Journal of Vascular Surgery

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Invited commentary

30 November 2018 - 11:00pm
The study of the unique pathobiology of abdominal aortic aneurysm (AAA) can be traced to the seminal observation by M. David Tilson that “the pathogenic mechanism [of AAA] is not indiscriminate destruction of the media by atherosclerotic involvement” made 30 years ago.1 Dr Tilson was also the earliest to suggest that the unique inflammation of the AAA might well be due to inappropriate antibody responses to self antigens within the matrix of the aortic wall.2 Aneurysms developing in arterial xenografts have been described since 1955,3 and Dr Coscas and colleagues provide a novel modification of this model in the current manuscript that helps elucidate antibody-mediated immune responses to arterial mural matrix.

Invited commentary

30 November 2018 - 11:00pm
Since current guidelines based on randomized clinical trials1-6 have established degree of carotid stenosis as the primary surrogate for stroke risk and indication for carotid endarterectomy or stenting, accurate assessment of the degree of carotid stenosis has been the traditional focus of carotid imaging.7 However, the degree of carotid stenosis is an inadequate assessment of stroke risk, and other key factors for determining carotid plaque vulnerability include intraplaque hemorrhage, plaque rupture, and luminal thrombus.

Invited commentary

30 November 2018 - 11:00pm
The potential involvement of exogenous pathogens in clinical progression of abdominal aortic aneurysm (AAA) remains controversial. Several investigative groups reported the detection of genetic materials of viruses in aneurysmal tissues using the polymerase chain reaction-based technique. However, analysis of host immunoglobulin G antibodies against cytomegalovirus (CMV), one of the viruses implicated in AAAs, failed to show different infection burdens among patients with nonruptured AAAs, ruptured AAAs, or no aneurysm.

Invited commentary

30 November 2018 - 11:00pm
In addition to managing patients who present with solid organ ischemia due to acute arterial insufficiency, vascular surgeons also inflict more short-term end-organ ischemia than most other specialists because we control vessels for open reconstructions. With restoration of nutritive blood flow, various forms of reperfusion injury can substantially impair the recovery of patients with prolonged end-organ ischemia. Long clamp times, especially involving large bulk of tissues (eg, the pelvis and both legs) and susceptible organs (such as the brain, nerves, and viscera), remain a significant risk for the ischemia-reperfusion injury storm.

Invited commentary

30 November 2018 - 11:00pm
Abdominal aortic aneurysm (AAA) accounts for >20 million deaths worldwide.1 Extrapolating from the National Inpatient Sample data set capturing 20% of inpatients in the United States, approximately 500,000 operations for AAA were performed from 2000 to 2010.2 The number of aneurysms fixed by endovascular aneurysm repair increased from 5% to approximately 75% during that period, with concomitant improvements in mortality and morbidity within 2 to 3 years of surgery.2,3 Similar to the advancements offered by endovascular aneurysm repair, medical treatments that could reduce the growth rate of AAA even modestly would save lives and radically alter clinical practice.

Invited commentary

30 November 2018 - 11:00pm
The goal of developing a small-caliber, prosthetic vascular graft comparable to autologous vein conduit remains elusive. More than 30 years ago, Dr Alexander Clowes and his group observed that excessive intimal hyperplasia associated with exuberant smooth muscle cell and endothelial cell proliferation occurred in anastomotic stenosis of polytetrafluoroethylene bypass grafts. Over time, this phenomenon has been attributed to factors such as compliance mismatch between the prosthetic graft and the native artery, vascular wall sheer stress, and response to injury.

Nellix Endobag rupture associated with a fatal outcome

25 November 2018 - 11:00pm
Endovascular treatment of a type IA endoleak was conducted using a Nellix chimney graft technique for an expanding abdominal aortic aneurysm in an 84-year-old man. During the procedure, a polymer leak occurred from one of the endobags. Postoperatively, the patient developed hemodynamic instability and a swollen leg on the side of the leaking endobag, resulting in a fatal outcome.

The “bare branch” for safe spinal cord ischemia prevention after total endovascular repair of thoracoabdominal aneurysms

25 November 2018 - 11:00pm
Staged endovascular treatment of thoracoabdominal aortic aneurysms (TAAAs) with temporary perfusion of the sac through a branch left unstented or a dedicated branch is a strategy intended to reduce the risk of postoperative spinal cord ischemia (SCI). However, potential complications of this approach are aneurysm sac progression between stages, visceral embolism, and occlusion or displacement of components. We here present the “bare branch” technique, a safe adjunct to TAAA repair in terms of interstage complications.

Drug-eluting stents are associated with improved outcomes for the treatment of infrainguinal bypass graft stenoses

25 November 2018 - 11:00pm
Existing endovascular therapies for failing infrainguinal bypass grafts are associated with modest patency rates. The use of everolimus drug-eluting stents (eDESs) for endovascular bypass graft revision has not yet been reported. The objective of this study was to describe and to compare clinical outcomes of eDESs vs percutaneous cutting balloons (PCBs) vs percutaneous transluminal angioplasty (PTA) for the treatment of infrainguinal bypass graft stenoses.

Simulation training streamlines the real-life performance in endovascular repair of ruptured abdominal aortic aneurysms

25 November 2018 - 11:00pm
Difficulties in distributing endovascular experience among all operating room (OR) personnel prevented full-scale use of endovascular aneurysm repair (EVAR) in emergencies. To streamline the procedure of EVAR for ruptured aneurysm (rEVAR) and to provide this method even to unstable patients, we initiated regular simulation training sessions.

Response of the popliteal artery to treadmill exercise and stress positioning in patients with and without exertional lower extremity symptoms

25 November 2018 - 11:00pm
Functionally limiting exertional lower extremity pain and neurologic symptoms are commonly encountered in military and civilian settings. Exertional muscle compression of the popliteal artery (PA) and tibial nerve in the proximal calf (the “popliteal outlet”) can be associated with these symptoms but is rarely investigated as a cause. Exertional ankle-brachial index (EABI) and dynamic PA ultrasound imaging may be suitable to screen for this syndrome of “functional” popliteal entrapment, but neither has been rigorously studied.

Extending endovascular aneurysm repair to more patients without better outcomes

25 November 2018 - 11:00pm
This study quantifies the survival and outcomes associated with endovascular aneurysm repair (EVAR) patients treated in two eras. We hypothesized that both end points will improve over time.

Survival prediction in patients with chronic limb-threatening ischemia who undergo infrainguinal revascularization

25 November 2018 - 11:00pm
Accurate survival prediction critically influences decision-making in caring for patients with chronic limb-threatening ischemia (CLTI). The Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial demonstrated that in patients who survived >2 years, there was a significant advantage to infrainguinal bypass compared with endovascular intervention, which increased with time. Validated survival models for patients with CLTI are lacking.

Impact of time to repair on outcomes in patients with lower extremity arterial injuries

25 November 2018 - 11:00pm
Six hours has long been considered the threshold of ischemia after peripheral artery injury. However, there is a paucity of evidence regarding the impact of operative delays on morbidity and mortality in patients with lower extremity arterial injuries.

Discussion

25 November 2018 - 11:00pm
Dr Melissa L. Kirkwood (Dallas, Tex). I would like to commend the authors on an excellent paper evaluating sex-based differences in survival in patients undergoing endovascular aneurysm repair. I would like to thank Dr Shutze for sending me the manuscript well in advance of the meeting and to thank the Southern Association for Vascular Surgery program committee for allowing me to comment.

Sex as an independent risk factor for long-term survival after endovascular aneurysm repair

25 November 2018 - 11:00pm
Several vascular surgical procedures, including repair of abdominal aortic aneurysms (AAAs), show poorer outcomes for women than for men. We evaluated the impact of sex-based demographic differences on survival after endovascular aneurysm repair (EVAR).

Anatomic predictors for late mortality after standard endovascular aneurysm repair

22 November 2018 - 11:00pm
Abdominal aortic aneurysm (AAA) management involves a decision process that takes into account anatomic characteristics, surgical risks, patients' preferences, and expected survival. Whereas larger AAA diameter has been associated with increased mortality after both standard endovascular aneurysm repair (EVAR) and open repair, it is unclear whether survival after EVAR is influenced by other anatomic characteristics. The purpose of this study was to determine the importance of baseline anatomic features on survival after EVAR.

Single-center experience with an inner branched arch endograft

22 November 2018 - 11:00pm
Whereas open repair is the “gold standard” for most aortic arch diseases, a subgroup of patients might benefit from an endovascular approach. The introduction of branched stent grafts with dedicated design to address the challenges of the ascending aorta and the aortic arch has opened an entirely new area of treatment for these patients. We investigated the early outcomes of branched thoracic endovascular aortic repair (b-TEVAR) in various types of disease of the aortic arch.

Factors associated with postoperative renal dysfunction and the subsequent impact on survival after open juxtarenal abdominal aortic aneurysm repair

22 November 2018 - 11:00pm
Renal dysfunction is a well-described complication of open juxtarenal abdominal aortic aneurysm repair, but the associated risk factors and corresponding impact on survival are not well described.

Predictors of perioperative and late survival in octogenarians undergoing elective endovascular abdominal aortic repair

22 November 2018 - 11:00pm
The appropriateness of endovascular aneurysm repair (EVAR) of uncomplicated abdominal aortic aneurysm depends on the risk-benefit ratio, particularly in elderly patients with short life expectancy. The aim of this study was to assess the efficacy of EVAR in >80-year-old patients by evaluating their postoperative survival and analyzing the possible predictors of late mortality.