Jordan Stern, MD

Abstract

OBJECTIVES: Iliac branch devices (IBDs) are modular, bifurcated endografts designed to preserve hypogastric flow during endovascular aortoiliac aneurysm repair. We report our single center outcomes, and describe the unique complications of these devices: inability to cannulate the hypogastric artery (technical failure), occlusion of the internal branch, and type III endoleak from separation of components between the main body and IBD.METHODS: A prospectively maintained institutional database of patients undergoing IBD implantation between 2014 and 2019 was reviewed. Technical and clinical outcomes were evaluated. We then identified patients having one of the IBD-specific complications and patient, anatomic, and procedural data were analyzed to identify factors associated with these failures.RESULTS: 64 IBDs were placed in 59 patients during the study period. Mean age was 71.28.6, and 92% were male. 74.6% of patients had a current or prior abdominal aortic aneurysm, and 9.4% had a hypogastric aneurysm. Technical success was achieved in 60/64 cases (93.8%); prior EVAR was associated with technical failure (p=0.04). There were 5 instances of component separation between the main body and the IBD: 3 occurred intraoperatively and were repaired with additional bridging components, and 2 occurred on late follow-up and required reintervention. Increased tortuosity index of both aortoiliac (1.70.4 vs. 1.302, p=0.04) and iliac-specific (3.92.4 vs. 1.90.9, p=0.03) segments were significantly associated with component separation, as was the use of larger internal iliac components (13.92.4 vs. 11.12.3 mm, p=0.04). Internal branch occlusions occurred in 4 patients (6.7%). Two were successfully reopened with endovascular procedures, with two being asymptomatic. No specific factors were found to be predictive of branch occlusion.CONCLUSIONS: IBD-specific complications occur rarely. History of prior EVAR is associated with technical failure, while increased aortic and iliac tortuosity are predictive of component separation and type III endoleak. Severe tortuosity should be carefully considered when planning for IBD.

View details for DOI 10.1016/j.avsg.2021.03.008

View details for PubMedID 33836229

Abstract

PURPOSE: To describe a novel, entirely ipsilateral femoral technique for distal endograft extension using the Gore Iliac Branch Endoprosthesis.TECHNIQUE: Femoral arterial access is obtained on the side of the intended repair, and a 16F sheath is inserted over a stiff wire. A looped wire is used to pre-cannulate the internal gate of the IBE device prior to insertion, and the device is then positioned and deployed. This through-wire guides access over the IBE flow divider and into the internal gate with a steerable sheath. The internal iliac artery is then selected, and a Viabahn VBX balloon-expandable stent (W.L. Gore, Flagstaff, AZ) is advanced into position and deployed. We present the successful completion of this technique in 4 patients.CONCLUSION: This novel technique allows distal endograft extension with an IBE device using only ipsilateral femoral access and is particularly useful for patients with aneurysmal iliac degeneration in the setting of prior open or endovascular aneurysm repair. This eliminates the need for upper extremity access or contralateral femoral access and navigation across the steep flow divider.

View details for DOI 10.1177/1526602821989335

View details for PubMedID 33478350

Abstract

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) is an effective treatment for blunt thoracic aortic injury (BTAI), but the risks and benefits of administering intraoperative heparin in trauma patients are not well-defined, especially with regard to bleeding complications.METHODS: The Vascular Quality Initiative (VQI) registry was queried from 2013 to 2019 to identify patients who underwent TEVAR for BTAI with or without administration of intraoperative heparin. Univariate analyses were performed with Student's t-test, Fisher exact, and chi-squared tests where appropriate. Multivariable logistic regression was then performed to assess the association of heparin with inpatient mortality.RESULTS: 655 patients were included, of whom the majority presented with grade III (53.3%) or IV (20%) BTAI. Patients receiving heparin were less likely to have an injury severity score (ISS) 15 (70.2% vs. 90.5%, p<0.0001), or major head or neck injury (39.6% vs. 62.9%, p<0.0001). Patients receiving heparin had lower incidence of inpatient death (5.1% vs. 12.9%, p<0.01). Across all injury grades, heparin use was not associated with intraoperative transfusion, postoperative transfusion, or hematoma. In patients with grade III BTAI, non-use of heparin was associated with an increased risk of lower extremity embolization events (7.4% vs 1.8%, P < 0.05). On multivariable logistic regression for inpatient mortality, intraoperative heparin use (OR = 0.31, 95% Confidence Interval [CI] 0.11 - 0.86, P < 0.05) and female gender (OR = 0.11, 95% CI 0.11 - 0.86, P < 0.05) were associated with better survival, even when controlling for head and neck trauma and injury grade. In contrast, increased age (OR = 1.06, 95% CI 1.03 - 1.1, P <0.001), postoperative transfusion (OR = 1.06, 95% CI 1.02 - 1.11, P < 0.01), Higher ISS (OR = 1.04, 95% CI 1.01 - 1.07, P < 0.05), postoperative dysrhythmia (OR = 4.48, 95% CI 1.10 - 18.18, P < 0.05), and postoperative stroke or transient ischemic attack (OR = 5.54, 95% CI 1.11 - 27.67, P < 0.05) were associated with increased odds of inpatient mortality.CONCLUSIONS: Intraoperative heparin use is associated with reduced inpatient mortality in patients undergoing during TEVAR for BTAI, including those with major head or neck trauma and high injury severity scores. Heparin did not increase risk of hemorrhagic complications across all injury grades, and in patients with grade III BTAI heparin use was associated with a reduced risk of lower extremity embolic events. Heparin appears to be safe during TEVAR for BTAI, and should be administered when no specific contraindication exists.

View details for DOI 10.1016/j.jvs.2020.12.068

View details for PubMedID 33348003

View details for DOI 10.1001/jama.2020.10426

View details for PubMedID 33107946

Abstract

OBJECTIVES: Paclitaxel-eluting stents have demonstrated improved patency over balloon angioplasty and bare metal stenting for endovascular interventions in the femoral-popliteal segment. Recently, concerns have arisen regarding the safety of paclitaxel use and its association with mortality. This study aims to examine real-world, long-term mortality, and patency of patients treated with the Zilver PTX drug-eluting stent.METHODS: Patients treated with the PTX stent after FDA approval between 2013 and 2015 were identified from an institutional database. Demographic, procedural, and device information was collected and initial- and lifetime-exposure dose of paclitaxel was calculated. The primary outcome was all-cause mortality and its association with paclitaxel exposure. Long-term patency was also evaluated.RESULTS: Seventy-nine procedures involving PTX placement were performed on 64 individual patients during the study period, with 15 (23.4%) having bilateral procedures. Average age was 70 years, and 71.9% were male. Forty-five patients (70.3%) were claudicants, and 19 (29.7%) had chronic, limb-threatening ischemia. An average of 2.3 PTX stents, totaling 203 mm in length, were placed per procedure. Paclitaxel exposure was 1.87mg/procedure initially (range 0.38-4.03mg), and average lifetime exposure was 4.65mg/patient (range 0.38-27.91mg). Average follow-up was 59.6 months. Kaplan-Meier estimated survival was 96.9%, 81.2% and 71.7% at one , three, and five years. On multivariate analysis, no specific factors were associated with overall morality including initial paclitaxel dose (HR 0.99, 95% CI 0.99-1.00) and lifetime paclitaxel exposure (HR 0.98, 95% CI 0.89-1.08). Kaplan-Meier primary patency was 76.2%, 60.1%, and 29.3% at one, two, and five years, respectively. Secondary patency was 92.2%, 85.4%, and 75.2% at the same intervals.CONCLUSIONS: At a mean follow-up of five years, exposure to higher doses of paclitaxel from Zilver PTX does not appear to be associated with increased mortality compared to lower doses in real-world patients. Long-term patency rates confirm the efficacy of Zilver PTX, and further investigation may be warranted before abandoning paclitaxel use altogether.

View details for DOI 10.1177/1708538120964371

View details for PubMedID 33054678

View details for Web of Science ID 000582798100129

View details for Web of Science ID 000582798100609

View details for Web of Science ID 000582792300648

Abstract

INTRODUCTION: The gold-standard for management of combined common femoral (CFA) and superficial femoral (SFA) atherosclerotic occlusive disease has traditionally been open femoral endarterectomy and femoral-popliteal bypass. Hybrid approaches involving an open and endovascular component are increasingly common. The aim of this study was to compare perioperative outcomes in patients who underwent an open versus hybrid revascularization.METHODS: NSQIP data, years 2012-2017, were queried for patients who underwent non-emergent CFA endarterectomy with either SFA transluminal intervention or bypass. The primary outcome of interest was a composite of cardiovascular, pulmonary, and renal complications (systemic) and mortality. Two propensity-weight adjusted analyses were performed: 1) comparing hybrid and prosthetic bypass 2) comparing hybrid and vein bypass.RESULTS: There were 4,478 patients included (1,537 hybrid, 1,408 prosthetic, 1,533 vein); 64.8% were men, and the mean age was 67.89.7 years; 29.9% had claudication, 38.8% had tissue loss, and 31.3 were unspecificed. In the propensity-weighted analysis comparing hybrid to prosthetic bypass, there was no difference in systemic complications (OR=1.29 for prosthetic vs. hybrid; 95% CI: 0.95-1.76; p=0.107) or mortality (OR=1.54;95% CI:0.71-3.33;p=0.275). Prosthetic bypass was associated with more deep surgical-site infections (OR=2.02;95%CI:1.19-3.45;p=0.010), post-operative sepsis (OR=2.07;95% CI:1.13-3.76;p=0.018), unplanned 30-day readmission (OR=1.28;95%CI:1.04-1.58;p=0.021), and the composite of any complication (OR=1.38;95%CI:1.18-1.61;p<0.001). In the propensity-weighted analysis comparing hybrid to vein bypass, there was no difference in systemic complications (OR=1.10 for vein vs. hybrid; 95%CI:0.81-1.49;p=0.552) or mortality (OR=0.91;95%CI:0.42-2.00;p=0.819). Vein bypass was associated with more superficial surgical-site infections (OR=1.45;95% CI:1.04-2.02;p=0.028), and the composite of any complication (OR=1.32;95%CI:1.13-1.54;p=0.001). Overall mortality was significantly higher patients with systemic complications (13.9% vs 0.1%; p<0.001). Systemic complications were less common in patients with claudication undergoing hybrid revascularization than vein or prosthetic bypass.CONCLUSION: Claudicants undergoing bypass experienced more systemic complications than those undergoing hybrid procedures, but there appears to be no increased risk of systemic complications or mortality with open reconstruction, when compared to hybrid procedure for other indications. Other complications such as infection, post-operative transfusion, and readmission were more common in the bypass groups.

View details for DOI 10.1016/j.avsg.2020.08.143

View details for PubMedID 32927041

View details for DOI 10.1001/jama.2020.2104

View details for PubMedID 32633802

View details for Web of Science ID 000544100700156

View details for Web of Science ID 000544100700326

View details for Web of Science ID 000544100700255

Abstract

We describe a novel endovascular technique in which three 0.014" guidewires are placed in parallel through a 0.035" lumen catheter, in order to create a stiff platform to allow for delivery of 0.035" profile devices through challenging anatomy. Three illustrative cases are presented: a difficult aortic bifurcation during lower extremity intervention, a tortuous internal iliac artery during placement of an iliac branch device, and salvage of a renal artery after inadvertent coverage during proximal cuff deployment for type 1a endoleak. We also quantify the relative stiffness of the triple 0.014" wire configuration, using several well-known 0.035" wires for comparison. The "triple-wire technique" is an effective method for tracking endovascular devices through difficult tortuous anatomy, and can be used in a variety of clinical settings. The technique is especially useful when a traditional, stiff 0.035" wire will not track without "kicking out." Each 0.014" wire is reasonably soft and traverses the tortuous vessel easily, but when the three wires are used together as a rail it provides a stiff enough platform for delivery.

View details for DOI 10.1016/j.avsg.2020.04.021

View details for PubMedID 32335254

Abstract

OBJECTIVES: Ultrasound-enhanced catheter-directed thrombolysis (UET) using the EKOS device for acute, peripheral arterial ischemia has been purported in clinical trials to accelerate the fibrinolytic process in order to reduce treatment time and lytic dosage. We aim to describe outcomes of UET in a real-world clinical setting.METHODS: We performed a retrospective review of all patients undergoing UET for acute limb ischemia at a single institution. Data collected included patient demographics, procedural details, and 30-day and 1-year outcomes. The primary endpoints for analysis were major adverse limb events (MALE; reintervention and/or amputation) and mortality within 30-days and 1-year. Secondary endpoints included technical success, use of adjunctive therapies, and postoperative complications.RESULTS: 32 patients (mean age 67.4 14.9 years; 25% female) underwent UET for acute limb ischemia between 2014-2018. Rutherford Acute Limb Ischemia Classification was R1 in 56.3%, R2a in 31.3%, and R2b in 12.5%. Etiology was thrombosis of native artery in 12.5% of patients, prosthetic bypass in 31.3%, autogenous bypass in 6.3%, and stented native vessel in 50.0%. Mean duration of thrombolytic therapy was 22.2 11.3 hours, and mean tissue plasminogen activator dose was 24.5 15.3 mg. Major adverse limb events occurred in 16.7% of patients within the first 30-days and 38.9% experienced a MALE by 1-year. Limb salvage at 30-days and 1-year was 93.8% and 87.5%, respectively. Ipsilateral reintervention was required in 12.5% of patients within 30 days and 37.5% of patients within 1 year. Overall mortality was 6.2% at 30-days and 13.5% at 1-year. In-line flow to the foot was re-established in 90.6% of patients, with a significant improvement in pre- to post-op ABI (0.31+0.29 vs. 0.78+0.34, p<0.001) and number of patent tibial runoff vessels (1.31+1.20 vs. 1.96+0.86, p <0.001). There was no significant difference in revascularization success between occluded vessel types. All but one patient required adjunctive therapy such as further thromboaspiration, stenting, or balloon angioplasty. Major bleeding complications occurred in 3 patients (9.4%), including 1 intracranial hemorrhage (3.1%).CONCLUSIONS: UET with the EKOS device demonstrates acceptable real-world outcomes in the treatment of acute limb ischemia. UET is generally safe and effective at re-establishing in line flow to yield high limb salvage rates. However, UET is associated with a high rate of reintervention. Further investigation is needed into specific predictors of limb salvage and need for reintervention, as well as cost-efficacy of this technology compared to traditional methods.

View details for DOI 10.1016/j.avsg.2019.12.026

View details for PubMedID 31917220

Abstract

The superficial femoral artery can be used as inflow for infra-geniculate bypass, but progressive proximal occlusive disease may affect graft durability. We sought to evaluate the effect of superficial femoral artery versus common femoral artery inflow on infra-geniculate bypass patency within a large contemporary multicenter registry.The vascular quality initiative was queried from 2013 to 2019 to identify patients with >30-day patency follow-up, Rutherford chronic limb ischemia stage 1-6, and an infra-geniculate bypass, excluding those with prior ipsilateral bypass. The cohort was stratified by inflow vessel, with primary, primary-assisted, and secondary patency serving as the primary outcome variables. Multivariate Cox-proportional hazard models and radius-based propensity-score matching were performed to reduce treatment-selection bias due to clinical covariates.A total of 11,190 bypass procedures were performed (8378 common femoral artery inflow, 2812 superficial femoral artery) on 10,110 patients, with a mean follow-up of 12.8 months (range 1-98). Patients receiving superficial femoral artery inflow bypasses were more commonly male (p=0.002), obese (p<0.0001) and had chronic, limb threatening ischemia (p<0.0001), whereas those with common femoral artery inflow were older (p<0.0004), and had higher baseline comorbidities including smoking (p<0.0001), coronary disease (p<0.0001), and pulmonary disease (p<0.0001). On life-table analysis, there was no significant difference in three year estimated primary (32.1 vs 30.1%, p=0.928), primary assisted (60.5 vs 65.8%, p=0.191), or secondary patency (62.5 vs 66.7%, p=0.139) between superficial femoral artery and common femoral artery inflow groups, respectively. A multivariate Cox model found no significant association between inflow vessel and primary patency (0.96 [0.88-1.04], HR [95%CI]), primary-assisted (1.07 [0.95-1.20], HR [95%CI]), or secondary patency (1.08 [0.96-1.22]). In a propensity-matched cohort (n=11,151), there were small but statistically significant differences in primary, primary-assisted, and secondary patency at latest follow-up (non-time-to-event data) between groups. The largest difference was observed when evaluating secondary patency, with common femoral artery inflow having a marginally higher secondary patency of 88.1% compared to 85.6% for those with superficial femoral artery inflow at latest follow-up (p=0.009).Within the vascular quality initiative, there is no significant difference in life-table determined three-year primary, primary-assisted, and secondary patency between infra-geniculate bypasses using common femoral artery inflow compared to superficial femoral artery inflow. Small, statistically significant differences exist in primary, primary-assisted, and secondary patency favoring common femoral artery inflow after propensity score matching. Long-term follow-up data are required in the vascular quality initiative to better evaluate bypass graft durability as this study was limited by a mean follow-up of one year.

View details for DOI 10.1177/1708538120924908

View details for PubMedID 32408857

Abstract

Thoracic outlet syndrome (TOS) surgery is relatively rare and controversial given the challenges in diagnosis as well as wide variation in symptomatic and functional recovery. Our aims were to measure trends in utilization of TOS surgery, complications, and mortality rates in a nationally representative cohort and compare higher- versus lower-volume centers.The National Inpatient Sample was queried using ICD-9 codes for rib resection and scalenectomy paired with axillo-subclavian aneurysm [arterial (aTOS)], subclavian DVT [venous (vTOS)], or brachial plexus lesions [neurogenic (nTOS)]. Basic descriptive statistics, non-parametric tests for trend, and multivariable hierarchical regression models with random intercept for center were used to compare outcomes for TOS types, trends over time, and higher- and lower-volume hospitals, respectively.There were 3,547 TOS operations (for an estimated 18,210 TOS operations nationally) performed between 2010-2015 (89.2% nTOS, 9.9% vTOS, 0.9% aTOS) with annual case volume increasing significantly over time (p=0.03). Higher-volume centers (10 cases/year) represented 5.2% of hospitals and 37.0% of cases, and these centers achieved significantly lower overall major complication (defined as neurologic injury, arterial or venous injury, vascular graft complication, pneumothorax, hemorrhage/hematoma or lymphatic leak) rates [adjusted Odds Ratio (OR) 0.71 (95% confidence interval 0.52-0.98); p=0.04], but no difference in neurologic complications such as brachial plexus injury (aOR 0.69 (0.20-2.43); p=0.56) or vascular injuries/graft complications [aOR 0.71 (0.0.33=1.54); p=0.39]. Overall mortality was 0.6%, neurologic injury was rare (0.3%), and the proportion of patients experiencing complications decreased over time (p=0.03). However, vTOS & aTOS had >2.5 times the odds of major complication compared to nTOS [OR 2.68 (1.88-3.82) & aOR 4.26 (1.78-10.17); p<0.001], and 10 times the odds of a vascular complication [aOR 10.37 (5.33-20.19) & aOR 12.93 (3.54-47.37); p<0.001], respectively. As the number of complications decreased, average hospital charges also significantly decreased over time (p<0.001). Total hospital charges were on average higher when surgery was performed in lower-volume centers (< 10 cases/year) compared to higher-volume centers [mean $65,634 (standard deviation 98,796) vs. $45,850 (59,285), p<0.001].The annual number of TOS operations have increased in the United States from 2010-2015, while complications and average hospital charges have decreased. Mortality and neurologic injury remain rare. Higher-volume centers delivered higher-value care: less or similar operative morbidity with lower total hospital charges.

View details for DOI 10.1016/j.avsg.2020.10.046

View details for PubMedID 33340669

Abstract

Thoracic endovascular aneurysm repair (TEVAR) has become the current standard of care for emergent treatment of blunt traumatic aortic injuries (BTAI). Although aortic dilation of the infrarenal neck following EVAR for aortic aneurysms has been studied, changes in aortic diameter following TEVAR for BTAI is not well understood. This study aims to characterize changes in thoracic aortic diameter following stent graft placement in the setting of non-aneurysmal traumatic aortic injury.A single-center, retrospective review was performed involving patients presenting with BTAI treated with TEVAR. Only patients with at least 12 months follow-up were included. Aortic diameter, defined as the outer-to-outer diameter on 3D center-line imaging, was measured at six locations along the proximal and mid thoracic aorta. The first post-operative CT (1 month) served as a baseline from which interval measurements were compared.Twenty patients with BTAI treated from 2011-2017 had adequate imaging available for review and were included in this study cohort. Median follow-up time was 46.8 (12-80, range) months. At latest follow-up, aortic dilation (AD) occurred at all measured locations within the endograft, starting from the proximal graft edge (0.620.69mm, p=.027) to the distal graft edge (1.211.28mm, p=.003). AD was most pronounced in the distal graft segment 2cm proximal to the distal graft edge, with a mean AD of 1.321.59mm (+5.3%, p<.001). At this location, AD was found to increase in a linear manner with an estimated rate of 0.670.20mm /year (p=0.006). The native aorta proximal and distal to the endograft was not found to significantly dilate during follow-up (p=.280-.897). 70% of patients were found to have AD >5%. The amount of aortic dilation was not found to be associated with either graft oversizing (p=.151) or age (p=.340). There were no cases of graft migration, erosion or endoleak.Aortic dilation is a common benign finding after TEVAR for BTAI. AD is most pronounced at the near the distal end of the stent graft. In late-term follow-up, there are no known associated complications related to AD.

View details for DOI 10.1016/j.avsg.2020.06.049

View details for PubMedID 32603842

Abstract

OBJECTIVE: True profunda femoris artery aneurysm (TPFAA) is rare. Most cases of profunda femoris artery aneurysm are classified as pseudoaneurysms. TPFAAs are mostly asymptomatic, but some are manifested with pain, swelling, paresthesia, gait and movement disturbances, thrombosis, and rupture. There is a paucity of evidence on the effectiveness of diagnostic and therapeutic measures for management of TPFAA. The aim of this paper was to systematically review the incidence, diagnosis, and management of TPFAA.METHODS: A comprehensive systematic review on the diagnosis and management of TPFAAs was conducted by a search through PubMed, Cochrane, Embase, and Google Scholar databases to identify and to evaluate publications on TPFAA since 2012. Only publications on TPFAA were included in this review.RESULTS: A total of 19 publications published from 2012 were included in the review. The studies were 18 case reports and a cadaver study reporting 27 TPFAAs in 26 patients with a mean age of 69.6years. Rupture was reported in 18.5% of the cases (n= 5); the conventional clinical presentation of unruptured TPFAA was reported in 48% of cases (n= 13), with 40.9% of unruptured aneurysms being asymptomatic (n= 9). Computed tomography angiography was used as a diagnostic tool in 85.2% of the cases (n= 23); Doppler ultrasound was applied in 33.3% of cases (n= 9). The common therapeutic approaches were resection and revascularization (n= 13 [48.1%]) and ligation or resection without reconstruction (n= 6 [22.2%]). Cumulative analysis for cases reported before and after 2012 yielded similar results.CONCLUSIONS: Review of the current literature supports that computed tomography angiography and Doppler ultrasound are the mainstay diagnostic approaches for TPFAA. Surgical repair through ligation, resection, and revascularization remains the most common and effective therapeutic procedure. Endovascular embolization is recommended for aneurysms when surgery is not tenable because of the patient's comorbidities and the aneurysm's anatomy.

View details for DOI 10.1016/j.jvs.2019.10.086

View details for PubMedID 31882317

Abstract

OBJECTIVES: Transplant renal stenosis (TRAS) is a serious complication associated with graft loss. Selective carbon dioxide angiography allows for effective diagnosis and therapy with the use of minimal to no contrast agent. This study sought to evaluate the efficacy of the adjunctive use of carbon dioxide angiography in the treatment of TRAS.METHODS: Patients undergoing endovascular therapy (percutaneous transluminal angioplasty with or without stent) for TRAS between the years 2012 and 2017 at a single tertiary care academic medical center were studied. Outcomes of interest included technical success, post-operative glomerular filtration rate (GFR), and renal ultrasound hemodynamic parameters.RESULTS: Of the 37 patients who underwent angiography for TRAS during the study period, 34 underwent a therapeutic intervention. Of those, 24 patients (70.6%) underwent adjunctive carbon dioxide angiography vs. 10 patients (29.4%) who underwent standard contrast angiography. Baseline characteristics between the carbon dioxide angiography and traditional angiography groups were similar. Patients undergoing carbon dioxide angiography received significantly less contrast agent than patients undergoing traditional angiography [9.5 ml (IQR 2-19.5) vs. 19.5 ml (IQR 15-30)], p =0.03)] and maintained equivalent technical success rates (92.2% vs. 91.7%, p=0.9).CONCLUSIONS: The adjunctive use of carbon dioxide angiography allows for significantly less contrast administration compared to standard angiography while achieving an equivalent rate of technical success. Selective carbon dioxide angiography should be considered a first line modality for patients with TRAS in need of endovascular therapy.

View details for DOI 10.1016/j.avsg.2019.08.085

View details for PubMedID 31626944

View details for DOI 10.1016/j.jvs.2018.12.036

View details for Web of Science ID 000486615200036

View details for DOI 10.1016/j.avsg.2019.01.028

View details for Web of Science ID 000479186900025

View details for DOI 10.1016/j.jvs.2019.04.236

View details for Web of Science ID 000469220300232

View details for DOI 10.1016/j.jvs.2019.04.142

View details for Web of Science ID 000469220300139

Abstract

Importance: Ambulatory surgery in geriatric populations is increasingly prevalent. Prior studies have demonstrated the association between frailty and readmissions in the inpatient setting. However, few data exist regarding the association between frailty and readmissions after outpatient procedures.Objective: To examine the association between frailty and 30-day unplanned readmissions after elective outpatient surgical procedures as well as the potential mediation of surgical complications.Design, Setting, and Participants: In this retrospective cohort study of elective outpatient procedures from 2012 and 2013 in the National Surgical Quality Improvement Program (NSQIP) database, 417840 patients who underwent elective outpatient procedures were stratified into cohorts of individuals with a length of stay (LOS) of 0 days (LOS=0) and those with a LOS of 1 or more days (LOS1). Statistical analysis was performed from June 1, 2018, to March 31, 2019.Exposure: Frailty, as measured by the Risk Analysis Index.Main Outcomes and Measures: The main outcome was 30-day unplanned readmission.Results: Of the 417840 patients in this study, 59.2% were women and unplanned readmission occurred in 2.3% of the cohort overall (LOS=0, 2.0%; LOS1, 3.4%). Frail patients (mean [SD] age, 64.9 [15.5] years) were more likely than nonfrail patients (mean [SD] age, 35.0 [15.8] years) to have an unplanned readmission in both LOS cohorts (LOS=0, 8.3% vs 1.9%; LOS1, 8.5% vs 3.2%; P<.001). Frail patients were also more likely than nonfrail patients to experience complications in both cohorts (LOS=0, 6.9% vs 2.5%; LOS1, 9.8% vs 4.6%; P<.001). In multivariate analysis, frailty doubled the risk of unplanned readmission (LOS=0: adjusted relative risk [RR], 2.1; 95% CI, 2.0-2.3; LOS1: adjusted RR, 1.8; 95% CI, 1.6-2.1). Complications occurred in 3.1% of the entire cohort, and frailty was associated with increased risk of complications (unadjusted RR, 2.6; 95% CI, 2.4-2.8). Mediation analysis confirmed that complications are a significant mediator in the association between frailty and readmissions; however, it also indicated that the association of frailty with readmission was only partially mediated by complications (LOS=0, 22.8%; LOS1, 29.3%).Conclusions and Relevance: These findings suggest that frailty is a significant risk factor for unplanned readmission after elective outpatient surgery both independently and when partially mediated through increased complications. Screening for frailty might inform the development of interventions to decrease unplanned readmissions, including those for outpatient procedures.

View details for DOI 10.1001/jamanetworkopen.2019.4330

View details for PubMedID 31125103

Abstract

BACKGROUND: Prescription opioids account for 40% of all U.S. opioid overdose deaths, and national efforts have intensified to reduce opioid prescriptions. Little is known about the relationship between peripheral artery disease (PAD) and high-risk opioid use. The objectives of this study were to evaluate this relationship and to assess the impact of PAD treatment on opiate use.METHODS: In this retrospective cohort study, the Truven Health MarketScan database (Truven Health Analytics, Ann Arbor, Mich), a deidentified national private insurance claims database, was queried to identify patients with PAD (two or more International Classification of Diseases, Ninth Revision diagnosis codes of PAD 2months apart, with at least 2years of continuous enrollment) from 2007 to 2015. Critical limb ischemia (CLI) was defined as the presence of rest pain, ulcers, or gangrene. The primary outcome was high opioid use, defined as two or more opioid prescriptions within a 1-year period. Multivariable analysis was used to determine risk factors for high opioid use.RESULTS: A total of 178,880 patients met the inclusion criteria, 35% of whom had CLI. Mean standard deviation follow-up time was 5.3 2.1years. An average of 24.7% of patients met the high opioid use criteria in any given calendar year, with a small but significant decline in high opioid use after 2010 (P< .01). During years of high opioid use, 5.9 5.5 yearly prescriptions were filled. A new diagnosis of PAD increased high opioid use (21.7% before diagnosis vs 27.3% after diagnosis; P<.001). A diagnosis of CLI was also associated with increased high opioid use (25.4% before diagnosis vs 34.5% after diagnosis; P< .001). Multivariable analysis identified back pain (odds ratio [OR], 1.89; 95% confidence interval [CI], 1.84-1.93; P< .001) and illicit drug use (OR, 1.87; 95% CI, 1.72-2.03; P< .001) as the highest predictors of high opioid use. A diagnosis of CLI was also associated with higher risk (OR, 1.61; 95% CI, 1.57-1.64; P< .001). A total of 43,443 PAD patients (24.3%) underwent 80,816 PAD-related procedures. After exclusion of periprocedural opioid prescriptions (4.9% of all opioid prescriptions), the yearly percentage of high opioid users increased from 25.8% before treatment to 29.6% after treatment (P< .001).CONCLUSIONS: Patients with PAD are at increased risk for high opioid use, with nearly one-quarter meeting described criteria. CLI and treatment for PAD additionally increase high opioid use. In addition to heightened awareness and active opioid management, our findings warrant further investigation into underlying causes and deterrents of high-risk opioid use.

View details for PubMedID 30922747

View details for DOI 10.1016/j.avsg.2018.08.072

View details for Web of Science ID 000455942200012

View details for DOI 10.1177/1708538118797556

View details for Web of Science ID 000456447900014

Abstract

Compartment syndrome (CS) is a feared complication after revascularization for acute limb ischemia (ALI), and patients often undergo prophylactic 4-compartment fasciotomy at the time of revascularization to avoid developing CS and its associated complications. However, fasciotomy carries its own morbidity and surgeons may opt against this initially. The subsequent development of CS would mandate fasciotomy in a delayed fashion. We sought to investigate relationships between fasciotomy timing and patient outcomes.Patients who underwent lower extremity revascularization for ALI from 2005-2017 were retrospectively identified from an institutional database. Fasciotomy was classified as either prophylactic (occurring with revascularization) or delayed. Associations between patient characteristics, comorbidities, fasciotomy timing and patient outcomes were evaluated.A total of 138 patients met study inclusion criteria. Forty-two patients (30.4%) underwent fasciotomy, and of these, 8 (19%) were delayed. Patients with higher Rutherford acute limb ischemia classification were more likely to undergo fasciotomy (I 4.2%, IIA 13.2%, IIB 53.3%, p<0.001), and patients with coronary artery disease were less likely (16.1% vs. 83.9% fasciotomy, p=0.003). Ischemia time > 6 hours was noted in 66.7% of patients, though this was not significantly associated with fasciotomy occurrence (6 hours 21.7% fasciotomy vs. >6 hours 34.8% fasciotomy, p=0.17). Patients undergoing delayed fasciotomy were more likely to require major amputation within 30 days (50% vs. 5.9%, p=0.002).The decision to perform prophylactic fasciotomy in the setting of ALI is complex. When not performed, the subsequent development of CS requiring delayed fasciotomy appears to be associated with increased risk of major amputation at 30 days. This suggests that a liberal approach to prophylactic fasciotomy at the time of revascularization may improve limb salvage rates.

View details for PubMedID 31034949

View details for DOI 10.1016/j.avsg.2018.03.029

View details for Web of Science ID 000452541600017

View details for DOI 10.1016/j.jamcollsurg.2018.08.062

View details for Web of Science ID 000447772500053

Abstract

Objectives Upper extremity arterial access is often required for endovascular procedures, especially for antegrade access to the visceral aortic branches. Radial arterial access has been shown previously to have low complication rates, and patients tolerate the procedure well and are able to recover quickly. However, transradial access remains relatively uncommon amongst vascular surgeons. Methods The radial artery was evaluated by ultrasound to evaluate for adequate caliber, and to identify any aberrant anatomy or arterial loops. A modified Barbeau test was performed to ensure sufficient collateral circulation. A cocktail of nitroglycerin, verapamil and heparin was administered intra-arterially to combat vasospasm. Sheaths up to 6 French were utilized for interventions. On completion of the procedure, a compression band was used for hemostasis in all cases. Results Twenty-five interventions were performed in 24 patients. The left radial artery was used in 23/25 cases (92.0%). Procedures included visceral and renal artery interventions; stent graft repair of a renal artery aneurysm; embolization of splenic, pancreaticoduodenal and internal mammary aneurysms; embolization of bilateral hypogastric arteries following blunt pelvic trauma; interventions for peripheral arterial disease; delivery of a renal snorkel graft during endovascular aortic aneurysm repair, and access for diagnostic catheters during thoracic endovascular aortic aneurysm repair. Technical success was 92.0%. There was one post-operative radial artery occlusion (4.3%) which led to paresthesias but resolved with anticoagulation. There were no instances of arterial rupture, hematoma, or hand ischemia requiring intervention. Conclusions Using the transradial approach, we have demonstrated a high technical success rate over a range of clinical contexts with minimal morbidity and no significant complications such as bleeding or hand ischemia. The safety profile compares favorably to historical complication rates from brachial access. Radial access is a safe and useful skill for vascular surgeons to master.

View details for PubMedID 30205780

Abstract

INTRODUCTION: and Objectives: Retrograde arterial access (RA) of the popliteal, tibial or pedal arteries may facilitate endovascular treatment of complex infrainguinal lesions in patients with critical limb ischemia (CLI). Here, we assess the safety and efficacy of this technique.METHODS: A retrospective review of prospectively collected institutional data (consecutive M2S entries) was performed to identify patients with CLI undergoing peripheral vascular intervention from February, 2012 through December, 2017. Demographics, co-morbidities, procedural characteristics and outcomes were analyzed, and comparisons made between outcomes of patients undergoing RA and those undergoing a standard antegrade approach (SA).RESULTS: 566 patients were identified, of whom 26 (4.6%) underwent RA. Of these, 4 were accessed via the popliteal artery (15.4%), 13 via the tibial vessels above the ankle (50.0%), and 9 via pedal vessels (34.6%). RA facilitated procedural success in 96.2% of cases. There were no instances of distal embolization, perforation, or loss of distal target with RA. Primary, primary assisted and secondary patency rates were consistently lower for RA than for SA patients, as was limb salvage and amputation-free survival. No difference was seen in overall survival.CONCLUSIONS: RA represents a viable and safe option for revascularization when SA fails. Although outcomes are poorer than with SA, this technique can be useful in CLI patients, especially when open surgical revascularization is not an option.

View details for PubMedID 30217705

View details for Web of Science ID 000433036700076

View details for DOI 10.23736/S0021-9509.18.10342-9

View details for Web of Science ID 000445207000010

Abstract

The advancement of endovascular therapy has led to minimally invasive solutions to increasingly complex aortic pathology, including thoracoabdominal aneurysms and those involving the visceral segment. Upper extremity access is beneficial in a variety of these complex interventions, and may be absolutely required for certain procedures such as placement of parallel chimney grafts. Traditionally, the brachial artery has been the primary access site on the arm, using either a percutaneous or open approach. Brachial access is safe and effective, and remains suitable for the majority of clinical situations. More recently though, descriptions of axillary and radial access have emerged and may provide a useful alternative in specific cases. These options should be viewed as complementary rather than competitive, and facility with all three techniques is desirable. Here, we describe in detail the various options for upper extremity access during complex aortic aneurysm repair and their relative advantages.

View details for PubMedID 29327566

Abstract

INTRODUCTION: /Objectives: The purpose of this study was to characterize utilization and outcomes of TEVAR in New York State during the first decade of commercial availability, with respect to evolving indications, results, and costs. Of specific interest was evaluation of the volume-outcome relationship for this relatively uncommon procedure.METHODS: The New York Statewide Planning and Research Cooperative System (SPARCS) database was queried to identify patients undergoing TEVAR from 2005-2014 for aortic dissection (AD), non-ruptured aneurysm (NRA), and ruptured aneurysm (RA). Outcomes assessed included in-hospital mortality, complications and costs. Linkage to the NPI and NY Office of Professions databases facilitated comparisons by surgeon and facility volume.RESULTS: 1838 patients were identified: 334 AD, 226 RA, and 1278 NRA. Since introduction, TEVAR implantation increased significantly over the 10-year period in all groups (p<0.01), with recent increase in utilization for AD. Increased in-hospital mortality correlated to RA [OR 5.52 (3.02-10.08), p<0.01], coagulopathy [3.38 (2.02-5.66), p<0.01], cerebrovascular disease [2.47 (1.17-5.22), p=0.02], and non-white/non-black race [1.74 (1.08-2.82), p=0.02]. Early in the experience (2005-2007), patients were more likely to be treated at high-volume facilities (>17 per year) and by high volume surgeons (>5 per year), (p<0.01). Since 2011, however, most patients (53%) have undergone TEVAR by low volume surgeons (<3 per year). Neither surgeon nor hospital volume were associated with clinical outcomes.CONCLUSIONS: Since the introduction of TEVAR, comparable results have been obtained across hospital and surgeon volume strata. Favorable outcomes, even in low-volume settings, underscore the complexity of volume-outcome relationships in high-acuity procedures. These findings have implications for credentialing, regionalization, and future dissemination of advanced endovascular technology.

View details for PubMedID 29778610

Abstract

Here, we describe a totally percutaneous technique for longitudinal fenestration of a chronic dissection flap in the setting of endovascular aneurysm repair (EVAR), where the septum would otherwise preclude proper endograft sealing. This technique is demonstrated in a 65-year-old man with a history of open surgical repair of a Stanford type A aortic dissection, with a type B component that was managed nonoperatively. The patient developed aneurysmal degeneration of the infrarenal aorta during follow-up, and his anatomy was well suited for EVAR with the exception of a chronic dissection flap dividing the proximal seal zone. Using bilateral percutaneous access, a wire was passed through an existing fenestration in the septum from true to false lumen and snared from the contralateral side. Downward traction on this through-wire was then used as a "cheese-wire" to divide the septum longitudinally and clear it from the proximal fixation site. Removal of the septum provided an adequate proximal seal zone for the endograft, and standard infrarenal EVAR was then performed with a good technical result. Longitudinal fenestration using this technique is a useful adjunctive maneuver to facilitate EVAR in the setting of chronic aortic dissection and is safely achievable via a totally percutaneous approach.

View details for DOI 10.1177/1538574417753006

View details for PubMedID 29334863

Abstract

We describe successful endovascular treatment of a patient with fibromuscular dysplasia of the celiac axis leading to development of a common hepatic artery pseudoaneurysm with contained rupture. An 81-year-old woman was transferred to our quaternary care center with concern for a hepatic artery rupture. Further imaging demonstrated a common hepatic artery pseudoaneurysm with surrounding hematoma as well as multifocal areas of narrowing and dilatation in the celiac trunk consistent with fibromuscular dysplasia. A similar pattern was subsequently identified in the bilateral renal and carotid arteries. The patient underwent successful endovascular exclusion of the pseudoaneurysm with a balloon-expandable covered stent and was discharged home without incident. Fibromuscular dysplasia is a nonatherosclerotic arteriopathy that can lead to stenosis, occlusion, dissection, and aneurysm formation. While it primarily affects the carotid and renal arteries, there are rare case reports involving the mesenteric vasculature. Endovascular therapy appears to be a feasible treatment option for the complicated sequelae of this condition in the rare case of mesenteric arterial involvement.

View details for PubMedID 30114972

Abstract

We describe successful endovascular treatment of a patient with fibromuscular dysplasia of the celiac axis leading to development of a common hepatic artery pseudoaneurysm with contained rupture. An 81-year-old woman was transferred to our quaternary care center with concern for a hepatic artery rupture. Further imaging demonstrated a common hepatic artery pseudoaneurysm with surrounding hematoma as well as multifocal areas of narrowing and dilatation in the celiac trunk consistent with fibromuscular dysplasia. A similar pattern was subsequently identified in the bilateral renal and carotid arteries. The patient underwent successful endovascular exclusion of the pseudoaneurysm with a balloon-expandable covered stent and was discharged home without incident. Fibromuscular dysplasia is a nonatherosclerotic arteriopathy that can lead to stenosis, occlusion, dissection, and aneurysm formation. While it primarily affects the carotid and renal arteries, there are rare case reports involving the mesenteric vasculature. Endovascular therapy appears to be a feasible treatment option for the complicated sequelae of this condition in the rare case of mesenteric arterial involvement.

View details for DOI 10.1177/1538574418794075

Abstract

Inferior vena cava filters (IVCFs) are often placed for prophylactic indications. We sought to better define the range of practice indications for placement of prophylactic IVCFs, as well as the specific retrieval rate and risk factors for nonretrieval.A retrospective, single-institution review of patients undergoing IVCF placement over a 2-year period was performed. Patients undergoing prophylactic IVCF placement were selected from a prospectively collected database. Risk factors for nonretrieval were identified using a multivariate logistic regression model.Of 615 IVCFs placed, 256 were retrievable filters placed for prophylactic indications and comprised the study cohort. The most common indications were a history of venous thromboembolic disease (43.7%), malignancy (35.1%), bleeding risk precluding anticoagulation (33.9%), and trauma (22.6%). One hundred sixty-three (63.6%) were placed preoperatively. Placement was performed in 70.3% by interventional radiology, 21.4% by vascular surgery, and 8.2% by cardiology. The most common requesting services were orthopedics (67%), general surgery (11%), neurosurgery (9%), and bariatric surgery (7%). Of all, 67.6% were placed in the inpatient setting and 32.4% in outpatients. Seventy-one (27.7%) of the 256 prophylactic filters were retrieved, with a mean indwelling time of 92 74 days. Inpatients were significantly less likely to have their IVCF removed (32.4% vs 57.8%; P < .001), as were preoperative patients.This study helps define current practice trends for the placement of prophylactic IVCFs. Importantly, the specific retrieval rate for prophylactic filters is low. This suggests that prophylactic IVCF usage is suboptimal and efforts should be taken to increase retrieval, especially among inpatients and perioperative patients.

View details for DOI 10.1177/1538574417740507

View details for PubMedID 29121841

Abstract

A majority of patients undergoing lower limb amputations have diabetes or peripheral artery disease. Despite improvements in care, there remains a substantial perioperative mortality associated with these procedures. Less well-defined is the mortality risk to these patients going forward, once outside the perioperative period. The aim of this systematic review is to summarize and pool the available data to determine the long-term mortality associated with amputation in the diabetic and peripheral vascular patient, as well as to define specific factors associated with increased mortality risk.Four databases were searched from January 2005 through July 2015 using the Medical Subject Headings terms "amputation," "lower extremity," and "mortality." Inclusion criteria were observational and cohort studies where 50% of amputations were attributable to diabetic or vascular etiologies. Final article inclusion was approved by reviewer consensus. Bias was assessed with the Joanna Briggs Institute Critical Appraisal Tool for cohort studies.Of the 365 unique records screened, 43 abstracts and 21 full articles were reviewed and 16 studies ultimately included. The overall mortality rate was 47.9%, 61.3%, 70.6%, and 62.2% at 1-, 2-, 3- and 5-year follow-up, respectively. In addition to diabetes and peripheral vascular disease, comorbid factors associated with at least a 2-fold increased mortality were coronary artery disease, cerebrovascular disease, renal dysfunction, American Society of Anesthesiologists class 4, dementia, and nonambulatory status. Surgical factors, including higher amputation level and need for staged surgery with up-front guillotine amputation, were also correlated with increased mortality.The overall mortality rate after primary lower limb amputation in the diabetic and peripheral vascular population is substantial, and should not be underestimated when making decisions regarding limb salvage. Similar to patients undergoing revascularization, comorbid conditions associated with higher mortality should be optimized before surgery whenever possible.

View details for DOI 10.1016/j.avsg.2016.12.015

View details for PubMedID 28389295

Abstract

Endovascular treatment of thoracoabdominal aortic aneurysms (TAAAs) with branched and fenestrated stent grafts often requires upper extremity arterial access for antegrade delivery of bridging covered stents into the visceral arteries. Axillary, brachial, and radial artery approaches have been described, but data on the safety and utility of the different approaches remain limited. We have preferentially used axillary artery conduits for upper extremity arterial access during endovascular repair of TAAA and describe our technique and report our experience herein.Thirty-two patients were treated within an investigator-sponsored investigational device exemption clinical trial of endovascular repair of TAAAs using custom-manufactured stent grafts. In 29 of these cases, the axillary artery was exposed through an infraclavicular incision, and an axillary conduit was used for antegrade delivery of bridging visceral artery stent components. In all cases, a 12F sheath was placed through the conduit for delivery of stent graft components. The left axillary artery was used in 27 of these 29 cases, and the right axillary artery was used in 2 patients. Proximal brachial artery access was used in two patients, and one patient did not require upper extremity access. Aneurysms treated included pararenal (n= 3) and Crawford TAAA extent I (n= 1), extent II (n= 3), extent III (n= 10), and extent IV (n=15). Patients have been followed up to 2years after the procedure, with a mean follow-up of 226days.Axillary conduits were used to deliver a total of 170 stent components placed into 81 branches and 27 fenestrations with 99.1% technical success (one accessory renal branch could not be cannulated). There were no intraoperative complications related to the construction or use of the conduit. There were two postoperative complications (6.9%) potentially attributable to the conduit; one patient experienced ipsilateral hand weakness and one patient had postoperative minor stroke, which resolved by the first postoperative visit. There were no cases of arm ischemia, wound hematoma, or reoperation related to the conduit.The use of an axillary conduit during endovascular repair of complex aortic aneurysms provides safe and effective upper extremity access for delivery of visceral branches. Moreover, axillary conduits facilitate delivery of 12F sheaths without interrupting upper extremity perfusion and provide a shorter working distance compared with brachial artery approaches.

View details for DOI 10.1016/j.jvs.2016.12.107

View details for PubMedID 28259569

Abstract

May-Thurner syndrome (MTS), the clinical sequelae of left iliac vein compression between the right iliac artery and the spine, is an accepted cause of lower extremity edema and venous thromboembolism. It is more prevalent in younger women and typically presents with left lower extremity symptoms. Atypical presentations such as right-sided symptoms, chronic pelvic pain, and even fatal venous rupture have been reported. Here, we describe iliac vein compression presenting as a chronic left-sided testicular varicocele.A 22-year-old man presented with left testicular varicocele, scrotal edema, and pain after failing multiple attempts at surgical repair. MRI revealed left iliac vein compression and marked cross-pelvic collaterals. Venography and intravascular ultrasound confirmed left common iliac vein compression and typical changes of MTS. There was no gonadal vein (GV) reflux. An iliac vein stent (WALLSTENT, Boston Scientific) was placed.A good technical result was achieved, with elimination of internal iliac vein reflux and marked reduction in pelvic collateral flow (see image). The patient reported resolution of his symptoms.Varicocele is a leading cause of testosterone insufficiency and infertility in young males. In the majority of cases, successful treatment can be achieved by addressing reflux in the internal spermatic vein (ISV) and/or GV by a variety of surgical or endovascular approaches. In unusual cases, the culprit pathology may be reflux in the vein of the vas deferens, which unlike the ISV and GV, drains into the internal iliac vein. In such cases, iliac vein compression usually associated with MTS may result in varicocele. To our knowledge, this is the first report of refractory varicocele secondary to iliac vein compression successfully treated with endovenous stenting.

View details for DOI 10.1016/j.avsg.2016.12.001

View details for PubMedID 28258018

Abstract

Transradial access has been described in a variety of clinical contexts but has been rarely utilized for visceral artery interventions and during complex endovascular aortic aneurysm repair (EVAR) when upper extremity access is required. This is usually accomplished via brachial artery access, and although brachial access is generally safe and effective, radial access may offer some benefits with regard to patient comfort and potential complications. Here we report a case of successful delivery of a renal snorkel via a radial artery approach during EVAR. A 71-year-old man presented for endovascular repair of an asymptomatic abdominal aortic aneurysm. Anatomic limitations dictated the need for a left renal snorkel in order to augment the proximal seal zone. Via a right radial approach, a 6-Fr sheath and then a 6-mm iCast stent (Atrium Medical, Hudson, New Hampshire) were delivered into the left renal artery. Endovascular aortic aneurysm repair was then completed with a bifurcated Endurant stent graft (Medtronic, Fridley, Minnesota). The renal stent and aortic stent grafts were successfully deployed. Completion angiography demonstrated a patent left renal snorkel, with no evidence of endoleak. Hemostasis was achieved at the radial puncture site with no complications. This demonstrates the feasibility of radial artery access for the delivery of adjunctive stents during complex EVAR.

View details for DOI 10.1177/1538574417723158

View details for PubMedID 28774222