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Chronic limb-threatening ischemia (CLTI) in patients with end-stage renal disease (ESRD) poses significant challenges in clinical management due to its unique pathology and poor treatment outcomes. This review calls for a tailored classification and risk assessment for these patients to guide better revascularization choices with early minor amputation as a first-line strategy in advanced stages.

This is a comprehensive review of carotid artery revascularization techniques: Carotid Endarterectomy (CEA), Transfemoral Carotid Artery Stenting (TFCAS), and Transcarotid Artery Revascularization (TCAR). CEA is the gold standard and is particularly effective in elderly and high-risk patients. TFCAS, introduced as a less invasive alternative, poses increased periprocedural stroke risks. TCAR, which combines minimally invasive benefits with CEA's neuroprotection principles, emerges as a safer option for high-risk patients, showing comparable results to CEA and better outcomes than TFCAS. The decision-making process for carotid revascularization is complex and influenced by the patient’s medical comorbidities and anatomic factors.

Thoracic endovascular aortic repair (TEVAR) and complex endovascular aneurysm repair (cEVAR) are effective and minimally invasive treatment options for preventing rupture and decreasing mortality of aortic aneurysms. Patients with renal insufficiency are prone to worse postoperative cardiovascular morbidity and mortality due to the atherosclerosis burden as well as increased levels of angiotensin II. Nonetheless, knowledge about the outcomes of aortic stent graft therapy in patients with chronic kidney disease (CKD) or dialysis is scarce. This study aimed to examine outcomes after TEVAR and cEVAR in patients on CKD and dialysis.

Dialysis access is a fundamental procedure performed by vascular surgeons. Commonly, upper extremity access is utilized via a brachiobasilic fistula (BBF) or brachiocephalic fistula (BCF). BCF is preferred due to ease compared to BBF without documented improved function. Few studies compare patency outcomes between BBF and BCF over time. Our goal was to evaluate the difference in outcomes between BBF and BCF.

Neuraxial anesthesia (NA) has been hypothesized to decrease postoperative complications and reduce mortality. However, studies regarding the impact of anesthesia type on outcomes of infrainguinal bypass (IIB) have demonstrated mixed results. In this multi-institutional study, we aimed to investigate the association of NA versus general anesthesia (GA) and perioperative and 1-year outcomes of IIBs.

The size selection of the arteriovenous (AV) anastomosis in dialysis access creation requires a careful balance: the diameter must be large enough to accommodate sufficient flow for hemodialysis but small enough to minimize the complication of steal syndrome. Steal syndrome affects up to 10% of patients after creation of dialysis access with sometimes devastating consequences. Conventional teaching recommends a 7–10 mm anastomosis. We sought to assess the efficacy of using a smaller (5–6 mm) anastomosis in new arteriovenous fistula (AVF) creation.

Physician-modified endografts and custom-manufactured devices use branched and fenestrated techniques (F/BEVAR) to repair complex aneurysms. Traditionally, many of these are deployed through a combination of upper and lower extremity access. However, with newer steerable sheaths, you can now simulate upper extremity (UEM) access from a transfemoral approach. Single-institution studies have demonstrated increased risks of access site complications and stroke when UEM access is used. This study compares outcomes after F/BEVAR in a national database between total transfemoral (TTF) access and mixed UEM access.

Cardiovascular disease (CVD) represents 32% of all global deaths. Studies have shown an increase in CVD prevalence and mortality with the most substantial increase in low-income and middle-income countries (LMICs). Within LMICs, we sought to 1) measure the burden of CVD with respect to aortic aneurysm (AA), ischemic stroke (IS), and peripheral arterial disease (PAD); 2) quantify surgical access to vascular surgery services; and 3) identify challenges and solutions to addressing disparities.

Type II endoleaks (ELII) are the most common complication following endovascular aneurysm repair (EVAR). Persistent ELII require continual surveillance and have been shown to increase the risk of Type I and III endoleaks, sac growth, need for intervention, conversion to open or even rupture, directly or indirectly. These are often difficult to treat following EVAR, and there are limited data regarding the effectiveness of prophylactic treatment of ELII. The aim of this study is to report the midterm outcomes of prophylactic perigraft arterial sac embolization (pPASE) performed in patients undergoing EVAR.

While Transfemoral Carotid Artery Stenting (TFCAS) is a valid minimally invasive option for patients who also might be suitable for carotid endarterectomy (CEA) or transcarotid artery revascularization (TCAR), alternative access sites such as transbrachial (TB) or transradial (TR) are only utilized when anatomic factors preclude direct carotid or transfemoral access. In this study, we aimed to evaluate the outcomes of TR/TB access in comparison to TF for percutaneous carotid artery revascularization.

TransCarotid Artery Revascularization (TCAR) has been effectively performed to prevent stroke in patients with carotid artery stenosis (CS). Prior studies established that TCAR can be safely performed in high-risk patients such as octogenarians, patients with prior carotid endarterectomy (CEA), contralateral occlusion, and heavily calcified lesions. Hemodialysis patients are at an increased risk of exhibiting cardiovascular complications. This study aims to investigate how dialysis may affect TCAR outcomes.

In-hospital stroke (IHS) has been associated with worse outcomes than out-of-hospital stroke (OHS) due to delays in diagnosis and treatment. A paucity of studies exists comparing the timing of postoperative stroke after carotid revascularization. We aimed to study the effect of IHS versus OHS on postoperative mortality in carotid revascularization patients in a large-scale national database.

IMPORTANCE: Carotid artery stenting has been limited to use in patients with high surgical risk; outcomes in patients with standard surgical risk are not well known. OBJECTIVE: To compare stroke, death, and myocardial infarction outcomes following transcarotid artery revascularization vs carotid endarterectomy in patients with standard surgical risk. DESIGN, SETTING, AND PARTICIPANTS: This retrospective propensity-matched cohort study was conducted from August 2016 to August 2019 with follow-up until August 31, 2020, using data from the multicenter Vascular Quality Initiative Carotid Artery Stent and Carotid Endarterectomy registries. Patients with standard surgical risk, defined as those lacking Medicare-defined high medical or surgical risk characteristics and undergoing transcarotid artery revascularization (n = 2962) or carotid endarterectomy (n = 35 063) for atherosclerotic carotid disease. In total, 760 patients were excluded for treatment of multiple lesions or in conjunction with other procedures. EXPOSURES: Transcarotid artery revascularization vs carotid endarterectomy. MAIN OUTCOMES AND MEASURES: The primary outcome was a composite end point of 30-day stroke, death, or myocardial infarction or 1-year ipsilateral stroke. RESULTS: After 1:3 matching, 2962 patients undergoing transcarotid artery revascularization (mean [SD] age, 70.4 [6.9] years; 1910 [64.5%] male) and 8886 undergoing endarterectomy (mean [SD] age, 70.0 [6.5] years; 5777 [65.0%] male) were identified. There was no statistically significant difference in the risk of the primary composite end point between the 2 cohorts (transcarotid 3.0% vs endarterectomy 2.6%; absolute difference, 0.40% [95% CI, −0.43% to 1.24%]; relative risk [RR], 1.14 [95% CI, 0.87 to 1.50]; P = .34). Transcarotid artery revascularization was associated with a higher risk of 1-year ipsilateral stroke (1.6% vs 1.1%; absolute difference, 0.52% [95% CI, 0.03 to 1.08]; RR, 1.49 [95% CI, 1.05 to 2.11%]; P = .02) but no difference in 1-year all-cause mortality (2.6% vs 2.5%; absolute difference, −0.13% [95% CI, −0.18% to 0.33%]; RR, 1.04 [95% CI, 0.78 to 1.39]; P = .67). CONCLUSIONS AND RELEVANCE: In this study, the risk of 30-day stroke, death, or myocardial infarction or 1-year ipsilateral stroke was similar in patients undergoing transcarotid artery revascularization compared with those undergoing endarterectomy for carotid stenosis.

Flow reversal is a key component of transcarotid artery revascularization (TCAR). However, the impact of flow reversal duration on neurological outcomes and the duration of flow reversal which optimizes TCAR's outcomes is not known. We evaluated the association of flow reversal time with the intraoperative and postoperative neurological outcomes of TCAR.

Different renin-angiotensin-aldosterone system inhibitor (RAASI) usage patterns exist among patients undergoing lower extremity bypass (LEB) for peripheral arterial disease. We studied the association of RAASI usage patterns with LEB outcomes to determine which pattern is associated with improved survival after LEB.

Despite many patients undergoing carotid endarterectomy (CEA) being on dual antiplatelet therapy (DAPT) for cardiac or neurologic indications, the impact of such therapy on perioperative outcomes remains unclear. We aim to compare rates of postoperative bleeding, stroke and major adverse events (stroke, death or MI) among patients on Aspirin alone (ASAA) versus DAPT (Clopidogrel and Aspirin).

Patients undergoing open or endovascular infrainguinal revascularization are at an elevated risk for postoperative cardiovascular complications due to high rates of comorbidities and the physiologic stress of surgery. Transfusions are known to be associated with adverse events but knowledge of specific risks associated with transfusion timing, product type, and long-term outcomes while accounting for preoperative cardiovascular risk factors is not well understood in this population.

Aneurysmal arteriovenous fistulas (AVF) can pose a difficult treatment dilemma for the vascular surgeons. Prolonged tunneled dialysis catheters (TDCs) in patients requiring long-term dialysis are associated with significantly increased mortality compared to AVF. We aimed to elucidate the outcomes of aneurysmal arteriovenous (AV) access revision with aneurysm resection and Artegraft® (LeMaitre, New Brunswick, NJ) Collage Vascular Graft placement to avoid prolonged use of TDCs.

Endovascular and open surgical modalities are currently used to treat popliteal artery aneurysms (PAA). However, there is limited data on the comparative durability of both repairs to guide physicians especially in the treatment of patients presenting symptomatic. We aimed to study the comparative effectiveness of endovascular PAA repair (EPAR) versus open PAA repair (OPAR).

Challenging aortoiliac anatomy such as short neck and narrow access vessels is responsible for endovascular repair of abdominal aortic aneurysm (EVAR) ineligibility in up to 50% of cases. The Ovation stent graft helped widen the range of abdominal aortic aneurysms (AAAs) suitable for EVAR thanks to its low-profile delivery system and polymer-filled sealing rings. However, its advantages are offset by a tight sizing chart that can lead to increased risk of type Ia endoleak or endograft infolding from under- or oversizing, respectively. We sought to assess the safety and efficacy of a novel endovascular technique developed to expand the use of the Ovation endograft while avoiding these issues.

Aortic aneurysms are normally treated by an endovascular approach. Due to the lack of devices and increasing experience, there is a growing number of complex aneurysms undergoing repair by physician modified endografts (PMEGs). Previously, our practice was to target visceral vessels exclusively through upper extremity access. We have since then shifted to an all transfemoral approach when possible. This study aims to show the operative benefits of transfemoral only approaches.

Supplemental Digital Content is available in the text.

Supplemental Digital Content is available in the text.

Several studies have reported lower mortality and morbidity after thoracic endovascular aortic repair (TEVAR) when compared to open surgical repair (OSR) in the treatment of type B aortic dissection (TbAD). However, there are few studies in the literature on the cost of both treatment options. Thus, the aim of this study is to focus on in-hospital outcomes and cost associated with TbAD repair procedures in a national database in the United States.

Treatment of massive and submassive pulmonary embolism (PE) has been shown to be a valuable therapeutic modality. However, a paucity of data exists, regarding length and guidelines for treatment and typically these patients are treated by other than vascular surgery specialists. The aim of this study is to evaluate the effectiveness and safety of short duration treatment of massive and submassive PE, exclusively by vascular surgeons, without routine follow-up pulmonary angiography.

Common iliac artery aneurysms (CIAAs) are seen in 20–40% of patients with abdominal aortic aneurysms. Historically treated with sacrifice of the hypogastric artery, which can result in significant morbidity related to pelvic ischemia, new devices have made hypogastric artery preservation more feasible but are only applicable to a small subset of aneurysm anatomy. We sought to assess the safety and efficacy or a novel technique for hypogastric artery preservation applicable to a wider variety of patients with CIAAs.

Peripheral arterial occlusive disease (PAOD) continues to be a vexing problem despite the advent of endovascular techniques augmenting traditional open repair. At our institution, we have found there is a growing number of patients with PAOD who are vein-challenged and have undergone prosthetic bypass previously for infrainguinal arterial reconstruction. When occluded, these grafts have been abandoned for a new bypass strategy or amputation. We present a novel technique of reestablishing flow through chronically occluded prosthetic bypass grafts.

Transfemoral carotid artery stenting (TFCAS) was introduced as a less invasive option for carotid revascularization in patients at high risk for complications from carotid endarterectomy (CEA). The increased perioperative stroke and death risk of TFCAS has however prevented TFCAS from widespread acceptance as an alternative to CEA in high-risk patients. Recent research suggests that transcarotid artery revascularization (TCAR) may be associated with a low stroke and death risk and potentially meet the needs of patients at high surgical risk. We aimed to estimate the 30-day risk of stroke or death of TCAR and compare it to TFCAS and CEA.

The prevalence of obesity is increasing in the United States. The treatment of end-stage renal disease (ESRD) via hemodialysis spans the spectrum of body mass index (BMI). This study examines the impact of BMI on outcomes of autogenous fistulas for hemodialysis access in a large population-based cohort of patients.

Brachiocephalic arteriovenous fistulas (BCFs) are commonly placed in outpatient settings. The impact of general anesthesia (GA), regional anesthesia (RA), or local anesthesia (LA) on perioperative recovery and fistula maturation/patency after outpatient BCF creations is unknown. We evaluated whether outcomes of outpatient BCF creations vary based on anesthesia modality.

Chronic iliocaval obstruction is a challenging clinical entity to treat. Endovenous iliocaval stenting is becoming the treatment of choice for central vein stenosis and occlusion. However, outcomes in thrombotic disease have not been as robust as nonthrombotic disease. In this article, we describe our experience utilizing covered stents as a novel tool for chronic total occlusions of the iliocaval veins.

To evaluate gender-based patterns of utilization and outcomes of arteriovenous fistulas (AVFs) and grafts (AVGs) in a population-based cohort of hemodialysis (HD) patients.

Although the majority of vascular surgeons perform conventional carotid endarterectomy (c-CEA), others prefer eversion CEA (e-CEA). Despite several randomized controlled trials and single center studies, the advantage of one technique over the other is still not clearly defined. The purpose of this study is to compare the postoperative outcomes and durability of c-CEA versus e-CEA in a nationally representative cohort.

Endovascular aneurysm repair (EVAR) is the dominant treatment modality for abdominal aortic aneurysm (AAA). Periprocedural risks are low, and cardiovascular events are the principle determinants of long-term survival. Recently, the concept of endovascular aneurysm sealing (EVAS) has been introduced into clinical investigation. In previous cohort studies, EVAS has been associated with a lower all-cause mortality than expected despite device issues. We used a propensity weighted approach to investigate whether EVAS was associated with lower all-cause mortality after aneurysm repair.

Patients with end-stage renal disease (ESRD) whether on dialysis therapy (DT) or who received a kidney transplant (KT) have previously shown unfavorable surgical outcomes. Little is known about the comparative efficacy and durability of lower extremity bypass (LEB) in those patients. The Vascular Quality Initiative database was explored to identify DT or KT recipients (2003–2016) who had LEB. We included 1,714 bypass procedures; DT: 1,512 (88.2%). Primary patency (PP) at 2 year was comparable between KT and DT groups (PP [95% confidence interval {CI}]: 77.0% [69.7%–82.8%] vs. 80.5% [77.8%–82.9%]; P = 0.212), and the risk-adjusted hazard was similar (adjusted hazard ratio [aHR] [95% CI]: 0.89 [0.61–1.30]; P = 0.540). Amputation-free survival (AFS) at 2 year was more favorable in KT group (AFS [95% CI]: 73.1% [66.3%–78.8%] vs. 48.0% [45.4%–50.6%]; P < 0.001), (aHR [95% CI]: 2.29 [1.62–3.23]; P < 0.001). Patients on DT exhibited a higher risk of mortality than KT recipients (aHR [95% CI]: 2.94 [2.07–4.17]; P < 0.001). This study demonstrated superior limb outcomes in KT recipients than patients on DT after LEB. Despite the comparable PP, the risk of amputation or death was doubled in patients on DT compared with KT recipients. Because both groups were similar in several baseline characteristics, the difference in outcome is likely driven by the positive effect of KT on the physiological milieu of these patients.

The vast majority of patients undergoing hemodialysis (HD) are anemic. The severity of anemia in these patients may influence the postoperative outcomes and the durability of vascular access. Thus, the purpose of this study is to assess the association between anemia and adverse outcomes in patients undergoing HD access placement (arteriovenous grafts and fistula).

Supplemental Digital Content is available in the text.

Thoracic endovascular aortic repair (TEVAR) and complex endovascular thoraco-abdominal aneurysm repair (cEVAR) has been increasingly adopted in the treatment of thoracic and thoracoabdominal aorta aneurysms, offering a less invasive approach for patients with appropriate anatomy. Women usually present with smaller aortic diameter. However, they usually have greater aneurysm growth rates. How sex can affect postoperative and short-term outcomes after TEVAR is not well reported. The aim of this study was to assess outcomes in female versus male patients undergoing TEVAR for treatment of thoracic and thoracoabdominal aneurysms in a Medicare-linked database.

The gold standard for determining carotid artery stenosis intervention is based on a combination of percent stenosis and symptomatic status. Few studies have assessed plaque morphology as an additive tool for stroke prediction. Our goal was to create a predictive model and risk score for 30-day stroke and death inclusive of plaque morphology.

Prior studies have shown that beginning hemodialysis (HD) with a hemodialysis catheter (HC) is associated with worse mortality than with an arteriovenous fistula (AVF) or arteriovenous graft (AVG). We hypothesized that transplant waitlisting would modify the effect of HD access on mortality, given waitlist candidates’ more robust health status. Using the US Renal Data System, we studied patients with incident ESRD who initiated HD between 2010 and 2015 with an AVF, AVG, or HC. We used Cox regression including an interaction term for HD access and waitlist status. There were 587,607 patients that initiated HD, of whom 82,379 (14.0%) were waitlisted for transplantation. Only 26,264 (4.5%) were transplanted. Among patients not listed, those with an AVF had a 34% lower mortality compared to HC [adjusted hazard ratio (aHR) 0.66, 95% confidence interval (CI) 0.65–0.67] while those with an AVG had a 21% lower mortality compared to HC (aHR 0.79, 95% CI 0.77–0.81). Transplant waitlisting attenuated the association between hemodialysis access type and mortality (interaction p< 0.001 for both AVF and AVG vs. HC). Among patients on the waitlist, those with an AVF had a 12% lower mortality compared to HC (aHR 0.88, 95% CI 0.84–0.93), while those with an AVG had no difference in mortality (aHR 0.95, 95% CI 0.84–1.08). While all patients benefit from AVF or AVG over HC, the benefit was attenuated in waitlisted patients. Efforts to improve health status and access to healthcare for non-waitlisted ESRD patients might decrease HD-associated mortality and improve rates of AVF and AVG placement.

Significant national variation exists in defining the degree of stenosis that requires intervention in patients with asymptomatic carotid artery stenosis (ACAS). We aimed to evaluate the risk of perioperative and 2-year stroke and death in ACAS patients undergoing carotid endarterectomy (CEA) and carotid artery stenting (CAS) for severe versus very severe stenosis in a contemporary population.

Patients with peripheral arterial disease often have high comorbidity burden that may complicate post-interventional course and drive increased health-care expenditures. Racial disparity had been observed in lower extremity revascularization (LER) patterns and outcomes. In 2014, Maryland adopted an all-payer rate-setting system to limit the rising hospitalization costs. This resulted in an aggregate payment system in which hospital compensation takes place as an overall per capita expenditure for hospital services. We sought to examine racial differences and other patient-level factors that might lead to discrepancies in LER hospital costs in the State of Maryland.