguinal bypass. Alternative autologous conduits (AACs) and nonautologous biologic conduits (NABCs) are thought to be a better alternative to traditional prosthetic conduits (PCs) in the absence of the ssGSV. We analyzed the outcomes of these alternative conduits in lower extremity bypass (LEB) in patients with chronic limb threatening ischemia. The Vascular Quality Initiative LEB database from 2003 to 2020 was queried to identify LEB in patients with chronic limb threatening ischemia. The primary outcomes were graft patency, major adverse limb events (MALE), and MALE-free survival at 1 year. Standard statistical methods were used as appropriate. We identified 22,671 LEB procedures (12,810 ssGSVs, 6002 PCs, 1907 AACs, and 1952 NABCs). Compared with the ssGSV group, the other conduit patients were significantly older, had more comorbidities, had an increased rate of prior lower extremity interventions, had a higher rate of infrageniculate bypass targets, and had been less ambulatory at baseline. The PC, AAC, and NABC groups had significantly higher rates of postoperative morbidity compared with the ssGSV group. The PC group had higher 30-day mortality compared with the ssGSV, AAC, and NABC groups (3% PC vs 2% ssGSV, 2% AAC, and 2% NABC; P = .049). The PC and NABC groups had higher 1-year mortality compared with the ssGSV and AAC groups (13% PC and 13% NABC vs 10% ssGSV and 10% AAC; P = .02). In an adjusted Cox regression model (Fig; stratified by infrageniculate target and adjusted for age, comorbidities, and prior vascular interventions), AAC (hazard ratio [HR], 1.41; 95% confidence interval [CI], 1.19-1.67; P < .001) and NABC (HR, 1.9; 95% CI, 1.61-2.25; P < .001) were associated with an increased risk of loss of primary patency compared with PC. A similar association with MALE was observed: both AAC (HR, 1.35; 95% CI, 1.15-1.58; P < .001) and NABC (HR, 1.8; 95% CI, 1.53-2.11; P < .001) were associated with an increased risk of MALE compared with PC. However, PC was not significantly different from ssGSV. In the absence of ssGSV, alternative autologous or nonautologous biologic materials do not confer a benefit with regard to graft patency or MALE compared with PCs. The increased operating time or costs associated with the use of these conduits was not justified from the results from the present study.

The proximally pedicled anterolateral thigh flap for reconstruction of complex soft tissue wounds of the hip and caudal trunk region

Groin and lower trunk defects are common problems, especially for elderly patients. While groin defects are often due to prior vascular interventions, trochanteric defects are mainly caused by pressure sores. Plastic reconstructive methods are manifold; however, the pedicled anterolateral thigh (ALT) flap is supposed to be reliable with sustainable results. We present our experiences using the pedicled ALT flap for soft tissue reconstruction in patients with large wounds of the medial and lateral proximal thigh. A total of 16 patients with groin and lower trunk defects due to prior vascular surgery or pressure sores received locoregional soft tissue reconstruction using aproximal pedicled ALT flap. Patient characteristics, defect size, surgery time, clinical outcome and complication rate were assessed. With the exception of two cases, sufficient soft tissue reconstruction was achieved. In all, 81,3% of patients were categorized as ASA (American Society of Anesthesiologists)3. The average duration of surgery was 149 min. Length of stay was 18,3days. A total of 31% needed revision surgery due to limited wound healing problems. Two patients died. All patients showed healed wound conditions when they were discharged. The proximal pedicled ALT-flap is areliable method for soft tissue reconstruction in groin and lower trunk defects. This reconstructive procedure enables reliable wound closure, especially in elderly patients with substantially reduced general health condition.

LOWER EXTREMITY VASCULAR COMPLICATIONS AFTER SIMULTANEOUS PANCREAS KIDNEY TRANSPLANT

Introduction: Type 1 diabetes mellitus (DM) is the leading indication for simultaneous pancreas kidney transplantation (SPK). Prior work has demonstrated a 2% incidence of lower extremity (LE) vascular complications in kidney recipients, and a 5-23% incidence in SPK recipients, yet there is no standard vascular evaluation or follow up for these patients. The purpose of this study was to describe the incidence and risk factors for LE vascular complications following SPK at a single United States transplant center. Methods: A retrospective review of all patients who underwent SPK at our institution between 2000-2019 was performed. Patients were excluded for age<18 or prior pancreas transplant. Baseline demographics, comorbidities, transplant details, medications, and vascular complication data were collected from the electronic medical record, and tested for differences by LE intervention status using t-tests and Fisher’s exact tests. Graphs of the Kaplan-Meier survival estimates, along with Cox proportional hazards regression models, were used to determine the effect of various risk factors on the need for LE intervention after SPK. Significance was set at 0.05. Results: 373 patients were included, of whom 52 (14%) required at least one LE intervention following SPK (Table). A total of 75 interventions were performed in this cohort: 16 endoluminal revascularization procedures, 2 open bypass grafts, 36 amputations, and 21 podiatry procedures. Only 3 patients (0.8%) had pre-transplant ankle brachial indices (ABIs). Compared with white patients, African American patients were significantly more likely to undergo LE vascular intervention after SPK (HR 2.54 CI 1.26-5.10, p=0.01). Patients with a prior LE vascular intervention (HR 4.42, CI 1.96-9.96, p<0.001) or previous diagnosis of PAD (HR 3.80, CI 1.60-8.99, p=0.002, Figure) were also significantly more likely to require intervention after SPK compared with patients who had no prior history of vascular interventions and no documented PAD, respectively. In a MV model including the risk factors of diabetes, dialysis, race and PAD, PAD remained significantly associated with LE vascular intervention after SPK (HR 3.39 95% CI 1.36-8.21, p=0.01). Discussion: LE vascular complications after SPK are a major source of morbidity. In our population, 14% of SPK recipients required a LE vascular intervention after transplant and only 3 patients (0.8%) had pre-operative ABIs. Pre-operative non-invasive arterial evaluation may help to identify SPK recipients at high risk for LE vascular complications and prompt close follow-up with a vascular provider. Conclusion: Fourteen percent of SPK patients required one or more LE vascular interventions after SPK. African American patients, and those patients with a history of PAD or prior LE intervention are at particularly high risk for LE vascular events after SPK.AS is part of the Biostatistics Core that is generously supported by the UCSF Department of Surgery.

A comparative study of postrevascularization limb salvage rate in early versus delayed presentation of rutherford class IIb acute lower extremity ischemia

Background: Acute limb ischemia (ALI) is the most common vascular emergency with potential morbidity and mortality, which can be prevented by early appropriate treatment. Delayed presentation because of diagnostic delays and referrals continues to be a challenge for vascular surgeons. The purpose of this study is to evaluate the postrevascularization limb salvage rate in patients with delayed presenting ALI Rutherford Class IIb and compare it with early presenting ALI in a tertiary referral center in India. Materials and Methods: Fifty-one patients with Rutherford Class IIb acute lower limb ischemia, who underwent revascularization over a period of 2 years from June 2015 to May 2017 at Jain Institute of Vascular Sciences, Bengaluru, were evaluated in this study. Patients were divided into early presenting (<24 h) (n = 10) and delayed presenting (>24 h–14 days) (n = 41), and both the groups were compared with respect to limb salvage at 1 year. Patients with prior vascular intervention, posttraumatic ALI, and Rutherford Class I, IIa, and III were excluded. Results: Both the groups were comparable with respect to demographics, lesion characteristics, and comorbidities. The mean age in the early and delayed presenting groups was similar. Majority of the patients were male. The most common level of occlusion was femoropopliteal segment. All patients underwent transfemoral/transpopliteal thrombectomy + angioplasty/stenting. Fasciotomy was performed in almost half of the patients based on clinical need. The limb salvage rate was 91.67% in the early presenting group, whereas in the delayed presenting group, it was 72.73%, but the difference was not statistically significant (P = 0.178). None of the patients in the early presenting group had morality, whereas it was 12.20% in the delayed group, which was statistically not significant (P = 0.249). Conclusion: In patients with Rutherford Class IIb ALI in spite of delayed presentation, good limb salvage rate can be achieved if revascularized.

Comparative study of outcomes between single-vessel versus multiple-vessel infrapopliteal angioplasties in patients with chronic limb-threatening ischemia

Purpose: To determine whether the number of infrapopliteal arteries undergoing endovascular treatment is associated with the limb salvage and wound healing in patients with chronic limb-threatening ischemia (CLTI). Materials and Methods: This was a single-center, prospective, nonrandomized study comprising 143 CLTI patients who underwent successful infrapopliteal angioplasty without or corrected inflow femoropopliteal disease, at Jain Institute of Vascular Sciences, Bengaluru, between May 2017 and October 2018. Patients were divided into two groups, based on either a single vessel (SV group, n=91) or a multiple infrapopliteal vessels (MV group, n =52) were angioplastied. Patients with isolated femoropopliteal revascularization, femorodistal bypass, prior vascular intervention, technical failure, and lost to follow-up were excluded. Primary outcomes were limb salvage and wound healing at 6th month. Secondary outcomes were changes in ankle–brachial index (ABI), toe–brachial index (TBI), transcutaneous oxygen saturation (TcPO2), plantar arch quality (PAQ), major adverse cardiac events (MACE), and all-cause mortality at 6th month. Results: Baseline characteristics were comparable in both groups. The wound healing rate (70.12% vs. 62.79%) and limb salvage rate (93.51% vs. 90.70%) at 6th month were comparable among SV and MV groups (P = 0.88 and 0.59, respectively). The mean wound healing time was significantly better in MV group (83 ± 40 vs. 108 ± 43 days) (P = 0.003). MACE (6.59% vs. 9.80%), mortality (15.38% vs. 17.30%), PAQ [complete (31.87% vs. 36.54%), incomplete (48.35% vs. 57.69% ) and absent arch (19.78% vs. 5.76%) in SV and MV groups, respectively], and changes in ABI, TBI, and TcPO2among both groups were comparable, except TcPO2changes at 1 month which showed a significant improvement in MV group (P = 0.03). Conclusions: MV infrapopliteal angioplasties are associated with shorter wound healing time, but have no effect on limb salvage and wound healing rates at 6th month.

Disease Activity in Takayasu’s Arteritis Affects Long-term Graft Related Outcomes

Introduction - Takayasu’s Arteritis (TA) is a rare, inflammatory large-vessel vasculitis of unknown etiology. This disease occasionally requires surgical intervention. There is a paucity of published data on the long-term outcomes of surgical intervention in these patients. There is limited data on the results of these procedures in patients with or without active disease. Methods - A retrospective review was conducted of patients with Takayasu’s arteritis who underwent open, noncardiac vascular procedures at our institution between 1994 and 2017. Basic demographics, diagnostic workup, treatment and outcomes were reviewed. Active disease was defined by the National Institute of Health or/and the Mayo Clinic criteria. Results - Between 1994 and 2017, 51 patients with Takayasu’s Arteritis underwent open noncardiac vascular surgery. Forty-four patients (86) were female with a mean age of 38 years (range 10-72 years). At the time of surgery 36 patients (77%) were on steroids, with 23 patients (49%) taking an additional immunomodulate pharmaceutical. Twenty patients (42%) had required prior vascular interventions. Six patients (13%) had an additional autoimmune disorder diagnosed previously. The most common location for disease was the aorta (86%) with the subclavian (80%), carotid (69%), innominate (41%), and the renal (33%) arterial lesions also seen. Vascular reconstruction was performed on 82 arterial lesions. The most common locations requiring reconstruction was the carotid artery (28%) followed by the subclavian (22%), aorta (15%) and renal arteries (11%). Mean follow-up was 74 months (range 1-265 months). Early complications (less than 30 days) occurred in 14 patients (31%). Late complications (greater than 31 days) occurred in 22 patients (49%). There were two perioperative mortalities (4%). Eighteen patients (40%) required endovascular and/or surgical reintervention. The primary and primary assisted patency were 72% and 89% respectively. Seventeen patients (35%) had active disease at the time of surgery and three (18%) of these patients developed graft occlusion and underwent revision. Six patients (35%) with active disease required eight additional graft related re-interventions. Thirty-one patients (65%) had quiescent disease with three (10%) of patients occluding their reconstruction follow-up. Four patients (13%) with quiescent disease required four additional graft related re-interventions. The incidence of graft related re-interventions was higher on patients with active disease (p<0.05). Erythrocyte sedimentation rate (ESR) demonstrates a sensitivity rate of 29% with a positive predictive valve of 63% in active disease. 71% of patients with active disease had a normal ESR. Conclusion - The outcome of the intervention appears to be related to the presence of active disease. Patients with active disease had worse graft related outcomes compared to patients with quiescent disease. Normalized ESR is not a good predictor of quiescent disease.

CT-Derived Pretreatment Thoracic Sarcopenia Is Associated with Late Mortality after Thoracic Endovascular Aortic Repair

Frailty, characterized by physiologic depletion, predicts postoperative morbidity and mortality in vascular surgery patients. CT-derived sarcopenia is a valuable method for objectively staging frailty preoperatively. With prior analyses primarily measuring psoas cross-sectional area on CT, we compared a method of measuring thoracic sarcopenia to existing techniques of lumbar sarcopenia and assessed the association with long-term survival and outcomes post-Thoracic Endovascular Aortic Repair (TEVAR). Prospectively collected data of 217 patients undergoing TEVAR from 2009 to 2012 were reviewed. Thoracic sarcopenia was quantified by measuring total area of the rectus abdominis, latissimus dorsi, intercostal, erector spinae, and external and internal oblique muscles at the T12 vertebral level. Total psoas area at the L3 was used to measure lumbar sarcopenia. 200 patients had preoperative imaging enabling measurements of thoracic sarcopenia, 186 of these patients were also assessed for lumbar sarcopenia. Thoracic sarcopenic patients were older, had lower body mass indices, were more commonly female, and most commonly being treated for aneurysms. Thoracic sarcopenic patients had significantly higher rates of congestive heart failure, hypertension, prior vascular intervention, and TEVAR-related adverse events. Thoracic sarcopenia was associated with significantly higher mortality at 2 and 5years post-TEVAR (2-year mortality: 19% vs 8%, P=0.02; 5-year mortality: 31% vs 18%, P=0.03). Lumbar sarcopenia was not associated with increased mortality at any time point. Patients whose muscle mass degraded over 48-month follow-up did not experience significantly higher rates of adverse events. CT-derived thoracic sarcopenia, but not lumbar sarcopenia, is significantly associated with 5-year mortality post-TEVAR.

RS01. Mortality After Paclitaxel-Coated Balloon Angioplasty and Stenting of Superficial Femoral and Popliteal Artery

A recent meta-analysis of 4663 patients reported higher 2- and 5-year mortality in patients with femoral-popliteal artery occlusive disease treated with paclitaxel-coated balloons and stents compared with plain balloon angioplasty and bare metal stenting. Our aim was to compare mortality after similar treatments using a multicenter vascular registry. Patients (n = 6992) without prior peripheral vascular intervention undergoing endovascular treatment of superficial femoral-popliteal artery occlusive disease in the Vascular Quality Initiative (VQI) were studied from September 2016 to September 2017. All-cause mortality was compared between patients treated with nondrug-coated devices (n = 3905) versus paclitaxel-coated balloons and/or eluting stents (paclitaxel group; n = 3087). Mortality rates with hazard ratios (HR) and 95% confidence intervals (CI) were compared between unadjusted and propensity matched cohorts and illustrated by Kaplan-Meier analysis. Subgroup analysis was performed for intermittent claudication and critical limb ischemia (CLI). Mortality was higher in the nondrug group (13.4%) compared with the paclitaxel group (10.8%) in the unmatched cohorts (HR, 0.80; 95% CI, 0.69-0.93; P < .01). After 1:1 propensity matching the paclitaxel (n = 2440) and nondrug-coated device (n = 2440) groups were similar except for differences at the extremes of age and symptom status (CLI 54% vs 59% respectively; P < .01). Mortality was similar for the nondrug group (13.2%) and paclitaxel group (11.5%) after propensity matching (HR, 0.87; 95% CI, 0.73-1.04; P = .12) at a mean follow-up of 509 days (17 months; range, 0-813 days [0-27 months]). Subgroup analysis of patients with claudication showed no mortality difference in the matched cohorts; nondrug coated device (5.1%; n = 41/804) and paclitaxel (3.8%; n = 32/842; HR, 0.74; 95% CI, 0.46-1.17; P = .20). Subgroup analysis of patients with CLI showed no mortality difference in the matched cohorts; nondrug-coated device (18.9%; n = 191/1012) and paclitaxel (18.5%; n = 200/1081) groups (HR, 0.99; 95% CI, 0.81-1.20; P = .90). By Kaplan-Meier analysis mortality was similar in the paclitaxel versus nondrug device group (Fig). At a mean follow-up of 17 months, mortality is similar for patients with claudication and CLI after treatment of femoral-popliteal occlusive disease with paclitaxel coated and nondrug coated devices. Additional VQI analysis is planned for 2019 to assess for mortality differences at later time points. This work highlights the potential use of the VQI for surveillance of the safety of new peripheral arterial devices.

Common femoral artery antegrade and retrograde approaches have similar access site complications

ObjectiveIpsilateral antegrade access (AA) is an alternative access option for contralateral retrograde access (RA) in treating infrainguinal occlusive disease. Our goal was to assess whether AA is associated with higher access site complications. MethodsThe Vascular Quality Initiative database was searched from 2010 to 2017 for all infrainguinal peripheral vascular interventions. Cases without access through the common femoral artery or those with multiple accesses were excluded. Access types were classified on the basis of whether the approach was AA or RA. Propensity matching and multivariable analyses were performed to determine the effect of AA on access site complications. ResultsThere were 45,816 access events identified, 6600 (14.4%) AA and 39,216 (85.6%) RA cases. Patients with AA were older (70.7 vs 69.1 years) and more frequently male (66.5% vs 59.1%), white (79.4% vs 74.6%), and on Medicare (58.4% vs 56%); they were more likely to have end-stage renal disease (12.1% vs 11%), and they were less frequently obese (29.3% vs 36.1%) and less likely to be currently smoking (25.5% vs 28.7%), to be diabetic (56% vs 59.8%), to have chronic obstructive pulmonary disease (20.7% vs 21.8%), and to ambulate independently (69.8% vs 72.5%; P < .05 for all). Patients with AA were more likely to have a history of a prior percutaneous vascular intervention (9.3% vs 7%), inflow bypass (6.2% vs 1.8%), and leg bypass (12.6% vs 8.9%; P < .001 for all). The AA technique was more frequently used in the setting of tissue loss (51.8% vs 45.1%) and for tibial intervention (46.3% vs 35.3%; P < .001 for both). There were no significant differences between AA and RA in overall hematoma (3% vs 2.7%; P = .21) or hematoma requiring intervention (0.4% vs 0.4%; P = .75) rates. There was no significant difference in access site occlusion or stenosis between AA and RA (0.2% vs 0.3%; P = .68). These findings were confirmed with 2:1 matching based on preoperative data and type of intervention. Multivariable analysis demonstrated that AA is not associated with increased risk of any hematoma (odds ratio [OR], 1.15; 95% confidence interval [CI], 0.98-1.35; P = .082) or hematoma requiring intervention (OR, 0.88; 95% CI, 0.57-1.35; P = .56). Multivariable analysis of the matched data confirmed these findings between AA and RA for hematoma (OR, 0.88; 95% CI, 0.73-1.06; P = .17) and hematoma requiring intervention (OR, 1.17; 95% CI, 0.7-1.95; P = .55). ConclusionsAA is safe, and it was not found to be associated with increased access site complications, such as hematoma, in the large Vascular Quality Initiative sample. This approach remains a viable alternative to traditional RA.

Microbiological and clinical profile of infective endocarditis patients: an observational study experience from tertiary care center Karachi Pakistan

BackgroundThe study analyzed microbiological and antimicrobial susceptibility profile of organisms isolated from patients with infective endocarditis (2015–17) and compared disease outcomes in cohorts of endocarditis patient with history of prior invasive vascular intervention (high risk group) vs those without (native valve group). We hypothesized that high risk group would be more likely to have severe disease outcomes.MethodsThis was a prospective cohort study (2015–17). All blood and cardiac tissue samples of enrolled patients suspected of endocarditis according to modified Duke’s criteria were followed for microbiological and antimicrobial susceptibility profile. The high risk group was compared with the native valve group with 90 day follow up to determine difference in clinical course and outcome in terms of disease severity (defined as any patient with endocarditis undergoing surgical management, readmission or dying). The data was analyzed using SPSS 21.0 software and chi-square test. 90 day mortality was calculated using Kaplan Meier survival curves.ResultsTotal 104 patients with endocarditis were enrolled. Overall culture positivity rate was 71.2%. Streptococcus species were the most common isolate (36.7%), followed by S. aureus (17.3%) cases. In Streptococcus species, 14.2% showed intermediate susceptibility to penicillin. Thirty six patients were included in the cohort analysis. A poor outcome was seen in 85.7% high risk group as compared to 50% of native valve group. The overall mortality rate was 19.4%.ConclusionsWe found Streptococcus species to be the predominant pathogen for endocarditis overall. However Staphylococcus aureus predominated native valve group. High risk group showed more complicated clinical course.

Peripheral atherectomy practice patterns in the United States from the Vascular Quality Initiative

ObjectivePeripheral atherectomy has been shown to have technical success in single-arm studies, but clinical advantages over angioplasty and stenting have not been demonstrated, leaving its role unclear. We sought to describe patterns of atherectomy use in a real-world U.S. cohort to understand how it is currently being applied. MethodsThe Vascular Quality Initiative was queried to identify all patients who underwent peripheral vascular intervention from January 2010 to September 2016. Descriptive statistics were performed to analyze demographics of the patients, comorbidities, indication, treatment modalities, and lesion characteristics. The intermittent claudication (IC) and critical limb ischemia (CLI) cohorts were analyzed separately. ResultsOf 85,605 limbs treated, treatment indication was IC in 51% (n = 43,506) and CLI in 49% (n = 42,099). Atherectomy was used in 15% (n = 13,092) of cases, equivalently for IC (15%; n = 6674) and CLI (15%; n = 6418). There was regional variation in use of atherectomy, ranging from a low of 0% in one region to a high of 32% in another region. During the study period, there was a significant increase in the proportion of cases that used atherectomy (11% in 2010 vs 18% in 2016; P < .0001). Compared with nonatherectomy cases, those with atherectomy use had higher incidence of prior peripheral vascular intervention (IC, 55% vs 43% [P < .0001]; CLI, 47% vs 41% [P < .0001]), greater mean number of arteries treated (IC, 1.8 vs 1.6 [P < .0001]; CLI, 2.1 vs 1.7 [P < .0001]), and lower proportion of prior leg bypass (IC, 10% vs 14% [P < .0001]; CLI, 11% vs 17% [P < .0001]). There was lower incidence of failure to cross the lesion (IC, 1% vs 4% [P < .0001]; CLI, 4% vs 7% [P < .0001]) but higher incidence of distal embolization (IC, 1.9% vs 0.8% [P < .0001]; CLI, 3.0% vs 1.4% [P < .0001]) and, in the CLI cohort, arterial perforation (1.4% vs 1.0%; P = .01). ConclusionsDespite a lack of evidence for atherectomy over angioplasty and stenting, its use has increased across the United States from 2010 to 2016. It is applied equally to IC and CLI populations, with no identifiable pattern of comorbidities or lesion characteristics, suggesting that indications are not clearly delineated or agreed on. This study places impetus on further understanding of the optimal role for atherectomy and its long-term clinical benefit in the management of peripheral arterial disease.

Disease Activity in Takayasu Arteritis Affects Long-Term Graft-Related Outcomes

Takayasu arteritis (TA) is a rare inflammatory large-vessel vasculitis of unknown etiology that occasionally requires surgical intervention. There is a paucity of published data on the long-term outcomes of surgical intervention in these patients, with or without active disease. A retrospective review was conducted of patients with TA who underwent open, noncardiac vascular surgery at our institution in three geographic locations between 1994 and 2017. Basic demographics, diagnostic workup, treatment, and outcomes were reviewed. Active disease was defined by National Institutes of Health and Mayo Clinic criteria. Between 1994 and 2017, there were 51 patients with TA who underwent open, noncardiac vascular surgery. Forty-four patients (86%) were female, with a mean age of 38 years (range, 10-72 years). At the time of surgery, 36 patients (77%) were taking steroids, with 23 patients (49%) taking an additional immunosuppressant. Twenty patients (42%) had required prior vascular surgical intervention. Six patients (13%) had an additional autoimmune disorder diagnosis. The most common location for disease was the aorta (86%), with subclavian (80%), carotid (69%), innominate (41%), and renal (33%) arterial lesions also seen. Vascular reconstruction was performed on 82 arterial lesions. The most common location for reconstruction was the carotid artery (28%), followed by the subclavian (22%), aorta (15%), and renal artery (11%). Mean follow-up was 74 months (range, 1-265 months). Early complications (<30 days) occurred in 14 patients (31%). Late complications (>30 days) occurred in 22 patients (49%). There were two perioperative deaths (4%). Eighteen patients (40%) required endovascular and surgical reintervention. The primary and primary assisted graft patency rates were 72% and 89%, respectively. Seventeen patients (35%) had active disease at the time of surgery, and three (18%) of these patients developed graft occlusion and underwent revision. Six patients (35%) with active disease required eight additional graft-related reinterventions. Thirty-one patients (65%) had quiescent disease, with three (10%) patients occluding their reconstruction in follow-up. Four patients (13%) with quiescent disease required four additional graft-related reinterventions. Incidence of graft-related reinterventions was higher in patients with active disease (P = .0497). The outcome of the intervention appears be related to the presence of active disease. Patients with active disease had worse graft-related outcomes compared with patients with quiescent disease.

Abstract 111: Health Status Implications for Comorbid Diabetes in Patients with Symptomatic Peripheral Arterial Disease: Insights from PORTRAIT Registry

Introduction: Patients with peripheral arterial disease (PAD) and coexisting diabetes mellitus (DM) have an increased rate of PAD progression and reduced walking performance as compared with non-diabetic PAD patients. It is unknown, however, whether patients with PAD and comorbid diabetes also experience worse PAD-specific health status (symptoms, functioning, quality of life) and what factors might mediate such a difference. Methods: PORTRAIT is a 16-center international registry that includes patients with exacerbated or new-onset symptomatic PAD presenting to specialty clinics. We measured PAD-specific health status at the time of PAD evaluation, 3, 6 and 12 months using the Peripheral Artery Questionnaire (PAQ). Hierarchical, multivariable, repeated measures analysis was used to assess the association between DM and health status at baseline and over time. Sequential adjustments for demographics, socioeconomic factors, PAD severity, comorbidities, psychosocial characteristics, primary treatment strategy and quality of care were made. Results: Of 1,204 patients, 398 patients had diabetes (33%, of whom 94% had Type II). Patients with PAD and DM had lower unadjusted PAQ summary scores at 0, 3, 6 and 12 months respectively (46.1 vs. 50.8, p &lt; 0.001; 63.6 vs. 68.2, p &lt; 0.01; 65.7 vs. 71.7, p &lt; 0.001; 65.4 vs. 72.6, p &lt;0.001). Patients with PAD and DM were more likely to be unemployed, depressed, of non-White race and to have more cardiovascular comorbidities, bilateral disease, non-healing ulcers and prior peripheral vascular interventions. When sequentially adjusting for relevant confounders, the effect for diabetes was mostly explained by comorbidities and psychosocial factors (Figure 1). Conclusion: Patients with PAD and co-existing DM have poorer health status upon PAD diagnosis and the year thereafter as compared with those who do not have DM, potentially explained by a higher burden of clinical comorbidities and psychosocial factors. Future work will need to further evaluate whether more emphasis on psychosocial aspects of care in these patients can improve their PAD-specific health status.

Penile venous stripping surgery is a viable option for erectile dysfunction after unsuccessful vascular interventions

To study whether penile venous stripping can improve erectile function after unsuccessful prior vascular interventions. Methods: This study is a retrospective review of the 49 consecutive patients that sought our assistance between 1999 and 2016 after receiving unsatisfactory vascular interventions elsewhere. Patients were evaluated by the abridged 5-item version of the International Index of Erectile Function (IIEF-5) and pharmaco-cavernosography. After the evaluation, the 36 patients without cardiovascular problems underwent a salvaging penile venous stripping and while the 13 remaining patients did not undergo the procedure. A circumferential incision was first made to strip the erection-related veins with 6-0 nylon sutures. A median longitudinal pubic incision was used to complete the stripping proximally until the infrapubic angle was reached. Finally, the wound was closed with 5-0 chromic sutures. Results: The follow-up period ranged between 1.0 and 16.5 years. Patients reported adequate and acceptable penile morphology postoperatively. Though there was no significant difference in IIEF-5 scores between the two groups preoperatively (n=13, 7.3 ± 1.9 vs. n=36, 7.6 ± 2.3, p=0.11), there was a statistically significant difference between treatment (n=36, 7.6 ± 2.1 vs. 17.4 ± 4.1, p<0.001) and control groups (ni¼13, 5.9 ± 1.8 vs. n=29, 18.7 ± 3.4, p<0.001). Postoperative cavernosograms confirmed that the paired corpora cavernosa are an ideal chamber for intracorporeal fluid retention in all patients, particularly, the penile crura displayed a stronger radiopaque than that of femoral cortex. Furthermore, we identified certain unexpected complications, such as embolization coils lodged in the cardiopulmonary avenues and electrocautery-induced fibrosis from prior interventions. Conclusions: Penile venous stripping appears to be a viable option for those who have undergone unsatisfactory prior vascular interventions for erectile dysfunction.

Inflow Can Be Enough: A Limited Approach to Revascularization in Critical Limb Ischemia

Objectives: Traditionally, in-line vascular reconstruction is held as the gold standard for the treatment of critical limb ischemia (CLI). However, there is a paucity of data regarding treatment of inflow alone to resolve rest pain or heal tissue loss. Thepurposeof this studywas todetermine theoutcomesofpatients with CLI who underwent an inflow-only approach to revascularization as their initial treatment of CLI. Methods: All patients undergoing femoral endarterectomy with or without endovascular treatment were reviewed. Patients were included for analysis if they had CLI defined by rest pain or tissue loss and did not present acutely. Exclusion criteria were prior vascular surgical interventions, concomitant distal bypass, and claudication as an indication. Preoperative imaging was reviewed and a runoff score for the whole leg, as well as above-knee and below-knee scores were calculated using the modified Bollinger runoff score. Results: A total of 247 in-flow procedures were identified over a 5-year period, and 65 met criteria. Mean age was 72.4 years; 57% had tissue loss. The average followup was 18 (standard deviation [SD], 17.3) months (range, 0-68 months). There was one 30-day mortality (1.5%).