Publications by authors named "Graham Roche-Nagle"

86 Publications

Thresholds for abdominal aortic aneurysm repair in Canada and United States.

J Vasc Surg 2021 Sep 29. Epub 2021 Sep 29.

Division of Vascular Surgery, Peter Munk Cardiac Centre & University Health Network, University of Toronto, Toronto, Ontario, Canada. Electronic address:

Background: Previous studies have demonstrated significant geographic variations in the management of abdominal aortic aneurysms (AAA) despite standard guidelines. Differences in patient selection, operative technique, and outcomes for AAA repair in Canada versus United States were assessed.

Methods: The Vascular Quality Initiative was used to identify all patients who underwent elective endovascular or open AAA repair between 2010 and 2019 in Canada and the United States. Demographic, clinical, and procedural characteristics were recorded and differences between countries were assessed using independent t test and χ test. The primary outcome was the percentage of AAA repaired below recommended diameter thresholds (men, <5.5 cm; women, <5.0 cm). The secondary outcomes were in-hospital and 1-year mortality rates. Associations between region and outcomes were assessed using univariate/multivariate logistic regression and Cox proportional hazards analysis.

Results: There were 51,455 US patients and 1451 Canadian patients who underwent AAA repair in Vascular Quality Initiative sites during the study period. There was a higher proportion of endovascular repairs in the United States (83.7% vs 68.4%; odds ratio [OR], 2.38; 95% confidence interval [CI], 2.13-2.63; P < .001). US patients had more comorbidities, including hypertension, congestive heart failure, chronic kidney disease, and prior revascularization. The percentage of AAA repaired below recommended thresholds was significantly higher in the United States (38.8% vs 15.2%; OR, 3.57; 95% CI, 3.03-4.17; P < .001). This difference persisted after controlling for demographic, clinical, and procedural characteristics (adjusted OR, 3.57; 95% CI, 2.63-4.17; P < .001). Factors that predicted AAA repair below recommended thresholds were US region (adjusted OR, 3.57; 95% CI, 3.03-4.17), male sex (adjusted OR, 2.89; 95% CI, 2.72-3.07), and endovascular repair (adjusted OR, 2.08; 95% CI, 1.95-2.21). The in-hospital mortality rate was low (1.0% vs 0.8%) and the 1-year rate mortality was similar between countries (hazard ratio, 0.96; 95% CI, 0.70-1.31; P = .79).

Conclusions: There are significant variations in AAA management between Canada and the United States. A greater proportion of US patients underwent AAA repair below the recommended diameter thresholds. This finding is partly driven by a higher percentage of endovascular repairs. Despite these differences, the perioperative and 1-year mortality rates are similar. Future studies should investigate reasons for these variations and quality improvement projects are needed to standardize care.
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http://dx.doi.org/10.1016/j.jvs.2021.08.091DOI Listing
September 2021

Endovascular community response to mortality data in use of paclitaxel devices for peripheral vascular disease.

J Vasc Surg 2021 Jun 25. Epub 2021 Jun 25.

Joint Department of Medical Imaging, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada. Electronic address:

Objectives: Examine the endovascular community response to data demonstrating increased mortality in paclitaxel devices for the treatment of peripheral arterial disease in femoropopliteal lesions.

Methods: A retrospective observational study using the Vascular Quality Initiative Peripheral Vascular Intervention registry dataset was performed examining paclitaxel device use for peripheral arterial disease in femoropopliteal arteries treated from 2017-2019. A total of 41707 patients and 52208 procedures were analyzed during the study period. Post-hoc analysis was performed to examine use during selected time periods in 2019.

Results: Total femoropopliteal procedures in 2017, 2018, and 2019 were 17458, 21140, and 21322, respectively. Paclitaxel devices were used for 8852 arteries in 2017, 10691 in 2018, and 6732 in 2019, which was significantly reduced, when comparing 2019 volumes to 2017 or 2018 (p < .0001) and 2019 versus 2018 + 2017 volumes (p < .0001). Post-hoc analysis of selected times in 2019 demonstrated variable use throughout 2019.

Conclusions: Following publication of data with concerns of mortality associated with paclitaxel device use in 2018, a rapid reduction in overall paclitaxel device use was observed in 2019.
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http://dx.doi.org/10.1016/j.jvs.2021.05.058DOI Listing
June 2021

Permanent IVC filter strut penetration into an abdominal aortic aneurysm.

BMJ Case Rep 2021 Jun 7;14(6). Epub 2021 Jun 7.

Vascular Surgery, Toronto General Hospital, Toronto, Ontario, Canada.

An 85-year-old man with a known history of abdominal aortic aneurysm (AAA) presented to a vascular surgery clinic with a severely swollen, tender and erythematous left leg. An urgent CT angiogram demonstrated a left-sided, proximal deep vein thrombosis, and a permanent, Bird's Nest inferior vena cava (IVC) filter (Cook, Inc., Bloomington, Ind.) penetrating his AAA. The patient was treated with a course of apixaban 5 mg two times per day and the decision was made to closely observe his IVC filter and AAA, given his numerous comorbidities and age. This case highlights the unique considerations associated with an approach to permanent IVC filter complications among patients with AAAs.
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http://dx.doi.org/10.1136/bcr-2021-241962DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8186758PMC
June 2021

Chylothorax post transaxillary first rib resection for thoracic outlet syndrome.

BMJ Case Rep 2021 Mar 8;14(3). Epub 2021 Mar 8.

Department of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada

We present a patient who developed high output chyle leak post left transaxillary first rib resection for venous thoracic outlet syndrome. The high output chylorrhoea was successfully treated by conservative measures, bed rest, parenteral nutrition and low-fat diet. The patient was discharged after an 18-day hospital stay with a complete resolution of his chylous fistula prior to discharge. This is the first documented chylothorax post transaxillary first rib resection likely due to anomalous chyle anatomy.
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http://dx.doi.org/10.1136/bcr-2020-236006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7942259PMC
March 2021

A survey of Canadian surgeons on the indications for home care nursing following vascular surgery.

Can J Surg 2021 03 5;64(2):E149-E154. Epub 2021 Mar 5.

From the Department of Surgery, University of Toronto, Toronto, Ont. (Jacob-Brassard, Al-Omran, Salata, Hussain, Kayssi, Roche-Nagle); the Li Ka Shing Knowledge Institute of St. Michaels Hospital, Toronto, Ont. (Al-Omran, Salata, Hussain, de Mestral); the Sunnybrook Research Institute of Sunnybrook Health Sciences Centre, Toronto, Ont. (Kayssi); and the Peter Munk Cardiac Center of the University Health Network, Toronto, Ont. (Roche-Nagle).

Background: Recent evidence suggests that home care nursing is variably prescribed after vascular surgery, and may reduce emergency department visits and hospital readmissions. We therefore sought to characterize the indications for home care nursing following vascular surgery from the surgeon's perspective.

Methods: An online survey was distributed to the 141 members of the Canadian Society for Vascular Surgery with questions related to home care nursing after carotid endarterectomy (CEA), endovascular aortic aneurysm repair (EVAR), open abdominal aortic aneurysm (AAA) repair and open or hybrid revascularization for peripheral arterial disease (PAD). We included all questionnaires in our analysis; the frequency denominator changes according to the number of respondents who completed each survey item.

Results: There were 46 survey respondents (33% of 141) from across the country. A total of 28 (62% of 45) worked in a teaching hospital. Home care nursing was routinely prescribed by 5%, 10%, 31% and 41% of respondents following CEA, EVAR, open AAA repair and open or hybrid revascularization for PAD, respectively. Across all procedure types, the same procedure-related criteria were most often deemed to warrant a prescription for home care nursing: surgical site infection, wound complications (e.g., open wound, lymphatic leak) and use of negative-pressure wound therapy. Across all procedure types, lack of social support, physical frailty and cognitive impairment were most frequently identified as patient-specific considerations for prescribing home care nursing. Few respondents reported restrictions or standards that informed their prescribing practice.

Conclusion: Most surgeon respondents agreed on the indications for home care nursing after vascular surgery. However, evidence-based standards to guide patient selection for home care nursing after vascular surgery are needed.
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http://dx.doi.org/10.1503/cjs.001220DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8064247PMC
March 2021

A Canadian multicenter experience describing outcomes after endovascular abdominal aortic aneurysm repair stent graft explantation.

J Vasc Surg 2021 09 16;74(3):720-728.e1. Epub 2021 Feb 16.

University of Toronto, Toronto, Ontario, Canada.

Background: Most studies describing the outcomes after endovascular abdominal aortic aneurysm repair (EVAR) explantation have been from single, high-volume, centers. We performed a multicenter cross-Canadian study of outcomes after EVAR stent graft explantation. Our objectives were to describe the outcomes after late open conversion and EVAR graft explantation at various Canadian centers and the techniques and outcomes stratified by the indication for explant.

Methods: The Canadian Vascular Surgery Research Group performed a retrospective multicenter study of all cases of EVAR graft explantation at participating centers from 2003 to 2018. Data were collected using a standardized, secure, online platform (RedCap [Research Electronic Data Capture]). Univariate statistical analysis was used to compare the techniques and outcomes stratified the indication for graft explantation.

Results: Patient data from 111 EVAR explants collected from 13 participating centers were analyzed. The mean age at explantation was 74 years, the average aneurysm size was 7.5 cm, and 28% had had at least one instructions for use violation at EVAR. The average time between EVAR and explantation was 42.5 months. The most common indication for explantation was endoleak (n = 66; type Ia, 46; type Ib, 2; type II, 9; type III, 2; type V, 7), followed by infection in 20 patients; rupture in 18 patients (due to type Ia endoleak in 10 patients, type Ib in 1, type II in 1, type III in 2, and type V in 1), and graft thrombosis in 7 patients. The overall 30-day mortality was 11%, and 45% of the patients had experienced at least one major perioperative complication. Mortality was significantly greater for patients with rupture (33.3%) and those with infection (15%) compared with patients undergoing elective explantation for endoleak (4.5%; P = .003). The average center volume during the previous 15 years was 8 cases with a wide range (2-19 cases). A trend was seen toward greater mortality for patients treated at centers with fewer than eight cases compared with those with eight or more cases (19% vs 9%). However, the difference did not reach statistical significance (P = .23). Overall, 41% of patients had undergone at least one attempt at endovascular salvage before explantation, with the highest proportion among patients who had undergone EVAR explantation for endoleak (51%). Only 22% of patients with rupture had undergone an attempt at endovascular salvage before explantation.

Conclusions: The performance of EVAR graft explantation has increasing in Canada. Patients who had undergone elective explantation for endoleak had lower mortality than those treated for either infection or rupture. Thus, patients with an indication for explanation should be offered surgery before symptoms or rupture has occurred. A trend was seen toward greater mortality for patients treated at centers with lower volumes.
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http://dx.doi.org/10.1016/j.jvs.2021.01.049DOI Listing
September 2021

Fenestrated endovascular abdominal aortic aneurysm repair with concomitant horseshoe kidney.

BMJ Case Rep 2021 Jan 25;14(1). Epub 2021 Jan 25.

Department of Vascular Surgery, Toronto General Hospital, Toronto, Ontario, Canada

Horseshoe kidney, representing abnormal fusion of the inferior renal poles, is a rare anatomic anomaly posing challenges in the setting of surgical abdominal aortic aneurysm repair. Historically, open repair has been the favoured surgical approach. However, due to the location of the renal isthmus and wide-ranging variation in anomalous renal vasculature, endovascular aneurysm repair (EVAR) has emerged as a popular, less invasive alternative. We describe one of the first published cases of two-fenestration EVAR in a patient with concomitant horseshoe kidney, followed by a discussion of current trends in surgical management. With the increasing availability to customise fenestrated grafts to patients' unique anatomy, this advanced EVAR technique may emerge as the preferred approach in certain cases.
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http://dx.doi.org/10.1136/bcr-2020-236755DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7839873PMC
January 2021

Chylous ascites following elective abdominal aortic aneurysm repair.

J Surg Case Rep 2020 Dec 30;2020(12):rjaa512. Epub 2020 Dec 30.

Toronto General Hospital, Department of Vascular Surgery, Toronto, Ontario, Canada.

Postoperative chylous ascites is a rare complication of abdominal surgery. Chyle depletion results in nutritional, immunologic and metabolic deficiencies, making it a serious and potentially life-threatening condition for which prompt diagnosis and management is imperative. A 72-year-old male was referred for open repair of a 62 cm juxtarenal abdominal aortic aneurysm (AAA). Following resumption of diet, he developed abdominal distention. Therapeutic paracenteses confirmed chylous ascites. Failed conservative management and lymphatic embolization lead to surgical sealance of lymphatic leak using glue. Postoperatively, a full diet was tolerated with no further ascites. Paracentesis is the diagnostic modality of choice in evaluating patients with ascites. Management is challenging and should be multifaceted and tailored to individual patient needs. Cornerstones of therapy include correction of the underlying etiology and conservative measures. When conservative measures fail, other interventions can be considered, such as somatostatin analogs, surgical ligation or glue embolization.
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http://dx.doi.org/10.1093/jscr/rjaa512DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7773140PMC
December 2020

Adverse Outcomes after Advanced EVAR in Patients with Sarcopaenia.

Cardiovasc Intervent Radiol 2021 Mar 3;44(3):376-383. Epub 2021 Jan 3.

Department of Vascular Surgery, University Health Network - Toronto General Hospital, Toronto, ON, Canada.

Purpose: To determine whether low total psoas muscle area (tPMA), as a surrogate for sarcopaenia, is a predictor of adverse outcomes in patients undergoing advanced EVAR.

Materials And Methods: A retrospective review of medical records was performed for 257 patients who underwent advanced EVAR (fenestrated or branched technique) in a single tertiary centre from 1 January 2008 to 1 September 2019. The study cohort was divided into tertiles based on tPMA measurement performed independently by two observers from a peri-procedural CT scan at the level of mid-L3 vertebral body. The low tertile was considered sarcopaenic. Logistic regression analysis was used to assess the association of tPMA with 30-day mortality and post-procedural complications. Univariable analysis and adjusted multivariable Cox regression were used to assess the association of tPMA with all-cause mortality.

Results: A total of 257 patients comprised 193 males and 64 females with the mean age of 75.4 years (± 6.8) were included. Adjusted multivariable Cox regression revealed an 8% reduction in all-cause mortality for every 1 cm increase in tPMA, P < 0.05. TPMA was associated with 30-day mortality (OR 0.85, 95% CI 0.75-0.96, P < 0.05) and spinal cord ischaemia (SCI) (OR 0.89, 95% CI 0.82-0.97, P < 0.05). For remaining post-procedural complications, tPMA was not a useful predictive tool. TPMA correlated negatively with hospital stay length (r-0.26, P < 0.001). Patients with lower tPMA were more likely to be discharged to a rehabilitation center (OR 0.93, 95% CI 0.87-0.98 , P < 0.05).

Conclusion: Measurement of tPMA can be a useful predictive tool for adverse outcomes after advanced EVAR.

Level Of Evidence: Level 3, Retrospective cohort study.
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http://dx.doi.org/10.1007/s00270-020-02721-0DOI Listing
March 2021

Ten-year trends in iliofemoral deep vein thrombosis treatment and referral pathways.

Vascular 2020 Nov 29:1708538120975244. Epub 2020 Nov 29.

Division of Vascular Surgery, University Health Network, Toronto, ON, Canada.

Objectives: Iliofemoral deep venous thrombosis is associated with an increased risk of developing post-thrombotic syndrome resulting in reduced quality of life. As there is debate about best management practices, this study aimed to examine the referral and treatment pathways for patients presenting with iliofemoral deep venous thrombosis over an 11-year period at our institution.

Methods: We conducted a retrospective review of patients diagnosed with lower limb deep vein thrombosis between 2010 and 2020. Ultrasound report findings were reviewed for the presence of iliofemoral deep venous thrombosis with acute, occlusive, or proximal clot. Multiple factors were extracted, including patient demographics, risk factors, diagnostic methods, interventions, referrals, and details of follow-up. The CaVenT and ATTRACT trials studied the benefit of thrombolysis in the early phase of iliofemoral deep venous thrombosis management as compared to anticoagulation alone. An analysis was conducted of patients requiring thrombolysis to determine whether these trials impacted physician practice patterns for thrombolysis. Data were organized and examined by year for trends in treatment and referral pathways.

Results: The review yielded 2792 patients assessed for lower limb deep venous thrombosis by ultrasound. Four hundred and sixty-seven (16.7%) patients were confirmed to have an occlusive iliofemoral deep venous thrombosis. The average age was 62.7 years (18-101 years). Half (50.4%) of the patients were male. The most common etiology for clot was malignancy-induced hypercoagulable state (39.0%). There was no difference in incidence of iliofemoral deep venous thrombosis diagnosed by ultrasound per year, with an average of 42.5 per year and a peak of 61. There was a trend towards increased rates of computed tomography imaging, ranging between 9.1% and 52.9%. The rate thrombolysis per year ranged between 1.8% and 8.9%, with a range of 4.3% ( = 20) to 8.9% ( = 5) in 2018. The use of pharmacomechanical thrombolysis increased, from 25% ( = 1) in 2010-2012 to 87.5% ( = 7) in 2018-2020. The rate of inferior vena cava filter insertion alone decreased from 18.2% in 2010 ( = 4) to 5.9% ( = 1) in 2020. The length of thrombolysis treatment also decreased, from 100% of patients ( = 4) receiving treatment duration greater than 24 h in 2010-2012 to 0% ( = 0) in 2018-2020. About 45% of patients receiving thrombolysis ( = 9) had venous stenting. No difference in treatment outcomes were observed, with greater than 87.5% of patients reaching intermediate to full resolution of clot burden. No patients experienced intracranial hemorrhage.

Conclusions: The results of this analysis highlight the change in practice in our institution over time. The low rate of intervention likely reflects the current lack of consensus in published guidelines. It is important for future work to elicit the most appropriate management pathways for patients with iliofemoral deep venous thrombosis.
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http://dx.doi.org/10.1177/1708538120975244DOI Listing
November 2020

Large pseudoaneurysm arising from the deep femoral artery after hip fracture fixation.

J Surg Case Rep 2020 Oct 26;2020(10):rjaa408. Epub 2020 Oct 26.

Department of Interventional Radiology, University Health Network, Toronto, Ontario, Canada.

Hip fracture is a common condition of increasing global concern. Vascular injury as a complication after hip fracture repair is rare. A 90-year-old woman developed swelling and pain to her proximal thigh 1 month after uneventful hip fracture fixation. Ultrasound revealed a large pseudoaneurysm of the deep femoral artery, which was successfully treated with transcatheter embolization. Pseudoaneurysms have numerous etiologies. In this case, vascular injury is suspected to be a consequence of proximal migration of the lesser trochanteric fragment. Unfortunately, pseudoaneurysms are often not appreciated due to the nonspecific nature of the presenting symptoms. Diagnosis should be confirmed radiologically and management depends on the location and size of the pseudoaneurysm, as well as patient comorbidities. Pseudoaneurysm after hip fracture fixation is a rare but serious complication. Diagnosis is challenging due to nonspecific symptoms. A high index of suspicion is imperative to prevent life-threatening rupture.
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http://dx.doi.org/10.1093/jscr/rjaa408DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7587505PMC
October 2020

Endovascular repair of abdominal aortic aneurysm in octogenarians: clinical outcomes and complications.

Can J Surg 2020 07 9;63(4):E329-E337. Epub 2020 Jul 9.

From the Faculty of Medicine, University of Toronto, Toronto, Ont. (Raju, Roche-Nagle); the Division of Vascular Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ont. (Raju, Roche-Nagle); and the Division of Obstetrical Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ont. (Eisenberg, Montbriand).

Background: Endovascular aneurysm repair (EVAR) is associated with decreased perioperative morbidity and mortaliy in comparison with open repair, and thus octagenarians are traditionally offered EVAR given their age and medical comorbidities. The aim of this study was to investigate outcomes and predictors of complications associated with EVAR in octogenarians.

Methods: We conducted a retrospective chart review of consecutive patients aged 80 years and older who received an EVAR between August 2010 and January 2017 at a single centre in Toronto, Ontario. We conducted univariate comparisons and then completed logistic regression to determine predictors of complications. We used Kaplan-Meier analysis to explore survival times.

Results: A total of 154 octogenarians underwent an EVAR during the study period for an infrarenal aneurysm with a mean size of 64.8 (standard deviation [SD] 12.7) mm. The mean age of the patients was 84.1 (SD 3.7) years, and most patients (81%) were men. Eighteen patients presented with a ruptured abdominal aortic aneurysm (AAA). Ninety-five (62%) patients sustained a complication. Fifty percent of patients experienced an intraoperative complication. A majority of these (77%) resulted in an endoleak, with type II endoleaks requiring no further intervenion being the most common (58%, n = 45). The remaining complications (n = 70) occurred postoperatively, with myocardial ischemia (n = 24) and dysrhythmias (n = 10) being the most common. Past aortic surgery (χ2 = 8.62, p = 0.014, Cramer V = 0.27) was found to be a multivariate predictor of complications. Most patients (88%) continued follow-up to an average of 20.9 months. Twenty-one patients (13%) died. Nine of these deaths (43%) occurred during the index admission and involved a ruptured AAA. Past aortic surgery was the only predictor of vascular complications. The mean survival time after EVAR was 57.63 months for patients without events.

Conclusion: Endovascular aneurysm repair in octogenarians is a suitable form of therapy with acceptable short- and long-term results in the elective setting. Past aortic surgery was a predictor of complications in this population.
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http://dx.doi.org/10.1503/cjs.009019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7458675PMC
July 2020

Vascular Quality of Care Assessment: Clinicians' Adherence to Lipid-Lowering Therapy for Patients with Atherosclerotic Cardiovascular Disease.

Ann Vasc Surg 2020 Nov 15;69:197-205. Epub 2020 Jun 15.

Department of Vascular Surgery, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada. Electronic address:

Background: Lipid-lowering medication can considerably lessen the risk for cardiovascular events in patients with atherosclerotic cardiovascular disease (ASCVD). Despite well-publicized guidelines and the accessibility of effective therapies, many patients do not attain their lipid goals and remain at high cardiovascular risk. Guidelines recommend statins as first-line therapy to reduce cardiovascular morbidity and mortality in ASCVD. We aimed to analyze admission lipid levels in a broad contemporary population of patients with ASCVD attending a vascular clinic or admitted to an inpatient vascular unit.

Methods: Patients with known ASCVD, current cholesterol levels, and lipid-lowering medications were documented and compared with published current Canadian Cardiovascular Society Guidelines recommendations for achieving <2.0 mmol/L or >50% reduction in low-density lipoprotein cholesterol (LDL-C). Cholesterol levels (current and previous), demographic characteristics, cardiovascular risk factors, and medical therapy were assessed from available patient records.

Results: Two hundred eight adult patients were identified. The mean age of the patients was 72 (±10) years, and 76% were men. About half had peripheral arterial disease (n = 118, 56.7%), one-third had coronary artery disease (n = 78, 37.5%), and one-third had diabetes (n = 76, 36.5%). Most were hypertensive (n = 140, 67.3%) and half gave a history of dyslipidemia (n = 103, 49.5%). Most patients (n = 183, 88%) were taking a statin and the majority at a moderate-intensity dose (n = 79, 43.2%) or high-intensity dose (n = 101, 55.2%). However, 32.7% of patients (n = 68) did not reach target of LDL-C level of <2.0 mmol/L or had ≤50% reduction from the baseline level. Of the patients who did not reach goals, 7 (10.3%) did not fill their statin prescriptions in the last 3 months. Only 26 patients (12.5%) were also on ezetimibe, a guideline-recommended second-line therapy if targets are not reached with maximally tolerated statin therapy. One patient, who was able to reach target LDL-C, was on evolocumab monotherapy, a PCSK9 inhibitor, a contemporary nonstatin therapy that could be considered in ASCVD in those not at LDL-C goal. Of the 16 patients who were not prescribed any lipid-lowering therapy and did not reach target, 8 (50%) did not have any identified or documented reasons. Of the remaining 8 patients, 7 (87.5%) reported intolerance or side effects to statins only, and could benefit from nonstatin LDL-lowering therapy.

Conclusions: In this observational study, we established suboptimal adherence to guideline recommendations for statin therapy and hesitancy to use nonstatin LDL-lowering agents in high-risk patients with ASCVD. These treatment gaps have an enormous effect on achieving improved cardiovascular clinical outcomes and must be tackled.
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http://dx.doi.org/10.1016/j.avsg.2020.06.003DOI Listing
November 2020

The Vascular Implant Surveillance and Interventional Outcomes (VISION) Coordinated Registry Network: An effort to advance evidence evaluation for vascular devices.

J Vasc Surg 2020 12 20;72(6):2153-2160. Epub 2020 May 20.

Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH; VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vt. Electronic address:

The Vascular Implant Surveillance and Interventional Outcomes Network (VISION) is a Coordinated Registry Network (CRN) a member of Medical Device Epidemiology Network, a U.S. Food and Drug Administration (FDA)-supported global public-private partnership that seeks to advance the collection and use of real-world data to improve patient outcomes. The VISION CRN began in September 2015 and held its first strategic meeting on September 10, 2018, at the FDA headquarters in Silver Spring, Maryland. VISION is a collaboration of the Vascular Quality Initiative (VQI), the FDA, and other stakeholders. At this annual meeting, leaders from the FDA, VQI, industry representatives, population health researchers, and regulatory science experts gathered to discuss strategic goals and opportunities for VISION. One of the key focus areas for VISION is linkage of VQI registry data to Medicare, longitudinal data sources maintained by various states, and other relevant data sources, as a model for efficient, cost-saving, and effectual evidence generation and appraisal. This would provide the means to expand data collection, assess long-term procedural outcomes across the carotid, lower extremity, aortic, and venous intervention datasets, and execute registry-based trials through the CRN structure in an efficient, cost-effective manner. Looking forward, VISION strives to validate long-term outcome data in the VQI using industry datasets, in hopes of using CRNs to make device regulatory decisions. With the guidance of a steering committee, VISION will provide vascular surgeons, industry, and regulators the appropriate data to improve care for patients with vascular disease.
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http://dx.doi.org/10.1016/j.jvs.2020.04.507DOI Listing
December 2020

Subclavian steal syndrome treated by kissing stenting of the subclavian and vertebral arteries.

BMJ Case Rep 2020 May 18;13(5). Epub 2020 May 18.

Department of Interventional Radiology, Toronto General Hospital, Toronto, Ontario, Canada

The prevalence of subclavian artery (SA) stenosis is approximately 2%. The exact prevalence of extracranial vertebral artery (VA) stenosis is undetermined, with estimates ranging from 7% to 40%. Nearly 25% of ischaemic strokes involve the vertebrobasilar circulation, and arteriosclerotic disease and narrowing of the proximal VA may be the cause for up to one-fifth of these incidents. The bulk of SA stenoses occur proximally to the ostium of the VA. Vertebrobasilar ischaemia can be caused both by VA and SA stenosis. Surgical and endovascular approaches are potential treatment options for SA/VA stenosis. It has been demonstrated that endovascular intervention is considerably safer for this pathology, and with advances in device technology, angioplasty with stenting has become the preferred treatment option. We present the case of a 76-year-old man who presented with vertebrobasilar ischaemia from coexisting stenosis of the SA/VA which was treated by endovascular methods.
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http://dx.doi.org/10.1136/bcr-2019-233153DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7239543PMC
May 2020

Primary venous aneurysms: A 20-year retrospective analysis.

Vascular 2020 Oct 11;28(5):577-582. Epub 2020 May 11.

Division of Vascular Surgery, University Health Network, Toronto General Hospital, Toronto, Canada.

Objective: Primary venous aneurysms are unusual vascular occurrences. Our aim is to document our institution's experience with this pathology; describing frequency, diagnosis, outcomes and medical histories of patients with primary venous aneurysms within a 20-year time frame.

Methods: A retrospective study at our institution using its radiology database was conducted. Results were isolated to primary venous aneurysms diagnosed between 1997 and 2017. Basic demographics and medical history were collected.

Results: We identified 32 patients with primary venous aneurysms. Eighteen were male and 14 were female. The average age of presentation was 54 years old, with a range of 17-86. None of these patients reported a family history of aneurysmal disease. The majority were incidental. Of these aneurysms, 3 were of the head and neck, 1 was contained in the thorax, 17 were intra-abdominal and 11 were peripheral. Diagnosis was made by computed tomography, duplex ultrasound, or magnetic resonance imaging. Conservative management was most frequently employed, but four patients underwent surgical repair. Three aneurysms required operation for symptom management (external jugular, subclavian, inferior vena cava), whereas one aneurysm of the popliteal vein was prophylactically managed, given the high risk for pulmonary embolism.

Conclusions: Primary venous aneurysms present infrequently. Despite their rarity, primary venous aneurysms have been reported to occur throughout the venous system. The majority of primary venous aneurysms in this series were found incidentally and can present both symptomatically or asymptomatically. The findings of our 20-year experience were consistent with the existing literature. Because the risk of rupture is negligible, the indications for surgical management remain for cosmesis, symptom management or high risk of thromboembolic events.
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http://dx.doi.org/10.1177/1708538120913703DOI Listing
October 2020

Acute infrarenal aortic occlusion.

BMJ Case Rep 2020 Mar 29;13(3). Epub 2020 Mar 29.

Department of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada

Acute aortic occlusion (AAO) is an uncommon but potentially devastating vascular emergency with reported perioperative mortality rates of up to 75%. We present the case of AAO in a 69-year-old woman who was transferred to our institution after presenting with sudden onset bilateral acute limb ischaemia. Imaging showed a completely obstructed aortoiliac segment with renal infarcts. She was treated successfully with aortoiliac over the wire thrombectomy.
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http://dx.doi.org/10.1136/bcr-2019-233238DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7167434PMC
March 2020

Leveraging vascular quality initiative data to improve hospital length of stay for patients undergoing endovascular aneurysm repair

Can J Surg 2020 02 28;63(2):E88-E93. Epub 2020 Feb 28.

From the Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, Ont. (Eisenberg, Roche-Nagle, Lindsay, Oreopoulos); the Faculty of Medicine, University of Toronto, Toronto, Ont. (Roche-Nagle, Lindsay, Oreopoulos); and the Division of Vascular Interventional Radiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ont. (Roche-Nagle, Oreopoulos).

Background: The Society for Vascular Surgery Vascular Quality Initiative (SVS-SVQI) is a database that provides insight into standards of care and highlights opportunities for quality improvement by benchmarking institutional data against local, regional and national trends. Endovascular aneurysm repair (EVAR) is a frequently performed vascular operation. Postoperative length of stay in hospital (LOS) varies among institutions. We reviewed the morbidity and mortality of patients who underwent EVAR at our institution and the financial impact of increased LOS for these patients. In addition, we sought to identify modifiable factors associated with prolonged LOS.

Methods: We identified all patients who underwent elective EVAR between Jan. 1, 2011, and Dec. 31, 2014. Preoperative patient characteristics, intraoperative details, postoperative factors, long-term (1 yr) outcomes and cost data were reviewed. Univariate analysis was used to determine statistical differences between patients with LOS less than or equal to 2 days and greater than 2 days. Interventions were implemented to modify factors identified as having a negative impact on EVAR LOS.

Results: Identified factors that negatively affected EVAR LOS included social, neurologic, cardiovascular, urologic and renal issues. Following targeted interventions, LOS after EVAR decreased from an average of 3.8 to 3.0 days (p < 0.05). Logistic regression (n = 124) identified cardiovascular issues as the most significant predictor of LOS greater than 2 days (p = 0.001, odds ratio 14.24, 95% confidence interval 2.8–71.4). Reduction in LOS was associated with the additional benefit of 6.6% adjusted cost savings.

Conclusion: By leveraging SVS-VQI data, we were able to reduce EVAR LOS by identifying modifiable factors and instituting focused interventions. The reduction in LOS was associated with cost savings to the hospital.
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http://dx.doi.org/10.1503/cjs.003219DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7828953PMC
February 2020

IVC filter removal after extended implantation periods.

Surgeon 2020 Oct 25;18(5):265-268. Epub 2019 Nov 25.

Division of Interventional Radiology, University Health Network, Toronto General Hospital, Canada; Division of Vascular Surgery, University Health Network, Toronto General Hospital, Canada. Electronic address:

Objective: Life-threatening complications have been reported in patients with chronic retrievable IVC filters. National health agencies have urged hospitals to assess all patients with retrievable IVC filters for filter removal. The aim of the current study was to identify those patients with unretrieved chronic IVC filters, document complications and removal techniques.

Methods: We identified a cohort with unretrieved IVC filters inserted between January 2001 and December 2013. These patients were invited back to clinic for review with CT imaging to determine complications, if any, and offer removal. Data collected included demographics, complications and retrieval characteristics.

Results: 289 patients were discovered to still have a filter in situ. Of these, 193 patients were verified as deceased. Eighty-nine patients were notified, with no current contact information available on the remaining seven. Thirty-six attended for review, 20 females, 16 males, with an average age of 63.5 years. Complications identified at CT were 2 occluded IVCs (5.8%), 4 fractured filters (11.7%) and filter penetration in all cases (37.5% grade 2, 56.25% grade 3). Sixteen patients agreed to proceed with filter removal, 10 declined the opportunity and 6 were unfit or had ongoing indication for the filter. Two are awaiting removal and two had IVC occlusion. Subsequent retrieval was successful in 93% of cases (14/15). The mean time to removal from implant was 3846.9 days (SD 980.3). Advanced techniques were utilized in 10 cases and there were no mortalities or morbidities.

Conclusion: Retrievable inferior vena cava filters are not benign and practitioners need to be aware of regulatory guidelines. Unretrieved filters can be successfully retrieved using standard and advanced methods with low morbidity and mortality.
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http://dx.doi.org/10.1016/j.surge.2019.10.003DOI Listing
October 2020

Unplanned early hospital readmissions in a vascular surgery population

Can J Surg 2019 12;62(6):412-417

From the Department of Vascular Surgery, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ont. (Papadopoulos, Devries, Montbriand, Eisenberg, De Mestral, Roche-Nagle); and the Department of Obstetrical Anesthesia, Sunnybrook Research Institute, Toronto, Ont. (Montbriand).

Background: Patients who undergo vascular surgery are burdened by high early readmission rates. We examined the frequency and cause of early readmissions after elective and emergent admission to the vascular surgery service at our institution to identify modifiable targets for quality improvement.

Methods: Over a 5-year period, all patients admitted and readmitted to the vascular surgery service were identified. Medical records were then individually reviewed to identify baseline characteristics from the index admission and the most responsible diagnosis for readmission within 28 days of discharge.

Results: Of a total of 3324 patients, 421 (12.7%) were readmitted to our institution within 28 days of discharge. Forty-seven were found to have more than 1 readmission following their index admission. The readmission rate ranged from 11.8% to 14.1% over the 5-year study period, resulting in an average readmission rate of 12.7%. There were similar rates for men (12.9%) and women (12.3%). Of the readmitted cases, 236 (63.1%) were unplanned readmissions. The most common diagnoses for unplanned readmissions were worsening of peripheral arterial disease status including complications related to peripheral bypass graft (30.9%), surgical site infections (15.3%) and nonsurgical infections (14.8%).

Conclusion: To reduce readmission rates effectively, institutions must identify highrisk patients. In our study cohort, the most frequent pathology resulting in readmission was peripheral arterial disease. The most frequent preventable reason for readmission was surgical site infection. Interventions focused on early assessment of clinical status and wounds in addition to avoidance of infectious complications could help reduce readmission rates. Preventive resources can be efficiently targeted by focusing on subgroups at risk for readmission.
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http://dx.doi.org/10.1503/cjs.010318DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6877383PMC
December 2019

Vascular Complications and Procedures Following Transcatheter Aortic Valve Implantation.

Eur J Vasc Endovasc Surg 2019 Sep 18;58(3):437-444. Epub 2019 Jul 18.

Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Vascular Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada. Electronic address:

Objectives: Vascular complications (VCs) remain a significant cause of morbidity in transcatheter aortic valve implantation (TAVI) patients and are associated with worse outcomes. This research analysed the incidence, impact, and predictors of VCs in transfemoral cases.

Methods: A retrospective chart review was performed of 388 consecutive TAVI patients between January 2007 and April 2015, which included 237 transfemoral cases. Major and minor VCs were characterised according to the Valve Academic Research Consortium (VARC) guidelines. Logistic regression was completed to identify predictors of VCs.

Results: While VCs occurred in 68 (28.7%) cases, only seven (3.38%) were classified as major complications. Twenty-six (10.9%) of these complications occurred intra-operatively, with four being major (1.6%) and 22 minor (9.3%). Post-operative VCs occurred in 42 cases (17.2%), with three (1.3%) being major. Procedures to correct VCs occurred in 10 (4.2%) cases, with the majority (90%) being surgical and the remainder being treated by endovascular techniques. Nine surgical procedures, predominantly embolectomy, were performed to correct post-operative complications. Female gender was a predictor of all major VCs (B = -2.1, p < .006). Further, a logistic regression analysis found that when the largest sheath was located on the left side, there were increased minor post-operative complications (B = -0.99, p = .007). Dissections and haematomas made up the majority of VCs. Thirty day mortality was six patients (n = 2.5%), and peri-operative VCs were significantly correlated with 30 day mortality (p = .001, R = 0.21). The 30 day readmission rate comprised nine patients (3.8%), with three (1.3%) due to VCs, including haematomas and groin infections.

Conclusions: VCs contribute to operative morbidity in TAVI patients. This study demonstrated low major VC rates over an eight year period. Left sided location of largest sheath size and female gender were predictors of VC.
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http://dx.doi.org/10.1016/j.ejvs.2019.03.014DOI Listing
September 2019

Home care nursing after elective vascular surgery: an opportunity to reduce emergency department visits and hospital readmission.

BMJ Qual Saf 2019 11 24;28(11):901-907. Epub 2019 May 24.

Surgery, University Health Network, Toronto, Ontario, Canada.

Background: Events occurring outside the hospital setting are underevaluated in surgical quality improvement initiatives and research.

Objective: To quantify regional variation in home care nursing following vascular surgery and explore its impact on emergency department (ED) visits and hospital readmission.

Methods: Patients who underwent elective vascular surgery and were discharged directly home were identified from population-based administrative databases for the province of Ontario, Canada, 2006-2015. The index surgeries included carotid endarterectomy, open and endovascular aortic aneurysm repair and bypass for lower extremity peripheral arterial disease. Home care nursing within 30 days of discharge was captured and compared across regions. Using multilevel logistic regression, we characterised the association between home care nursing and the risk of an ED visit or hospital readmission within 30 days of discharge.

Results: The cohort included 23 617 patients, of whom 9002 (38%) received home care nursing within 30 days of discharge home. Receipt of nursing care after discharge home varied widely across Ontario's 14 administrative health regions (range 16%-84%), even after accounting for differences in patient case mix. A lower likelihood of an ED visit or hospital readmission within 30 days of discharge was observed among patients who received home care nursing following three of four index surgeries: carotid endarterectomy OR 0.74, 95% CI 0.61 to 0.91; endovascular aortic aneurysm repair OR 0.85, 95% CI 0.72 to 0.99; open aortic aneurysm repair OR 1.06, 95% CI 0.91 to 1.23; bypass for lower extremity peripheral arterial disease OR 0.81, 95% CI 0.72 to 0.92.

Conclusion: Home care nursing may contribute to reducing ED visits and hospital readmission and is variably prescribed after vascular surgery.
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http://dx.doi.org/10.1136/bmjqs-2018-009161DOI Listing
November 2019

Penetrating paediatric neck trauma.

BMJ Case Rep 2019 May 14;12(5). Epub 2019 May 14.

Division of Vascular Surgery, Toronto General Hospital, Toronto, Ontario, Canada.

Penetrating injuries to the internal carotid artery are infrequent but potentially devastating and can be a significant challenge to the operating surgeon. In this article, we present a case of an 11-year-old girl who suffered a serious vascular injury when she fell on a pencil. We also discuss the most up-to-date recommendations concerning the management of zone II injuries to the neck of a paediatric patient.
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http://dx.doi.org/10.1136/bcr-2018-226436DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6536251PMC
May 2019

Adherence to recommended imaging surveillance of acutely presenting Stanford type-B aortic dissections.

Vascular 2019 Oct 8;27(5):524-534. Epub 2019 Apr 8.

Faculty of Medicine, University of Toronto, Toronto, ON, Canada.

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http://dx.doi.org/10.1177/1708538119841453DOI Listing
October 2019

Real-Time Quantitative Measurements of Foot Perfusion in Patients With Critical Limb Ischemia.

Vasc Endovascular Surg 2019 May 24;53(4):310-315. Epub 2019 Feb 24.

1 Division of Interventional Radiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Introduction: Current methods of evaluating adequacy of endovascular procedures are imperfect and do not always predict which patients will do well. The purpose of this study was to evaluate the role of real-time quantitative measurements of perfusion among patients with critical limb ischemia.

Materials And Methods: Thirty-four patients with critical limb ischemia undergoing endovascular treatment were recruited. Perfusion Images of the foot were obtained pre and post successful angioplasty using an SPY Elite System (Novadaq Technologies, Ontario, Canada). Patients were followed for 6 months. Subsequently a logistic regression was performed to determine whether intraprocedural perfusion parameters predicted the odds of wound healing.

Results: Twenty-nine patients had successful angioplasty. Median age was 69.5% ± 8.3; 75% were men and 64% were diabetic. Rutherford stages were (4%-39%, 5%-57%, 6%-4%), and the average target limb ankle-brachial index (ABI) was 0.58 (SD 2.24). There was no significant correlation between the ABI and perfusion parameters. Inflow perfusion rate correlated significantly with Rutherford stage (Spearman rho 0.398, P = .036). After successful angioplasty 39% had a decrease in inflow rate and 57% had a decreased total inflow. In all, 25 patients completed 6 months of follow-up. Resolution of rest pain and/or healing of the ischemic wound occurred in 10 (40%) patients at 1 month, 4 (16%) at 3 months, and 2 (8%) at 6 months. One patient underwent a major amputation at 2 months. Eight (32%) patients never healed or had persistent rest pain. None of the real-time perfusion variables were significant predictors of wound healing.

Conclusion: Many patients experience a paradoxical decrease in perfusion following successful angioplasty suggesting perfusion may not correlate with angiographic outcome, possibly due to microemboli, microvascular disease, or vasospasm. Real-time perfusion imaging following intra-arterial infusion of indocyanine green does not predict the odds of wound healing.
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http://dx.doi.org/10.1177/1538574419833223DOI Listing
May 2019

Utility of the Vascular Quality Initiative in improving quality of care in Canadian patients undergoing vascular surgery

Can J Surg 2019 02;62(1):66-69

From the Faculty of Medicine, University of Toronto, Toronto, Ont. (Liao); the Division of Vascular Surgery, University Health Network, Toronto, Ont. (Eisenberg, Roche-Nagle); the Faculty of Medicine, University of Edinburgh, Edinburgh, Scotland (Kaushal); the Pain Research Unit, Department of Anesthesia and Pain Management, University Health Network (Montbriand); and the Division of Vascular and Interventional Radiology, University Health Network, Toronto, Ont. (Tan, Roche-Nagle).

The Vascular Quality Initiative (VQI) is a national cooperative quality-improvement initiative designed to evaluate processes of care and outcomes in vascular surgery. The purpose of this report is to show the utility of such a database to provide insight into the standard of care provided, to highlight areas of local quality improvement, to benchmark our data against local, regional and national trends, and to ultimately improve safety in Canadian patients undergoing vascular surgery. We present the history of the database, its spread in the Canadian health care system and examples of quality improvements achieved from analyses of data recorded and retrieved from the VQI. Using the VQI, our institution was able to decrease the length of stay after endovascular aneurysm repair, decrease the contrast volume in endovascular aneurysm repair, save on costs, and provide medium-term outcome data on peripheral vascular interventions and smoking cessation strategies. The VQI is a powerful tool to improve patient safety and quality in vascular surgery. Its ability to create local regional improvement groups fosters a quality-focused culture and is important for Canadian patients.
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http://dx.doi.org/10.1503/cjs.002218DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6351256PMC
February 2019

Pre-operative Aneurysm Thrombus Volume, But Not Density, Predicts Type 2 Endoleak Rate Following Endovascular Aneurysm Repair.

Ann Vasc Surg 2019 May 28;57:98-108. Epub 2018 Nov 28.

Division of Vascular Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada. Electronic address:

Background: The impact of aneurysm thrombus characteristics on type 2 endoleak rate following endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) is unclear. The purpose of this study is to determine the impact of pre-operative aneurysm thrombus volume and density on the incidence of type 2 endoleak following EVAR for infrarenal AAA.

Methods: A retrospective analysis was completed on all patients who underwent standard EVAR at an academic medical institution between May 1, 2010 and June 1, 2016 with a minimum follow-up period of 12 months. The final analysis included 170 patients. Thrombus volume and density were determined by analyzing pre-operative computed tomography angiography (CTA) scans using the TeraRecon plaque analysis module. The number and diameter of patent infrarenal aortic branch vessels were also identified. Type 2 endoleak was diagnosed by post-operative CTA, duplex ultrasound, or angiography.

Results: Over a median follow-up period of 29 months, 88 (51.8%) of 170 patients had a type 2 endoleak. The thrombus volume as a proportion of the infrarenal aorta volume was significantly lower in patients with type 2 endoleak (odds ratio [OR] 0.034, 95% confidence interval [CI] 0.005-0.291, P = 0.002). The number of patent lumbar arteries was significantly greater in patients with type 2 endoleak (OR 1.45, 95% CI 1.16-1.56, P < 0.0005). Both variables independently predicted the incidence of type 2 endoleak in a multivariate analysis. Thrombus density was not related to the incidence of type 2 endoleak.

Conclusions: A lower ratio of thrombus volume/infrarenal aorta volume and a higher number of patent lumbar arteries were associated with an increased incidence of type 2 endoleak. A multivariate logistic regression model was generated to pre-operatively predict the risk of type 2 endoleak. This model can guide the stratification of patients for intensity of endoleak surveillance following EVAR and consideration of pre-operative treatment.
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http://dx.doi.org/10.1016/j.avsg.2018.09.012DOI Listing
May 2019

Regarding "Increasing the number of integrated vascular surgery residency positions is important to address the impending shortage of vascular surgeons in the United States".

J Vasc Surg 2018 11;68(5):1617-1618

Divisions of Vascular Surgery and Vascular Interventional Radiology, Departments of Surgery and Medical Imaging, University Health Network, University of Toronto, Toronto, Ontario, Canada.

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http://dx.doi.org/10.1016/j.jvs.2018.06.201DOI Listing
November 2018

Outcomes of minor amputations in patients with peripheral vascular disease over a 10-year period at a tertiary care institution.

Vascular 2019 Feb 29;27(1):8-18. Epub 2018 Aug 29.

1 Division of Vascular Surgery, Toronto General Hospital, Peter Munk Cardiac Centre, Toronto, Ontario, Canada.

Objectives: Choosing an optimal amputation level requires balance between maximizing limb salvage while minimizing chances of non-healing wounds and re-amputation. Our aim was to assess the long-term outcome for minor amputations in patients with peripheral vascular disease.

Methods: A retrospective study of minor amputations between January 1, 2005 and December 31, 2015 was performed. Electronic medical records of eligible patients were examined to extract demographics, co morbidities and clinical data.

Results: Within the study period, 220 patients underwent 296 primary minor amputations in 244 lower extremities. Wound healing was achieved in 18.2% (54 of 296 amputations) and 43.6% (129 of 296 amputations) at 90 days and 365 days, respectively. Rates of progression to major amputation were 16.4% (40 or 244 limbs) and 21.7% (53 of 244 limbs) at 90 days and 365 days, respectively. In the final multivariate model, lower ipsilateral posterior tibial waveforms predicted poor 90-day healing (OR = 2.22, p = 0.01) as well as limb loss (OR = 3.02, p = 0.02) in a dose-response manner. In the final logistic regression model, emergency department admission (OR = 0.20, p < 0.01), ipsilateral posterior tibial waveform (OR = 2.63, p < 0.01), and post-operative infection (OR = 0.30, p < 0.01) were predictors of poor healing status at study endpoint.

Conclusion: This study shows that a majority of foot amputees require ongoing care for non-healing wounds and a proportion necessitate conversion to major amputation. Adequate vascularization is essential to promote and maintain healing.
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http://dx.doi.org/10.1177/1708538118797544DOI Listing
February 2019

Long-term results of thigh arteriovenous dialysis grafts.

J Vasc Access 2019 Mar 25;20(2):153-160. Epub 2018 Jul 25.

1 Department of Surgery, Division of Vascular Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.

Introduction:: A proportion of hemodialysis patients exhaust all options for arteriovenous access in upper extremities. Arteriovenous thigh grafts are a potential vascular access option in such patients.

Methods:: We performed a retrospective study of all thigh arteriovenous access grafts placed between 1995 and 2015. The clinical, demographic patient information and patency of each thigh graft was determined from the time of surgical creation placement until abandonment, transfer to other modality, or center or end of study, and the reason for access failure documented.

Results:: In total, 44 patients received 49 thigh arteriovenous accesses. The average age was 60 years (13-79 years); Half (53%) of the patients (n = 24) were female and 61% of the patients (n = 30) of arteriovenous accesses were left-sided. The cumulative proportion surviving (primary patency rates) at 12, 24, and 28 months were 43% (standard error = 9%), 33% (standard error = 9%), and 13% (standard error = 9%), respectively. The cumulative proportion of surviving grafts at 12, 24, and 48 months were 61% (standard error = 8%), 58% (standard error = 9%), and 31% (standard error = 13%), respectively. In total, 37 revisions were performed in 22 patients to maintain patency or eradicate infection. Infection occurred in 20 patients (39%) of thigh grafts requiring 16 patients (80% of those affected) to be removed; 14 patients had grafts (33.3%) that served as the lone hemodialysis arteriovenous access during the patients' lifetime on dialysis.

Conclusion:: Arteriovenous thigh graft access is used infrequently, but they have an acceptable patency. Some accesses require revisions and they have a high infection rate. Despite this, an acceptable proportion of leg grafts provide durable access for the dialysis lifetime of the patient.
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http://dx.doi.org/10.1177/1129729818787994DOI Listing
March 2019
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