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A 57-year-old male patient who underwent an open hemiarch repair with a femoral-femoral crossover bypass and right lower extremity fasciotomies for an acute Type A aortic dissection with limb ischemia presented 5 weeks' postrepair with a 20-pound weight loss due to intermittent hemodynamic collapse of the dissection flap over the origin of the superior mesenteric artery. This case highlights the challenges a dissection flap can cause after an urgent Type A aortic dissection repair., Competing Interests: None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Kidney Transplant is the preferred treatment for end-stage renal disease (ESRD) patients. However, a subset of otherwise eligible patients have severe iliac artery calcification that preclude them from receiving a kidney transplant. This report highlights the application of a physician-modified external iliac artery stent graft with a side branch extension (SBE) to facilitate successful kidney transplantation in a 69-year-old African American female who was otherwise ineligible for kidney transplant due to the presence of severe circumferential bilateral iliac artery calcification. Four months later, the patient received a kidney transplant and recovered without complications. Her duplex ultrasound (DUS) revealed patent vasculature to the kidney graft, she produced adequate urine output, and creatinine and glomerular filtration rate (GFR) normalized by discharge. This underscores the potential for stent graft with SBE as an option for patients who were traditionally ineligible for kidney transplantation due to the presence of severe aortoiliac calcification., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: Improving representation of women in medicine and surgery has been tempered by higher rates of attrition from residencies and from academic medicine among women compared to men. The attrition of women from the practicing vascular surgery workforce has not been studied., Methods: We utilized the Center for Medicare and Medicaid Services' Doctors and Clinicians database to study vascular surgery employment patterns from 2015 to 2022. We examined gender balance within the workforce and attrition rates among male and female vascular surgeons. We utilized a logistic regression to calculate the odds of attrition by gender., Results: The percentage of female vascular surgeons grew from 11% to 16% between 2015 and 2022, with each graduating class since 2005 having between 20% and 38% women. Yet, female surgeons were 2.05 (95% confidence interval: 1.36-3.08) times more likely to leave practice than their male counterparts when controlling for graduation year and practice in academic medicine., Conclusions: The proportion of women in vascular surgery is increasing as more women graduate into the specialty. Despite increasing representation, women are more likely than men to leave the workforce., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Direct common carotid puncture (DCP) is conventionally used as a bailout technique in stroke patients. However, little is known about the relevant anatomy. Our objective was to examine the relationship of the common carotid artery (CCA) to surrounding structures based on different DCP trajectories passing through the artery's center., Methods: Fifty randomly selected head/neck CTAs were analyzed. The trajectory of DCP and relationship to the internal jugular vein (IJV) and thyroid were analyzed at 1 cm intervals above the clavicle on 7 axial sections. Using the trans-carotid sagittal plane as the 0° trajectory, we plotted 3 additional trajectories at 30° intervals and the relationship with the IJV and thyroid proximity was graded as following: 0=absent, 1=adjacent, and 2=crossing. The CCA tortuosity index was also analyzed for each vessel., Results: Analysis of 2800 trajectories across 100 CCAs showed that the IJV and thyroid were least encountered on the axial sections 2 cm above the clavicle, at 0° on the right (9 thyroids and 6 IJV), and at 90° on the left (0 Thyroids and 14 IJVs). The tortuosity index of the CCA was significantly lower above the clavicle than its entire length (P < 0.001)., Conclusions: DCP performed 2 cm above the clavicle at 0° on the right, and 90° on the left appears to minimize encounters with the IJV and thyroid gland, reducing potential complications. However, despite these findings, ultrasound guidance remains vital for DCP safety. Further focus on endovascular device safety in DCP is needed., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Loeys-Dietz syndrome (LDS) has been associated with multiple vascular abnormalities involving the entire arterial tree. However, limited reports regarding compromise in the aortoiliac and femoral bifurcation are available. Further, recommendations for optimal approach, thresholds for diameter at the time of surgery, and surveillance are also limited. We present a case of a 67-year-old male patient with LDS and aneurysmal aortoiliac and enlarging common femoral arteries aneurysms, who underwent open surgical repair. His past surgical history included multiple vascular interventions for lower extremity claudication and bilateral hip replacements. The right hip arthroplasty was previously removed due to infection. From the vascular standpoint, the patient underwent staged endovascular left hypogastric artery embolization and open aorto-bi-profunda bypass with a Rifampin-soaked Dacron graft. At 5-month follow-up, he remains asymptomatic with healed incisions and patent bypasses. This case highlights the challenges in managing peripheral aneurysms in LDS patients, emphasizing the need for tailored treatment strategies. While open repair is preferred, endovascular options may be considered in selected cases. Surveillance remains critical with annual cross-sectional imaging. Surgical planning is intricate due to comorbidities, anatomical complexities, and previous surgical infection. Surveillance of these patients must be strict as multiple vascular and non-vascular complications may arise. Therefore, collaborative decision-making is essential for optimal outcomes in this known high-risk population with connective tissue disorders., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Median arcuate ligament syndrome (MALS) is a rarely diagnosed and treated etiology of abdominal pain with no established diagnostic approach. The effectiveness of our institutional protocol in identifying these patients was investigated by analyzing their surgical outcomes., Methods: A retrospective review was conducted of patients treated for MALS at our institution from 2001 to 2022. Patients were considered for a diagnosis of MALS if there was evidence of abdominal pain (unprovoked, provoked by eating, and physical activity) and celiac artery dynamic compression on diagnostic imaging. During the study period, an institutionalized management protocol was developed for these patients. Patients were then categorized as having positive surgical outcomes if their symptoms improved or resolved entirely during the latest follow-up visit, while those whose symptoms remained unchanged or worsened were classified as having negative outcomes. Of the patients considered for MALS diagnosis, a patient was confirmed positive if there is either a positive provocative mesenteric angiogram, celiac plexus block, or both, along with a negative gastroenterology workup. Comparative analysis was performed using a chi-square test. Multivariable logistic regression models were performed to evaluate the association between risk factors and symptom relief with the adjusted follow-up length. All tests were 2-sided, with P value <0.05 considered statistically significant., Results: A total of 163 patients with a mean follow-up duration of 17.7 + 23.4 months were included in the study. Patients who were part of the protocol had a higher rate of improvement in their abdominal pain (65.9% vs. 50.0%, P < 0.04). Furthermore, patients diagnosed positive by the protocol experienced greater relief of abdominal pain compared to patients with a negative diagnosis (77.8% vs. 52.5%, P = 0.014)., Conclusions: By using a standardized protocol, patients who received a positive diagnosis demonstrated symptomatic improvement in their outcomes. Further investigation is warranted on a larger scale to assess its generalizability for the management of this challenging patient population., (Copyright © 2024. Published by Elsevier Inc.)

Objective: We sought to identify differentially expressed proteins in serum, plasma, and plaque samples of patients with carotid atherosclerotic lesions., Methods: We performed a systematic review of the proteomic profile of serum, plasma, and plaque samples of patients with carotid artery disease. We included full-length peer-reviewed studies of adult humans and reported them using PRISMA guidelines. The quality of the design and content of the articles included in the review was assessed using the Newcastle-Ottawa scale., Results: We included six peer-reviewed articles reporting protein expression in serum, plasma, or plaque samples from patients with carotid atherosclerosis. Three were single-center cross-sectional studies, two were single-center case-control studies, and one was a single-center cohort study. Thirty-six proteins were found to be expressed differentially when comparing samples from healthy subjects and individuals with diseased carotid vessels and between patients with symptomatic and asymptomatic carotid artery atherosclerotic lesions. Some of these were shown to be related to inflammatory or anti-inflammatory pathways in atherogenesis. CD5L and S100A12 were both found to be upregulated in patients with unstable plaque, the former owing to its anti-inflammatory properties and the latter for its pro-oxidant effects in atherosclerosis. ACTB is involved in cellular structure and integrity and was found to be downregulated in patients with ruptured carotid plaques., Conclusions: Atherosclerotic carotid disease places the patient at increased risk of ischemic neurological events. Proteomics may help to understand their pathophysiological processes and can identify differential protein expression in blood samples from healthy subjects and patients with carotid artery plaques. This patient-centered approach will allow for the timely identification of individuals at higher risk of experiencing stroke., Competing Interests: None., (© 2024 The Author(s).)

Introduction: Studies have suggested that experiences of gender and racial discrimination are widespread among surgeons and surgical residents. This study examines the relationship between experienced microaggressions and traumatic stress., Methods: A one-time, deidentified survey was distributed over email to academic surgical societies. The survey consisted of 35 items including questions on prevalence of microaggressions, perceived job impacts as well as a shortened version of the Trauma Symptoms of Discrimination Scale. Chi-square tests and an independence test for trends were utilized to determine significance., Results: We collected data from 130 participants with majority (81%) having experienced microaggressions in the workplace. On measures of worry (P < 0.001), avoidance (P = 0.012), anxiety (P = 0.004), and trouble relaxing (P = 0.002), racial/ethnic minority surgeons and trainees demonstrated significantly higher scores. With perceived job impacts, significant agreement was seen with occurrences of working harder to prove competence (P = 0.005), gaining patient confidence (P < 0.001), reduced career satisfaction (P = 0.011), work-related negative talk (P = 0.018), and burnout at work due to microaggressions (P = 0.019). Among participants who underwent behavioral modifications, female surgeons were more likely to change their nonverbal communication styles (P < 0.001) and spend more time with patients (P < 0.001)., Conclusions: Experiences of microaggressions are associated with increased anxiety-related trauma symptoms in racial/ethnic minority surgeons and surgical trainees. Additionally, these experiences of microaggression can influence job satisfaction, burnout, career perceptions and workplace behaviors. As the field of surgery becomes more diverse, this study contributes to growing awareness of the role of implicit discrimination in the attrition and retention of racial/ethnic minority surgeons and female surgeons., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Sex-based outcome studies have consistently documented worse results for females undergoing care for abdominal aortic aneurysms. This review explores the underlying factors that account for worse outcomes in the females sex. A scoping review of studies reporting sex-based disparities on abdominal aortic aneurysms was performed. The review was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews. Factors that account for worse outcomes in the females sex were identified, grouped into themes, and analyzed. Key findings of each study are reported and a comprehensive framework of these factors is presented. A total of 35 studies were identified as critical in highlighting sex-based disparities in care of patients with aortic aneurysms. We identified the following 10 interrelated themes in the chain of aneurysm care that account for differential outcomes in females: natural history, risk factors, pathobiology, biomechanics, screening, morphology, device design and adherence to instructions for use, technique, trial enrollment, and social determinants. Factors accounting for worse outcomes in the care of females with aortic aneurysms were identified and described. Some factors are immediately actionable, such as screening criteria, whereas device design improvement will require further research and development. This comprehensive framework of factors affecting care of aneurysms in females should serve as a blueprint to develop education, outreach, and future research efforts to improve outcomes in females., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: This study aims to define the proportion of Medicare neuroendovascular procedures performed by different specialists from 2013 to 2019, map the geographic distribution of these specialists, and trend reimbursement for these procedures., Methods: The Medicare Provider Utilization Database was queried for recognized neuroendovascular procedures. Data on specialists and their geographic distribution were tabulated. Reimbursement data were gathered using the Physician Fee Schedule Look-Up Tool and adjusted for inflation using the United States Bureau of Labor Statistics' Consumer Price Index Inflation calculator., Results: The neuroendovascular workforce in 2013 and 2019, respectively, was as follows: radiologists (46% vs 44%), neurosurgeons (45% vs 35%), and neurologists (9% vs 21%). Neurologists increased proportionally (p=0.03). Overall procedure numbers increased across each specialty: radiology (360%; p=0.02), neurosurgery (270%; p<0.01), and neurology (1070%; p=0.03). Neuroendovascular revascularization (CPT 61645) increased in all fields: radiology (170%; p<0.01), neurosurgery (280%; p<0.01), neurology (240%; p<0.01); central nervous system (CNS) permanent occlusion/embolization (CPT61624) in neurosurgery (67%; p=0.03); endovascular temporary balloon artery occlusion (CPT61623) in neurology (29%; p=0.04). In 2019, radiologists were the most common neuroendovascular specialists everywhere except in the Northeast where neurosurgeons predominated. Inflation adjusted reimbursement decreased for endovascular temporary balloon occlusion (CPT61623, -13%; p=0.01), CNS transcatheter permanent occlusion or embolization (CPT61624, -13%; p=0.02), non-CNS transcatheter permanent occlusion or embolization (CPT61626, -12%; p<0.01), and intracranial stent placement (CPT61635, -12%; p=0.05)., Conclusions: The number of neuroendovascular procedures and specialists increased, with neurologists becoming more predominant. Reimbursement decreased. Coordination among neuroendovascular specialists in terms of training and practice location may maximize access to acute care., Competing Interests: Competing interests: YME receives a grant from the National Institutes of Health for a study in neurology: Expanding insights into FTD disease mechanisms (R35NS097273-01). JFM is chair of the NeuroNEXT Data Safety Monitoring Board and receives grants from the National Institutes of Health for several studies related to stroke: CREST-2 Clinical Coordinating Center (U01NS080168), CREST-2 Long-term Observational Extension (U01NS119169), and DISCOVERY Recruitment and Retention Core (U19NS115388). SS is a stockholder and board member of StrokeDx., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The aim of this study was to explore the effect of patient sex on short-term and long-term outcomes after endovascular treatment for aortoiliac occlusive disease (AIOD)., Methods: A multicenter retrospective analysis was performed on all patients who underwent iliac artery stenting for AIOD across the 3 participating sites from October 1, 2018 to September 21, 2021. Preoperative clinical, operative, and postoperative data were collected on a dedicated database. Demographics and outcomes were compared between male and female patients and the probability of freedom from amputation and freedom from target lesion reintervention were estimated with the Kaplan-Meier method., Results: Of 574 patients, 346 (60%) were male and 228 (40%) were female. Mean follow-up was 12 months. Female patients were significantly older (69.2 ± 10.2 years vs. 67.8 ± 8.9 years, P = 0.025) and more likely to have Trans-Atlantic Inter-Society Consensus II D disease (P = 0.003). The female cohort had significantly less coronary artery disease (40% vs. 50%, P = 0.013), coronary stenting (14% vs. 21%, P = 0.039), and coronary artery bypass grafting (13% vs. 25%, P < 0.001) than the male cohort, as well as less statin use (69% vs. 80%, P = 0.004). There were no differences in stent type, concomitant open surgery, intraoperative events, or hospital length of stay. For 30-day postoperative complications, female patients had a significantly higher rate of thrombotic acute limb ischemia (2% vs. 0%, P = 0.01), while male patients had a higher rate of amputation (4% vs. 9%, P = 0.048). On mid-term outcomes, there was no difference in freedom from amputation or target lesion reintervention between male and female patients (P = 0.14 and P = 0.32, respectively)., Conclusions: Female patients had lower incidence of cardiovascular risk factors but presented with higher Trans-Atlantic Inter-Society Consensus II classification and had higher rates of 30-day thrombotic acute limb ischemia. Male patients were more likely to require amputation within 30 days. Despite no differences in the mid-term, these short-term findings suggest that patient sex may be a relevant consideration in postoperative management and surveillance after endovascular treatment of AIOD., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Surgical simulation has come to the forefront to enhance the training of residents. The aim of our scoping review is to analyze the available simulation-based carotid revascularization techniques, including carotid endarterectomy (CEA) and carotid artery stenting (CAS) and suggest critical steps for evaluating competency in a standardized fashion., Methods: A scoping review of all reports on simulation-based carotid revascularization techniques including CEA and CAS was performed in PubMed/MEDLINE, Scopus, Embase, Cochrane, Science Citation Index Expanded, Emerging Sources Citation Index, and Epistemonikos databases. Data were collected according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. The English language literature was searched from January 1, 2000 to January 9, 2022. The outcomes evaluated included measures of assessment of operator performance., Results: Five CEA and 11 CAS manuscripts were included in this review. The methods of assessments employed by these studies to judge performance were comparable. The 5 CEA studies sought to validate and demonstrate improved performance with training or distinguish surgeons by their experience level, either through assessing operative performance or end-product results. The 11 CAS studies used 1 of 2 types of commercial simulators and focused on determining the efficacy of simulators as teaching tools. By examining the steps of the procedure associated with preventable perioperative complications, it provides a reasonable framework for determining which elements of the procedure should be emphasized most. Furthermore, using potential errors as a basis for assessment of competency could reliably distinguish operators based on level of experience., Conclusions: Competency-based simulation training is becoming more relevant as our surgical training paradigm shifts with the increased scrutiny within training programs of work-hour regulations and the need to develop a curriculum to assess our trainees' ability to perform specific operations competently during their stipulated training period. Our review has given us an insight into the current efforts in this space regarding 2 specific procedures that are key for all vascular surgeons to master. Although many competency-based modules are available, there is a lack of standardization in the grading/rating system of what surgeons consider vital steps of each procedure to assess these simulation-based modules. Therefore, the next steps of curriculum development should be based on standardization efforts for the different protocols available., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: To perform a systematic literature review to assess the usefulness of performing magnetic resonance angiography (MRA) with vessel wall imaging (VWI) sequences for the assessment of symptomatic carotid artery plaques and the identification of risky plaque features predisposing for stroke., Methods: We performed a systematic review of the literature pertaining to MRA with VWI techniques in patients with carotid artery disease, focusing on symptomatic patients' plaque features and morphology. Independent reviewers screened and analyzed data extracted from eligible studies, and a modified Newcastle-Ottawa Scale was used to appraise the quality of the design and content of the selected manuscripts to achieve an accurate interpretation., Results: This review included nineteen peer-reviewed manuscripts, all of them including MRA and VWI assessments of the symptomatic carotid artery plaque. We focused on patients' comorbidities and reviewed plaque features, including intraplaque hemorrhage, a lipid-rich necrotic core, a ruptured fibrous cap, and plaque ulceration., Conclusions: MRA with VWI is a useful tool in the evaluation of carotid artery plaques. This imaging technique allows clinicians to identify plaques at risk of causing a neurovascular event. The presence of intraplaque hemorrhage, plaque ulceration, a ruptured fibrous cap, and a lipid-rich necrotic core are associated with neurovascular symptoms. The timely identification of these features could have a positive impact on neurovascular event prevention., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Microaggressions are statements or actions taken in a discriminatory manner. Microaggressions can be subtle or explicit, intentional or unintentional, but regardless of the type of microaggressions, it is important to identify and address them, as they are linked to physician burnout and add to levels of depression, anxiety, and stress. In this study, we evaluated the prevalence, quality, and impacts of gender-based microaggressions on surgeons and surgical trainees using simulation-based education. Further, we plan to iteratively develop more simulation sessions based on the findings of this study., Methods: We used simulation-based education to develop and implement microaggression scenarios. Those scenarios were performed by standardized patients (trained actors) who demonstrated the different microaggression situations previously seen at the workplace and wards. Published tools to address gender-based microaggressions were outlined in preparation (prebrief) for a discussion of recorded simulations. A debrief of developing potential resolutions as learners and future allies and how similar microaggressions may have been perpetuated in our own careers followed each scenario. Additionally, an 11-item survey was developed based on validated surveys of sexist and Microaggressions Experience and Stress Scale and disseminated through email listservs and social media links. Data collection occurred from November to December 2022., Results: When surveyed after the workshop, 100% of participants (n = 6) said that they would recommend this session to follow colleagues, and 100% completely agreed the content of the simulation was relevant to their future practice. Further, 100% of participants agreed or completely agreed that their ability to perform these tasks (addressing microaggressions) has improved after this course. Most respondents to the disseminated survey (n = 147) were vascular surgeons (95/147; 64.6%) and identified as White (93/147; 63.3%), and as women (142/147; 96.6%). Most were identified as targets of gender-based microaggressions (128/147; 87.1%) and or silent witnesses to such microaggressions (87/147; 59.2%). However, there were reports of having a perpetrator of a microaggression (2/147; 1.4%), a nonsilent witness (3/147; 2.0%), or having no target, witness, or perpetrator (3/147; 2.0%). Of the quality of microaggressions, the most common impacts were when the targeted individual attempted to hide their emotions to not appear too emotional (described in the literature as "leaving gender at the door") (32/147; 21.8%), were told that women no longer experience discrimination (25/147; 17.0%), and were asked when one would have children (24/147; 16.3%). The most stressful types of microaggressions were ones in which male peers were the only ones receiving recognition for work (55/147; 37.4%), targets were told women no longer experience discrimination (49/147; 33.3%), and in which men spoke about women in degrading terms regarding their gender or on topics related to their gender (35/147; 23.8%). Qualitative responses to the survey included comments remarking on the relevancy and prevalence of gender-based microaggressions, reasons for silence, the personal and professional impacts (e.g., pay equity) of microaggressions and gender bias, and future areas of work to address bias in medicine., Conclusions: Given the prevalence of microaggressions seen in surgery, especially among vascular surgeons, future steps include discussion of how techniques can be developed and applied to other types of microaggressions (e.g., due to race/ethnicity, sexuality, disability, religion), implementation of future workshops that address intersectionality in scenarios and potentially virtual sessions to increase accessibility to these types of training options for learners at other institutions., (Copyright © 2023 Elsevier Inc. All rights reserved.)

This study investigated vascular surgeon workload and its association with specific procedural drivers over different procedure types. Thirteen attending vascular surgeons (two females) were emailed a survey over a 3-month period. Data from 253 surgical procedures (118 open, 85 endovascular, 18 hybrid, and 32 venous) revealed high physical and cognitive workload among vascular surgeons. Based on the statistically significant findings and similar non-significant trends in the data (significance level of 0.01), open and hybrid vascular procedures showed higher levels of physical and cognitive workload compared to venous cases, while endovascular procedures were relatively more moderate. Additionally, the workload subscales for five subcategories of open procedures (e.g., arteriovenous access) as well as three subcategories of endovascular procedures (e.g., aortic) were compared. The granularity of the intraoperative workload drivers across various vascular procedure types and adjunct equipment could be the key to create targeted ergonomic interventions to reduce workload during vascular surgeries., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Nutcracker syndrome (NCS) is an uncommon syndrome that presents with signs and symptoms caused by compression of the left renal vein (LRV), whereas 'nutcracker phenomenon' is solely used to refer to the anatomical configuration without clinical symptoms. Treatment for NCS may include nonoperative management, open surgical intervention, and in some instances endovascular stenting. We present a single-center retrospective case series of patients who presented with NCS managed with open surgical interventions., Methods: A single-center, retrospective review of patients managed from 2010-2021. We diagnosed NCS via a thorough clinical examination and additional cross-sectional imaging studies including magnetic resonance venography and/or computed tomography venography. For further confirmation of the diagnosis, duplex ultrasound was frequently combined with contrast venography., Results: Thirty eight patients were included in our study from 2010-2021. Twenty one (55.3%) patients presented with symptoms including flank pain, abdominal pain, hematuria, and fatigue. The remaining 17 (44.7%) patients had nutcracker phenomenon. Within the group of patients diagnosed with NCS, 11 patients underwent LRV transposition. Symptoms related to NCS improved in 10 patients. Hematuria in 1 patient did not improve., Conclusions: Transposition of the LRV is an effective treatment for NCS. Nonoperative management is an option for those patients experiencing less severe or nonspecific clinical symptoms., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

We offer an overview of lipid lowering, antiplatelet, antihypertensive, and glucose-lowering therapies for vascular surgeons and their respective medical teams. Further reviews should offer additional guidance on smoking cessation, exercise therapy, and nutritional optimization., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Previous studies suggest a coprevalence of intracranial aneurysms (IA) in patients with infrarenal abdominal aortic aneurysms (AAA). We reviewed our multicenter experience in the detection/treatment of IAs in patients with ascending thoracic aortic aneurysms (ATAA) relative to patients without ATAA., Methods: Surgical cases of ATAA repaired at 3 sites from January 1998 to December 2018 were retrospectively reviewed. Out of these patients, those with intracranial vascular imaging were selected for our study, and these individuals were concurrently randomly matched with a control group of patients who underwent intracranial vascular imaging without an ATAA in a 1:1 ratio by age, sex, smoking history, and year of intracranial vascular imaging. Conditional logistic regression was used to calculate odds ratios (OR)., Results: We reviewed 2176 ATAA repairs. 74% (n = 1,615) were men. Intracranial vascular imaging was available in 298 (13.7%) patients. Ninteen patients were found to have 22 IAs for a prevalence of 6.4%. Mean size of IA was 4.6 ± 3.3 mm; mean age at IA detection, 63.4 ± 12.1 years. IA was present on head imaging in 4.7% of male and 12.5% of female patients. Eleven (58%) patients were men. The OR of having IA in female versus male patients is 2.90, 95% confidence interval [CI] [1.08-7.50], P = 0.029. Time from IA diagnosis to ATAA repair was 1.7 ± 116.2 months. Two patients underwent treatment for IA, one ruptured and one unruptured. All were diagnosed before ATAA repair. Treatment included 1 clipping and 1 coiling with subsequent reintervention of the coiling using a flow diversion device. In the matched group of patients who had intracranial vascular imaging without ATAA, the rate of IA is 5.0%. IA was detected in 3.8% of males and 9.4% of female patients for an OR of 2.59, 95% CI [0.84-7.47], P = 0.083. Association within our study and matched groups, the OR of developing an IA with and without ATAA was not statistically significant 1.29, 95% CI [0.642.59], P = 0.48. There was also no evidence of sex differences in the association of ATAA with IA (interaction P = 0.88). The OR for the association of ATAA with IA was 1.33, 95% CI [0.46-3.84], P = 0.59 in females and 1.25, 95% CI [0.49-3.17], P = 0.64 in males., Conclusions: Our study found that IA was present in 6.4% of patients with ATAA who had intracranial vascular imaging available. The odds of IA were 1.29 times higher than a matched cohort of patients who had intracranial vascular imaging without ATAA but this failed to achieve statistical significance. We found that the odds of IA were more than 2 times higher in females than males for both those with ATAA (OR = 2.90) and those without ATAA (OR = 2.59); however, it only reached statistical significance in those with ATAA., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background and Aims: To investigate the prognostic value of blood neurofilament light chain protein (NfL) levels in the acute phase of coronavirus disease 2019 (COVID-19)., Methods: We conducted an individual participant data (IPD) meta-analysis after screening on MEDLINE and Scopus to May 23rd 2022. We included studies with hospitalized adult COVID-19 patients without major COVID-19-associated central nervous system (CNS) manifestations and with a measurement of blood NfL in the acute phase as well as data regarding at least one clinical outcome including intensive care unit (ICU) admission, need of mechanical ventilation (MV) and death. We derived the age-adjusted measures NfL Z scores and conducted mixed-effects modelling to test associations between NfL Z scores and other variables, encompassing clinical outcomes. Summary receiver operating characteristic curves (SROCs) were used to calculate the area under the curve (AUC) for blood NfL., Results: We identified 382 records, of which 7 studies were included with a total of 669 hospitalized COVID-19 cases (mean age 66.2 ± 15.0 years, 68.1% males). Median NfL Z score at admission was elevated compared to the age-corrected reference population (2.37, IQR: 1.13-3.06, referring to 99th percentile in healthy controls). NfL Z scores were significantly associated with disease duration and severity. Higher NfL Z scores were associated with a higher likelihood of ICU admission, need of MV, and death. SROCs revealed AUCs of 0.74, 0.80 and 0.71 for mortality, need of MV and ICU admission, respectively., Conclusions: Blood NfL levels were elevated in the acute phase of COVID-19 patients without major CNS manifestations and associated with clinical severity and poor outcome. The marker might ameliorate the performance of prognostic multivariable algorithms in COVID-19., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Background: Surgical residents prepare during their training for independent operating experience. However, there is a fine balance between supervised intraoperative teaching and the need to keep operations short since this is associated with improved patient safety. We aim to understand if the composition of the vascular surgical team-presence of anesthesia and surgical trainees as well as the number of circulating nurses-affects elective operative times at our institution. As a secondary aim, we analyzed how time of day affects overall operative time., Methods: We performed a retrospective review of all vascular surgery elective operations occurring between January 1, 2019, and October 15, 2021. Our reference operation between procedures was the construction of an arteriovenous fistula (AVF). Reference teams included circulating staff (fewer than two nurses), anesthesia (anesthesiologist with certified registered nurse anesthetist [CRNA]), and surgery (surgeon with nurse practitioner). The primary dependent variable was the time interval in minutes from wheels-in to wheels-out of surgery, which was divided into three subintervals: wheels-in to cut, cut to close, and close to wheels-out. Univariate analysis was performed to examine each surgical procedure's distribution of wheels-in to wheels-out time interval. Linear regression was performed to determine the effect of team composition and time of day on operative durations., Results: We included a total of 853 vascular operations. Regarding overall operative time, different procedures took various amounts of time compared with the reference operation (AVF creation). Amputations and arteriograms were shorter (-30 min, P = 0.03, and -12 min, P = 0.05, respectively). Other procedures were longer: endarterectomy (+48 min, P < 0.01), rib resection (+78 min, P < 0.01), endovascular aorta repair (+120 min, P < 0.01), lower extremity bypass (+170 min, P < 0.01), and open aortic repair (+410 min, P < 0.01). No significant difference was found in carotid artery stent placement. Overall, there was a significant reduction in the close to wheels-out interval for anesthesiologists with a trainee (mean: -2.4 min; 95%; CI: -4.7, -0.12; P = 0.04). AVF took significantly more time with a surgical resident: wheels-in to cut time (mean: +4.2 min; 95%; CI: 0.92, 7.4; P = 0.01) and cut to close time (mean: +13 min; 3.2, 23; P < 0.01). Arteriogram wheels-in to cut time took longer with a surgeon alone (mean: +5.6; 95%; CI: 0.29, 11; P = 0.04). There were no other statistically significant findings with change in composition of the surgical team or changes in start time., Conclusions: General surgery residents generally do not add time to vascular surgery cases but may do so in certain cases, perhaps when they are given more autonomy (i.e. AVF creation). Future studies should look at multiple centers, specific vascular procedures, and level of training to explore whether experience among residents (i.e., intern versus senior resident) and case complexity play a role in procedural length, as this may indirectly affect attending surgeon burnout and patient outcomes., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: The aim of the present study was to assess the current strategies of endovascular and laparoscopic extravascular stenting for symptomatic compression of the left renal vein (LRV), most frequently between the aorta and superior mesenteric artery (nutcracker syndrome [NCS])., Methods: We performed a systematic review of all studies of endovascular and laparoscopic extravascular LRV stenting for NCS using the PubMed/MEDLINE, Scopus, Embase, Cochrane, Science Citation Index Expanded, Emerging Sources Citation Index, and Epistemonikos databases. Data were collected in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analysis) guidelines. The English, Spanish, and German language literature was searched from January 1, 1946 to February 9, 2022. The outcomes assessed included symptom resolution, hematuria resolution, and reintervention at follow-up., Results: The search yielded 3498 reports. After removing the duplicates and those without the full text available, 1724 studies were screened. Of these, 11 studies were included in the present review. Of the 11 studies, 7 were on endovascular stenting and 4 on laparoscopic extravascular stenting; all 11 studies were retrospective, single-center case series. Of the 233 patients, 170 (80 women) had undergone endovascular stenting and 63 (9 women) had undergone extravascular stenting. The follow-up period varied from 1 to 60 months after endovascular stenting and 3 to 55 months after extravascular stenting. The symptoms had resolved in 76% (range, 50%-100%) after endovascular stenting and 83% (range, 71%-100%) after extravascular stenting. Hematuria had resolved in 86% (range, 60%-100%) after endovascular stenting and 89% (range, 77%-100%) after extravascular stenting. Of 185 patients, 9 had required reintervention after endovascular stenting and none after extravascular stenting., Conclusions: Endovascular and laparoscopic extravascular stenting are less invasive and, thus, more attractive treatment options that have been more recently developed for the management of NCS. The results from the present study have shown that symptom and hematuria resolution must be provided before they can be considered preferred management options for patients affected by NCS. Given the limited number of patients involved, no definitive conclusion could be drawn regarding the superiority of one technique compared with the other., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of the present study was to explore the racial disparities in the incidence of deep vein thrombosis (DVT), pulmonary embolism (PE), and acute kidney injury (AKI) in hospitalized patients with coronavirus disease 2019 (COVID-19)., Methods: A retrospective analysis was performed of prospectively collected data of consecutive COVID-19 patients hospitalized from March 11, 2020 to May 27, 2021. The primary outcome measures were the incidence of DVT/PE and mortality. The secondary outcome measures included differences in the length of hospitalization, need for intensive care unit care, readmission, and AKI. Multivariable regression models were used to assess for independent predictors of the primary and secondary outcome measures., Results: The present study included 876 hospitalized patients with COVID-19. The mean age was 64.4 ± 16.2 years, and 355 were women (40.5%). Of the 876 patients, 694 (79.2%) had identified as White, 111 (12.7%) as Black/African American, 48 (5.5%) as Asian, and 23 (2.6%) as other. The overall incidence of DVT/PE was 8.7%. The DVT/PE incidence rates differed across the race groups and was highest for Black/African American patients (n = 18; 16.2%), followed by Asian patients (n = 5; 10.4%), White patients (n = 52; 7.5%), and other (n = 1; 4.4%; P = .03). All but one of the hospitalization outcomes examined demonstrated no differences according to race, including the hospitalization stay (P = .33), need for intensive care unit care (P = .20), readmission rates (P = .52), and hospital all-cause mortality (P = .29). The AKI incidence differed among races, affecting a higher proportion of Black/African American patients (P=.003). On multivariable regression analysis, Black/African American race (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.0-4.0; P = .04) and higher D-dimer levels (OR, 1.1; 95% CI, 1.1-1.2; P < .0001) were predictors of DVT/PE. In addition, Black/African American race (OR, 2.3; 95% CI, 1.4-3.7; P = .001), lower hemoglobin levels (OR, 0.84; 95% CI, 0.8-0.9; P ≤ .0001), male sex (OR, 1.7; 95% CI, 1.2-2.4; P = .005), hypertension (OR, 2.1; 95% CI, 1.4-3.1; P = .0005), and older age (OR, 1.02; 95% CI, 1.006-1.03; P = .003) were predictors of AKI., Conclusions: In our single-center case series, we found a higher incidence of DVT/PE and AKI among Black/African American patients with COVID-19. Black/African American race and D-dimer levels were independent predictors of DVT/PE, and Black/African American race, hemoglobin, and D-dimer levels were independent predictors of AKI., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The formation of postaortic coarctation aneurysms (pCoAA) is well-described in the literature and carries a significant risk of rupture and death. Treatment strategies include open surgical, hybrid, and endovascular repair, depending on the clinical presentation, risk assessment, and anatomy. The aim of this study was to report the early and midterm results of open surgical and endovascular repair of pCoAA., Methods: This is an international multicenter retrospective study including patients who underwent open surgical or endovascular repair for pCoAA between 2000 and 2021 at 14 highly specialized academic cardiovascular centers. The preoperative, intraoperative, and postoperative data were recorded and analyzed., Results: A total of 74 patients (46 male; median age, 44 years; interquartile range [IQR], 35-53 years) underwent pCoAA repair. All patients had previously undergone surgical repair of aortic coarctation at a median age of 11 years for the index procedure (IQR, 7-17 years). The most common first surgical correction was synthetic patch aortoplasty in 48 patients, followed by graft interposition in 11. The median pCoAA diameter was 54 mm (IQR, 44-63 mm). The median time from the aortic coarctation repair to the pCoAA diagnosis was 33 years (IQR, 25-40 years). A total of 33 patients had symptoms at presentation, including thoracic or back pain in 8 patients. Open surgical repair was performed in 28 patients, including four frozen elephant trunk procedures and one Bentall. The remaining 46 patients underwent endovascular repair of the pCoAA. Two in-hospital deaths were observed (one frozen elephant trunk and one endovascular). After a median follow-up of 50 months (IQR, 14-127 months), there were a total of seven reinterventions., Conclusions: This international multicenter study demonstrates that patients with pCoAA can be safely treated with either open surgical or endovascular interventions. Because the median time between the coarctation repair and the aneurysm formation was more than 30 years, life-long surveillance of these patients is warranted., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Blood neurofilament light chain (NFL) is proposed to serve as an estimate of disease severity in hospitalized patients with coronavirus disease 2019 (COVID-19). We show that NFL concentrations in plasma collected from 880 patients with COVID-19 within 5 days of hospital admission were elevated compared to controls. Higher plasma NFL associated with worse clinical outcomes including the need for mechanical ventilation, intensive care, prolonged hospitalization, and greater functional disability at discharge. No difference in the studied clinical outcomes between black/African American and white patients was found. Finally, vaccination associated with less disability at time of hospital discharge. In aggregate, our findings support the utility of measuring NFL shortly after hospital admission to estimate disease severity and show that race does not influence clinical outcomes caused by COVID-19 assuming equivalent access to care, and that vaccination may lessen the degree of COVID-19-caused disability., Competing Interests: B.O. has consulted for Biogen, MediciNova, Mitsubishi, Amylyx, and Tsumura. K.A.N. has performed consulting for Alector, AI Therapeutics, Biogen, MT Pharma, Avanir Pharmaceuticals, and Biohaven. J.B.H. is the CLIA director for the Lung Bioengineering facility at Mayo Clinic Florida campus, a non-Mayo corporation. Z.K.W. also serves as PI or Co-PI on Biohaven Pharmaceuticals, Inc. (BHV4157-206 and BHV3241-301), Neuraly, Inc. (NLY01-PD-1), and Vigil Neuroscience, Inc. (VGL101-01.001 and VGL101-01.002) grants; as well as a Co-PI of the Mayo Clinic APDA Center for Advanced Research and as an external advisory board member for the Vigil Neuroscience, Inc. L.P. is a consultant for Expansion Therapeutics. The other authors declare that they have no competing interests., (© 2022 The Author(s).)

Background: To evaluate and describe the radiographic imaging findings in a series of patients who underwent reintervention after radiation induced carotid artery stenting (RICAS)., Methods: A retrospective review of patients with prior RICAS and subsequent reintervention., Results: We describe 10 patients including 8 male and 2 female patients with 12 reinterventions due to prior diagnosed radiation-induced carotid artery stenosis and subsequent stenting during the period 2000-2019. The rate of reintervention was found to be 10%. The pattern of stenosis is unique to this patient population including specifically long-segment stenosis, proximal and distal to the stent location, which tends not to occur in the atherosclerotic patient population., Conclusions: Careful surveillance after RICAS is necessary to assess for the risk and the unusual pattern of stenosis to offer reintervention in this high-risk patient population., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to evaluate the association between aortic endograft diameter and long-term outcomes following endovascular aneurysm repair (EVAR) performed in accordance with manufacturer instructions for use (IFU)., Methods: A retrospective review of consecutive patients undergoing on-IFU EVAR (2000-2018) was performed to facilitate a comparative analysis of long-term patient outcomes based on device diameter. "Large diameter" devices were defined as >34 mm. The primary outcome of interest was freedom from sac expansion throughout long-term follow-up. Analyses included standard bivariate analyses, Kaplan-Meier with log-rank comparison, and Cox proportional hazards multivariate analysis., Results: A total of 1,099 underwent on-IFU EVAR from 2000-2018. Follow-up data were available for 980 patients. Of these, 75 patients (7.6%) were treated with >34-mm devices. There were no significant differences in demographics or comorbidities between the 2 groups, although preoperative abdominal aortic aneurysm size was greater in patients undergoing implantation of >34-mm devices (58 ± 8.5 mm vs. 56 ± 17.4 mm; P = 0.05). Median follow-up was 10.3 years. Patients with grafts >34 mm had reduced freedom from sac expansion throughout follow-up (P = 0.038). There were no significant differences in reintervention rates, open conversion, or rupture when stratified by graft diameter. A multivariate Cox regression identified patient age, preoperative abdominal aortic aneurysm size, need for reintervention, and use of >34-mm endografts as independent factors associated with expansion., Conclusions: The use of large diameter aortic endografts is associated with higher rates of sac expansion during long-term follow-up. Although there is undoubtedly a role for large diameter graft use in selected patients, it is important to recognize that these devices were typically approved post hoc without the same regulatory scrutiny of smaller endografts. These findings underscore the importance of ongoing surveillance for patients treated with >34-mm grafts, irrespective of compliance with manufacturer IFU., (Copyright © 2022 Elsevier Inc. All rights reserved.)