Early carotid endarterectomy in symptomatic patients is associated with poorer perioperative outcomes

ObjectiveThe optimal timing of carotid endarterectomy (CEA) after ipsilateral hemispheric stroke is controversial. Although early studies suggested that an interval of about 6 weeks after a completed stroke was preferred, more recent data have suggested that delaying CEA for this period of time is not necessary. With these issues in mind, we reviewed our experience to examine perioperative outcome with respect to the timing of CEA in previously symptomatic patients.MethodsA retrospective review of a prospectively maintained database of all CEAs performed at our institution from 1992 to 2003 showed that 2537 CEA were performed, of which 1158 (45.6%) were in symptomatic patients. Patients who were operated on emergently ≤48 hours of symptoms for crescendo transient ischemic attacks (TIAs) or stroke-in-evolution were excluded from analysis (n = 25). CEA was considered “early” if performed ≤4 weeks of symptoms, and “delayed” if performed after a minimum of a 4-week interval following the most recent symptom.ResultsOf nonurgent CEAs in symptomatic patients, in 87 instances the exact time interval from symptoms to surgery could not be precisely determined secondary to the remoteness of the symptoms (>18 months), and these were excluded from further analysis. Of the remaining 1046 cases, 62.7% had TIAs and 37.3% had completed strokes as their indication for surgery. Among the entire cohort, patients who underwent early CEA were significantly more likely to experience a perioperative stroke than patients who underwent delayed CEA (5.1% vs 1.6%, P = .002). Patients with TIAs alone were more likely to be operated on early rather than in a delayed fashion (64.3% vs 46.7%, P < .0001), likely reflecting institutional bias in selecting delayed CEA for stroke patients. However, even when examined as two separate groups, both TIA patients (n = 656) and CVA patients (n = 390) were significantly more likely to experience a perioperative stroke when operated upon early rather than in a delayed fashion (TIA patients, 3.3% vs 0.9%, P = .05; CVA patients, 9.4% vs 2.4%, P = .003). There were no significant differences in demographics or other meaningful variables between patients who underwent early CEA and those who underwent delayed CEA.ConclusionsIn a large institutional experience, patients who underwent CEA ≤4 weeks of ipsilateral TIA or stroke experienced a significantly increased rate of perioperative stroke compared with patients who underwent CEA in a more delayed fashion. This was true for both TIA and stroke patients, although the results were more impressive among stroke patients. On the basis of these results, we continue to recommend that waiting period of 4 weeks be considered in stroke patients who are candidates for CEA

Upscaling marine forest restoration: challenges, solutions and recommendations from the Green Gravel Action Group

IntroductionTo counteract the rapid loss of marine forests globally and meet international commitments of the UN Decade on Ecosystem Restoration and the Convention on Biological Diversity ‘30 by 30’ targets, there is an urgent need to enhance our capacity for macroalgal restoration. The Green Gravel Action Group (GGAG) is a global network of 67 members that are working on the restoration of a diverse range of macroalgal forests and it aims to facilitate knowledge exchange to fast-track innovation and implementation of outplanting approaches worldwide. MethodsHere, we overview 25 projects conducted by members of the group that are focused on testing and developing techniques for macroalgal restoration. Based on these projects, we summarise the major challenges associated with scaling up the area of marine forests restored. ResultsWe identify several critical challenges that currently impede more widespread rollout of effective large-scale macroalgal restoration worldwide: 1) funding and capacity limitations, 2) difficulties arising from conditions at restoration sites, 3) technical barriers, and 4) challenges at the restoration-policy interface. DiscussionDespite these challenges, there has been substantial progress, with an increasing number of efforts, community engagement and momentum towards scaling up activities in recent years. Drawing on the collective expertise of the GGAG, we outline key recommendations for the scaling up of restoration efforts to match the goals of international commitments. These include the establishment of novel pathways to fund macroalgal restoration activities, building skills and capacity, harnessing emerging innovations in mobile hatchery and seeding technologies, and the development of the scientific and governance frameworks necessary to implement and monitor macroalgal restoration projects at scale

Non-Reversed and Reversed Great Saphenous Vein Graft Configurations Offer Comparable Early Outcomes in Patients Undergoing Infrainguinal Bypass

OBJECTIVE: Data on the efficacy of non-reversed and reversed great saphenous vein bypass (NRGSV and RGSV) techniques are lacking. The aim of the study was to compare the outcomes of patients undergoing open infrainguinal revascularisation using NRGSV and RGSV from a multi-institutional database. METHODS: The Vascular Quality Initiative database was queried for patients undergoing infrainguinal bypasses using NRGSV and RGSV for symptomatic occlusive disease from January 2003 to February 2021. The primary outcome measures included primary and secondary patency at discharge and one year. Secondary outcomes were re-interventions at discharge and one year. Cox proportional hazards models were used to evaluate the impact of graft configuration on outcomes of interest. RESULTS: Of 7 123 patients, 4 662 and 2 461 patients underwent RGSV and NRGSV, respectively. At one year, the rates of primary patency (78% vs. 78%; p = .83), secondary patency (90% vs. 89%; p = .26), and re-intervention (16% vs. 16%; p = .95) were similar between the RGSV and NRGSV cohorts, respectively. Subgroup analysis based on outflow bypass target and indication for revascularisation did not show differences in primary and secondary outcomes between the two groups. Multivariable analysis confirmed that RGSV (NRGSV as the reference) configuration was not independently associated with increased risk of primary patency loss (hazard ratio [HR] 1.01; 95% confidence interval [CI] 0.91 - 1.13; p = .80), secondary patency loss (HR 0.94; 95% CI 0.81 - 1.10; p = .44), and re-intervention (HR 1.03; 95% CI 0.91 - 1.16; p = .67) at follow up. CONCLUSION: The study shows that RGSV and NRGSV grafting techniques have comparable peri-operative and one year primary and secondary patency and re-intervention rates. This effect persisted when stratified by outflow targets and indication for revascularisation. Therefore, optimal selection of vein grafting technique should be guided by the patient\u27s anatomy, vein conduit availability, and surgeon\u27s experience

Comparative Analysis of Patients Undergoing Lower Extremity Bypass Using In-Situ and Reversed Great Saphenous Vein Graft Techniques

OBJECTIVE: Autologous great saphenous vein (GSV) is considered the conduit of choice for lower extremity bypass (LEB). However, the optimal configuration remains the source of debate. We compared outcomes of patients undergoing LEB using in-situ and reversed techniques. METHODS: The Vascular Quality Initiative database was queried for patients undergoing LEB with a single-segment GSV in in-situ (ISGSV) and reversed (RGSV) configurations for symptomatic occlusive disease from 2003 to 2021. Patient demographics, procedural detail, and in-hospital and follow-up outcomes were collected. The primary outcome measures included primary patency at discharge or 30 days and one year. Secondary outcomes were secondary patency, and reinterventions at discharge or 30 days and one year. Cox proportional hazards models were created to determine the association between bypass techniques and outcomes of interest. RESULTS: Of 8234 patients undergoing LEBs, in-situ and reversed techniques were used in 3546 and 4688 patients, respectively. The indication for LEBs was similar between the two cohorts. ISGSV was performed more frequently from the common femoral artery and to more distal targets. RGSV bypass was associated with higher intraoperative blood loss and longer operative time. Perioperatively, ISGSV cohort had higher rates of reinterventions (13.2 vs 11.1%; = 0.004), surgical site infection (4.2 vs 3%; = 0.003), and lower primary patency (93.5 vs 95%; = 0.004) but a comparable rate of secondary patency (99 vs 99.1%; = 0.675). At 1 year, in-situ bypasses had a lower rate of reinterventions (19.4% vs 21.6%; =0.02), with similar rates of primary (82.6 vs 81.8%; = 0.237) and secondary patency (88.7 vs 88.9%; = 0.625). After adjusting for significant baseline differences and potential confounders, in-situ bypass was independently associated with decreased risks of primary patency loss (HR 0.9; 95% CI, 0.82-0.98; = 0.016) and reinterventions (HR 0.88; 95% CI, 0.8-0.97; = 0.014) but a similar risk of secondary patency loss (HR 0.99; 95% CI, 0.86-1.16; = 0.985) at follow-up, compared to reversed bypass. A subgroup analysis of bypasses to crural targets showed that in-situ and reversed bypasses had similar rates of primary patency loss and reinterventions at 1 year. Among patients with chronic limb-threatening ischemia, in-situ bypass was associated with a decreased risk of reinterventions but similar rates of primary and secondary patency and major amputations at 1 year. CONCLUSIONS: In patients undergoing LEBs using the GSV, in-situ configuration was associated with more perioperative reinterventions and lower primary patency rate. However, this was offset by decreased risks of loss of primary patency and reinterventions at 1 year. A thorough intraoperative graft assessment with adjunctive imaging may be performed to detect abnormalities in patients undergoing in-situ bypasses to prevent early failures. Furthermore, closer surveillance of reversed bypass grafts is warranted given the higher rates of reinterventions

Safety And Efficacy Of Drug-eluting Stents For Treatment Of Transplant Renal Artery Stenosis

INTRODUCTION AND OBJECTIVES: There is a paucity of clinical data on use of drug-eluting stent (DES) for transplant renal artery stenosis (TRAS). Therefore, we investigated outcomes of patients with clinically significant TRAS undergoing DES placement. METHODS: A retrospective review of patients with clinically significant TRAS undergoing percutaneous balloon angioplasty with DES from 2014 to 2021 was conducted. Patient demographics, procedural details, and follow-up outcomes were collected. Primary endpoints were the in-stent primary patency and graft survival. Secondary endpoints were freedom from reintervention and primary-assisted patency RESULTS: Thirteen TRAS in twelve patients with graft function alteration were treated with DES. The median age was 57 years (interquartile range (IQR), 48-63), and nine (75%) were male. The median follow-up was 9 months (IQR, 4-52). The median time from transplant to intervention was 5.8 months. TRAS was most commonly found at the proximal portion (92%). The procedure was performed with carbon dioxide angiography with minimal amount of contrast (median, 3 mL) under local and general anesthesia in nine (69%) and four (21%) TRAS, respectively. The rates of stenosis-free primary patency of the DES and graft survival were 75% and 100%, respectively. Three reinterventions for restenosis resulted from the kinking of the transplant renal artery proximal to the DES, which were treated by extending the stent more proximally into the origin of the transplant renal artery. The median time to reintervention was 0.9 months (range, 0.23-2 months). Freedom from reintervention and primary-assisted patency were 75% and 100%, respectively. CONCLUSIONS: Despite the lack of evidence in literature, these data demonstrate that DES is safe and effective in treating patients with TRAS at short to midterm. As all reinterventions after DES were performed due to kinking of the transplant renal artery proximal to the stent, bridging of the DES into the external iliac artery is recommended

The Impact of Aorto-Uni-Iliac Graft Configuration on Outcomes of Endovascular Repair for Ruptured Abdominal Aortic Aneurysms

INTRODUCTION: Endovascular aneurysm repair has improved outcomes for ruptured abdominal aortic aneurysms (rAAA) compared with open repair. We examined the impact of aorto-uni-iliac (AUI) vs standard bifurcated endograft configuration on outcomes in rAAA. METHODS: Patients 18 years or older in the Vascular Quality Initiative database who underwent endovascular aneurysm repair for rAAA from January 2011 to April 2020 were included. Patient characteristics were analyzed by graft configuration: AUI or standard bifurcated. Primary and secondary outcomes included 30-day mortality, postoperative major adverse events (myocardial infarction, stroke, heart failure, mesenteric ischemia, lower extremity embolization, dialysis requirement, reoperation, pneumonia, or reintubation), and 1-year mortality. A subset propensity-score matched cohort was also analyzed. RESULTS: We included 2717 patients: 151 had AUI and 2566 had standard bifurcated repair. There was no significant difference between the groups in terms of age, major medical comorbidities, anatomic aortic neck characteristics, or rates of conversion to open repair. Patients who underwent AUI were more commonly female (30% vs 22%, P = .011) and had a history of congestive heart failure (19% vs 12%, P = .013). Perioperatively, patients who underwent AUI had a significantly higher incidence of cardiac arrest (15% vs 7%, P \u3c .001), greater intraoperative blood loss (1.3 L vs 0.6 L, P \u3c .001), longer operative duration (218 minutes vs 138 minutes, P \u3c .0001), higher incidence of major adverse events (46.3% vs 33.3%, P = .001), and prolonged intensive care unit (7 vs 4.7 days, P = .0006) and overall hospital length of stay (11.4 vs 8.1 days, P = .0003). Kaplan-Meier survival analyses demonstrated significant differences in 30-day (31.1% vs 20.2%, log-rank P = .001) and 1-year mortality (41.7% vs 27.7%, log-rank P = .001). The propensity-score matched cohort demonstrated similar results. CONCLUSIONS: The AUI configuration for rAAA appears to be implemented in a sicker cohort of patients and is associated with worse perioperative and 1-year outcomes compared with a bifurcated graft configuration, which was also seen on propensity-matched analysis. Standard bifurcated graft configuration may be the preferred approach in the management of rAAA unless AUI configuration is mandated by patient anatomy or other extenuating circumstances