Journal of Vascular Surgery

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Clinical outcomes of bypass-first versus endovascular-first strategy in patients with chronic limb-threatening ischemia due to infrageniculate arterial disease

December 31, 2018 - 23:00
Chronic limb-threatening ischemia (CLTI), defined as ischemic rest pain or tissue loss secondary to arterial insufficiency, is caused by multilevel arterial disease with frequent, severe infrageniculate disease. The rise in CLTI is in part the result of increasing worldwide prevalence of diabetes, renal insufficiency, and advanced aging of the population. The aim of this study was to compare a bypass-first with an endovascular-first revascularization strategy in patients with CLTI due to infrageniculate arterial disease.

Invited commentary

December 31, 2018 - 23:00
Metabolic syndrome (MetS) and peripheral artery disease (PAD) are growing public health problems that are closely intertwined. However, few prospective studies have examined the association of MetS and PAD, with the existing literature showing conflicting results.1 In this edition of the Journal, Sorber et al explore the association between MetS and postoperative outcomes after lower extremity bypass surgery and question whether perioperative use of cardiovascular risk-modifying agents alters outcomes.

Frank C. Spencer, MD, FACS (1925-2018)

December 31, 2018 - 23:00
He is the quintessential surgical teacher first by example (as one of the finest surgeons of his generation), but also through the high standards he set for the scores of individuals who had the honor of working with him. At his widely renowned morbidity and mortality conferences, Dr Spencer stressed thoughtful analysis and introspection as fundamental to achieving surgical competence. He viewed compassion and professionalism as important as technical perfection in providing quality care to our patients.

Vascular interventions in head and neck cancer patients as a marker of poor survival

December 31, 2018 - 23:00
Head and neck cancer can involve the surrounding vasculature and require technically challenging vascular interventions. These interventions can be complicated by tumor invasion, history of prior surgery, and history of radiation therapy. Our aim was to examine patients with vascular interventions in association with head and neck cancer to determine outcomes and best practice.

Invited commentary

December 31, 2018 - 23:00
During the last three decades, vascular surgeons have successfully introduced and embraced a new, minimally invasive approach for the treatment of abdominal aortic aneurysms using endovascular aneurysm repair (EVAR). Whereas countless patients have benefited from EVAR, it is not without its limitations, which include a critical need for lifelong follow-up, a significant reintervention rate that does not plateau over time, and the increased cost.

Invited commentary

December 31, 2018 - 23:00
Dr Columbo and colleagues have used the Vascular Quality Initiative's database to compare long-term mortality in patients undergoing carotid endarterectomy vs carotid stenting. Administrative databases are notoriously unreliable with respect to cause of death, leaving mortality as the most reliable outcome measure in the study. The mortality difference between carotid endarterectomy and carotid stenting in this study is striking, reinforcing several precedent studies cited by the authors. Patients selected for carotid stenting would likely be at somewhat higher risk for any procedure than those patients thought suitable for carotid endarterectomy, although propensity matching would be expected to mitigate differences between the groups, and in this case the excess mortality after carotid stenting persisted despite propensity matching.

Invited commentary

December 31, 2018 - 23:00
Endovascular aneurysm repair (EVAR) represented a true paradigm shift in vascular surgery, evidenced by its rapid proliferation after its introduction in 1990.1 By 2003, EVAR surpassed open repair as the dominant treatment modality in the Medicare population.2 However, much as for other novel technologies, physicians experience a learning curve, and devices undergo multiple iterations as long-term data reveal previously unforeseen issues. To date, several endografts have been withdrawn from the market, and none of the most commonly implanted devices are in their first generation.

Invited commentary

December 31, 2018 - 23:00
This basic science study's goal is to address an area of clinical ambiguity: how to coat an endovascular stent graft with rifampin in a standard and optimized manner for immediate use in an infected field. It optimizes two variables, concentration and incubation period, in an ex vivo experiment and on the basis of the results suggests a rapid real-time perioperative protocol. The graft chosen to study is a standard Dacron endograft of various diameters and lengths. There are reports of using a rifampin-coated endograft in an infected field with preparation extrapolated from methods used during open operation (60 mg/mL rifampin incubated for 1 hour).

Iliac conduits remain safe in complex endovascular aortic repair

December 27, 2018 - 23:00
Iliac conduits (ICs) are used for challenging iliac access during endovascular aortic aneurysm repair (EVAR) with contradictory reports of safety and increased surgical complications, morbidity, and mortality in national database reviews. The objective of this study was to examine outcomes related to IC placement before or concomitant with EVAR at a high-volume single center.

Accuracy evaluations of three ruptured abdominal aortic aneurysm mortality risk scores using an independent dataset

December 27, 2018 - 23:00
To date, no single scoring system for predicting 30-day mortality in patients with ruptured abdominal aortic aneurysms (rAAAs) has been endorsed by any vascular society or proven to definitively predict treatment futility. Three recently developed scoring systems for predicting 30-day mortality in patients with rAAA have been validated by their respective institutional data. The purpose of this study was to evaluate the accuracy of these rAAA mortality risk scores using an independent community hospital dataset.

Comparison of major adverse event rates after elective endovascular aneurysm repair in New England using a novel measure of complication severity

December 27, 2018 - 23:00
Major adverse event (MAE) rates are used as an outcome measure after surgical procedures. Although MAE rates summarize the occurrences of adverse events, they do not reflect differences in severity of these events. We propose that a measure of complication severity could provide a more accurate assessment about the quality of care. We aimed to analyze and to describe the regional variation in elective endovascular aneurysm repair (EVAR) MAE rates across centers in the Vascular Study Group of New England and to create an index for describing complication severity.

Systematic review and meta-analysis of acute type B thoracic aortic dissection, open, or endovascular repair

December 27, 2018 - 23:00
The purpose of this study was to compare perioperative and mortality outcomes of endovascular aortic repair against open repair in acute type B thoracic aortic dissection.

Derivation and validation of thoracic sarcopenia assessment in patients undergoing thoracic endovascular aortic repair

December 27, 2018 - 23:00
Sarcopenia, as assessed by computed tomography (CT)-based measurements of muscle mass, is an objective and patient-specific indicator of frailty, which is an important predictor of operative morbidity and mortality. Studies to date have primarily focused on psoas-defined sarcopenia, which may not be valid among patients with thoracic aortic disease. Using psoas sarcopenia as the reference for sarcopenia, the purpose of this study was to create and to validate a new thoracic-level method of measuring sarcopenia as a novel method to assess frailty among patients undergoing thoracic endovascular aortic repair.

Preoperative beta blockade is associated with increased rates of 30-day major adverse cardiac events in critical limb ischemia patients undergoing infrainguinal revascularization

December 27, 2018 - 23:00
The association between beta blockers and cardiovascular or limb-related outcomes after revascularization for critical limb ischemia (CLI) remains unclear. The objective of this study was to assess the impact of preoperative beta blockade on 30-day major adverse cardiac events (MACEs) and major adverse limb events (MALEs) in patients undergoing infrainguinal revascularization for CLI. We hypothesized that rates of MALEs and MACEs will be higher in patients not receiving preoperative beta blockade.

Removal of infected arteriovenous grafts is morbid and many patients do not receive a new access within 1 year

December 23, 2018 - 23:00
Infection of a prosthetic arteriovenous graft (AVG), in patients who have many comorbidities and limited access options, is a feared complication. Our objective was to investigate our contemporary series of infected AVG operations and analyze perioperative and long-term outcomes.

Aortoiliac remodeling and 5-year outcome of an ultralow-profile endograft

December 23, 2018 - 23:00
Remodeling of the aortoiliac anatomy is a challenge to the long-term performance of stent grafts for endovacular aneurysm repair. Changes in vessel diameter and length can result in loss of seal at attachment sites, limb disunion, or kinking, with the development of high-pressure endoleaks, migration, or limb occlusion. The aim of this study was to assess the durability and conformability of the ultralow-profile INCRAFT AAA endograft (Cordis Corporation, Milpitas, Calif) during 5-year follow-up.

A novel swine model of abdominal aortic aneurysm

December 23, 2018 - 23:00
Few large-animal models exist for the study of aortic aneurysms. β-Aminopropionitrile (BAPN) is a compound known to cause aortic aneurysms by inhibiting lysyl oxidase, a collagen cross-linking enzyme. It is hypothesized that BAPN plus aneurysm induction surgery would result in significant aneurysm formation in swine with biologic properties similar to human disease.

Pre-emptive nonselective perigraft aortic sac embolization with coils to prevent type II endoleak after endovascular aneurysm repair

December 23, 2018 - 23:00
Pre-emptive selective embolization of inferior mesenteric artery (IMA), lumbar arteries (LAs), and perigraft sac for prevention of type II endoleak (T2EL) has not been widely adopted. We perform pre-emptive nonselective perigraft aortic sac embolization with coils (PNPASEC) in patients at high risk for development of T2EL (four or more patent LAs, patent IMA ≥3 mm, and ≥30-mm aortic flow lumen). The goal of this study was to see whether PNPASEC decreases T2ELs requiring reinterventions.

Scoping review of frailty in vascular surgery

December 23, 2018 - 23:00
This review sought to describe the current state of knowledge of the impact of frailty on perioperative clinical outcomes in patients undergoing vascular interventions.

Outcomes and complications after fenestrated-branched endovascular aortic repair

December 23, 2018 - 23:00
To report the outcomes of patients enrolled in a physician-sponsored investigational device exemption trial for endovascular treatment of complex thoracoabdominal aortic aneurysms with fenestrated and/or branched devices.