2026 Spring abstract view
Name: Bryan Bo-Ran Ho
Abstract Title: CCR4 Regulates Arteriovenous Fistula Wall Thickness and TGF-β Mediated Extracellular Matrix Protein Accumulation
Will this Author Present: Yes
Relevant History, Physical Exam & Test Results:
N/a
Teaching points, lessons learned, device or therapy modifications needed:
N/a
Abstract body:
Objectives: Arteriovenous fistula (AVF) maturation and remodeling is a complex process. There is increasing evidence that members of the adaptive immune system, including helper T cells, are involved in AVF maturation and remodeling. Regulatory T cells (Tregs) are a subset of helper T cells with a protective role in other cardiovascular diseases, such as atherosclerosis and abdominal aortic aneurysms. Our objective is to describe the role of Tregs in AVF maturation and remodeling.
Methods: Aorto-caval fistulae were created in CCR4-/- mice and their WT litter-mates and harvested at day 21. Samples were studied by using the Elastin van Gieson (EVG) stain, picrosirius red stain, and by immunofluorescence imaging.
Results: CCR4-/- mice have increased venous wall thickness on EVG stain at day 21 after AVF creation compared to their WT litter-mates (Fig. 1A). To understand whether extracellular matrix (ECM) remodeling was a source of increased wall thickness, we next studied ECM component accumulation. On picrosirius red stain, CCR4-/- mice have significantly decreased total collagen mean intensity at day 21 compared to their WT litter-mates (Fig. 1B). On immunofluorescent imaging, there is significantly decreased total venous wall type 1 collagen, type 3 collagen, and elastin mean fluorescent intensity at day 21 in the CCR4-/- mice (Fig. 1C). CCR4-/- mice also have significantly decreased TGF-β mean fluorescent intensity, as well as significantly decreased intensity of pSMAD2 and Tak-1, which are downstream mediators of canonical and non-canonical TGF-β signaling, respectively (Fig. 1D).
Conclusions: CCR4 regulates AVF wall thickness and is associated with ECM structural protein secretion through both canonical and non-canonical TGF-β signaling pathways. Because wall thickness can be associated with increases in ECM accumulation, further work is necessary to determine whether other ECM components, such as fibronectin and proteoglycans, or smooth muscle cellularity are increased after CCR4 knockout.
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Name: Brandon Nussenblatt
Abstract Title: A Unique Protective Solution for Tracheo-Innominate Fistula Secondary to Recurrent Laryngeal Squamous Cell Carcinoma
Will this Author Present: Yes
Relevant History, Physical Exam & Test Results:
Bleeding from laryngectomy stoma, close proximity of innominate bifurcation to stoma and encasement of large tumor
Teaching points, lessons learned, device or therapy modifications needed:
Use of covered stents in unique situation and configuration to prevent massive hemorrhage
Abstract body:
Objectives:
Tracheo-innominate fistula (TIF) is a rare and often fatal complication of tracheostomy, however there are only a few reports of fistula development after laryngectomy. We present the case of a patient with a herald bleed secondary to presumed TIF and the endovascular management to protect against massive hemorrhage.
Methods/Results:
A 54-year-old man presented with a history of laryngeal carcinoma who underwent chemotherapy and radiation with course complicated by recurrent disease requiring salvage total laryngectomy and flap reconstruction presented to his ENT surgeon with three days of bright-red blood from his stoma. The patient reported an episode of pulsatile bleeding that ceased shortly thereafter; however, he was able to produce streaks of blood mixed with mucous when coughing through his laryngectomy stoma. Direct laryngoscopic examination yielded a pulsatile mass without active hemorrhage. He was sent to the emergency department where CTA demonstrated bulky recurrent disease and circumferential encasement of the proximal right common carotid artery without evidence of active bleeding. Given his presentation with pulsatile stomal bleeding and proximity of the tumor to the innominate bifurcation, immediate concern was for a tracheo-innominate fistula. A multidisciplinary discussion was held between the ENT, vascular and cardiac surgery teams where it was determined the patient was not a candidate for open repair and decision was made to pursue endovascular management as a protective measure against further possibly catastrophic hemorrhage.
Arch aortogram was performed which did not demonstrate active extravasation. Access was via the right radial artery and right common femoral artery. Selective angiography was performed to mark out the takeoff of the vertebral artery and to ensure adequate purchase in the innominate. Two VBX stents were deployed in a double-barrel fashion from the right common carotid (6×59 mm) and subclavian arteries (7×39 mm, post-dilated to 10 mm) across the innominate bifurcation. Post-operative CTA demonstrated appropriate stent position with exclusion of the innominate bifurcation.
Conclusion:
This case demonstrates a unique protective solution to prevent possible massive hemorrhage secondary to TIF from a large head-and-neck tumor.
Name: Neysa Parag Sanghavi
Abstract Title: Iatrogenic Aortic and Iliac Artery Transections During Robotic Nephrectomies: A Case Series of Emergent Open Vascular Repairs
Will this Author Present: Yes
Relevant History, Physical Exam & Test Results:
Case 1: A 60 year old patient with DM type 2 and CKD stage 3 underwent robotic left nephrectomy for a large 8.7 x 7.1 x 8.4 cm necrotic renal mass previously treated with embolization, with intraoperative findings of dense hilar scarring and desmoplastic reaction that distorted vascular anatomy and contributed to infrarenal aortic transection.
Case 2: A 79 year old patient with BMI 36 with multiple comorbidities underwent surgery for a very large ~17cm left renal cyst requiring nephrectomy, during which complex dissection due to dense scarring led to difficult visualization resulting in infrarenal aortic transection for presumed renal artery.
Case 3: A 78 year old patient with history of prostate cancer and CKD stage 3 underwent right nephrectomy for a 4.1 x 3.9 cm papillary renal cell carcinoma in the setting of a malrotated pelvic kidney and high aortic bifurcation, leading to right common iliac artery transection detected intraoperatively.
Teaching points, lessons learned, device or therapy modifications needed:
1. Distorted hilar planes from tumor effect and prior intervention increase the risk of major vascular injury through vessel misidentification; prevention requires a structured review of preoperative imaging for anatomic landmarks, aberrant anatomy, and intraoperative verification.
2. Before stapling or dividing any presumed renal vessel, confirm identity by tracing the structure to a verified renal takeoff and reassessing its caliber, course, and relationship to the aorta and renal vein.
3. When anatomy remains uncertain or visualization is degraded, early conversion to an open approach should be treated as a proactive safety strategy to restore orientation and obtain vascular control.
4. If a major vascular injury occurs, optimal outcomes require immediate recognition, rapid exposure with proximal and distal control, early intraoperative vascular surgery involvement, and definitive repair without delay.
Abstract body:
Background
Robotic and laparoscopic radical nephrectomy are widely performed and are generally considered safe. Major vascular injuries are rare but potentially life-threatening, most often involving extrarenal visceral arteries. In contrast, injury to the aortoiliac axis during minimally invasive nephrectomy is exceptionally rare, and complete intraoperative transections have been seldom documented.
Case Presentations
Three cases are discussed with two patients sustaining complete infrarenal aortic transections and one with right common iliac artery transection. All injuries occurred during stapled division of a misidentified renal vessel, requiring emergent conversion to open surgery with interposition graft reconstruction. Distal perfusion was restored in all cases, and the patients experienced an uncomplicated postoperative recovery without further vascular compromise.
Conclusion
Life-threatening arterial injuries during robotic or laparoscopic nephrectomies commonly result from anatomic misperception of distorted planes rather than proximity to major vessels alone. Prevention requires a structured review of preoperative imaging for anatomic landmark confirmation and intraoperative verification of vessel origin and course prior to division. Additionally, there should be a low threshold to convert to open surgery when anatomy is uncertain. In the event of major vascular injury, rapid conversion, prompt proximal and distal vascular control, and early intraoperative collaboration with vascular surgery are critical for favorable patient outcomes.
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Name: Logan Stone MD
Abstract Title: Endovascular Management of Complicated Type B Aortic Dissection with Visceral Malperfusion
Will this Author Present: Yes
Relevant History, Physical Exam & Test Results:
history of prior type a repair, visceral malperfusion, lactic acidosis, leukocytosis
Teaching points, lessons learned, device or therapy modifications needed:
strategies for treatment of acute TBAD with evidence of visceral malperfusion
Abstract body:
Objective(s):
To describe endovascular management using a bare metal dissection stent strategy on proximal entry tear in a patient with complicated acute type B aortic dissection (TBAD) with visceral malperfusion
Methods:
61-year-old female with history of type A dissection repair in 2016 presented with acute chest, back, and abdominal pain. Labs demonstrated leukocytosis, elevated lactate, and acute kidney injury concerning for visceral malperfusion. CTA showed an acute TBAD from the left subclavian artery to the femoral arteries with true lumen compression, celiac artery occlusion with retrograde filling, and SMA dissection with distal reconstitution. Patient underwent Thoracic Endovascular Aortic Repair with intravascular ultrasound-guided true lumen access and deployment of a 46x185mm Cook Zenith® Dissection Endovascular Stent from left common carotid artery and extended with a 46x120mm Cook Zenith® Dissection Endovascular Stent to the distal descending thoracic aorta proximal to the celiac artery.
Results:
Mesenteric angiography prior to stent deployment showed celiac artery occlusion at its origin, dissection flap extending into the SMA with occlusion and distal reconstitution (Figure 2A). Completion angiography post stent deployment demonstrated aortic true lumen expansion and improved perfusion of the SMA and its distal branches (Figure 2B). The postoperative course was uncomplicated with down trending lactate, improved abdominal exam and tolerating PO intake. CTA at three weeks showed a patent endograft, improved true lumen flow, and no interval aneurysmal expansion.
Conclusions:
Provisional Extension To Induce Complete Attachment (PETTICOAT) technique has demonstrated promising results in TBAD to promote distal true lumen remodeling through deployment of a covered proximal stent over the entry tear with distal bare-metal extension. Our report shows a modification of the PETTICOAT technique to address patients with acute onset visceral ischemia and restore mesenteric perfusion timely. Covered stent placement for proximal entry tear coverage would involve Zone-0 thoracic branched endograft and carotid-carotid-subclavian bypass, which would prolong time to visceral reperfusion. Deployment of a bare-metal stent proximally allows perfusion of the arch vessels while addressing true lumen compression and visceral malperfusion. Further follow-up is warranted to assess long-term remodeling and durability.
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Name: Khaled El-Qawaqzeh
Abstract Title: Two-Stage Arteriovenous Loop and Free Latissimus Dorsi Flap Reconstruction for Chronic Radiated Scalp Wound
Will this Author Present: Yes
Relevant History, Physical Exam & Test Results:
69-year-old male with 17-year chronic right posterior scalp wound following liposarcoma resection, failed skin grafting, and radiation therapy. Imaging revealed skull erosion and cerebritis. After cross-sectional imaging, lumbar punctures, and infectious disease clearance for hardware implantation, a staged multidisciplinary approach was planned: arteriovenous loop creation, followed by cranioplasty and free flap reconstruction.
Teaching points, lessons learned, device or therapy modifications needed:
Multidisciplinary collaboration between vascular surgery, neurosurgery, and plastic surgery is essential for complex radiated scalp reconstruction. The common carotid-to-internal jugular configuration provides reliable, high-flow recipient vessels in the vessel-depleted scalp, highlighting the expanding role of vascular surgeons in complex reconstructive scenarios where traditional recipient vessels are unavailable.
Abstract body:
Objective: Chronic scalp wounds following radiation therapy for sarcoma present significant reconstructive challenges due to vessel depletion and tissue fibrosis. This case report describes a two-stage approach utilizing common carotid artery to internal jugular vein arteriovenous (AV) loop creation followed by cranioplasty and free latissimus dorsi flap for management of a complex radiated scalp defect.
Methods: A 69-year-old male presented with a 17-year history of chronic right posterior scalp wound following liposarcoma resection, failed skin grafting, and radiation therapy. Imaging demonstrated skull erosion and cerebritis. Infectious disease consultation cleared the patient for hardware implantation. The patient underwent a staged reconstruction: Stage 1 involved vascular surgery creation of a right common carotid artery to internal jugular vein AV loop using saphenous vein graft, tunneled anterior and superior to the ear (figure 1). Postoperatively, the patient received enoxaparin 40 mg twice daily and aspirin 81 mg daily with Doppler checks of the loop. Stage 2 (after 7 days) consisted of combined neurosurgical cranioplasty with titanium mesh and plastic surgical free latissimus dorsi flap with split-thickness skin graft coverage, anastomosed to the divided AV loop under microscopic technique. Internal Doppler probes were placed on both the artery and vein. The patient was transitioned to heparin infusion and aspirin 325 mg daily postoperatively.
Results: Following stage 1, the AV fistula remained patent and functioning, confirmed on duplex ultrasound demonstrating a low-resistance waveform. After successful flap reconstruction, repeat duplex ultrasound demonstrated an arterial bypass from the common carotid artery to the flap with a high-resistance waveform, as well as a venous bypass to the internal jugular vein with normal venous flow. There was no sonographic evidence of stenosis or technical complication. The patient was discharged home on postoperative day 8 from the second operation on aspirin 325 mg daily. At most recent follow-up (6 weeks post-reconstruction), the flap demonstrated excellent viability with warm, soft tissue, complete graft incorporation, and well-healed donor sites without infection (figure 2).
Conclusions: This case demonstrates that vascular surgeon-created AV loops represent a critical solution for complex radiated scalp defects. The common carotid-to-internal jugular configuration provides reliable, high-flow recipient vessels in the vessel-depleted scalp, highlighting the expanding role of vascular surgeons in complex reconstructive scenarios where traditional recipient vessels are unavailable.
Name: Kristine Gilligan
Abstract Title: Infected Prosthetic Graft in a High-Risk LVAD Patient: When Open Surgical Principles Meet Endovascular Salvage
Will this Author Present: Yes
Relevant History, Physical Exam & Test Results:
Past Medical History: Coronary artery disease, hypertension, hyperlipidemia, obstructive sleep apnea, depression, type II diabetes mellitus, GERD, ischemic cardiomyopathy and heart failure with reduced ejection fraction, and left bundle branch block.
Physical Exam on Admission:
General: cardiogenic shock on VA ECMO
Cardiac: V paced on monitor
Pulmonary: Bilateral respirations regular and synchronous with ventilator, bilateral course breath sounds with expiratory wheezing
Vascular: palpable radial pulses bilaterally, left dorsalis pedis and posterior tibial doppler signals, right posterior tibial doppler signals; bilateral feet cool to touch, left foot mottled
Physical Exam on Day of Discharge:
General: alert, conversational
Chest: ecchymosis over midline sternal incision site, noninflamed right axillary scar healing appropriately, left subclavian central line with minimal surrounding erythema but nontender
Cardiac: LVAD hum, drive line site clean
Vascular: Right groin incision mildly erythematous but dry, left groin incision intact with staples in place, extremities well perfused bilaterally
Physical Exam on Follow up:
General: no acute distress, using rolling walker
Vascular/ Extremities: right upper extremity warm, motor/sensory intact throughout, palpable radial pulse and ulnar doppler signal present; incision site well healed
Pertinent Labwork:
Intraoperative cultures from index operation: positive for candida albicans from Dacron specimen
Pertinent Imaging:
CT thorax with IV contrast (2/9/25) revealed findings consistent with hematoma in the right retro pectoral space measuring 7.8 x 4.9cm, with multiple foci of air.
CTA chest (4/19/25) revealed findings consistent with distal subclavian artery pseudoaneurysm measuring 5mm.
Right upper extremity arterial duplex (12/10/25) revealed a patent distal subclavian/axillary artery stent with no evidence of hemodynamically significant stenosis.
Pertinent Medications at Follow up: aspirin 81mg, Warfarin, high intensity statin
Teaching points, lessons learned, device or therapy modifications needed:
Abstract body:
Introduction:
Infected prosthetic grafts remain a challenging situation for the vascular surgeons. With advances in the fields of cardiovascular surgery, more and more patients are now being offered advanced therapies, including heart transplants and left ventricular assist devices (LVAD’s). Infected grafts in patients with heart transplants and LVAD’s present a unique challenge due to patients’ overall poor status and ability to tolerate complex operations.
Case Presentation:
The case reported is a 61-year-old male with past medical history including coronary artery disease with prior percutaneous intervention, diabetes mellitus, and ischemic cardiomyopathy who was admitted in the setting of central line associated bacteremia and cardiogenic shock. He was initially cannulated for peripheral VA ECMO with additional Impella 5.5 support via right axillary access, but after failing to improve clinically, ultimately underwent HeartMate 3 LVAD implantation via hemi sternotomy and L anterior thoracotomy approach. He required right axillary artery conduit with dacron graft for ECMO. Cardiac surgery team performed stump ligation of the graft after ECMO decannulation. Postoperative course was complicated by candida infection of Dacron stump. Vascular Surgery was consulted and performed complete explant of the graft, and repair of the arterial defect with great saphenous vein patch. Four days later, he developed large hematoma, at surgical site, which required surgical debridement and washout. Two months later, he presented with anastomotic pseudoaneurysm at the vein patch site. Due to severe surgical scarring, a decision was made to repair the pseudoaneurysm with covered stent graft (Viabahn). Patient has been maintained on long term oral antibiotics and has had no new complications for past one year.
Discussion:
Vascular surgical principles dictate complete explant of the infected grafts. Patients who are high surgical risk and keep developing recurrent infections may need to be treated with endovascular interventions as salvage with acceptable long-term outcomes.
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Name: Andrew Henderson, MD
Abstract Title: Endovascular Salvage: GORE TAMBE and IBE for Proximal EVAR Extension and Relining
Will this Author Present: Yes
Relevant History, Physical Exam & Test Results:
Teaching points, lessons learned, device or therapy modifications needed:
Abstract body:
Objective:
We describe a case of treating Type 1 and 3 endoleaks with GORE TAMBE and IBE for proximal extension and EVAR relining.
Case Presentation:
The patient is a 65-year-old woman with a prior EVAR for ruptured 5.7cm AAA (AneuRx, 2010) and underwent numerous interventions for endoleaks, including aortic cuff proximal extension, Endoanchors, extension of R CIA limb with parallel grafts into the right internal and external iliac arteries, and IMA coil embolization. She eventually developed severe abdominal pain from a 13cm AAA and 4 cm R hypogastric aneurysm, found to have multiple endoleaks (Figure 1). She also had a large ventral hernia from previous abdominal surgeries. She was taken to the OR. Initial angiography confirmed large type 1A endoleak, which we treated by extending proximally with a GORE TAMBE device, 4-vessel visceral/renal stenting and bridging with a 26mm aortic cuff into the previous AneuRx graft. The Type 1A endoleak resolved. We decided to stage intervention of the R hypogastric aneurysm to minimize spinal cord and colonic ischemia risk. Postoperatively she still had abdominal pain, so we took her for repeat angiography and identified a Type III endoleak at the junction between the gate of the AneuRx graft and the R iliac limb (Figure 2). Due to limited distance between the TAMBE visceral stents and the original EVAR flow divider, we relined the AneuRx graft with a 23mm GORE IBE device and VBX stents. We also coil embolized the right hypogastric aneurysm and covered the origin of the parallel graft into the hypogastric artery with a new VBX covered stent. The type I and III endoleaks resolved. She recovered well with resolution of her abdominal pain. Interval CTA at one month showed stable sac size with no type I or III endoleak. She has a persistent type II endoleak that we will monitor.
Conclusion:
TAMBE can be useful for proximal extension and the IBE device can also be considered as an option for relining previously failed bifurcated endografts.
Name: Tarek Khrisat
Abstract Title: When No Inflow Remains: Carotid-to-Profunda Bypass for End-Stage Lower-Extremity Ischemia
Will this Author Present: Yes
Relevant History, Physical Exam & Test Results:
Upon presentation to our institution, CT angiography of the chest, abdomen, pelvis, and lower-extremity runoff demonstrated complete occlusion of all prior bypass grafts, including the aortobi-iliac, axillobifemoral, femoral–femoral, and femoropopliteal reconstructions. The left subclavian artery was completely occluded, eliminating axillary inflow. Despite extensive proximal occlusive disease, distal reconstitution was noted: the posterior tibial and peroneal arteries reconstituted via collaterals, and the dorsalis pedis and plantar arteries remained patent. Additionally, while the superficial femoral artery was occluded, profunda femoris–based collateralization contributed to distal pedal perfusion (Figure 2a–c).
Physiologic testing confirmed severe ischemia, with markedly diminished ABIs and near-flatline PVRs in the left foot (Figure 3). These findings indicated critically impaired inflow and suggested that the patient would be unlikely to heal even a major amputation without revascularization.
Teaching points, lessons learned, device or therapy modifications needed:
Abstract body:
Revascularization for chronic limb-threatening ischemia (CLTI) in patients with multilevel aortoiliac and infrainguinal occlusive disease often requires a staged sequence of endovascular and open procedures. Aortobifemoral bypass remains the gold standard for durable aortoiliac reconstruction, offering excellent long-term patency,¹˒² while axillobifemoral bypass serves as an established extra-anatomic alternative when direct aortic reconstruction is not feasible.³ However, the durability of these reconstructions decreases substantially in patients with diffuse disease, hostile anatomy, or multiple prior interventions.
Our patient exhausted all conventional inflow sources over the course of more than a decade, having undergone multiple femoropopliteal bypasses, iliac stents, aortobi-iliac bypass, axillobifemoral bypass, and a redo perivisceral aorto–femoral reconstruction. She presented in 2025 with progressive ischemic rest pain and digital gangrene. Pulse-volume recordings (PVRs) demonstrated severely depressed waveforms, indicating perfusion insufficient even for reliable major amputation healing. Given the well-established association between near-flatline PVRs and stump failure,⁴ revascularization was required to permit limb salvage or predictable amputation healing.
Descending thoracic aorta–to–femoral bypass was considered; however, contemporary series report 30-day mortality rates of 3–5% and major complication rates approaching 30–34%, particularly in patients with hostile thoracic or abdominal anatomy.⁵–⁷ Given this patient’s extensive surgical history, supraceliac clamping, and frailty, the morbidity of thoracic exposure was deemed prohibitive.
Axillary inflow was also unavailable due to chronic left subclavian artery occlusion, which was not amenable to endovascular recanalization. In this context, the common carotid artery represented the only remaining viable inflow source. Although rarely reported, carotid-based inflow has been described in isolated salvage cases when all conventional and extra-anatomic options have been exhausted.⁸–¹⁰ We present a case of carotid-to-profunda femoris bypass performed as an extreme limb-salvage strategy in a patient with complete exhaustion of standard inflow pathways.
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Name: Alex Houser
Abstract Title: Validation of the Giant Cell Arteritis Probability Score at a Tertiary Hospital
Will this Author Present: Yes
Relevant History, Physical Exam & Test Results:
Teaching points, lessons learned, device or therapy modifications needed:
Abstract body:
Giant cell arteritis (GCA) is a large vessel vasculitis that preferentially affects the branches of the common carotid artery, particularly the superficial temporal artery. Symptoms may manifest as jaw claudication, headache, scalp tenderness, and visual disturbances with possible permanent vision. While the initial diagnosis is based on clinical suspicion, temporal artery biopsy (TAB) remains the gold standard diagnostic test. The necessity of TAB has been called into question on the basis that results seldom change management and clinical findings are sufficient for a diagnosis. Despite TAB being a minor procedure and having a relatively low complication rate, it is still incumbent upon vascular surgeons to ensure proper patient selection. Application of a practical risk stratification tool could reduce the likelihood of futile procedures and facilitate a multidisciplinary approach between vascular surgery and other specialists. The purpose of this study was to validate the Giant Cell Arteritis Probability Score (GCAPS) in a retrospective cohort of patients with suspected GCA and to assess if this score is a reliable predictor to rule out GCA by comparison to our TAB samples. A retrospective cohort study of patients undergoing temporal artery biopsy at Stony Brook University Hospital (SBUH) between August 2002 to May 2024. Patient demographics, symptoms, signs, laboratory markers and (possible) alternative diagnosis at presentation were collected from the patients’ records at the time of the initial consult. A modified version of the GCAPS was used due to poor documentation of the variable extra-cranial artery abnormality i.e. m-GCAPS (GCAPS without extra-cranial artery abnormality). Continuous variables were expressed as mean with standard deviation (SD), whereas categorical variables were expressed as numbers and percentages. Welch’s two-sample t-test, the Mann-Whitney U test, and Chi-square test (or Fisher’s exact tests when appropriate) were used for statistical analysis. The discriminatory performance of the mGCAPS was determined using the area under the curve (AUC) of the receiver operating characteristic curve (ROC). A p value 14.5. GCA prevalence was 0% in the low (score12). Performance of the m-GCAPS for risk stratification has shown to be a promising tool for providers to use in an inpatient setting. This provides aid in identifying equivocal cases of GCA and allowing surgeons to make informed decisions about who would most benefit from TAB.
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Name: Angelina Kim
Abstract Title: Endovascular Salvage of an Occluded Aorta-Hepatic Bypass Complicated by Distal Anastomotic Pseudoaneurysm
Will this Author Present: Yes
Relevant History, Physical Exam & Test Results:
Teaching points, lessons learned, device or therapy modifications needed:
Abstract body:
Background: Aorta-hepatic bypass grafts are rarely performed and can present complex complications. Management of pseudoaneurysms involving occluded visceral bypass grafts is challenging, particularly in patients with hostile anatomy and extensive prior surgery.
Case Description: A 78-year-old man with myelofibrosis, OSA, and hyperlipidemia previously underwent an aorta-hepatic bypass with gastroduodenal artery embolization in 2016 for a GDA aneurysm, complicated by recurrent hepatic abscesses after the bypass occluded. He later required pancreaticoduodenectomy in 2025 due to erosion of aneurysm coils into the duodenum. He presented with right upper quadrant pain, recurrent hepatic abscesses, and a CT angiography demonstrated occlusion of the aorta-hepatic bypass with a 3.4 cm rapidly enlarging pseudoaneurysm at the distal anastomosis. Given rapid expansion and concern for hepatic arterial ischemia contributing to recurrent abscesses, intervention was recommended.
Given the patient’s surgical history, an endovascular approach was pursued. The right common femoral artery was accessed, and the occluded celiac bypass was selected using a steerable sheath. The occlusion was successfully traversed, allowing selection of the pseudoaneurysm and advancement of a wire and catheter into the native hepatic artery distal to the lesion. The bypass graft was relined with a 7 × 39 mm VBX stent, followed by advancement of a sheath through the graft. A 5 × 50 mm Viabahn stent was deployed in the distal hepatic artery, and a 7 × 59 mm VBX stent was placed to bridge the two stents. Completion angiography demonstrated a patent bypass, preserved hepatic arterial flow, and complete exclusion of the pseudoaneurysm without delayed filling.
He had complete resolution of right upper quadrant pain. Surveillance CTA demonstrated a stable aneurysm sac with decreased flow and a type II endoleak from the native splenic artery, with resolution of hepatic abscesses. Repeat angiography with coil embolization of a communicating aortic branch achieved complete resolution of the endoleak. He continues to do well and remains under routine surveillance imaging.
Conclusions: Endovascular relining and bridging stent graft placement can provide a durable, minimally invasive solution for complex pseudoaneurysms involving occluded visceral bypass grafts. Adjunctive embolization may be required for secondary endoleaks, allowing avoidance of high-risk open reoperation.
Name: Maha Haqqani
Abstract Title: Outcomes Following Endovascular versus Open Management of Carotid Artery Injury in the National Trauma Data Bank
Will this Author Present: Yes
Relevant History, Physical Exam & Test Results:
N/A
Teaching points, lessons learned, device or therapy modifications needed:
Overall severe outcomes of carotid artery injuries are determined by injury burden and concomitant traumatic brain injury. These factors may help inform clinical management, and guide family discussions in order to make appropriate decisions regarding the care of patients with carotid injuries.
Abstract body:
OBJECTIVES: We analyze contemporary management of blunt and penetrating carotid injuries and compare outcomes following endovascular and open repair.
METHODS: The National Trauma Data Bank (2017-2023) was queried for carotid injuries in patients aged ≥16 managed with endovascular or open repair. Baseline characteristics, associated injuries, and in-hospital outcomes were compared between ENDO and OPEN, stratified by mechanism [(BLUNT vs. penetrating (PEN)]. Primary outcomes were stroke and mortality. Multivariable analysis identified independent predictors of stroke and composite strokemortality.
RESULTS: Of 3,339 carotid injuries, 54.5% were treated ENDO and 45.5% OPEN. ENDO group were predominantly BLUNT (81%), and OPEN mostly PEN (66%; P<0.0001). ENDO were more likely to have high injury severity (ISS≥15; 74% vs. 69%; P<0.001), longer time to intervention (41h vs. 3h; P<0.001), and interfacility transfer (30% vs. 23%; P<0.0001). Most common ENDO modalities were stenting (60%), embolization (18%), and angioplasty (5.6%); OPEN were primary repair (31%), interposition/bypass (27%), ligation (9.7%), and patch angioplasty (4.7%).
On unadjusted analysis, ENDO were more likely to suffer stroke (31% vs. 26%; P=0.025), with no mortality difference (14% vs. 12%; P=0.2). Among PEN injuries, there was no difference between ENDO vs. OPEN for stroke (24% vs. 25%; P=0.9) or mortality (14% vs. 14%; P=0.9). For BLUNT, ENDO had greater mortality (14% vs. 9.0%; P=0.004) but not stroke (33% vs. 29%; P=0.2).
On multivariable analysis, ENDO/OPEN/BLUNT/PEN were not independently associated with stroke or stroke-mortality. Predictors of stroke were male gender (OR 0.67;0.49-0.92;P=0.012), smoking (OR 1.50;1.09-2.06;P=0.012), and hypertension (OR 1.74;1.20-2.52;P=0.004).
Predictors of stroke-mortality included concomitant TBI (OR 2.49;1.69-3.68;P<0.001), hypertension (OR 1.71;1.20-2.44;P=0.003), cardiac complication (OR 2.43;1.52-3.91;P<0.001), and ISS≥15 (OR 2.03;1.43-2.90;P<0.001).
CONCLUSIONS: Carotid trauma carries significant morbidity, with over a quarter of patients experiencing stroke. Mechanism or operative approach do not seem to predict stroke or strokemortality, which is more likely driven by overall injury burden.
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