Acute Complicated Type B Aortic Dissection: Do Alternative Strategies Versus Central Aortic Repair Make Sense?

Current guidelines dictate emergency repair for an acute complicated type B aortic dissection (TBAD). Surgical approaches for the treatment of acute complicated TBAD can be divided into open and endovascular. The endovascular approach is further divided into central aortic repair and alternative endovascular techniques. Central repair includes endoluminal aortic stent graft repair, such as thoracic endovascular aortic aneurysm repair and provisional extension to induce complete attachment, extended provisional extension to induce complete attachment and stent-assisted balloon-induced intimal disruption and re-lamination in aortic dissection repair techniques. Alternative endovascular techniques include reno-visceral stenting, endovascular aortic membrane fenestration and targeted false lumen thrombosis. This review discusses and compares the various endovascular approaches to repair of acute complicated TBAD, focusing on central versus alternative endovascular techniques. We also discuss indications for technique selection, focusing on the acute management of complicated TBAD

Analysis of Outpatient Telemedicine Reimbursement in an Integrated Healthcare System

BACKGROUND: Current reimbursement policy surrounding telemedicine has been cited as a barrier for the adaptation of this care model. The objective of this study is to analyze the reimbursement figures for outpatient telemedicine consultation in vascular surgery. METHODS: Patients first underwent synchronous telemedicine visits after receiving point-of-care ultrasound at one of 3 satellite locations of Henry Ford Health System in Michigan. Visit types included new, return, and postoperative patients. Reimbursement information related to payor, adjustment, denial, paid and outstanding balances were recorded for each telemedicine visit. Then, using an enterprise data warehouse, a retrospective analysis was performed for the aforementioned telemedicine visits. The data were analyzed to determine the outcome of total billed charges, number of denied claims, reimbursement per payor, reimbursement per patient, and out-of-pocket costs to the patients. RESULTS: Among 184 virtual clinical encounters, the payors included Aetna US Healthcare, Blue Advantage, Blue Cross Blue Shield, Cofinity Plan, Health Alliance Plan, HAP Medicare Advantage, Humana Medicare Advantage, Medicaid, Medicare, Molina Medicaid HMO, United Healthcare, Blue Care Network, Aetna Better Health of Michigan, Priority Health, and self-pay. Among the 15 payors, reimbursement ranged from 0% to 67% of the total charges billed. Among the 184 virtual visits, a grand total of $22,145 was collected or an average of$120.35 per virtual encounter. The breakdown of charges billed was 40% adjusted, 41% paid by insurance, 10% paid by patient, and 13% denied. There were 27 total denials (15%). Denial of payment included telehealth and nontelehealth reasons, citing noncovered charges, payment included for other prior services, new patient quality not met, and not covered by payor. The average out-of-pocket cost to patients was $12.59 per visit. CONCLUSIONS: These reimbursement data validate the economic potential within this new platform of healthcare delivery. As our experience with the business model grows, we expect to see an increase in reimbursement from private payors and acceptance from patients. Within a tertiary care system, telemedicine for chronic vascular disease has proven to be a viable means to reach a broader population base, and without significant cost to the patients

Progressive stenosis of a popliteal artery stent graft by laminated thrombus

We present a case of failed popliteal artery aneurysm repair using a Viabahn stent graft (W. L. Gore & Associates, Flagstaff, Ariz) due to laminated thrombus formation. A 75-year-old man presented with a symptomatic popliteal artery aneurysm. He was treated with a Viabahn stent graft. On follow-up, the patient complained of lower extremity claudication, and duplex ultrasound examination showed a focal intrastent stenosis. A computed tomography scan showed a significant stenosis within the stent graft, at the level of the knee joint creases. The patient underwent superficial femoral artery to distal popliteal surgery. This case report aims to expand on the mechanism of stent graft failure in popliteal aneurysms

Early clinical experience using telemedicine for the management of patients with varicose vein disease

INTRODUCTION: The use of telemedicine services may be effective in the perioperative management of patients with varicose veins. METHODS: Over a seven-month period, patients with varicose veins were evaluated in the virtual clinic via two-way secure videoconferencing or the traditional clinic by the same physician provider. Data sources included institutional Vascular Quality Initiative registry and patient satisfaction surveys. RESULTS: Among a total of 121 patients with varicose veins who underwent endovenous catheter ablation of the saphenous vein, 20 patients (16.5%) chose the telemedicine clinic (Group A) and 101 patients (83.5%) chose the traditional clinic (Group B) for their perioperative management. Comparing Group A and Group B, the mean age was 59.2 ± 12.1 versus 59.6 ± 13.0, respectively ( p = 0.944); women were 75% versus 73.3%, respectively ( p = 0.872); African Americans comprised 5% versus 22.8%, while Caucasians comprised 95% versus 63%, respectively ( p = 0.049). Half of the telemedicine patients had multiple virtual visits for a total of 31 virtual encounters. Among telemedicine patients using SurveyMonkey®, 29 telemedicine encounters (93.5%) reported that their virtual visit is Yes, definitely or Yes, somewhat more convenient over traditional methods. All patients answered that they were able to communicate clearly with the provider, able to have their questions answered, and able to clearly hear and see the provider via telemedicine methods. DISCUSSION: Telemedicine services enable another means to deliver high-quality care for patients with venous disease in a safe and coordinated manner. Patients with varicose veins are highly satisfied with the use of telehealth services over the traditional healthcare delivery model

Men present with higher clinical class of chronic venous disease before endovenous catheter ablation

BACKGROUND: Risk factors for chronic venous disease (CVD) have been widely reported in population health management. However, predisposing factors associated with patients treated for advanced stages of CVD have yet to be established. We examined the demographics and risk factors associated with advanced clinical presentation of CVD for patients referred for vein ablation. METHODS: Retrospective analysis of our institutional Vascular Quality Initiative Varicose Vein Registry included endovenous laser treatment and radiofrequency ablation procedures at our tertiary institution, community hospital, and outpatient vein clinic between January 2015 and December 2016. All incompetent truncal veins were divided into two groups based on the Clinical, Etiology, Anatomy, and Pathophysiology clinical class of CVD: mild-moderate (C1-C3) and severe (C4-C6). The two groups were compared in terms of their demographics and medical comorbidities using univariate and multivariate analysis. Data analysis was conducted on SPSS 22.0 (IBM Corp, Armonk, NY). RESULTS: During the study period, a total of 650 incompetent truncal veins were ablated. The mean age of patients was 58 years, and 73% were female. Severe CVD composed 21% of the cohort. Male sex was a risk for advanced CVD (odds ratio, 2.6; P \u3c .001). Older age was also associated with severe CVD; the average age was 63 years for patients with advanced stage CVD vs 56 years for mild to moderate CVD (P \u3c .001). Race, diabetes, body mass index, number of pregnancies, congestive heart failure, history of venous thromboembolism, current anticoagulation, and history of smoking or current smoking status did not affect the severity of CVD. CONCLUSIONS: Among patients treated with vein ablation for superficial venous insufficiency, older age and male sex were associated with increased severity of advanced CVD. Despite the higher incidence of varicose veins among women, men are more likely to have clinically advanced CVD when they present for truncal vein ablation

Retrograde open celiac stenting for ischemic hepatitis after pancreaticoduodenectomy

A 74-year-old man with pancreatic cancer had undergone pancreaticoduodenectomy and subsequently developed ischemic hepatitis secondary to high-grade celiac artery stenosis. Celiac antegrade stenting via brachial artery access was unsuccessful, and open antegrade bypass would have required takedown of the pancreatic and/or biliary anastomoses for adequate exposure. Retrograde open celiac stenting was, therefore, successfully performed via the gastroduodenal artery stump. His ischemic hepatitis resolved, and he was ultimately discharged with dual antiplatelet therapy. Computed tomography angiography at 6 months demonstrated a widely patent celiac stent. Retrograde open celiac stenting via the gastroduodenal artery stump is an alternative to open bypass for celiac revascularization not amenable to percutaneous antegrade stenting in patients who have undergone pancreaticoduodenectomy

Superficial femoral artery balloon angioplasty stent implantation-outcome stratified by type of follow-up evaluation: Arterial duplex imaging versus ankle-brachial index only

Objectives: Endovascular therapy with transluminal angioplasty with stent deployment has become a commonly performed intervention in the management of superficial femoral artery (SFA) occlusive disease. In-stent stenosis occurs in approximately 16% to 32% of patients at one-year follow-up and can lead to stent occlusion and symptom recurrence. Arterial duplex stent imaging (ADSI) of the stented segment can be diagnostic for recurrent stenosis, however, its uniform application and benefit is controversial. With this study we aim to determine whether follow-up with ADSI yielded a better outcome than those with Doppler and ankle-brachial index (ABI) follow-up alone. Methods: We performed a retrospective analysis collecting data of patients undergoing SFA stent implantation for occlusive disease at a tertiary care referral center between 2009 and 2016. Patients with PTA only, those with an in-stent restenosis, and those with no follow-up were excluded. The remaining patients were divided into those with at least one ADSI (ADSI group) and those with clinical/ABI follow-up only (ABI group). Variables analyzed included patients demographics, comorbidities, indication and procedural details. The two groups were compared via univariate analysis with respect to the following variables: patency, proximal/distal (relative to stent) progression and intervention, major adverse limb event, limb loss and mortality. Results: There were 238 patients with SFA stent implantation included in the study, 152 into ADSI and 86 into ABI. There was no difference in demographics and comorbidities between the groups. ADSI and ABI were homogenous regarding clinical presentation (claudication/critical limb ischemia ADSI 39.1%/60.9% vs ABI 37.6%/62.4%; P = .982) and Trans-Atlantic Inter-Society Consensus classification (P = .546). The 1-year outcome showed a similar primary patency rates for ADSI (63.8%) versus ABI (65.1%; P = .841). Both groups had improvement in assisted patency, however, ADSI had a higher assisted patency compared with ABI (81.6% vs 69.8%; P = .037). Secondary patency was also higher for ADSI (88.1%) vs ABI (72.9%; P = .003). Despite similar clinical presentations, ABI patients were more likely to undergo a major amputation (ABI 14.7% vs ADSI 3.4%; P = .002) at the 1-year follow-up. Conclusions: In SFA stent implantation, ADSI follow-up shows an advantage in assisted patency and secondary patency, which may contribute to a decreased rate of major amputation. Within the first year of follow-up evaluation of SFA stent implantation, ADSI would seem to be advantageous and consideration should be given to more uniform application of surveillance ADSI

Outcome Benefit of Arterial Duplex Stent Imaging After Superficial Femoral Artery Stent Implantation

INTRODUCTION: In-stent stenosis is a frequent complication of superficial femoral artery (SFA) endovascular intervention and can lead to stent occlusion and/or symptom recurrence. Arterial duplex stent imaging can be used in the surveillance for recurrent stenosis, however, its uniform application is controversial. In this study, we aim to determine, in patients undergoing SFA stent implantation, whether surveillance with arterial duplex stent imaging yielded a better outcome than those with only ankle-brachial index (ABI) follow-up. METHODS: We performed a retrospective analysis of all patients undergoing SFA stent implantation for occlusive disease at a tertiary care referral center between 2009 and 2016. The patients were divided into those with arterial duplex stent imaging (ADSI group) and those with ankle brachial index follow-up only (ABI group). Life table analysis was performed, comparing stent patency, major adverse limb event, limb salvage, and mortality between groups. RESULTS: Two hundred forty-eight patients with SFA stent implantation were included: 160 into ADSI; 88 into ABI. Groups were homogenous regarding clinical indication (claudication/critical limb ischemia ADSI 39/61% vs ABI 38/62%; P = 0.982) and TASC classification (TASC A/B/C/D for ADSI 17/45/16/22% and ABI 21/43/16/20%; P = 0.874). Primary patency was similar between groups at 12/36/56 months: ADSI (65/43/32%) vs ABI (69/34/34%) (P = 0.770), whereas ADSI patients showed an improved assisted primary patency (84/68/54%) vs ABI (76/38/38%; P = 0.008) and secondary patency. There was a greater freedom from major adverse limb event in the ADSI group (91/76/64%) vs the ABI group (79/46/46%) (P \u3c 0.001) at 12/36/56 months follow-up. Arterial duplex stent imaging patients were more likely to undergo an endovascular procedure as their initial post-SFA stent implantation intervention (P = 0.001) whereas ABI patients were more likely to undergo an amputation (P \u3c 0.001). CONCLUSIONS: In SFA stent implantation, patients with arterial duplex stent imaging follow-up demonstrate an advantage in assisted-primary patency and secondary patency and are more likely to undergo an endovascular re-intervention. These factors likely effected a decrease in major adverse limb events, indicating the benefit of a more universal adoption of post-SFA stent implantation follow-up arterial duplex stent imaging

Retrograde open celiac stenting for ischemic hepatitis after pancreaticoduodenectomy

A 74-year-old man with pancreatic cancer had undergone pancreaticoduodenectomy and subsequently developed ischemic hepatitis secondary to high-grade celiac artery stenosis. Celiac antegrade stenting via brachial artery access was unsuccessful, and open antegrade bypass would have required takedown of the pancreatic and/or biliary anastomoses for adequate exposure. Retrograde open celiac stenting was, therefore, successfully performed via the gastroduodenal artery stump. His ischemic hepatitis resolved, and he was ultimately discharged with dual antiplatelet therapy. Computed tomography angiography at 6 months demonstrated a widely patent celiac stent. Retrograde open celiac stenting via the gastroduodenal artery stump is an alternative to open bypass for celiac revascularization not amenable to percutaneous antegrade stenting in patients who have undergone pancreaticoduodenectomy

GWAS and colocalization analyses implicate carotid intima-media thickness and carotid plaque loci in cardiovascular outcomes.

Carotid artery intima media thickness (cIMT) and carotid plaque are measures of subclinical atherosclerosis associated with ischemic stroke and coronary heart disease (CHD). Here, we undertake meta-analyses of genome-wide association studies (GWAS) in 71,128 individuals for cIMT, and 48,434 individuals for carotid plaque traits. We identify eight novel susceptibility loci for cIMT, one independent association at the previously-identified PINX1 locus, and one novel locus for carotid plaque. Colocalization analysis with nearby vascular expression quantitative loci (cis-eQTLs) derived from arterial wall and metabolic tissues obtained from patients with CHD identifies candidate genes at two potentially additional loci, ADAMTS9 and LOXL4. LD score regression reveals significant genetic correlations between cIMT and plaque traits, and both cIMT and plaque with CHD, any stroke subtype and ischemic stroke. Our study provides insights into genes and tissue-specific regulatory mechanisms linking atherosclerosis both to its functional genomic origins and its clinical consequences in humans