98.18 Risk Factors for Pulmonary Artery Embolization (PE) following Deep Venous Thrombosis (DVT)

Posted on January 31, 2019

N. J. Gargiulo1, L. Flores1, A. J. Tortolani1, P. Haser1, G. AlAwawa1, M. Amman1, M. Leiva1, M. Khalil1, C. LaPunzina1, F. J. Veith1  1The Brookdale University Hospital & Medical Center,Vascular,New York, NEW YORK, USA

Introduction:   The prevention of deep venous thrombosis (DVT) and pulmonary artery embolization (PE) continues to remain a vexing clinical challenge not only for inpatients but also in outpatients.  Numerous recommendations have been advocated for DVT/PE prophylaxis and yet there still remains a national reported incidence of 0.5% to 1.9%.  Several risk factor scales have been employed to predict the development of DVT.  It remains unclear, however, which DVTs progress to pulmonary artery embolization (PE).  The purpose of this study was to elucidate which risk factors, if any, may result in venous thrombotic embolization to the pulmonary arteries (PE).

Methods:   A prospective hospital-wide quality study was initiated over an 8 month period evaluating all inpatients and outpatients presenting with acute DVT.   All DVTs were diagnosed by duplex ultrasound performed by certified vascular technologists.  The real time images were interpreted by 2 certified vascular surgeons.  An acute DVT was diagnosed by thrombus echogenicity, change in vein diameter, diminished compressibility and lack of respiratory phasicity.  All PEs were diagnosed by pulmonary artery computed tomographic arteriography (PACTA).

Results:  A total of 234 patients were identified with acute DVT (190 (81%) patients with DVT alone and 44 (19%)  patients with DVT and PE).  The two cohorts were similar with regards to age, gender, site of venous thrombosis, hypercoagulable profile, oncologic manifestations, neurosurgical and orthopedic injuries, and other associated traumatic (i.e. abdominal, chest, vascular) injuries.  Those patients with DVT and concomitant PE had a statistically higher incidence of catheter directed thrombolysis and inferior vena cava filter placement (p<0.05).  There were no identifiable risk factors in the DVT/PE cohort that could have predicted the observed pulmonary artery embolization (PE). 

Conclusion:  In this prospective study, there are no identifiable risk factors for patients with DVT and concomitant PE to explain the observed pulmonary artery embolization (PE).  This may support the concept that DVT and PE are in fact intrinsic venous thromboses unrelated to embolic physiology.    

 

89.20 Scrotal Hematoma with Pseudoaneurysm after Trans-Femoral Catheterization

Posted on January 31, 2019

S. Hung Fong1, S. Jaafar1, S. Misra1,2, V. Narasimha1  1Brandon Regional Hospital,GME – Surgery,Brandon, FL, USA 2HCA,West Florida,Tampa, FL, USA

Introduction:  Trans-femoral catheterization is a relative safe, minimally invasive procedure to assess coronary arteries and limb ischemia and subsequently revascularization with the placement of a stent or balloon angioplasty. However, complications can still manifest as bleeding, infection, hematoma, pseudoaneurysm, arteriovenous (AV) fistula formation and femoral artery thrombosis. In spite of appropriate use of vascular closing devices (VCD) and its lower rate of vascular complications as compared to manual compression, there have also been reported rare cases of scrotal hematoma following post trans-femoral catheterization for coronary intervention. We report a similar case of scrotal and right groin hematoma post trans-femoral vascular access, but for evaluation of limb ischemia.

Methods: A case report was described of a 72-year-old male who underwent transfemoral catheterization for evaluation of limb ischemia complicated by groin and scrotal hematoma that was successfully treated conservatively. Four different reported  cases were found on Pubmed, Google scholar and Cohchrane on scrotal hematoma associated with transfemoral access approach. Several characteristic were compared from each reported cases including sign and symptoms of hemorrhagic shock, history of use of anticoagulation, use of vascular closing device, whether mechanical compression was done, the injured vessel involved, the level of drop in hemoglobin and the mode of management. Our case report also included all of these characteristic for comparison with the other four reported cases

Results: Three out of four cases present with hemorrhagic shock, and reported use of VCD; two cases reported use of anticoagulation; the most common vessel injured is the common femoral artery; an average of 2 g/dL of hemoglobin lead to symptoms of hemorrhagic shock; three cases required groin exploration and one case managed conservatively.

Conclusion: Scrotal hematoma can present with or without signs of hemorrhagic shock. Symptoms most commonly present are groin and scrotal pain associated with swelling and ecchymosis. Scrotal hematoma is a rare complication, but the increasing popularity of transfemoral access approach lead to increase risk of urologic complications, warranting a urologic consultation and groin/genital exploration. Identifying those may be at high risk for this complication may prevent significant morbidity and mortality in these patients.

89.17 An Easily Reproducible 3D Printed AAA Model Using Open Source Digital Tools

Posted on January 31, 2019

J. Coles-Black1, J. Chuen1  1Austin Health,Department Of Surgery,Heidelberg, VICTORIA, Australia

Introduction:
There has been strong interest in the application of 3D printing to Vascular Surgery. However, consistently major barriers to uptake include the lack of technical expertise amongst surgeons, and the perceived cost of 3D printing technologies. We present a low-cost, low-complexity, easily reproducible CT-to-3D-printed-model workflow developed using open source software packages and inexpensive desktop 3D-printers.

Methods:
Using 3D Slicer (version 4.5; Harvard, US, 2015), abdominal CT aortogram DICOM datasets were automatically segmented using the "Threshold" function. The "Dilate" and “Subtract Scalar Volume” functions were used to generate a 3D hollow vessel. The mural thrombus was isolated using the "Volume Clip" extension. This was subtracted from the luminal contents in order to create a non-intersecting thrombus model. The model was printed on a Filament Fused Deposition Modelling 3D Printer (Makerbot Replicator 2X; Stratasys, Minnesota, USA). The subsequent 3D printed model was shown to experienced vascular surgeons, who rated its utility for the preoperative planning of complex cases.

Results:
The model was well received, with immediate requests for more models. Manual inspection of the physical model was felt to be a valuable addition to standard CT angiogram reconstructions, especially in tortuous or complex aortic aneurysms. Hollow flexible models were deemed particularly useful for rehearsal of endograft insertion and positioning via the iliac arteries, and in predicting the trajectory of guidewires and devices.

Conclusion:
There are clear applications for 3D printing in the field of Vascular Surgery, with positive feedback from the assessed cohort of experienced surgeons that the AAA models would be useful in challenging cases.

89.14 The feasibility of hepatectomy with vascular reconstruction to treat the liver tumor

Posted on January 31, 2019

A. Li1, A. Li1  1Eastern Hepatobiliary Surgery Hospital,Division Of The 2nd Special Treatment,Shanghai, SHANGHAI, China

Introduction:

Radical surgery remains the main treatment for the patients with liver cancer,But resectability rate is low when clinically diagnosed, portal vein,hepatic vein or inferior caval vein invaded by tumors are a few of the  main reasons.How to increase resectability ofliver cancer still is very challenging to the clinician. This study was clone to explore the feasibility of the new surgical approach for the treatment of liver cancer with portal vein,hepatic vein or inferior caval vein invasion. 

 

Methods:

25 patients received hepatectomy with vascular reconstruction between February 2011 and June 2018.  15 patients with ICC underwent hepatectectomy combined with portal vein resection and vascular reconstruction and 5 patients with ICC underwent hepatectomy combined with inferior caval vein resection and vascular reconstruction. 4 patients with HCC underwent hepatectomy combined with inferior caval vein resection and vascular reconstruction, 1 patient with HCC underwent hepatectomy combined with hepatic vein resection and vascular reconstruction.

Results:

There was no surgery related death. After surgery,3 patients died 10 months later, 20 patient died 24 months later, two patients survived for over 3 years and one patient over 4 years.

Conclusion:

Hepatectomy with vascular reconstruction for patients with carcinoma of the liver invading portal vein,hepatic vein or inferior caval vein has been proved to be a safe treatment, it could improve the resectability of the tumor and prolong survival.

 

89.13 The Current Landscape of 3D Printing in Endovascular Intervention

Posted on January 31, 2019

J. Coles-Black1, J. Chuen1  1Austin Health,Department Of Surgery,Heidelberg, VICTORIA, Australia

Introduction:
3D printing has started to establish itself as an adjunct to endovascular procedures, where the ability to visualise complex anatomy with physical 3D models provides better anatomical clarity than can be achieved with 3D reconstructions or 2D imaging modalities.

Methods:
We performed a literature search using Ovid MEDLINE, Ovid EMBASE and PubMed. The search terms used were “Printing, Three-Dimensional” AND “Vascular Surgery” AND “Endovascular”. This resulted in 18 articles, which were independently read in full to identify relevant studies. The findings from these studies were then compared against our own centre’s experiences with the technology.

Results:

Our literature search identified 10 publications reporting on the use of 3D printing in endovascular procedures, of which 3 (30%) related to the planning of fenestrated grafts. In 6 (60%) of the articles, the 3D printed models were used for simulation. The vast majority (80%) of articles utilised the 3D printed models for interventional planning. In addition, in 100% of cases, the 3D printed models developed for the studies did not degrade after simulation or manual interrogation. Despite this, only 3 (30%) of articles involved the use of 3D printed models for trainee education.  Therefore, we highlight the largely untapped potential for these models to be reused for trainee education, which was not explored in the majority of articles.

The studies’ conclusions correlate with our own experiences from our 3D printing lab, where expert vascular surgeons have deemed 3D printed models valuable in the planning of complex cases, such as in cases with short or very angulated

Conclusion:

Vascular Surgery units worldwide, including our own, are starting to explore the applications of 3D printing in endovascular surgery. We attest to the enormous potential for growth in this field, and the ease of adoption of this new technology.

 

88.19 The Association Between Abdominal Aortic Aneurysm Expansion Rates and Inflammation

Posted on January 31, 2019

E. S. Lee1, K. C. Chun2, Z. T. Irwin2, A. T. Nguyen2, K. J. Dolan2, R. E. Noll1, P. A. Ghosh2  1Sacramento Veterans Affairs Medical Center,Surgery,Mather, CA, USA 2Sacramento Veterans Affairs Medical Center,Research,Mather, CA, USA

Introduction: Predicting abdominal aortic aneurysm (AAA) expansion rates upon first clinical presentation is challenging to clinicians. AAA is an inflammatory disease and monocyte/ macrophage infiltration is important for AAA development. However, a link between inflammation and AAA expansion has not been well defined. We hypothesize that expanding AAA will have increased inflammation versus stable AAA.  The purpose of this study is to explore the relationship of inflammation and AAA expansion rates.

Methods: Patients screened for AAA with 1-yr minimum follow up were recruited for this study. Subjects received a one-time study abdominal ultrasound and 30mL blood draw after ultrasound. The expansion rate (cm/yr) was calculated from the AAA screening results and the study ultrasound. Patients were then divided into stable (<0.1 cm/yr) or expanding (≥0.1 cm/yr) AAA groups. Inflammation status was determined by monocyte activity via activated RhoA protein levels from collected patient blood using Western-blot assay. RhoA was then compared to current cardiovascular risk factors such as age, race, blood pressure, total cholesterol, body mass index, hypertension, diabetes, current smoking status, statin use, coronary artery disease, peripheral vascular disease, chronic obstructive pulmonary disease, stroke, and estimated glomerular filtration rate for analysis between stable and expanding groups. A univariate analysis of risk factors and backwards selection logistic regression of significant univariate variables were then used to determine statistical significance.

Results: A total of 83 patients (mean±stdev: 73.4 ± 7.2 years old) were recruited for the study. There were 33 patients with stable AAAs and 50 patients with expanding AAAs. Average maximum aortic diameter was smaller in the stable AAA group versus the expanding AAA group (3.3 ± 0.8 cm vs 4.9 ± 0.9 cm, p<.01). Only increased RhoA (p=.01; OR=2.75, 1.26-5.98) and eGFR<60 ml/min (p=.01; OR=.27, 0.10-0.77) were significantly associated with AAA expansion.

Conclusion: Patients with stable AAA have smaller aortic diameters, less monocyte RhoA activity, and greater renal function when compared to patients with expanding AAA. Patients with larger AAA may have higher inflammation levels and expansion rates versus patients with smaller AAA. There is insufficient data to suggest that RhoA would serve as a viable biomarker for AAA expansion.

88.15 An Animal Model of Human Peripheral Arterial Bending and Deformation

Posted on January 31, 2019

R. El Khoury1, A. Nikanorov2, E. McCarroll3, G. LeClerc4, L. Guy4, M. Laflamme4, A. Mailloux4, L. B. Schwartz1,3  1Advocate Lutheran General Hospital,Department Of Surgery,Park Ridge, IL, USA 2National Coalition on Healthcare,Washington, DC, USA 3EFemoral Medical,Los Altos, CA, USA 4AccelLAB,Boisbriand, QUEBEC, Canada

Introduction:  Endovascular recanalization has become the treatment-of-choice for peripheral arterial disease. Although a wide variety of intravascular devices are approved for this purpose, anatomic and clinical outcomes following catheter-based intervention remain suboptimal as implanted stents will repetitively deform and fatigue during lower extremity movement. Pre-clinical testing of devices is often inadequate, given the lack of relevant animal models that genuinely mimic the complex motion of peripheral human arteries. The purpose of this study was to test the hypothesis that deformation of the human peripheral vasculature could be qualitatively and quantitatively modeled using an experimental animal. 

Methods:  Pelvic and lower extremity contrast angiography was performed in domestic Landrace-Yorkshire farm pigs weighing 25-35 kg. Anteroposterior images were obtained with the hind limbs naturally extended then repeated, (1) flexed approximately 90° at the hip and knee, (2) over-flexed in a non-physiological fashion. Two separate peripheral arterial segments were studied: an iliac segment between the circumflex iliac and deep femoral arteries and a femoral segment between the deep femoral and circumflex femoral arteries. Quantitative vascular angiographic analysis was utilized to measure arterial diameter, length and deformation. Percent axial arterial compression was calculated as the distance between constant arterial branches before and after hind limb flexion; bending was measured by planimetry and expressed in degrees.

Results: Eight iliofemoral arteries in four animals were imaged. Mean luminal diameters of the iliac and femoral segments in the neutral position were 5.4±0.5 mm and 4.6±0.5 mm. Hind limb flexion induced profound arterial compression, 17±8% and 29±6% within the iliac and femoral segments. Bending was also severe; with physiologic flexion to 90°, iliac and femoral arteries bent 36°±10° and 76°±13°. With extreme flexion of the porcine hind limb, the femoral artery could be reliably bent >90°. The observed deformation within the porcine iliac artery quantitatively exceeded the deformation observed historically within the human superficial femoral artery (~5% compression and 10° bending). Similarly, the degree of deformation within the porcine femoral artery quantitatively exceeded the deformation observed historically within the human popliteal artery (~10% compression and 70° bending).

Conclusion: Significant non-radial deformation of the porcine iliofemoral arteries was observed during manual hind limb flexion. The measured axial compression and bending deformation exceeded that observed in human peripheral arteries. The porcine iliofemoral model constitutes a “worst case” scenario for testing deformation and fatigue of intravascular devices indicated for the human peripheral vasculature.

 

88.14 Decreased Patency in Left-Sided Arteriovenous Grafts in a Porcine Model

Posted on January 31, 2019

S. Liu1, T. Wang1, J. Wang2, T. Isaji1, A. Feher4,5, N. Boutagy4,5, A. Sinusas4,5, L. Niklason2,3, A. Dardik1  1Yale University School Of Medicine,Surgery,New Haven, CT, USA 2Yale University School Of Medicine,Anesthesiology,New Haven, CT, USA 3Yale University School Of Medicine,Biomedical Engineering,New Haven, CT, USA 4Yale University School Of Medicine,Cardiology,New Haven, CT, USA 5Yale University School Of Medicine,Translational Research Imaging Center,New Haven, CT, USA

Introduction:
Complications of vascular access for hemodialysis remain a major source of morbidity and cost. Patients unable to have a fistula require a prosthetic graft, most commonly polytetrafluorethylene (PTFE), despite poor primary patency and increased thrombosis, stenosis, and need for reinterventions. Choice of laterality of arteriovenous graft placement is typically dependent on patient handedness, after consideration of adequate vessel diameters. Since temporary dialysis catheters may have reduced patency on the left side, we hypothesized that left-sided arteriovenous grafts may have reduced patency in a pre-clinical model.

Methods:
Ten Yorkshire male pigs (mean weight 48 kg, age 3.4 months) underwent ipsilateral or bilateral placement of arteriovenous grafts from the proximal common carotid artery (CCA) to the distal internal jugular vein (IJV) using PTFE (6 mm diameter, 6-7 cm length). Pigs were observed for 1, 2, or 3 weeks. Select pigs underwent ultrasound measurements of flow and ultrasound and caliper measurements of vessel diameters prior to graft placement, and some pigs underwent computed tomography angiography prior to the terminal procedure. Grafts and peri-anastomotic vessels were excised and analyzed with histology and immunostaining.

Results:
At baseline there was no significant difference in peak systolic or end diastolic velocities between the left and right CCA and IJV but the outer diameters of the CCA were smaller on the left side (4.2 versus 4.7 mm; p=0.0354). 10 left-sided and 8 right-sided PTFE grafts were placed; only 4/10 (40%) were patent on the left and 7/8 (88%) were patent on the right (p=0.03996, Chi-square). Post-operative histology showed thicker peri-anastomotic arterial walls on the left side (0.7 vs. 0.6 mm; p=0.0383) with greater intima-media surface areas (1.1 vs. 0.8 mm2; p=0.0286) compared to the right side. These differences were not seen between the left and right IJV. There was no significant difference in the number of smooth muscle cells, total proliferative cells, or extracellular matrix composition between the left and right sides; however, left-sided grafts had increased luminal macrophages at the arterial anastomosis compared to right-sided grafts (8.4 vs. 2.8 cells/hpf; p=0.0007). 

Conclusion:
Left-sided arteriovenous grafts are associated with significantly lower short-term patency compared to right-sided grafts; left-sided peri-anastomotic carotid arteries had increased wall thickness, medial area and increased numbers of macrophages near the arterial anastomosis despite similar blood flow.  These results suggest that left and right-sided arteries used in arteriovenous grafts may have different remodeling that translates to altered patency, and these differences should be considered when planning graft placement.
 

88.12 Human Platelet Lysate Improves In vitro Survival of Human Diabetic Mesenchymal Stem Cells

Posted on January 31, 2019

L. P. Brewster1,2, J. Raykin1,2  1Emory University School Of Medicine,Surgery,Atlanta, GA, USA 2Atlanta VA Medical Center,Surgery And Research Services,Decatur, GA, USA

Introduction:  Diabetic persons undergo premature aging of their vasculature leading to an earlier onset and more severe presentations of cardiovascular disease. Thus, they have great need for regenerative therapies. Mesenchymal stem cells (MSC) are one promising regenerative therapy that may help prevent vascular complications of diabetes. The objective of this work is to identify whether MSC survival pathways are improved by platelet lysate (PL), and if so, whether PL gel confers benefit to MSC survival and regenerative function on endothelial cells (EC).

Methods:
MSCs from Diabetic PAD (dMSC) and healthy patients were used. Luminescence studies were performed in MSCs transfected with luciferin lentivirus. Secretome analysis was performed with RayBiotech angiogenesis assays. Akt cell survival pathways were quantified by multiplex analyses.

Results:  dMSCs and healthy MSCs have increased retention and survival (2-3x) in PL gel than that seen in saline injection (most commonly used clinically). EGF expression in dMSCs is significantly increased (>5x; P<.0001) in PL gel over that in control groups. dMSCs had significant down-regulation of pAKT compared to healthy MSCs and MSCs from PAD patients without diabetes. Further, PL drastically changes the secretome profile of dMSCs compared to FBS. (Figure

Conclusion:

Initial concerns with cells from cardiovascular patients have now come into question for PAD patients. Improving dMSC survival could be important to PAD patients. In this work, we show that PL gel improves MSC survival in vivo and dMSC EGF expression, and that dMSCs have Akt signaling defects that may be reversible with PL supplementation.

88.11 Vein Graft Failure And Single Cell Genomics

Posted on January 31, 2019

N. Momi2,6, P. Liang2,6, S. Bhasin2,5, F. W. LoGerfo2,6, C. Ferran2,4, L. Pradhan-Nabzdyk2,6, M. Bhasin2,5  2Harvard School Of Medicine,Brookline, MA, USA 4Beth Israel Deaconess Medical Center,Center For Vascular Biology Research And Division Of Nephrology, Department Of Medicine,Boston, MA, USA 5Beth Israel Deaconess Medical Center,Genomics And Proteomics Center, Division Of Interdisciplinary Medicine And Biotechnology,Boston, MA, USA 6Beth Israel Deaconess Medical Center,Division Of Vascular And Endovascular Surgery, Department Of Surgery,Boston, MA, USA

Introduction:  Bypass grafting using autologous vein conduits is the cornerstone therapy for arterial occlusive disease. However, 30–50% of lower extremity vein grafts (VG) fail within 5 years from surgery. We hypothesize that VG implantation injury causes spatial and temporal genetic changes in the VG, triggering a cascade of interrelated molecular events starting with inflammation and culminating in vessel wall remodeling eventually leading to Intimal Hyperplasia (IH). This study aims to investigate the genomic contribution of individual cells including smooth muscle cells (SMC), endothelial cells (EC), adipocytes (Adipo), fibroblasts (FB), immune cells (T-Cells, Macrophages, NK etc.) towards VG failure and IH. 

Methods:  Canines underwent cephalic vein to common carotid artery interposition surgery. Cephalic VG and contralateral vein (CV) were harvested 24hrs post-surgery. Upon collagenase-I digestion, samples were subjected to 10X Single Cell (sc) genomics-based droplet sequencing to quantify and compare cell enrichment by ImmuneQuant software-based annotation and t-SNE clustering. Further, individual cell pools were validated by IHC. Additionally, bulk RNA-seq and ingenuity pathway analysis (IPA) was performed to elucidate key mediators/pathways. 

Results: Our results show a dramatic difference in the cell types present in VG vs. CV 24hrs post-surgery. CV predominantly had non-immune cells (93% of total distributed in 9 clusters), including EC, SMC, FB and Adipo, with fewer immune (7%, T-Cells). In striking contrast, VG demonstrated partial loss of ECs, Adipo and FB with simultaneous infiltration of immune cells, accounting for 89% of total cells, with 4 T-cell clusters (52%) (CD3D+PTPRC+CD19+IL3RA+), primarily Th1 cells (67% of T-Cells), 4 monocyte/macrophages clusters (34%) (CD68+TGFB1_CANFA+IL1R1+) and 1 B-cell cluster (3%). Further, supervised analysis of individual clusters highlighted differential expression of several genes including, chemokines (IL-8, CCL4/2), TFs (FOS) and extracellular matrix/vascular components (collagen/COL1A1, endothelin/EDN). Intriguingly, these findings were corroborated by bulk-RNA-seq indicating significant activation of inflammatory pathway, Th1 pathway, CD28 signaling in Th1 cells, PI3K signaling in B-cells, IL-8 and chemokine signaling. Finally, IHC analysis also validated the higher number of CD3+ T-cells in the VG. 

Conclusion: Significant monocytes/macrophages and T-cell infiltrates in VG vs CV reveal an early contribution of both innate and adaptive immune response towards the pathophysiology of VG remodeling. Sc-genomics provide a better understanding of the complex ecosystem that governs implantation injury and unsuccessful adaptations of the VG leading to graft failure, thereby opening avenues for plausible effective preventive measures and early therapeutic targets. 

 

 

88.10 Molecular Mechanism of IL-1β Induced Endothelial Dysfunction After Vascular Injury

Posted on January 31, 2019

M. Polcz1, P. Komalavilas1, J. Cheung-Flynn1, C. Brophy1  1Vanderbilt University Medical Center,Department Of Surgery,Nashville, TN, USA

Introduction:

Exposure of human saphenous vein to normal saline (NS), a non-buffered, acidic solution (pH 5.0-5.6) results in endothelial injury and impaired endothelial function, potentially resulting in decreased patency of vein grafts used for bypass. Previous data have suggested that NS induced injury leads to membrane disruption, ATP release, activation of the P2X7 receptor and p38 MAPK pathway.  This leads to an amplifying response resulting in inflammation and endothelial dysfunction. We hypothesized that increases in proinflammatory cytokine IL-1β, after activation of the P2X7R/p38 MAPK pathway, directly participates in endothelial dysfunction after injury.

Methods:

To determine the effects of IL-1β on endothelial-dependent relaxation, rat aorta (RA, n=12-20) were treated with IL-1β at 10, 50, and 100ng/ml in a muscle bath for 3 hours. Additionally, co-treatment with SB203580 (SB; 20µM), a p38 MAPK inhibitor, was performed.

To determine whether endothelial dysfunction associated with IL-1β is related to decreased nitric oxide (NO) bioavailability, human saphenous vein endothelial cells (HSVEC; n=4-5) were treated with IL-1β (10ng/ml) for 3, 6, and 24 hours. Western Blot analysis of endothelial nitric oxide synthase (eNOS), phosphorylated eNOS, and arginase II levels were performed. Protein-antibody complexes were visualized and quantified using the Odyssey Infrared Imaging System (LiCor Biosciences, Lincoln, NE). Protein levels were normalized to GAPDH level and phosphorylation was calculated as a ratio of the phosphorylated protein to total protein.

Results:

Treatment of RA with IL-1β led to a dose-dependent impairment of endothelial relaxation of pre-contracted tissues. This effect of IL-1β on endothelial dysfunction was prevented by cotreatment with SB, suggesting that IL-1β signals via a p38 MAPK-associated pathway. Additionally, treatment of HSVEC with IL-1β resulted in increased relative levels of arginase II at 6 and 24 hours but had no effect on eNOS levels or phosphorylation in HSVEC (Figure 1).

Conclusion:

IL-1β promotes endothelial dysfunction through increased arginase II levels resulting in decreased NO bioavailability.  These data provide a plausible hypothesis by which NS-induced injury leads to inflammation and endothelial dysfunction which may be associated with eventual vein graft failure.
 

88.09 Lower Shear Stress Magnitude in Female Mice During Arteriovenous Fistula Maturation

Posted on January 31, 2019

S. Ono1, T. Kudze1, T. Isaji1, T. Hashimoto1, B. Yatsula1, H. Liu1, T. Nishibe2, J. Koizumi3, A. Dardik1,4  1Yale University School of Medicine,Vascular Biology And Therapeutics Program And Department Of Surgery,New Haven, CT, USA 2Tokyo Medical University,Department Of Cardiovascular Surgery,Shinjuku, Tokyo, Japan 3Tokai University School of Medicine,Department Of Diagnostic Radiology,Isehara, KANAGAWA, Japan 4VA Connecticut Healthcare System,Department Of Surgery,West Haven, CT, USA

Introduction: The arteriovenous fistula (AVF) is the preferred method of dialysis access due to its proven superior long term outcomes. However, women have lower rates of AVF maturation than men (38% vs. 60%), preventing optimal AVF use. We used a novel mouse AVF model that recapitulates human AVF maturation to test the hypothesis that there is a difference in male and female AVF maturation.

Methods:   Aortocaval fistulae were created in male and female C57BL/6 mice (9-10 wks). At days 0, 3, 7, 14 and 21, infrarenal aortic and IVC diameters and flow velocity were monitored by Doppler ultrasound and used to calculate the resistance index, blood flow and shear stress. AVF were harvested at day 21 and AVF wall thickness was measured by computer morphometry; proteins were examined using immunofluorescence and mRNA by qPCR.

Results:  Female mice weighed less throughout the whole period (p<0.0001). At baseline, female mice had lower infrarenal IVC velocity (p=0.0005) and smaller magnitudes of shear stress (p=0.0003); although female mice had smaller infrarenal aortic diameter (p=0.0198), there was no significant difference in infrarenal IVC diameter (p=0.5112).  After AVF creation, both the female and male aorta (p=0.5681) and IVC (p=0.5680) dilated similarly and the aortic resistance index decreased similarly (p=0.0743). However, female mice had lower aorta (p=0.0187) and IVC mean velocity (p<0.0001); female mice also showed less blood flow volume in the aorta (p=0.0069) and IVC (p=0.0087) and lower shear stress magnitude in the IVC (p<0.0001) without any significant differences in aortic shear stress magnitude (p=0.31).  There were no significant differences in infrarenal IVC wall thickness either at baseline (p=0.9617) or at day 21 (p=0.2931). Although KLF2 mRNA was decreased in the female AVF on day 21 (p=0.048), there were no differences in protein expression (p=0.5224).

Conclusion: AVF in female mice have lower velocity, blood flow volume and magnitudes of shear stress without any differences in wall thickness or protein expression.  These findings suggest that hemodynamic changes in the fistula may play an important role underlying the diminished rates of AVF maturation in women.

88.08 Topographic Vascular Grafts – A Biomimetic strategy for Anti-thrombotic Surfaces

Posted on January 31, 2019

L. Pocivavsek1, J. Pugar3, N. N. Nath2, K. Salem2, W. Wagner2, S. Ye2, E. Tzeng2, S. Velankar3  1The University Of Chicago,Vascular/Surgery,Chicago, IL, USA 2University Of Pittsburgh,Vascular/Surgery,Pittsburgh, PA, USA 3University Of Pittsburgh,Chemical Engineering,Pittsburgh, PA, USA

Introduction:  The inner surfaces of arteries and veins are naturally anti-thrombogenic, whereas synthetic materials placed in blood contact commonly experience thrombotic deposition that can lead to device failure or clinical complications. We present a bioinspired strategy for self-cleaning anti-thrombotic surfaces using actuating surface topography motivated by our biomechanical study of arterial topography. 

Methods:  Utilizing finite element simulations, we studied the evolution of arterial topography as a function of pressure. Arterial luminal and wall geometries were segmented from histology slides of un-fixed human and mouse muscular arteries. The reconstructed arteries were imported into the finite element software ABAQUS, and simulations at physiologic conditions were conducted. Experimental counterparts were constructed utilizing silicone composites cylinders, 3 mm in diameter, and with varying luminal wrinkle wavelengths between 50 and 1000 microns. The cylinders were actuated at 1 Hz between diastolic and systolic pressures while filled with whole blood. At the end of 3 hours of actuation, the adhered surface platelet density was measured. 

Results: The luminal surface at zero pressure is highly wrinkled with a large local curvature that is proportional to the inverse of the wrinkle wavelength. Computationally, we found that upon inflation, the arterial luminal topography changes from this highly wrinkled state to a nearly flat surface upon reaching systolic pressures (see figure 1I). Experimentally, we found that topographic surface actuation dramatically decreased surface platelet adhesion: 90%, 95%, and 98% decrease in platelet deposition relative to unactuated surfaces for 1000, 250, and 80 micron wavelength surfaces, respectively (see figure 1 II A-C). Furthermore, we found a strong correlation between the degree of surface self-cleaning and wavelength; shorter wavelengths proved to be far more efficient at preventing un-wanted platelet adhesion than longer wavelengths. 

Conclusion: We show that arterial topography in native vessels can actuate as a function of physiologic pulse pressure. Furthermore, such active surface topography is shown in an experimental system to prevent platelet adhesion, with smaller wavelengths being more effective than longer ones at surface renewal. This work presents a novel bio-mimetic strategy geared towards creating durable small caliber vascular grafts with long term patency by preventing unwanted platelet surface fouling. 

 

88.07 Differential expression of Cathepsin L in the coronary arteries of atherosclerotic swine.

Posted on January 31, 2019

P. Gunasekar1, J. Dabestani1, D. K. Agrawal1, J. A. Asensio1  1Creighton University Medical Center,Department Of Surgery, Div. Trauma Surgery, Department Of Clinical & Translational Science,Omaha, NE, USA

Introduction:
Neointimal hyperplasia and restenosis following interventional procedures, including percutaneous transluminal coronary angioplasty (PTCA) and intravascular stenting still remain a significant clinical problem. These interventional procedures cause endothelial denudation and damage to intimal and medial layer which stimulates intimal smooth muscle proliferation and extracellular matrix deposition resulting in intimal hyperplasia (IH) and restenosis. Vascular sterile inflammation has been attributed to the formation of IH. Cathepsin L (CTSL), a member of lysosome protease, is highly associated with diet-induced atherogenesis and IH in animal studies. Vitamin D regulates several proteases and protease inhibitors in different cell types, contributing to its regulatory effects of cell physiology. In our study, we examined the effect of vitamin D on CTSL activity in the coronary arteries of atherosclerotic swine.

Methods:
Yucatan microswine were fed with a high cholesterol atherosclerotic diet. The swine received approximately 500 IU of vitamin D3/per day on the vitamin D-deficient diet, 2,500-3,500 IU of vitamin D3/per day on vitamin D-sufficient diet, and 4,500-5,500 IU of vitamin D3/per day on the vitamin D-supplement diet. After 5-6 months of the experimental diet, PTCA (percutaneous transluminal balloon angioplasty) was performed in the left circumflex coronary artery (LCX) in each swine.  After a year of the diet, angiography and optical coherence tomography (OCT) imaging were performed and swine euthanized. Coronary arteries were embedded in methyl methacrylate or paraffin. Tissue sections were stained with H&E, trichrome, and Movat’s pentachrome.  The expression of Ki67 (proliferation marker), CCR7 (Macrophage marker), Cathepsin L (lysosomal proteases) was evaluated by Immunofluorescence and Immunohistochemistry.

Results:
There was significantly greater density of Ki-67+ cells in post angioplasty LCX in vitamin D-deficient swine compared to vitamin D-sufficient swine and vitamin D-supplemented swine. CCR-7 was found to be higher in vitamin D deficient than vitamin D-sufficient swine and vitamin D-supplemented swine. CTSL expression and its activity were significantly increased in post angioplasty LCX of vitamin D-deficient swine than the supplemented swine.

Conclusion:
Cathepsin L drives IH and macrophage infiltration in coronary arteries after angioplasty in atherosclerotic swine. These findings suggest that vitamin D inhibits CTSL and thus has direct effect on neointimal hyperplasia after coronary intervention.
 

88.06 Novel “TopoGraft”: A Potential Solution for Platelet Aggregation

Posted on January 31, 2019

N. Nath1, L. Pocivavsek2, Y. Gao3, K. Salem1, S. Velankar3, E. Tzeng1  1University of Pittsburgh,Vascular Surgery,Pittsburgh, PA, USA 2University Of Chicago,Vascular Surgery,Chicago, IL, USA 3University of Pittsburgh,Department Of Chemical Engineering,Pittsburgh, PA, USA

Introduction: The tissue-blood interface represents a dynamic interaction between the endothelial cells (EC) and circulating RBCs, platelets and inflammatory cells. While ECs and underlying smooth muscle cells are vital to vascular homeostasis, the contribution of an artery’s dynamic luminal surface to prevent vascular thrombosis has not been previously evaluated. It has been reported in literature that vasoconstricted or relaxed arteries exhibit a corrugated luminal surface that flattens uniformly under distention, a transition, however, with unclear significance. We have shown that the arterial lumen possesses a regular wrinkled pattern that undergoes phasic wrinkling and flattening, offering a unique surface renewal mechanism. We hypothesize that uniquely incorporating this dynamic topography into vascular grafts may reduce platelet aggregation.

Methods:  Pig carotid arteries were subjected to pressures ranging from 40-140 mmHg, fixed, and examined histologically for luminal surface wrinkle amplitudes. Synthetic grafts were created using strain mismatch between two layers of implantable silicone of different stiffness to produce grafts with wrinkled or smooth luminal surfaces. An ex vivo pulsatile pump circuit was designed to cyclically distend wrinkled and smooth grafts to create dynamic topography. Activated platelets were circulated through the pump system at systolic pressures of 100-120 mmHg. Optical coherence tomography was used to capture cyclic changes of luminal surface. Grafts that were restricted by an external constraint to prevent cyclical distention were also tested. After platelet exposure, grafts were stained with Wright stain to quantify platelet adherence.

Results: Arteries distended at 40 mmHg had an average wrinkle amplitude of 20.52 ± 4.13 µm which decreased to 5.86 ± 1.69 µm at 140 mmHg (p<0.05). Incorporating luminal wrinkles into vascular grafts (Fig. 1A) with pulsatile flow, undergoing dynamic surface wrinkling and flattening (Fig. 1C) , reduced platelet deposition by 83% compared to smooth grafts (547 ± 96 vs. 4704 ± 573 per HPF, respectively; p<0.05). Constrained wrinkled grafts with static topography exhibited a doubling of platelet accumulation similar to that of smooth surface grafts constrained or undergoing cyclical distention (p<0.05 vs. wrinkled grafts with dynamic topography, Fig. 1B).

Conclusion: Arteries possess luminal topography that consists of a wrinkled surface that flattens under systolic pressures. Incorporating this dynamic luminal topography onto a synthetic graft reduced platelet aggregation. Dynamic luminal topography offers a unique method of preventing thrombus formation and may improve prosthetic vascular graft patency.

 

88.02 Vitamin D supplementation Reduces HMGB1, TLRs and RAGE in Post-interventional Coronary Arteries

Posted on January 31, 2019

P. Gunasekar1, J. Dabestani1, D. K. Agrawal1, J. A. Asensio1  1Creighton University Medical Center,Department Of Surgery, Div. Trauma Surgery, Department Of Clinical & Translational Science,Omaha, NE, USA

Introduction:

Coronary angioplasty and stent implantation is a common coronary procedure for patients with coronary artery disease. These interventional procedures stretch and denude the endothelial layer. This promotes local inflammatory response in the injured vessel wall, which is characterized by smooth muscle cell proliferation, migration, neointimal formation. Clinical studies support that plasma vitamin D deficiency is associated with increased risk for coronary artery disease (CAD). It is unclear whether vitamin D status is causally related to CAD or is a marker of health. In this study, we examined the inflammatory profile of coronary arteries in atherosclerotic swine.

Methods:

Yucatan microswine were fed with high cholesterol atherosclerotic diet. The swine received approximately 500 IU of vitamin D3/per day on the vitamin D-deficient diet (VD DEF.), 2,500-3,500 IU of vitamin D3/per day on vitamin D-sufficient diet (VD SUF.), and 4,500-5,500 IU of vitamin D3/per day on the vitamin D-supplement diet (VD SUP.). After 5-6 months of the experimental diet, PTCA (percutaneous transluminal balloon angioplasty) was performed in the left circumflex coronary artery (LCX) and bare mental stent implantation in the left anterior descending coronary artery (LAD) for each swine. Six months following coronary intervention, angiogram and optical coherence tomography (OCT) imaging were performed and swine were euthanized. Coronary arteries were then embedded in methyl methacrylate or paraffin. Tissue sections were stained with H&E. The protein expression of HMGB1 (inflammation and necrosis marker), RAGE (receptor for advanced glycosylation end product), TLR2 and TLR4 (pattern recognition receptors) were evaluated by Immunohistochemistry.

Results:

Optical coherence tomography readings showed the degree of percentage area in-stent restenosis and PTCA was greatest in VD DEF. compared to VD SUF. or VD SUP. swine. We found a greater inflammatory profile in the coronary arteries of VD DEF. compared to VD SUF. or VD SUP. swine, based on histological staining and immunoreactivity to HMGB1, RAGE, TLR2, TLR4, in both LCX and LAD. The ligands for RAGE and receptor for HMGB1 (TLR2 and TLR4) were highly expressed in neointimal cells in stented LAD arteries of VD DEF. swine. This inflammatory profile decreases with increasing the levels of Vitamin D.

Conclusion:

Vitamin D deficiency increases the HMGB1-mediated pathways, resulting in the release of inflammatory cytokines from macrophages and other immune cells; and the recruitment of inflammatory cells through TLR4. Vitamin D supplementation suppresses the cytokine activity and prevents neointimal proliferation and restenosis from damage caused by PTCA in atherosclerotic swine. Vitamin D supplementation could be used as an adjunct therapy to prevent intimal hyperplasia and restenosis following coronary interventions.
 

81.10 Renal Function Changes Following Fenestrated Endovascular Abdominal Aortic Aneurysm Repair (fEVAR)

Posted on January 31, 2019

M. M. Oberdoerster1, M. M. Wynn1, P. D. DiMusto1  1University Of Wisconsin,Madison, WI, USA

Introduction:  Fenestrated endovascular abdominal aortic aneurysm repair (fEVAR) has been approved for clinical use since 2012.  One possible complication of this repair is impairment in renal function. We sought to assess the clinical outcomes related to renal function over time in patients undergoing fEVAR at our tertiary referral center.

Methods:  A retrospective review was conducted of prospectively collected data on all patients undergoing fEVAR at our institution between 2012 and 2017.  Patient characteristics, procedural variables, laboratory values, and imaging characteristics were collected. Serum creatinine was measured preoperatively, and at 1 month, 6 months, 1 year and yearly thereafter. Estimated glomerular filtration rate was calculated using the Cockcroft Gault equation.

Results: A total of 58 patients were included: 42 men and 16 women with an average age of 75 years. The average follow up time was 469 days; 6 patients were lost to follow up.  A total of 111 out of 116 main renal arteries were successfully revascularized. Only one main renal artery that was planned for revascularization was not due to the inability to place a stent intraoperatively. The other four were above the graft and did not require revascularization.  There were 11 accessory renal arteries that were covered with the aortic graft. 

Eighteen patients (31%) had advanced chronic kidney disease (CKD) prior to the repair; 17 stage III, 1 stage IV.  Nine patients (15.5%), including 3 of the 18 who had CKD prior to the repair, had an increase of at least 30% from baseline creatinine over two or more follow up visits.  All nine had evidence of post-operative renal insult including infarct, renal artery stenosis, or occlusion. Four patients (7%) with no prior history of CKD progressed to stage II, 13 (22%) patients progressed from stage II to III, and 3 patients (5%) progressed from stage III to stage IV over the follow up period. Only the patient with stage IV CKD at the time of the repair went on to require dialysis 8 months after his procedure. 

Eight patients (13.7%) developed stenosis in one of the renal artery stents.  Five of these patients had worsening of their renal function with progression by one CKD stage.  Two patients had an intervention due to the stenosis, but only one was successful.  Four additional patients developed a renal artery occlusion, three of which had a progression of CKD by one stage.  None of these patients went on to dialysis. A total of 24 patients (41%) developed renal infarction on imaging over the follow up period. Nine of these patients had progression of their CKD stage, however none went on to dialysis.  

Conclusion: Our review demonstrates that while kidney dysfunction can occur over the long term following fEVAR, rates of worsening renal function are relatively low.  Additionally, in patients with pre-operative CKD, fEVAR remains safe and effective with low rates of progression to dialysis.  
 

81.09 Assessment of the “Weekend Effect” in Lower Extremity Vascular Trauma

Posted on January 31, 2019

A. K. Jundoria1, B. Grant1, O. A. Olufajo1, E. De La Cruz1, D. Metcalfe2, M. Williams1, E. E. Cornwell1, K. Hughes1  1Howard University College Of Medicine,Washington, DC, USA 2University of Oxford,Nuffield Department Of Orthopaedics, Rheumatology And Musculoskeletal Sciences (NDORMS),Oxford, OX3 9BU, United Kingdom

Introduction:  Numerous studies have suggested that compared to the weekday, weekend admissions may be associated with worse patient outcomes across a range of patient diagnoses. Lower extremity vascular trauma is increasingly common and requires immediate/urgent surgical intervention. Although this weekend effect has been reported for several domains, it has not been elucidated in vascular trauma. The objective of this study was to determine if there is a weekend effect in patient outcomes of lower extremity vascular trauma (LEVT).

Methods:  Retrospective data was retrieved from the National Inpatient Sample database, a 20% stratified sample of the United States inpatient population, from 2005 – 2014. Patients ages 18 and above with International Classification of Diseases, 9th Edition codes indicating trauma to the lower extremity vessels were included. Patients and hospital characteristics were extracted including age, sex, race, insurance type, median household income, Injury Severity Score, Charlson comorbidity score, Abbreviated Injury Scale (AIS) for extremity body region, and location/teaching status of hospital. Outcomes (mortality, amputation, hospital length of stay, and discharge disposition) among patients admitted on weekdays versus patients admitted on weekends were measured. Independent factors associated with outcomes were identified using multivariable regression models. Supplementary analyses were performed using patients with only isolated LEVT, which was defined by AIS of zero in every body region except extremity.

Results: There were 9282 patient records with LEVT (2866 admitted on the weekend vs. 6416 admitted on the weekday). Compared to patients admitted on the weekday, patients admitted on the weekends were more likely to be younger than 45 years old (67.6% vs. 55.4%), males (80.5% vs. 74.6%), and uninsured (22.1% vs. 17.2%) [all p < 0.001]. Comparison of outcomes for patients on weekend vs. weekday showed mortality of 3.80% vs. 3.29% [p = 0.209], amputation rates of 7.85% vs. 7.19% [p = 0.258], hospital length of stay (LOS) of 15.5 days vs. 13.8 days [p = 0.009], and discharge home rates of 57.3% vs. 56.1% [p = 0.271]. The multivariable regressions showed the following outcomes for weekend vs. weekday admissions: mortality (Odds Ratio, OR [95% Confidence Interval, CI]); 1.06 [0.79-1.40], amputation (OR [95% CI]); 1.09 [0.89-1.30], discharge home (OR [95% CI]); 0.95 [0.85-1.06] and hospital LOS (predicted mean LOS [95% CI]); 0.33 [-0.34-1.00].

Conclusion: This study demonstrated there was no weekend effect identified in patients admitted with LEVT in the United States. This suggests that there is likely no difference in the level of care given to lower extremity vascular trauma patients, regardless of whether they present on a weekend or on a weekday.

 

81.08 Modified Metabolic Syndrome is Associated with Poor Access Outcomes Following EVR.

Posted on January 31, 2019

M. D. Balceniuk1, P. Zhao1, L. Cybulski1, M. C. Stoner1  1University Of Rochester,Division Of Vascular Surgery,Rochester, NY, USA

Introduction:
Metabolic syndrome (MetS) is a constellation of five clinical and laboratory findings associated with adverse cardiovascular outcomes as well as wound healing outcomes. MetS has also been reported to be associated with type 2 endoleak following endovascular aneurysm repair (EVR). We report impact of modified metabolic syndrome (mMetS) on groin access complications following EVR.

Methods:
The Vascular Quality Initiative (VQI) endovascular aortic repair module 2008-2016 was evaluated. MetS classification was modified based on the variables available within the VQI registry. Patients were considered to have mMetS (study group) if they had all three diagnosis of body mass index (BMI) >30, hypertension and diabetes. Patients missing one or more of these diagnoses were placed in the non-mMetS (control group) group. Access site complications were evaluated between patients with mMetS and those without.

Results:
Over 30,000 patients were included in the analysis, with over 3000 patients met the criteria for mMetS (Table). The non-metabolic group were significantly older and had higher rates of females and white race. The mMetS cohort had higher rates of coronary artery disease, chronic obstructive pulmonary disease and congestive heart failure. Groups were similar regarding access type for percutaneous (65% versus 65%, p=0.987).  Surgical site infections (SSI) were significantly higher in the mMetS group (24 (0.783%) vs 87 (0.317%), p?0.001), whereas no difference was noted for access site hematoma between groups.  Additionally, sub-group regression analysis of the mMetS cohort identified open access type to be a significant predictor of post-operative SSI (p=0.028).

Conclusion:
Our data demonstrates that there is a significantly higher rate of SSI in patients with mMetS following EVR. We have also shown that percutaneous access in patients with modified metabolic syndrome significantly reduced the incidence of post-operative SSI. These data suggest that percutaneous access should be attempted in EVR patients with metabolic syndrome to mitigate the risk of open femoral access SSI.
 

81.07 Transfemoral Carotid Artery Stenting Is Inferior To Carotid Endarterectomy In The Community

Posted on January 31, 2019

J. Nicklas1, J. Albright1, E. Jerzual1, A. Obi1, P. Henke1  1University Of Michigan,Vascular Surgery,Ann Arbor, MI, USA

Introduction: The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) suggested that there was no significant difference between carotid endarterectomy (CEA) and transfemoral carotid artery stenting (CAS) in the endpoint of major adverse cardiovascular events (MACE) including stroke, myocardial infarction, or death but a 2 fold increased risk of stroke with CAS. Limited reports exist in real world hospital outcomes for these procedures.

Methods: 11,290 patients (pts) who underwent CEA and 2,391 pts who underwent CAS in 34 hospitals between 1/3/2012 and 2/28/2018 were assessed for baseline demographics, anatomical variables, medications, and major outcomes, at 30 days. Statistical modeling was done with univariable and multivariable analysis for stroke and MACE.

Results: Demographics in CREST and our population were similar in age (69 vs 70 years), gender (65% vs 60% male), and race (93% vs 93% white). However, in our population, the 30-day incidence of MACE among pts undergoing CEA vs CAS was 2.8% (n=321) vs 5.9%, (n=141), p<0.001 and the incidence of stroke was 2.8% in CEA (n=309) vs 4.4% in CAS (n=105), p<0.001. After multivariable adjustment, CAS was associated with increased stroke risk – (OR = 1.323; 95% confidence interval = 1.018, 1.718, P = .036) and MACE- (1.261; 1.004, 1.584, P = .046) as compared with CEA.
Preoperative risk factors for stroke after CEA included: female gender – (1.33; 1.06-1.67), non-ambulatory status – (1.54; 1.17-2.02), contralateral carotid artery occlusion – (2.19; 1.51-3.17), restenosis of a prior CEA (2.22; 1.21-4.07), prior stroke (2.33; 1.56-3.17), and restenosis of a prior CAS (3.85; 1.31-11.34). Significant perioperative risks of stroke include: non-patch closure – (1.44; 1.03-2.02) and eversion CEA technique – (1.50; 1.02-2.22). 30-day MACE analysis showed that the use of a shunt – (1.28; 1.03-1.59) and renal failure requiring dialysis – (2.44; 1.25-4.74) increased the risk.
Preoperative risk factors for stroke after CAS included: low BMI – (1.06; 1.03-1.10), lack of anemia – (1.56; 1.05-2.57), diabetes – (2.18; 1.43-3.32), and non-white race – (2.25; 1.23-4.10). Significant perioperative risks include: increased operative time – (1.55; 1.23-1.95), embolic protection failure – (1.85; 1.01-3.39), and tracheostomy – (10.35; 1.72-62.33). 30-day MACE factors also included: advanced age – (1.024; 1.01-1.04), lack of Ace/ARB medications – (1.51; 1.05-2.15), >=2 coronary arteries >70% obstructed – (2.60; 1.28-5.27), and left main stenosis >50% – OR 2.84 (1.16-6.91).

Conclusion: Our large multi-hospital real world practice registry suggests that CEA in community practice is associated with better outcomes than transfemoral CAS, and diverges from the CREST results. Differential factors were associated with CEA and CAS risks for stroke and MACE.

 

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