Publications by authors named "Prasad Jetty"

41 Publications

Antithrombotic regimens in females with symptomatic lower extremity peripheral arterial disease: protocol for a systematic review and meta-analysis.

BMJ Open 2021 05 18;11(5):e042980. Epub 2021 May 18.

Department of Epidemiology, University of Ottawa, Ottawa, Ontario, Canada.

Introduction: Patients with peripheral arterial disease (PAD) are at increased risk for systemic arterial thromboembolic events. Females represent a unique subset of patients with PAD, who differ from males in important ways: they have smaller diameter vessels, undergo lower extremity bypass less frequently and experience higher rates of graft occlusion, amputation and mortality than males. Females also trend towards higher rates of major coronary events and cardiovascular mortality. Current guidelines recommend monoantiplatelet therapy (MAPT) for secondary prevention in patients with symptomatic PAD. However, indications for more intensive antithrombotic therapy in this cohort-especially among females who are frequently under-represented in randomised controlled trials (RCTs)-remain unclear. As newer antithrombotic therapies emerge, some RCTs have demonstrated differential effects in females versus males. A systematic review is needed to quantify the rates of arterial thromboembolic and bleeding events with different antithrombotic regimens in females with symptomatic PAD.

Methods And Analysis: We will search MEDLINE, Embase and the Cochrane Central Register of Controlled trials for published RCTs that include females with symptomatic PAD and compare full dose anticoagulation±antiplatelet therapy, dual pathway inhibition or dual antiplatelet therapy with MAPT. Title, abstract and full-text screening will be conducted in duplicate by three reviewers. Authors will be contacted to obtain sex-stratified outcomes as needed. Risk of bias will be assessed using the Cochrane Risk of Bias tool. Data will be extracted by independent reviewers and confirmed by a second reviewer. Quantitative synthesis will be conducted using Review Manager (RevMan) V.5 for applicable outcomes data. Planned subgroup analysis by PAD severity, vascular intervention and indication for antithrombotics will be conducted where data permits.

Ethics And Dissemination: Ethics approval is waived as the study does not involve primary data collection. This review will be submitted for publication in a peer-reviewed journal and for presentation at national and international scientific meetings.

Trial Registration Number: This protocol was registered with the PROSPERO International Prospective Register of Systematic Reviews (ID# CRD42020196933).
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http://dx.doi.org/10.1136/bmjopen-2020-042980DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8137217PMC
May 2021

From cellular function to global impact: the vascular perspective on COVID-19.

Can J Surg 2021 05 12;64(3):E289-E297. Epub 2021 May 12.

From the Division of Vascular Surgery, University of Ottawa at The Ottawa Hospital, Ottawa, Ont. (Strauss, Jetty); the Faculty of Medicine, University of Ottawa, Ottawa, Ont. (Strauss, Seo, Carrier, Jetty); the Division of Hematology, Department of Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, Ont. (Carrier); and the Ottawa Hospital Research Institute, Ottawa, Ont. (Carrier).

Since COVID-19 was declared a pandemic a year ago, our understanding of its effects on the vascular system has slowly evolved. At the cellular level, SARS-CoV-2 - the virus that causes COVID-19 - accesses the vascular endothelium through the angiotensin-converting enzyme 2 (ACE-2) receptor and induces proinflammatory and prothrombotic responses. At the clinical level, these pathways lead to thromboembolic events that affect the pulmonary, extracranial, mesenteric, and lower extremity vessels. At the population level, the presence of vascular risk factors predisposes individuals to more severe forms of COVID-19, whereas the absence of vascular risk factors does not spare patients with COVID-19 from unprecedented rates of stroke, pulmonary embolism and acute limb ischemia. Finally, at the community and global level, the fear of COVID-19, measures taken to limit the spread of SARS-CoV-2 and reallocation of limited hospital resources have led to delayed presentations of severe forms of ischemia, surgery cancellations and missed opportunities for limb salvage. The purpose of this narrative review is to present some of the data on COVID-19, from cellular mechanisms to clinical manifestations, and discuss its impact on the local and global surgical communities from a vascular perspective.
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http://dx.doi.org/10.1503/cjs.023820DOI Listing
May 2021

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

J Vasc Surg 2021 Feb 16. 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
February 2021

Carotid Endarterectomy Versus Carotid Artery Stenting: Survey of the Quality, Readability, and Treatment Preference of Carotid Artery Disease Websites.

Interact J Med Res 2020 Nov 3;9(4):e23519. Epub 2020 Nov 3.

Division of Vascular Surgery, University of Ottawa, Ottawa, ON, Canada.

Background: The internet is becoming increasingly more important in the new era of patient self-education. Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are recognized interventions to treat patients with carotid artery stenosis. Using the Google search platform, patients encounter many websites with conflicting information, which are sometimes difficult to understand. This lack of accessibility creates uncertainty or bias toward interventions for carotid artery disease. The quality, readability, and treatment preference of carotid artery disease (CAD) websites have not yet been evaluated.

Objective: This study aimed to explore the quality, readability, and treatment preference of CAD websites.

Methods: We searched Google Canada for 10 CAD-related keywords. Returned links were assessed for publication date, medical specialty and industry affiliation, presence of randomized controlled trial data, differentiation by symptomatic status, and favored treatment. Website quality and readability were rated by the DISCERN instrument and Gunning Fog Index.

Results: We identified 54 unique sites: 18 (33.3%) by medical societies or individual physicians, 11 (20.4%) by government organizations, 9 (16.7%) by laypersons, and 1 (1.9%) that was industry-sponsored. Of these sites, 26 (48.1%) distinguished symptomatic from asymptomatic CAD. A majority of sites overall (57.4%) and vascular-affiliated (72.7%) favored CEA. In contrast, radiology- and cardiology-affiliated sites demonstrated the highest proportion of sites favoring CAS, though they were equally likely to favor CEA. A large proportion (21/54, 38.9%) of sites received poor quality ratings (total DISCERN score <48), and the majority (41/54, 75.9%) required a reading level greater than a high school senior.

Conclusions: CAD websites are often produced by government organizations, medical societies, or physicians, especially vascular surgeons. Sites ranged in quality, readability, and differentiation by symptomatic status. Google searches of CAD-related terms are more likely to yield sites favoring CEA. Future research should determine the extent of website influence on CAD patients' treatment decisions.
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http://dx.doi.org/10.2196/23519DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7671836PMC
November 2020

A Novel Recurrent Genetic Variant Is Associated With a Dysplasia-Associated Arterial Disease Exhibiting Dissections and Fibromuscular Dysplasia.

Arterioscler Thromb Vasc Biol 2020 11 17;40(11):2686-2699. Epub 2020 Sep 17.

Division of Cardiovascular Medicine, Department of Internal Medicine (H.L.H., Y.W., M.-L.Y., K.L.H., J.L., A.E.K., S.K.G.), University of Michigan Medical School, Ann Arbor.

Objective: While rare variants in the gene have been associated with classical Ehlers-Danlos syndrome and rarely with arterial dissections, recurrent variants in underlying a systemic arteriopathy have not been described. Monogenic forms of multifocal fibromuscular dysplasia (mFMD) have not been previously defined. Approach and Results: We studied 4 independent probands with the pathogenic variant c.1540G>A, p.(Gly514Ser) who presented with arterial aneurysms, dissections, tortuosity, and mFMD affecting multiple arteries. Arterial medial fibroplasia and smooth muscle cell disorganization were confirmed histologically. The c.1540G>A variant is predicted to be pathogenic in silico and absent in gnomAD. The c.1540G>A variant is on a shared 160.1 kb haplotype with 0.4% frequency in Europeans. Furthermore, exome sequencing data from a cohort of 264 individuals with mFMD were examined for variants. In this mFMD cohort, c.1540G>A and 6 additional relatively rare variants predicted to be deleterious in silico were identified and were associated with arterial dissections (=0.005).

Conclusions: c.1540G>A is the first recurring variant recognized to be associated with arterial dissections and mFMD. This variant presents with a phenotype reminiscent of vascular Ehlers-Danlos syndrome. A shared haplotype among probands supports the existence of a common founder. Relatively rare genetic variants predicted to be deleterious by in silico analysis were identified in ≈2.7% of mFMD cases, and as they were enriched in patients with arterial dissections, may act as disease modifiers. Molecular testing for should be considered in patients with a phenotype overlapping with vascular Ehlers-Danlos syndrome and mFMD.
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http://dx.doi.org/10.1161/ATVBAHA.119.313885DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7953329PMC
November 2020

Declining institutional memory of open abdominal aortic aneurysm repair.

J Vasc Surg 2021 Mar 23;73(3):889-895. Epub 2020 Jul 23.

Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Division of Vascular and Endovascular Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada. Electronic address:

Objective: Since its introduction, endovascular aneurysm repair (EVAR) has become a mainstay in the treatment of abdominal aortic aneurysms (AAAs), resulting in the decline of open aneurysm repairs. The objective of this study was to determine whether reduced open aneurysm repair frequency has led to a reduction in perioperative efficiency and increase in postsurgical complications.

Methods: A retrospective cohort study compared perioperative data and complications of 49 consecutive juxtarenal AAA (<1-cm neck) open repairs performed between 2014 and 2017 and 53 consecutive juxtarenal AAA controls (2005-2007) at The Ottawa Hospital. There was no change in surgical personnel during this 10-year comparison.

Results: The Ottawa Hospital experienced a 61% decline in the number of open AAA repairs between the two time periods examined; 541 open AAA repairs and 86 EVARs were performed between 2005 and 2007, whereas 358 open AAA repairs and 385 EVARs were performed between 2014 and 2017. Age of participants significantly decreased in the 2014 to 2017 group (P = .01), as did the number of women undergoing open juxtarenal AAA repair (P = .05). Total operating room time and anesthesia time were longer in the 2014-2017 group (P = .02; P = .01), whereas surgical times remained consistent (P = .13). Suprarenal clamp time and blood loss during the procedure were decreased in the 2014-2017 group (P < .01; P < .01). Intensive care unit stay and overall hospital stay were not significantly different between groups (P = .77; P = .87); however, there were large standard deviations observed for the 2014-2017 group. As well, 18.4% of patients in the 2014-2017 group experienced postsurgical complications of Clavien-Dindo grade IIIa or higher compared with 11.3% of patients in the historical control group (P = .07). Mortality also trended toward an increase in the 2014-2017 group (P = .43).

Conclusions: The reduced rate of open repair performance at The Ottawa Hospital reflects the global trend toward EVAR. Anesthesia and operating room times increased during the period examined, reflecting a possible loss of expertise in the last decade. Complications also increased during this time for anatomically similar patients. Taken together, these findings may reflect a decreased institutional familiarity with open aneurysm repair and postsurgical care.
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http://dx.doi.org/10.1016/j.jvs.2020.06.125DOI Listing
March 2021

Diagnosing acute aortic syndrome: a Canadian clinical practice guideline.

CMAJ 2020 Jul;192(29):E832-E843

The Department of Emergency Medicine, Health Science North Research Institute (Ohle, Middaugh, Ansell, Scott), Northern Ontario School of Medicine, Sudbury, Ont.; Patient representative (Callaway), Alexandria, Ont.; Division of Cardiac Surgery (Rubens), University of Ottawa, Ottawa, Ont.; Division of Emergency Medicine, Department of Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Yadav), The Ottawa Hospital, University of Ottawa, Ottawa, Ont.; Department of Emergency Medicine (Cournoyer), Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Que.; Department of Emergency Medicine (Savage), Northern Ontario School of Medicine, Lakehead University, Thunder Bay, Ont.; Department of Vascular Surgery (Jetty), The Ottawa Hospital, University of Ottawa, Ottawa, Ont.; Division of Cardiac Surgery (Atoui), Health Sciences North, Northern Ontario School of Medicine, Sudbury, Ont.; Division of Cardiac Surgery (Atoui, Bittira), Health Sciences North, Northern Ontario School of Medicine, Sudbury, Ont.; Department of Radiology (Gupta), The Ottawa Hospital, University of Ottawa, Ottawa, Ont.; Department of Radiology (Coffey), Trillium Hospital, University of Toronto, Mississauga, Ont.; Division of Cardiac Anesthesiology (Wilson), Department of Anesthesiology and Pain Medicine, University of Ottawa Heart Institute, Ottawa, Ont.; Department of Emergency Medicine (Bignucolo), Espanola Regional Hospital, Northern Ontario School of Medicine, Espanola, Ont.; Department of Anaesthesia (McIsaac), Department of Critical Care, Health Science North, Northern Ontario School of Medicine, Sudbury, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary and Rockyview General Hospital (Lang), Calgary, Alta.

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http://dx.doi.org/10.1503/cmaj.200021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7828987PMC
July 2020

Wikipedia in Vascular Surgery Medical Education: Comparative Study.

JMIR Med Educ 2020 Jun 19;6(1):e18076. Epub 2020 Jun 19.

University of Ottawa, Ottawa, ON, Canada.

Background: Medical students commonly refer to Wikipedia as their preferred online resource for medical information. The quality and readability of articles about common vascular disorders on Wikipedia has not been evaluated or compared against a standard textbook of surgery.

Objective: The aims of this study were to (1) compare the quality of Wikipedia articles to that of equivalent chapters in a standard undergraduate medical textbook of surgery, (2) identify any errors of omission in either resource, and (3) compare the readability of both resources using validated ease-of-reading and grade-level tools.

Methods: Using the Medical Council of Canada Objectives for the Qualifying Examination, 8 fundamental topics of vascular surgery were chosen. The articles were found on Wikipedia using Wikipedia's native search engine. The equivalent chapters were identified in Schwartz Principles of Surgery (ninth edition). Medical learners (n=2) assessed each of the texts on their original platforms to independently evaluate readability, quality, and errors of omission. Readability was evaluated with Flesch Reading Ease scores and 5 grade-level scores (Flesch-Kincaid Grade Level, Gunning Fog Index, Coleman-Liau Index, Simple Measure of Gobbledygook Index, and Automated Readability Index), quality was evaluated using the DISCERN instrument, and errors of omission were evaluated using a standardized scoring system that was designed by the authors.

Results: Flesch Reading Ease scores suggested that Wikipedia (mean 30.5; SD 8.4) was significantly easier to read (P=.03) than Schwartz (mean 20.2; SD 9.0). The mean grade level (calculated using all grade-level indices) of the Wikipedia articles (mean 14.2; SD 1.3) was significantly different (P=.02) than the mean grade level of Schwartz (mean 15.9; SD 1.4). The quality of the text was also assessed using the DISCERN instrument and suggested that Schwartz (mean 71.4; SD 3.1) had a significantly higher quality (P=.002) compared to that of Wikipedia (mean 52.9; SD 11.4). Finally, the Wikipedia error of omission rate (mean 12.5; SD 6.8) was higher than that of Schwartz (mean 21.3; SD 1.9) indicating that there were significantly fewer errors of omission in the surgical textbook (P=.008).

Conclusions: Online resources are increasingly easier to access but can vary in quality. Based on this comparison, the authors of this study recommend the use of vascular surgery textbooks as a primary source of learning material because the information within is more consistent in quality and has fewer errors of omission. Wikipedia can be a useful resource for quick reference, particularly because of its ease of reading, but its vascular surgery articles require further development.
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http://dx.doi.org/10.2196/18076DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7334757PMC
June 2020

Unintended Consequences: Perils of Renal Revascularization for Severe Hypertension.

Can J Cardiol 2020 06 4;36(6):967.e9-967.e11. Epub 2020 Feb 4.

Division of Nephrology, Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada. Electronic address:

Revascularization of atherosclerotic renal artery stenosis may cure hypertension, but paradoxically, improvement in systemic blood pressure in response to successful revascularization may precipitate ischemia in other organs affected by previously silent atherosclerotic disease. We describe bowel ischemia secondary to preexisting celiac artery stenosis after revascularisation. Prior knowledge of multivessel disease facilitated prompt diagnosis and management of this condition.
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http://dx.doi.org/10.1016/j.cjca.2020.01.022DOI Listing
June 2020

Physiologic perfusion monitoring methods during endovascular revascularization for atherosclerotic peripheral arterial disease: protocol for a systematic review.

Syst Rev 2020 05 8;9(1):107. Epub 2020 May 8.

School of Epidemiology and Public Health, Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, K1Y4W7, Ottawa, Canada.

Background: Endovascular therapy is a fundamental treatment for peripheral arterial disease. However, the success rate of endovascular therapy remains poor, as a third of patients with critical limb ischemia ultimately require a major amputation for gangrene despite endovascular treatment. This failure rate has prompted investigation into methods of determining physiologic procedural success before and after treatment, before clinically apparent outcomes occur such as gangrene. The aim of this systematic review is to evaluate if in patients undergoing endovascular surgery for lower extremity atherosclerotic peripheral arterial disease, do changes in physiologic measures of perfusion during surgery correlate with clinical outcomes.

Methods: We registered and designed a study protocol for a systematic review. Literature searches will be conducted in MEDLINE, EMBASE, and CENTRAL (from January 1977 onwards). Grey literature will be identified through OpenGrey and clinical trial registries, and supplemented by citation searches. We will include randomized controlled trials, quasi-experimental trials, and observational (cohort, case-control) studies conducted in human adults (age 18 or older) who received elective arterial angioplasty for atherosclerotic peripheral vascular disease. The primary outcome of interest will be major adverse limb events. Two investigators will independently screen all citation, full-text articles, and abstract data. The study quality (risk of bias) will be appraised appropriate tools. Data analysis and synthesis will be qualitative; no meta-analysis is planned, as the anticipated homogeneity of measurement and outcome reporting standardization is low.

Discussion: The treatment of peripheral arterial disease is unique in that the tissue of the ischemic leg is easily accessible for direct monitoring during procedures. This is contrasted with cardiac and neurologic monitoring during cardiac and cerebral procedures, where indirect or invasive measures are required to monitor organ perfusion. Currently synthesized evidence describing limb perfusion focuses on static states of ischemia, and does not evaluate the value of change in perfusion measurement as an indicator of endovascular treatment success. These methods could potentially be applied to optimize procedural outcomes by guiding perfusion-based decision-making during surgery.

Systematic Review Registration: PROSPERO CRD42019138192.
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http://dx.doi.org/10.1186/s13643-020-01357-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7210685PMC
May 2020

Prolonged versus brief balloon inflation during arterial angioplasty for de novo atherosclerotic disease: a systematic review and meta-analysis.

CVIR Endovasc 2019 Aug 17;2(1):29. Epub 2019 Aug 17.

Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, K1H8L6, Canada.

Objective: Angioplasty is a fundamental treatment for atherosclerotic disease and may be performed as the sole therapy in small vessel disease. However, the ideal duration of balloon inflation has not yet been identified. Our study investigated whether prolonged inflation of at least 1-min duration, when compared with brief inflation, affects residual stenosis after arterial angioplasty.

Data Sources And Methods: Two independent reviewers conducted a systematic review of EMBASE, MEDLINE, CENTRAL, trial registries and grey literature, using pre-specified search syntax. Data abstraction and quantitative analysis was performed independently, according to pre-specified criteria. The primary outcome was residual stenosis after initial angioplasty, in addition to other pre-specific clinical and radiographic outcomes. All analyses were stratified by coronary, cerebrovascular, and peripheral territory. The study protocol is published and registered on PROSPERO (CRD42018092702).

Results: Six relevant articles were identified, of which one investigated peripheral vascular angioplasty and five investigated coronary artery angioplasty, encompassing 1496 procedures. The studies were at moderate risk of bias. Minimal heterogeneity within coronary studies allowed for subgroup meta-analysis. Prolonged inflation was significantly associated with lower risk of residual stenosis post-inflation in the pooled coronary trials (RR 1.76 [95% CI 1.46-2.12], I = 0%, p < 0.001) in addition to approaching significance in the peripheral vascular trial (RR 2.40 [95% CI 0.94-6.13], p = 0.07). Prolonged inflation was associated with less risk of arterial dissection and need for adjunctive procedures such as stenting. Following adjunctive procedures, less residual stenosis was still observed in the prolonged angioplasty group in the reported coronary studies. Follow-up data did not reveal a significant difference in the presence of restenosis, however there was a long-term benefit of prolonged inflation in reducing overall severity of stenosis.

Discussion: This is the first review investigating outcomes related to duration of balloon inflation. Both coronary and peripheral vascular evidence are in agreement that prolonged angioplasty balloon inflation greater than 60 s appears to be associated with improved immediate post-inflation results. However, long-term data is heterogeneous and inconsistently reported. We propose further investigation to address outstanding long-term outcomes, particularly in small vessel territories such as tibial vessels where angioplasty is often used as the only endovascular therapy.

Trial Registration: This protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO: CRD42018092702 ) prior to conduct of the review.
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http://dx.doi.org/10.1186/s42155-019-0072-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6966366PMC
August 2019

The futility of surveillance for old and small aneurysms.

J Vasc Surg 2020 07 22;72(1):162-170.e1. Epub 2020 Jan 22.

Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada.

Objective: We investigated the yield of ultrasound surveillance for small abdominal aortic aneurysms (AAAs) in patients older than 80 years compared with a younger population for detecting AAA growth reaching the threshold size for repair. Secondary objectives included analysis of the incidence of AAA repair and the cost-benefit of surveillance.

Methods: A retrospective cohort study was performed of all patients undergoing AAA surveillance in Ottawa between 2007 and 2015. Patients were dichotomized by enrollment age (<80 years vs ≥80 years) and stratified by enrollment AAA size. Cohorts were cross-referenced with the Ottawa surgical database, leveraging the common health region to ensure complete data capture. The threshold size for repair was sex specific (female, 5.0 cm; male, 5.5 cm). Factors influencing AAA growth rate were assessed with a general linear multiple mixed model. Analyses with Cox proportional hazards models with competing risk for mortality assessed aorta-related events, and cost-benefit was analyzed by referencing Ontario billing codes.

Results: A total of 1231 patients underwent serial ultrasound surveillance, of whom 500 were older than 80 years at some point during the study period. The mean AAA growth rate was 1.63 mm/y (95% confidence interval [CI], 1.54-1.71). Old age and small enrollment aneurysm size were significantly protective against AAA growth. Overall, 357 (29%) patients reached the AAA size threshold for repair, and 272 (22%) underwent AAA repair. Patients older than 80 years were less likely to reach the AAA threshold size for repair compared with their younger counterparts (adjusted hazard ratio, 0.77; 95% CI, 0.61-0.97). Of the 357 patients whose AAA reached the threshold size for repair, octogenarians were substantially less likely to undergo elective AAA repair (adjusted hazard ratio, 0.34; 95% CI, 0.24-0.47). Repair of ruptured AAA was rare (0.8%), and age differences were insignificant. For every octogenarian with an enrollment AAA size between 3.0 and 3.9 cm who ultimately received elective AAA repair, 51 patients were enrolled in surveillance without elective repair. This corresponded to an estimated $33,139 in ultrasound fees.

Conclusions: Surveillance of most patients with small AAA is appropriate. However, patients older than 80 years were significantly less likely than their younger counterparts to experience aortic growth reaching the threshold size for repair. Furthermore, in the unlikely event of AAA growth, patients older than 80 years were substantially less likely to undergo repair. These results suggest that in the context of patient-specific health and wishes, surveillance of AAAs <4 cm in octogenarians is costly and unlikely to be beneficial.
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http://dx.doi.org/10.1016/j.jvs.2019.09.063DOI Listing
July 2020

Protocol for a prospective observational diagnostic study: intraoperative simultaneous limb pressure monitoring (INSTANT) study.

BMJ Open 2019 08 22;9(8):e030456. Epub 2019 Aug 22.

School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.

Introduction: Peripheral vascular disease (PVD) is a condition caused by arterial blockages causing inadequate blood flow, resulting in pain and gangrene of the legs. Endovascular therapy, such as angioplasty, can be used to treat PVD, however, the operator feedback during surgery is primarily anatomic based on the angiogram. Because physiologic blood perfusion can be difficult to determine based on anatomic images, we propose introducing physiological measurements into the operating room. This study will investigate whether the change in intraoperative monitoring of haemodynamic measurements such as the Toe-Brachial Index during endovascular surgery for lower extremity atherosclerotic PVD is associated with clinical outcomes such as major adverse limb events (MALEs).

Methods And Analysis: This study will be a prospective, operator-blinded and blinded endpoint adjudicated observational diagnostic cohort study. A total of 80 legs will be enrolled in the study. Ankle and toe blood pressures will be measured non-invasively at predetermined time points before, during and after surgery, and we will assess associations between changes in intraoperative pressure measurements and postoperative clinical and haemodynamic outcomes. The primary outcome will be MALE within 1 year, and secondary outcomes include follow-up pressure measurements, vessel patency, reintervention, clinical staging improvement, amputation and death.

Ethics And Dissemination: Regional hospital ethics approval has been granted (Ottawa Hospital Research Institute - Research Ethics Board, Protocol 20180656-01H). On completion of data analysis, the study will submitted for presentation at international vascular surgical society meetings, in addition to submission for publication in publicly accessible medical journals.

Trial Registration Number: NCT03875846.
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http://dx.doi.org/10.1136/bmjopen-2019-030456DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6707646PMC
August 2019

Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia.

Eur J Vasc Endovasc Surg 2019 07 8;58(1S):S1-S109.e33. Epub 2019 Jun 8.

Sheffield Vascular Institute, UK.

Guideline Summary: Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
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http://dx.doi.org/10.1016/j.ejvs.2019.05.006DOI Listing
July 2019

Variability in aneurysm sac regression after endovascular aneurysm repair based on a comprehensive registry of patients in Eastern Ontario.

J Vasc Surg 2019 11 27;70(5):1469-1478. Epub 2019 May 27.

Division of Vascular Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada.

Background: Although the absence of aneurysm-related mortality, postimplantation rupture, and reintervention after endovascular aneurysm repair (EVAR) is desirable, it may not necessarily reflect successful aneurysm sac exclusion. Sac regression may be a more sensitive marker for EVAR success and may be influenced by factors beyond the presence or absence of an endoleak. The objective of this study is to determine the rate of overall long-term sac regression after EVAR and the influence of nonanatomic factors, and endograft devices used at our center.

Methods: This retrospective cohort study included all EVARs performed for intact and ruptured abdominal aortic aneurysms (AAAs) at a university teaching hospital. Preoperative, operative, and follow-up data were collected using clinical and radiologic institutional databases. Preoperative and post-EVAR sac diameters were determined by a blinded observer in accordance with Society for Vascular Surgery guidelines. Absolute and relative sac regression was determined at the following intervals: 0 to 6 months, 6 to 12 months, 12 to 18 months, 18 months to 2 years, 2 to 5 years, 5 to 10 years, and more than 10 years.

Results: From 1999 to 2015, 1060 patients underwent EVAR for an AAA at the Ottawa Hospital. Procedures were performed using a total of nine unique endograft devices, with five devices (Cook Zenith, n = 398; Medtronic Endurant, n = 375; Medtronic Talent, n = 183; Cook Zenith LP, n = 52; and Terumo Anaconda, n = 23) used in 97% of the procedures. The mean preoperative AAA diameter was 61.2 mm, with no detectable differences between endograft devices with respect to age, preoperative AAA diameter, or rupture diagnosis. Overall mean sac regression increased from -1.3 mm at 6 months, to -14.9 mm beyond 10 years. The majority of sac regression was achieved within 2 years. Only 90 of the 1060 patients (8.5%) experienced sac expansion of greater than 5 mm at some point during their follow-up period. Kaplan-Meier analyses revealed statistically significant device-specific variability in sac regression rates, even in the absence of an endoleak. Cox proportional hazard modeling demonstrated that age less than 75 years (hazard ratio [HR], 1.4; P = .001), female sex (HR, 1.4; P = .003), absence of type I endoleak (HR, 4.6; P < .0001), AAA greater than 70 mm (HR, 1.6; P < .0001), and both the Zenith (HR, 2.0; P < .0001) and Endurant (HR, 1.7; P = .001) devices were associated with shorter time to more than 5 mm sac regression.

Conclusions: This study demonstrated a pattern of sac diameter change after EVAR, with the majority of sac regression occurring within the first 2 years. Variability in sac regression was influenced by nonanatomic variables including age, sex, original AAA diameter, and specific endograft device, even after controlling for the presence or absence of an endoleak. The biophysical relationship between specific endograft design and materials, and sac regression is yet to be determined.
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http://dx.doi.org/10.1016/j.jvs.2019.01.091DOI Listing
November 2019

Management of transient ischemic attack or nondisabling stroke related to extracranial internal carotid artery stenosis.

CMAJ 2019 04;191(15):E418-E422

Division of Vascular Surgery (Kapila), William Osler Health System, Brampton, Ont.; Division of Vascular Surgery (Jetty), University of Ottawa, Ottawa, Ont.; Division of Neurology, Mackenzie Health System (Basile), Vaughan, Ont.; Division of Vascular Surgery (Dubois), Western University, London, Ont.

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http://dx.doi.org/10.1503/cmaj.180735DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6464884PMC
April 2019

A new "angle" on aortic neck angulation measurement.

J Vasc Surg 2019 09 2;70(3):756-761.e1. Epub 2019 Mar 2.

Division of Vascular Surgery, University of Ottawa, Ottawa, Ontario, Canada.

Objective: Infrarenal aortic neck angulation is one of the most powerful predictors of endovascular aneurysm repair failure. Whereas the "gold standard" to measure this angle is three-dimensional (3D) reconstruction and centerline measurement, many surgeons rely on estimations of angulation based on two-dimensional (2D) views of computed tomography imaging. Unfortunately, these views do not accurately represent the true angle, particularly if aortic angulation is oblique to the standard views. In response to this issue, our group has developed a novel trigonometric formula that uses coronal and sagittal measured angles to calculate the true angle. The purpose of this study was to compare the paired angle formula with 3D centerline measurements for estimating true aortic neck angulation.

Methods: Fifty randomly selected patients treated by endovascular aneurysm repair at The Ottawa Hospital between 2010 and 2015 were studied. The 3D centerline aortic neck angle measurements were made by a radiology staff physician. The paired angle formula was applied by a vascular surgeon, resident, and student using 2D coronal and sagittal angles from computed tomography imaging to estimate the true angle.

Results: The average age was 78 years; 74% of patients were male, and average preoperative aneurysm diameter was 5.7 cm. The mean neck length was 1.9 cm (1.1-3.2 cm), and mean neck angulation calculated by the gold standard measurements was 39 degrees (2-84 degrees). Linear regression demonstrated strong association between 3D measurements and the paired angle formula, with correlations comparable to the intraobserver variability (intraclass correlation coefficient values range, 0.74-0.87). The average user estimates deviated minimally from the gold standard (absolute difference, 6 degrees; 95% confidence interval, 4-8 degrees) without systemic bias. The paired angle formula accurately ruled out severe angulation >60 degrees with an overall negative predictive value of >99%. Compared with isolated 2D measurements, application of the paired angle formula significantly decreased the false-negative rate of unappreciated severe angulation >60 degrees from 4.8% to 0.7% (P = .032).

Conclusions: The paired angle formula detects significantly more severe angles than isolated 2D measurements and can accurately rule out severe angulation >60 degrees compared with the 3D measurements. The implementation of this angle estimation method is a useful adjunct in the measurement of aortic neck angulation, especially if 3D reconstruction software is not readily available. Furthermore, the importance of accurate angle measurement is not limited to vascular surgery and has direct relevance to any procedural specialty that relies on preoperative angle measurements.
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http://dx.doi.org/10.1016/j.jvs.2018.11.036DOI Listing
September 2019

Prolonged versus brief balloon inflation during arterial angioplasty for de novo atherosclerotic disease: protocol for a systematic review.

Syst Rev 2019 02 5;8(1):45. Epub 2019 Feb 5.

Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, K1H8L6, Canada.

Background: Angioplasty is a fundamental treatment for atherosclerotic disease in the cardiac, cerebrovascular, and peripheral vascular beds. However, the optimal duration of balloon inflation has not been identified. Our study will investigate whether prolonged angioplasty balloon inflation of at least 1 min duration, when compared with brief inflation, affects residual stenosis after arterial angioplasty.

Methods: In compliance with PRISMA, two independent reviewers will conduct a systematic review of EMBASE, MEDLINE, CENTRAL, trial registries, grey literature, and ancestry and citation search. Data abstraction, quantitative, and quantitative meta-analysis will be performed according to pre-specified criteria. The primary outcome is residual stenosis immediately after initial angioplasty; however, secondary outcomes will include multiple short and long term pre-specific clinical and radiographic outcomes. Risk of bias, subgroup analyses, and sensitivity analyses are planned.

Discussion: Despite the ubiquitous use of angioplasty in atherosclerotic disease and multiple trials investigating the ideal balloon inflation duration, there are no systematic reviews evaluating prolonged angioplasty balloon inflation. Currently synthesized evidence is insufficient to confidently direct clinical decision-making, and the current variation in operator preference of balloon angioplasty duration suggests ongoing clinical equipoise. Given the known availability of current primary evidence, our study intends to synthesize the evidence and guide future clinical decision making and investigation.

Systematic Review Registration: PROSPERO CRD42018092702.
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http://dx.doi.org/10.1186/s13643-019-0955-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6362580PMC
February 2019

Break out of the Classroom: The Use of Escape Rooms as an Alternative Teaching Strategy in Surgical Education.

J Surg Educ 2019 Jan - Feb;76(1):134-139. Epub 2018 Aug 17.

Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Division of Vascular and Endovascular Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada.

Objective: To implement and assess the impact of a Vascular Surgery-themed Escape Room on medical student motivation, satisfaction, and engagement in CanMEDS roles.

Design: The authors designed an Escape Room combining Vascular Surgery objectives, knowledge-based problems and technical skills into Vascular Surgery-themed stations. Groups of 3 to 4 medical students participated in the activity. Data collected included time to escape, CanMEDS roles covered during the activity, debriefing interview session, and satisfaction survey.

Setting: The Escape Room was installed at the University of Ottawa Skills and Simulation Centre at the Ottawa Hospital, a tertiary care center.

Participants: Medical students in their preclerkship years of study were invited to participate in the Escape Room. In total, 13 medical students completed the experience, divided into 4 groups.

Results: Thirteen medical students divided into 4 groups participated in the Escape Room. Two teams used a collaborative strategy to complete the activity and successfully escaped with an average time of 53.6 minutes, whereas only 1 of the 2 teams completing the experience employing an individualistic strategy successfully escaped. Following the experience, 83% of participants stated that the experience motivated them to prepare beforehand and believed that the experience consolidated the knowledge that they had read. All the participants also reported that the experience encouraged the use of the CanMEDS communicator and collaborator roles. As well, 76.9% of students mentioned that they enjoyed the practical exercises incorporated into the experience and 53.8% stated that they would like to see the Escape Room format included in the medical curriculum.

Conclusions: By combining knowledge-based problems, key learning objectives, technical skills, and CanMEDS themes into the Escape Room, the authors have developed a learning platform that may be more enjoyable and provide an adjunct to traditional didactic lectures.
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http://dx.doi.org/10.1016/j.jsurg.2018.06.030DOI Listing
June 2020

Point-of-Care Ultrasound Performed by a Medical Student Compared to Physical Examination by Vascular Surgeons in the Detection of Abdominal Aortic Aneurysms.

Ann Vasc Surg 2018 Oct 17;52:15-21. Epub 2018 May 17.

Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Division of Vascular and Endovascular Surgery, The Ottawa Hospital, Ottawa, ON, Canada.

Background: The use of point-of-care ultrasound (POCUS) has become increasingly prevalent in medical practice as a non-invasive tool for focused bedside diagnosis. Consequently, some medical schools have begun implementing POCUS training as a standard in their medical school curriculum. The feasability and value of introducing POCUS training at the medical student level to screen for abdominal aortic aneurysms (AAA) should be explored. Given this, the objective of our study was to determine the test characteristics of point-of-care ultrasonography performed by a medical student versus physical examination by vascular surgeons compared to a gold standard reference scan for the detection of AAAs.

Methods: We conducted a prospective, observer-blinded study recruiting patients from an outpatient vascular surgery clinic. Participants were screened for AAAs by standardized physical examination by a blinded vascular surgeon, followed by a POCUS examination by a blinded medical student. The student underwent prior training by a vascular sonographer and emergency physician on 60 patients (16 were supervised). Ultrasonography was used to visualize and measure the proximal, mid, and distal aortic diameters. The maximal aortic diameter was noted and compared with measurements obtained by the reference scan (computed tomography scan or vascular sonographer-performed ultrasound). Reference scans were completed within 3 months of the recruitment visit.

Results: A total of 57 patients were enrolled over a 5-month period between October 2015 and March 2016. Mean age of recruited patients was 71 years, and 61% were male. Mean body mass index was 27.9 ± 4.3, and mean waist-to-hip ratio was 0.96 ± 0.10. Sixteen AAAs were detected by the reference scan, with an average maximal aortic diameter of 44.9 mm. Physical examination by a vascular surgeon detected 11 of 16 AAAs with 2 false positives (sensitivity and specificity of 66.7% [95% confidence interval [CI], 38.4-88.2] and 94.4% [95% CI, 81.3-99.3], respectively). POCUS detected 15 of 16 AAAs (sensitivity and specificity of 93.3% [95% CI, 68.1-99.8] and 100% [95% CI, 88.4-100], respectively). Seven of the 64 POCUS scans were indeterminate (>1 cm of the aorta was not visualized). Average time to conduct the physical examination was 35 sec versus 4.0 min for point-of-care ultrasonography. There was a strong linear correlation (R = 0.95) between maximal aortic diameter measured by point-of-care ultrasonography versus reference scan with a mean absolute difference of 2.6 mm.

Conclusion: Point-of-care ultrasonography performed by a medical student is highly accurate and more effective in detecting AAAs than physical examination by vascular surgeons. The introduction of POCUS training at the medical student level and its wide-scale implementation as an extension to physical examination may lead to improved detection of AAAs.
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http://dx.doi.org/10.1016/j.avsg.2018.03.015DOI Listing
October 2018

Infolding of fenestrated endovascular stent graft.

J Vasc Surg Cases Innov Tech 2017 Sep 20;3(3):159-162. Epub 2017 Jul 20.

Division of Vascular Surgery, University of Ottawa, Ottawa, Ontario, Canada.

We report a case of infolding of a fenestrated stent graft involving the visceral vessel segment after a juxtarenal abdominal aorta aneurysm repair. The patient remains free of any significant endoleak, and the aortic sac has shown regression. The patient remains asymptomatic, with no abdominal pain, with normal renal function, and without ischemic limb complications. We hypothesize that significant graft oversizing (20%-30%) with asymmetric engineering of the diameter-reducing ties may have contributed to the infolding. Because of the patient's asymptomatic nature and general medical comorbidities, further intervention was deemed inappropriate as the aneurysmal sac is regressing despite the infolding.
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http://dx.doi.org/10.1016/j.jvscit.2017.04.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5764892PMC
September 2017

Subclavian steal syndrome without subclavian stenosis.

J Vasc Surg Cases Innov Tech 2017 Sep 18;3(3):129-131. Epub 2017 Jul 18.

Division of Vascular Surgery, University of Ottawa, Ottawa, Ontario, Canada.

Subclavian steal syndrome (SSS) has been well described in the setting of subclavian stenosis. We describe an unusual case of SSS caused by a high-flow arteriovenous dialysis fistula in the absence of subclavian stenosis, provide a review of the literature, and propose that arteriovenous fistula-induced SSS is an underdiagnosed cause of syncope in this population of patients.
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http://dx.doi.org/10.1016/j.jvscit.2017.02.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5764853PMC
September 2017

Editor's Choice - Late Open Surgical Conversion after Endovascular Abdominal Aortic Aneurysm Repair.

Eur J Vasc Endovasc Surg 2018 02 7;55(2):163-169. Epub 2017 Dec 7.

University of Ottawa, Division of Vascular Surgery, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada. Electronic address:

Introduction: Late open surgical conversion following endovascular aneurysm repair (EVAR) may occur more frequently after performing EVAR in anatomy outside the instructions for use (IFU). This study reviews predictors and outcomes of late open surgical conversion for failed EVAR.

Methods: This retrospective cohort study reviewed all EVARs performed at the Ottawa Hospital between January 1999 and May 2015. Open surgical conversions >1 month post EVAR were identified. Variables analysed included indication for conversion, pre-intervention AAA anatomy, endovascular device and configuration, operative technique, re-interventions, complications, and death.

Results: Of 1060 consecutive EVARs performed, 16 required late open surgical conversion. Endografts implanted were Medtronic Talent (n = 8, 50.0%), Medtronic Endurant (n = 3, 18.8%), Cook Zenith (n = 4, 25.0%), and Terumo Anaconda (n = 1, 6.2%). Eleven grafts were bifurcated (68.8%), five were aorto-uni-iliac (31.2%). The median time to open surgical conversion was 3.1 (IQR 1.0-5.2) years. There was no significant difference in pre-EVAR rupture status (1.4% elective, 2.1% ruptured, p = .54). Indications for conversion included: Type 1 endoleak with sac expansion (n = 4, 25.0%), Type 2 endoleak with expansion (n = 2, 12.5%), migration (n = 3, 18.8%), sac expansion without endoleak (n = 2, 12.5%), graft infection (n = 3, 18.8%), rupture (n = 2, 12.5%). Nine patients (56.2%) underwent stent graft explantation with in situ surgical graft reconstruction, seven had endograft preserving open surgical intervention. The 30 day mortality was 18.8% (n = 3, all of whom having had endograft preservation). Ten patients (62.5%) suffered major in hospital complications. One patient (6.5%) required post-conversion major surgical re-intervention. IFU adherence during initial EVAR was 43.8%, versus 79.0% (p < .01) among uncomplicated EVARs.

Conclusions: Open surgical conversion following EVAR results in significant morbidity and mortality. IFU adherence of EVARs later requiring open surgical conversion is markedly low. More data are required to elucidate the impact of increasing liberalisation of EVAR outside of IFU.
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http://dx.doi.org/10.1016/j.ejvs.2017.10.011DOI Listing
February 2018

Reply.

J Vasc Surg 2017 10;66(4):1310

Division of Vascular and Endovascular Surgery, Ottawa Hospital and the University of Ottawa, Ottawa, Ontario, Canada.

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http://dx.doi.org/10.1016/j.jvs.2017.07.069DOI Listing
October 2017

The effect of endograft device on patient outcomes in endovascular repair of ruptured abdominal aortic aneurysms.

Vascular 2017 Dec 31;25(6):657-665. Epub 2017 May 31.

2 Division of Vascular Surgery, University of Ottawa, Ottawa, Canada.

Objective Endovascular aneurysm repair for ruptured abdominal aortic aneurysm is being increasingly applied as the intervention of choice. The purpose of this study was to determine whether survival and reintervention rates after ruptured abdominal aortic aneurysm vary between endograft devices. Methods This cohort study identified all ruptured abdominal aortic aneurysms performed at The Ottawa Hospital from January 1999 to May 2015. Data collected included patient demographics, stability index at presentation, adherence to device instructions for use, endoleaks, reinterventions, and mortality. Kruskal-Wallis test was used to compare outcomes between groups. Mortality outcomes were assessed using Kaplan-Meier survival analysis, and multivariate Cox regression modeling. Results One thousand sixty endovascular aneurysm repairs were performed using nine unique devices. Ninety-six ruptured abdominal aortic aneurysms were performed using three devices: Cook Zenith ( n = 46), Medtronic Endurant ( n = 33), and Medtronic Talent ( n = 17). The percent of patients presented in unstable or extremis condition was 30.2, which did not differ between devices. Overall 30-day mortality was 18.8%, and was not statistically different between devices ( p = 0.16), although Medtronic Talent had markedly higher mortality (35.3%) than Cook Zenith (15.2%) and Medtronic Endurant (15.2%). AUI configuration was associated with increased 30-day mortality (33.3% vs. 12.1%, p = 0.02). Long-term mortality and graft-related reintervention rates at 30 days and 5 years were similar between devices. Instructions for use adherence was similar across devices, but differed between the ruptured abdominal aortic aneurysm and elective endovascular aneurysm repair cohorts (47.7% vs. 79.0%, p < 0.01). Notably, two patients who received Medtronic Talent grafts underwent open conversion >30 days post-endovascular aneurysm repair ( p = 0.01). Type 1 endoleak rates differed significantly across devices (Cook Zenith 0.0%, Medtronic Endurant 18.2%, Medtronic Talent 17.6%, p = 0.01). Conclusion Although we identified device-related differences in endoleak rates, there were no significant differences in reintervention rates or mortality outcomes. Favorable outcomes of Cook Zenith and Medtronic Endurant over Medtronic Talent reflect advances in endograft technology and improvements in operator experience over time. Results support selection of endograft by operator preference for ruptured abdominal aortic aneurysm.
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http://dx.doi.org/10.1177/1708538117711348DOI Listing
December 2017

Google Maps offers a new way to evaluate claudication.

J Vasc Surg 2017 05 1;65(5):1467-1472. Epub 2017 Mar 1.

Division of Vascular and Endovascular Surgery, Ottawa Hospital and the University of Ottawa, Ottawa, Ontario, Canada. Electronic address:

Background: Accurate determination of walking capacity is important for the clinical diagnosis and management plan for patients with peripheral arterial disease. The current "gold standard" of measurement is walking distance on a treadmill. However, treadmill testing is not always reflective of the patient's natural walking conditions, and it may not be fully accessible in every vascular clinic. The objective of this study was to determine whether Google Maps, the readily available GPS-based mapping tool, offers an accurate and accessible method of evaluating walking distances in vascular claudication patients.

Methods: Patients presenting to the outpatient vascular surgery clinic between November 2013 and April 2014 at the Ottawa Hospital with vasculogenic calf, buttock, and thigh claudication symptoms were identified and prospectively enrolled in our study. Onset of claudication symptoms and maximal walking distance (MWD) were evaluated using four tools: history; Walking Impairment Questionnaire (WIQ), a validated claudication survey; Google Maps distance calculator (patients were asked to report their daily walking routes on the Google Maps-based tool runningmap.com, and walking distances were calculated accordingly); and treadmill testing for onset of symptoms and MWD, recorded in a double-blinded fashion.

Results: Fifteen patients were recruited for the study. Determination of walking distances using Google Maps proved to be more accurate than by both clinical history and WIQ, correlating highly with the gold standard of treadmill testing for both claudication onset (r = .805; P < .001) and MWD (r = .928; P < .0001). In addition, distances were generally under-reported on history and WIQ. The Google Maps tool was also efficient, with reporting times averaging below 4 minutes.

Conclusions: For vascular claudicants with no other walking limitations, Google Maps is a promising new tool that combines the objective strengths of the treadmill test and incorporates real-world walking environments. It offers an accurate, efficient, inexpensive, and readily accessible way to assess walking distances in patients with peripheral vascular disease.
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http://dx.doi.org/10.1016/j.jvs.2016.11.047DOI Listing
May 2017

Predicting the need for vascular surgeons in Canada.

J Vasc Surg 2017 03 13;65(3):812-818. Epub 2016 Dec 13.

Division of Vascular Surgery, University of Ottawa, Ottawa, Ontario, Canada; Department of Vascular Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada. Electronic address:

Objective: With the introduction of direct entry (0+5) residency programs in addition to the traditional (5+2) programs, the number of vascular surgery graduates across Canada is expected to increase significantly during the next 5 to 10 years. Society's need for these newly qualified surgeons is unclear. This study evaluated the predicted requirement for vascular surgeons across Canada to 2021. A program director survey was also performed to evaluate program directors' perceptions of the 0+5 residency program, the expected number of new trainees, and faculty recruitment and retirement.

Methods: The estimated and projected Canadian population numbers for each year between 2013 and 2021 were determined by the Canadian Socio-economic Information and Management System (CANSIM), Statistics Canada's key socioeconomic database. The number of vascular surgery procedures performed from 2008 to 2012 stratified by age, gender, and province was obtained from the Canadian Institute for Health Information Discharge Abstract Database. The future need for vascular surgeons was calculated by two validated methods: (1) population analysis and (2) workload analysis. In addition, a 12-question survey was sent to each vascular surgery program director in Canada.

Results: The estimated Canadian population in 2013 was 35.15 million, and there were 212 vascular surgeons performing a total of 98,339 procedures. The projected Canadian population by 2021 is expected to be 38.41 million, a 9.2% increase from 2013; however, the expected growth rate in the age group 60+ years, who are more likely to require vascular procedures, is expected to be 30% vs 3.4% in the age group <60 years. Using population analysis modeling, there will be a surplus of 10 vascular surgeons in Canada by 2021; however, using workload analysis modeling (which accounts for the more rapid growth and larger proportion of procedures performed in the 60+ age group), there will be a deficit of 11 vascular surgeons by 2021. Program directors in Canada have a positive outlook on graduating 0+5 residents' skill, and the majority of programs will be recruiting at least one new vascular surgeon during the next 5 years.

Conclusions: Although population analysis projects a potential surplus of surgeons, workload analysis predicts a deficit of surgeons because it accounts for the rapid growth in the 60+ age group in which the majority of procedures are performed, thus more accurately modeling future need for vascular surgeons. This study suggests that there will be a need for newly graduating vascular surgeons in the next 5 years, which could have an impact on resource allocation across training programs in Canada.
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http://dx.doi.org/10.1016/j.jvs.2016.08.114DOI Listing
March 2017

Internal iliac coverage during endovascular repair of abdominal aortic aneurysms is a safe option: A preliminary study.

Vascular 2017 Feb 9;25(1):28-35. Epub 2016 Jul 9.

2 Division of Vascular Surgery, University of Ottawa, Ottawa, Canada.

Endovascular aneurysm repairs lacking suitable common iliac artery landing zones occasionally require graft limb extension into the external iliac artery, covering the internal iliac artery origin. The purpose of this study was to assess incidence of type II endoleak following simple coverage of internal iliac artery without embolization during endovascular aneurysm repair. Three hundred eighty-nine endovascular aneurysm repairs performed by a single surgeon (2004-2015) were reviewed. Twenty-seven patients underwent simple internal iliac artery coverage. Type II endoleak was assessed from operative reports and follow-up computed tomography imaging. No patient suffered type II endoleak from a covered internal iliac artery in post-operative computed tomography scans. Follow-up ranged from 0.5 to 9 years. No severe pelvic ischemic complications were observed. In conclusion, for selected cases internal iliac artery coverage without embolization is a safe alternative to embolization in endovascular aneurysm repairs, where the graft must be extended into the external iliac artery.
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http://dx.doi.org/10.1177/1708538116640077DOI Listing
February 2017