Author Disclosures: T. W. Cheng: Nothing to disclose; A. Farber: Nothing to disclose .... Author Disclosures: A. W. Beck: Nothing to disclose; M. A. Farber: Cook:.
Journal of Vascular Surgery
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Volume 67, Number 6 5.3 6 6.4 for assistant, 12.2 6 12.7 for associate, and 38.7 6 35.3 for professor (P < .001). The mean h-index was 5.9 6 5.4 for assistant, 12 6 7.7 for associate, and 24.9 6 12.6 for professor (P < .001). In multivariable analysis, independent predictors for appointment as associate professor were vascular surgery board certification (odds ratio [OR], 6.08; 95% confidence interval [CI], 1.15-32.2; P ¼ .034), appointment at a public medical school (OR, 1.99; 95% CI, 1.18-3.37; P ¼ .01), years since medical school graduation (OR, 1.13; 95% CI, 1.09-1.18; P < .001), and number of publications (per publication; OR, 1.05; 95% CI, 1.03-1.06; P < .001). Independent predictors for appointment as professor were central region (OR, 2.73; 95% CI, 1.09-6.84; P ¼ .033), years since graduation (OR, 1.18; 95% CI, 1.12-1.24; P < .001), and number of first or last author publications (OR, 1.05; 95% CI, 1.02-1.09; P ¼ .003). Division chief appointment was independently predicted by h-index (OR, 1.04; 95% CI, 1.01-1.08; P ¼ .012). Sex and a PhD degree were not predictive for academic appointment. Conclusions: Total number of publications was independently associated with promotion from assistant to associate professor, with number of first or last author publications particularly important for professor. The h-index was not an independent predictor for promotion in academic appointment but was predictive for appointment as division chief. This study provides relevant data for promotional guidance in academic vascular surgery. Author Disclosures: T. W. Cheng: Nothing to disclose; A. Farber: Nothing to disclose; D. Flynn: Nothing to disclose; D. W. Jones: Nothing to disclose; J. Kalish: Nothing to disclose; R. R. Rajani: Nothing to disclose; D. Rybin: Nothing to disclose; J. Siracuse: W. L. Gore: Fee.
VESS18. Outcomes of Endovascular Repair of Postdissection and Degenerative Thoracoabdominal Aortic Aneurysms Using Fenestrated-Branched Stent Grafts Emanuel R. Tenorio,1 Gustavo S. Oderich,1 Mark A. Farber,2 Darren B. Schneider,3 Carlos H. Timaran,4 Andres Schanzer,5 Adam W. Beck,6 Matthew P. Sweet7. 1Mayo Clinic, Rochester, Minn; 2University of North Carolina, Chapel Hill, NC; 3Weill Cornell Medical College, New York, NY; 4University of Texas Southwestern Medical Center, Dallas, Tex; 5University of Massachusetts Medical School, Worcester, Mass; 6 University of Alabama at Birmingham, Birmingham, Ala; 7University of Washington, Seattle, Wash Objective: The objective of this study was to analyze outcomes of fenestrated-branched endovascular aneurysm repair for treatment of postdissection and degenerative thoracoabdominal aortic aneurysms (TAAAs). Methods: We reviewed the clinical data of 221 patients with extent I to III TAAAs enrolled in seven prospective physician-sponsored investigational device exemption studies from 2014 to 2017. All patients had manufactured off-the-shelf and patient-specific fenestrated-branched stent grafts (Fig) used to target 790 renal-mesenteric arteries with a mean of 3.9 vessels per patient. End points were mortality, major adverse events (any cause mortality, stroke, paraplegia, acute kidney injury, myocardial infarction, respiratory failure, bowel ischemia, and estimated blood loss >1 L), technical success, target artery patency, target artery instability (occlusion or stenosis, endoleak, rupture, or death), and secondary interventions. Results: There were 46 patients (21%) treated for postdissection TAAAs and 175 patients (79%) who had degenerative TAAAs. Postdissection patients were significantly (P < .05) younger (67 6 10 vs 74 6 8 years), were more often male (76% vs 52%), and had more staged aortic repairs (85% vs 63%) and larger renal (6.2 6 1.2 mm vs 5.4 6 0.9 mm) and mesenteric (8.8 6 1.6 mm vs 7.6 6 1.2 mm) target artery diameters. There was no difference (P > .05) in aneurysm diameter (66 6 13 mm vs 67 6 11 mm), extent I or II TAAA classification (61% vs 50%), and length of supraceliac aortic coverage (22 6 9 cm vs 20 6 10 cm) between postdissection and degenerative TAAA patients, respectively. Patient-specific stent grafts (91% vs 81%), preloaded guidewire systems (81% vs 48%), and fenestrations as opposed to branches (61% vs 35%) were used more frequently to treat postdissection TAAAs (P < .05). Technical success was 100% for postdissection and 96% for degenerative TAAAs (P ¼ .24). At 30 days, there was no difference in mortality (2% each), major adverse events (26% postdissection, 22% degenerative), spinal cord injury (2% postdissection, 10% degenerative), paraplegia (0% postdissection, 6%
Fig. Staged endovascular repair of chronic postdissection thoracoabdominal aortic aneurysm (TAAA; A-C), followed by fenestratedbranched endovascular repair using re-entrance catheter (D-H).
Table. Outcomes for postdissection vs degenerative thoracoabdominal aortic aneurysm (TAAA)
P value
Postdissection TAAA (n ¼ 46)
Degenerative TAAA (n ¼ 175)
Technical success per vessel
166/166 (100)
624/631 (99)
.2
Technical success per patient
46/46 (100)
168/175 (96)
.2
30-Day outcomes
30-Day mortality
1 (2)
4 (2)
.96
12 (26)
39 (22)
.58
81.1 6 8.4
73.3 6 4.6
.23
Freedom from aortarelated mortality
97.8 6 2.2
97.4 6 1.3
.91
Primary branch patency
94.7 6 2.4
96.8 6 0.9
.69
Secondary branch patency
99.3 6 0.7
98.9 6 0.6
.66
Freedom from branch instability
88.6 6 3.1
93.3 6 1.4
.20
Freedom from secondary interventions1
67.8 6 8.2
77.7 6 3.9
.14
30-Day MAEs 2-Year Kaplan-Meier estimates Freedom from any cause mortality
MAEs, Major adverse events. Categorical variables are presented as n/N (%). Continuous variables are presented as mean 6 standard deviation. 1 At 1 year.
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Journal of Vascular Surgery
Abstracts
June 2018 degenerative), and dialysis (0% postdissection, 3% degenerative). Mean follow-up was 14 6 11 months. At 2 years, there was no difference (P > .05) in patient survival (81% 6 8% vs 73% 6 0.5%), freedom from aortic death (98% 6 2% vs 97% 6 1%), primary (95% 6 2% vs 97% 6 1%) and secondary target artery patency (99% 6 1% vs 99% 6 0.6%), target artery instability (89% 6 3% vs 93% 6 1%), and freedom from secondary interventions (68% 6 8% vs 78% 6 4% at 1 year) for postdissection and degenerative TAAAs, respectively (Table). Conclusions: Despite some differences in demographics, anatomic factors, and stent graft design, fenestrated-branched endovascular aneurysm repair was safe and effective with nearly identical outcomes in patients with postdissection and degenerative TAAAs. Larger clinical experience and longer follow-up are needed to better evaluate differences in mortality, spinal cord injury, target vessel instability, and secondary interventions. Author Disclosures: A. W. Beck: Nothing to disclose; M. A. Farber: Cook: Consulting fees (eg, advisory boards), Contracted Research, Endologix: Consulting fees (eg, advisory boards), Contracted Research, Medtronic: Consulting fees (eg, advisory boards), Contracted Research, W. L. Gore: Consulting fees (eg, advisory boards), Contracted Research; G. S. Oderich: Cook Medical: Contracted Research, GE Healthcare: Contracted Research, W. L. Gore: Contracted Research; A. Schanzer: Cook Medical: Other Financial or Material Support; D. B. Schneider: Abbott Vascular: Consulting fees (eg, advisory boards), Cook: Contracted Research, Endologix: Contracted Research, Medtronic: Consulting fees (eg, advisory boards), W. L. Gore: Consulting fees (eg, advisory boards), Contracted Research; M. P. Sweet: Nothing to disclose; E. R. Tenorio: Nothing to disclose; C. H. Timaran: Cook Medical, Inc: Consulting fees (eg, advisory boards), Contracted Research, Other Financial or Material Support.
VESS19. Addition of Proximal Intervention to Carotid Endarterectomy Increases Risk of Stroke and Death in the Vascular Quality Initiative Linda J. Wang,1 Emel A. Ergul,1 Mark F. Conrad,1 Mahmoud B. Malas,2 Vikram S. Kashyap,3 Philip P. Goodney,4 Virendra I. Patel,5 W. Darrin Clouse1. 1Massachusetts General Hospital, Boston, Mass; 2 Johns Hopkins Hospital, Baltimore, Md; 3University Hospitals Case Medical Center, Cleveland, Ohio; 4Dartmouth-Hitchcock Medical Center, Lebanon, NH; 5Columbia University Medical Center, New York, NY Objective: Adding ipsilateral, retrograde endovascular intervention (IPE) to carotid endarterectomy (CEA) for treatment of tandem bifurcation and supra-aortic trunk disease is controversial. Some suggest this combined strategy (CEA + IPE) confers no risk over isolated CEA. Others disagree, reserving CEA + IPE for symptomatic patients. Using the Vascular Quality Initiative (VQI), this study assessed the effect of adding IPE to CEA on stroke and death risk. We further weighed CEA + IPE outcomes in the context of symptomatic status and Society for Vascular Surgery guidelines. Methods: All CEAs in the VQI database from March 2003 to March 2017 were reviewed. Urgent and redo CEAs were excluded. CEA + IPE procedures were identified. To isolate effect of IPE, patients undergoing other concurrent procedures were removed, providing an isolated CEA cohort. Primary end points were perioperative (30-day) stroke and death. Univariate and logistic regression analyses were performed. Results: After exclusion and identification of CEA + IPE, 66,519 procedures were available for analysis. Of these, 66,115 represented isolated CEA and 404 CEA + IPE. Most patients (60%) were male, 93% were white, and 41% were symptomatic. Average age was 70 6 9 years. Those undergoing CEA + IPE were more likely to be female (50% vs 40%; P < .0005), to be smokers (87% vs 76%; P < .0005), and to have coronary artery disease (32% vs 27%; P ¼ .04), congestive heart failure (14% vs 10%; P ¼ .01), and chronic obstructive pulmonary disease (30% vs 22%; P < .0005). Isolated CEA patients were more likely to have severe ipsilateral stenosis (86% vs 80%; P ¼ .002) and to undergo intraoperative shunting (53% vs 49%; P ¼ .05). There was no difference in 30-day mortality between cohorts (1% vs 1%; p ¼ .23). However, CEA + IPE had higher rates of perioperative stroke (3.0% vs 1.4%; p ¼ .01) and combined 30-day stroke and death (3.5% vs 1.8%; P ¼ .02). When stratified by symptomatic status, there were no differences in primary end points between cohorts in asymptomatic
patients. In symptomatic patients, CEA + IPE carried significantly higher stroke (5% vs 2%; P ¼ .002) and stroke and death risk (6% vs 2%; P ¼ .001). After adjusting for age and comorbidities, independent predictors of stroke and death were diabetes (odds ratio [OR], 1.2; P ¼ .001), symptomatic status (OR, 1.7; P < .0005), and CEA + IPE (OR, 1.9; P ¼ .02). Conclusions: Addition of IPE to CEA confers increased stroke and death risk over isolated CEA. Risk is largely in symptomatic patients. Although CEA + IPE increases risk compared with isolated CEA, overall risk remains low. Based on this VQI analysis, CEA + IPE outcomes for asymptomatic patients fall within Society for Vascular Surgery guidelines for isolated CEA. Those for symptomatic patients do not, and consideration should be given to other surgical bypass, cerebral protection, and staged strategies. Author Disclosures: W. Clouse: Nothing to disclose; M. F. Conrad: Nothing to disclose; E. A. Ergul: Nothing to disclose; P. P. Goodney: Nothing to disclose; V. S. Kashyap: Nothing to disclose; M. B. Malas: Nothing to disclose; V. I. Patel: Nothing to disclose; L. J. Wang: Nothing to disclose.
VESS20. Response of the Popliteal Artery to Treadmill Exercise and Stress Positioning in Patients With and Without Exertional Lower Extremity Symptoms David S. Kauvar,1 Colin D. Brown2. 1San Antonio Military Medical Center, San Antonio, Tex; 2Dwight D. Eisenhower Army Medical Center, Augusta, Ga Objective: Exertional muscular compression of the popliteal artery (PA) in the proximal calf can be associated with lower extremity (LE) pain and neurologic symptoms. Exertional ankle-brachial index (EABI) and dynamic PA imaging are routinely used to identify this syndrome of functional popliteal entrapment, but neither has been rigorously studied. Our objective was to characterize the response of the PA to LE exertion and extrinsic compression in symptomatic and asymptomatic limbs. Methods: Limbs characterized as symptomatic (n ¼ 29) or asymptomatic (n ¼ 61) had duplex ultrasound PA diameter and peak systolic velocity (PSV) measurements in neutral and maximal ankle plantar flexion positions. EABIs were obtained at rest and 1 minute and 5 minutes after walking (5 minutes, 3 mph,10-degree incline) and running (5 minutes, 6 mph, 0 degrees). Significance was set at P ¼ .05. Data are expressed as mean 6 standard error of the mean. Results: Plantar flexion resulted in PA occlusion and changes in diameter and PSV in symptomatic (three occluded, 2.4 6 0.34 mm, +49 cm/ s) and asymptomatic (six occluded, 1.6 6 0.21 mm, +65 cm/s) limbs. Difference in percentage change was significant between groups only for diameter (Fig 1). EABIs were similar at rest, decreased with running and walking at 1 minute, and were not fully recovered by 5 minutes. EABI decrease was greater after running and significantly more pronounced in symptomatic (16% at 1 minute) than in asymptomatic (1.2%) limbs (Fig 2).
Fig 1. Percentage change in diameter and peak systolic velocity (PSV). Asx, Asymptomatic; Sx, symptomatic.
