AWARD-WINNING PAPER ESTABLISHED F/BEVAR ‘FEASIBLE AND SAFE’ IN PATIENTS WITH FAILED AORTIC REPAIRS

PRESENTING AWARD-WINNING

new research, Andrea Vacirca, MD, a research fellow at The University of Texas Health Science Center in Houston (UTHealth Houston), revealed how, despite prior records which demonstrate that fenestrated-branched endovascular aortic repair (F/BEVAR) is “feasible and safe” in patients with failed aortic repairs, few studies have outlined the “granular data” to support this claim, which his team aimed to provide through their analysis.

Vacirca was speaking during the opening scientific session at the 2023 Society for Clinical Vascular Surgery (SCVS) Annual Symposium in Miami (March 25–29), where he picked up the Peter B. Samuels Award for work looking at early and midterm outcomes of F/BEVAR in patients with or without a prior history of EVAR or open repair. And he set a course for his team’s main conclusions, he first highlighted the “increasingly utilized” F/BEVAR’s “high” technical success and “low” mortality rates in the study population.

Vacirca et al had set out to compare these outcomes of EVAR on complex abdominal aortic aneurysm (AAA) and thoracoab- dominal aortic aneurysms (TAAAs) in a prospective, non-randomized analysis of clinical data from 502 enrollees. They reviewed outcomes in 376 patients with no previous aortic repair (controls), 54 who had prior EVAR (group one), and 72 with prior abdominal open repair (group two).

The researchers reported on 30-day mortality and major adverse events (MAEs), patient survival and freedom from aortic-related mortality (ARM), secondary interventions, any type II endoleak, sac enlargement (≥5mm), and new-onset dialysis. Their results showed that EVAR was performed on average 7±4 and 12±6 years after the prior EVAR and open repair, respectively, with a complex AAA extent in 29% (143) of patients and TAAA in 72% (359) of patients. Breaking this down, Vacirca remarked that patients with prior open repair more frequently experienced TAAA, which were also “more extensive” when compared with the other two groups. However, freedom from type II endoleak and sac enlargement greater than 5mm, was “significantly lower” in patients with prior EVAR, Vacirca told SCVS 2023.

Continuing, he remarked that these ab- dominal open repair patients were younger at index procedure, and showed “lower” survival and freedom from new-onset hemodialysis which—when prompted on why the latter had occurred during audience discussion—raised a “very important” question for Vacirca and his team. “We evaluated this aspect—if new-onset dialysis was related with lower survival in group two. But we found that only four patients experienced this, and so we associated lower survival with more extensive aortic disease.”

Overall technical success, mortality, and MAE rates were 96%, 1%, and 28%, respectively, Vacirca outlined, though patient survival after 30-month follow-up was “significantly lower” in patients with prior

PAD

Quality Initiative (VQI) registry. The data revealed that 19.2% of patients in the VQI are not discharged on dual antiplatelets after stent placement via TCAR—9% receive a “triple therapy” involving DAPT plus anticoagulation, 5.8% are given single antiplatelet therapy (SAPT) plus anticoagulation, and 4% are directed to take either SAPT or a single anticoagulant.

RECENT

Data Presentations

have revealed reduced risks of stroke and mortality among transcarotid artery revascularisation (TCAR) patients who receive dual antiplatelet therapy (DAPT)—both preoperatively and at discharge—as compared to other drug regimens. Researchers believe these findings underscore the importance of compliance to DAPT regimens before and after a TCAR procedure.

At the 2023 Society for Clinical Vascular Surgery (SCVS) Annual Symposium (March 25–29) in Miami, Hanaa Dakour-Aridi, MD, a vascular surgery resident at Indiana University School of Medicine in Indianapolis, presented the results of a study evaluating post-TCAR discharge regimens among patients in the Vascular

“We demonstrated that patients discharged on a combination of single antiplatelets with anticoagulation witnessed increased [rates of] 30-day stroke, highgrade restenosis, and one-year mortality and stroke/death,” Dakour-Aridi noted. “The use of a single antiplatelet or single anticoagulant after TCAR was associated with increased 30-day and one-year stroke/ death risks. However, there was no significant association between triple therapy and 30-day stroke/death outcomes.”

Nevertheless, Dakour-Aridi concluded that the findings “reinforce our prior study on the importance of compliance to DAPT after TCAR, as well as the need for further follow-up studies to evaluate the appropriateness of TCAR in different patient populations.” Dakour-Aridi et al recently published a study in the Journal of Vascular Surgery (JVS) on the association between preoperative antiplatelet regimens and in-hospital outcomes after TCAR. This research produced similar results.—Jamie Bell open repair and was reported to be 45% at five years, consistently falling behind the other two groups.

“These procedures carry many technical challenges,” Vacirca stated, their data tentatively weighing up F/BEVAR and open repair for these complex patients. Allowing their research to speak for itself, Vacirca and his team offered an insight into their working practices, describing their hybrid operating room. “Our technique has evolved over the years […] We prefer a total femoral approach, without prophylactic drain whenever possible. We often request a preloaded system, and we now move to use the unibody fenestrated bifurcated devices, and we often double stent vessels coming from the suprarenal fixation devices,” Vacirca explained, making clear that procedural methods must continually be revaluated, and a hybrid approach adopted to provide the best treatment pathway for each individual in this complex patient population.

“We have limited contemporary evidence to support increasing antithrombotic therapies after bypass,” C.Y. Maximilian Png, MD, a vascular surgery resident at Massachusetts General Hospital in Boston told Vascular Specialist on his return from presenting the data at SCVS. The authors set about identifying optimal antithrombotic management of patients after lower-extremity bypass through a restriction analysis of wound, ischemia and foot infection (WIfI) scores. At a single hospital system, Png and colleagues extracted data from infrainguinal bypass procedures completed between January 2018–2021, assigning preoperative WIfI scores to each individual case through the associated documentation. Excluding patients with wound scores of two or three, ischemia scores of zero or one, or foot infection scores of three, Png’s study concerned patients at “[low] risk” of a negative outcome who may “theoretically benefit the most” from increased therapy. “The next challenge is to figure out how to get the most out of this valuable tool, and we thought one use of it could be to help differentiate patients who would benefit from increased anti-thrombotic medication therapy,” Png said.

With 191 procedures in the study, Png et al found 66 (34.6%) patients were discharged on single antiplatelet therapy (SAPT), compared with 125 (65.5%) on either DAPT or AC. The only difference that the authors identified between the two groups was a higher prevalence of atrial fibrillation in the DAPT/AC group. At 30 days, Png et al observed no significant difference in postoperative reintervention or graft occlusion rates, but the DAPT/AC group had a significantly lower rate of mortality (2.2% vs. 9.1%, p<0.05), major amputation (1.6% vs. 7.6%, p<0.05) and major adverse limb events (MALEs). Reflecting on their Kaplan-Meier analysis, the authors determined that MALE-free survival was higher amongst DAPT/AC patients compared with the SAPT group.—Eva Malpass

SOCIETY OF BLACK VASCULAR SURGEONS BUILDS BRIDGES,