The Effect of Severe Femoropopliteal Arterial Calcification on the Treatment Outcome of Femoropopliteal Intervention in Patients with Ischemic Tissue Loss

Carotid artery dissections from transcarotid artery revascularization as reported by the Food and Drug Administration

OBJECTIVES

Transcarotid artery revascularization (TCAR) is a hybrid procedure that allows reversal of blood flow away from the brain while placing a stent through direct surgical access of the common carotid artery. It has been shown to have a lower risk of perioperative stroke compared with any prospective trial of transfemoral carotid artery stenting. However, intraoperative injuries related to the procedure and its management are not well characterized. One of the intraoperative complications seen in TCAR is iatrogenic carotid artery dissection (CD). We aim to add qualitative insight in further characterizing CDs and its management in this emerging technology.

METHODS

The Food and Drug Administration (FDA) maintains the Manufacturer and User Facility Device Experience (MAUDE) database for surveillance of all medical devices approved for use. This database was queried for all cases associated with Silk Road Medical's ENROUTE Transcarotid Neuroprotection System from September 2016 to October 2020. Case narratives related to CD were individually analyzed to determine time of injury (intraoperative, recovery, and post-discharge follow-up). CD reporting was further analyzed for the associated procedural event at the time of injury, number of access attempts to CD repair, and type of CD repair. Reports associated with CD repair were further categorized into endovascular repair and open surgical repair.

RESULTS

Of the 115 unique adverse events in the database, there were 58 CDs. Most were identified intraoperatively (n = 55), while three were incidentally found postoperatively. Overall, sheath placement was the most common procedural event attributed to CD (N = 34). There was adequate narrative information about CD repair in 54 patients. Intraoperative repair was performed in 52 cases and two were repaired after post-discharge follow-up imaging was performed.Among CDs that did not require additional access to engage the true lumen, the proportion of endovascular repair (62.5%) was significantly higher (p = .044) compared to the proportion of open surgical repair (37.5%). However, the proportion of open surgical repair (75%) was significantly higher than the proportion of endovascular repair (25%) in CDs with persistent failure to engage the true lumen despite ≥2 access attempts (p = .039).

CONCLUSION

CD is the most common injury related to TCAR as reported on MAUDE. The most commonly reported procedural event associated with CD was sheath placement. The rate of intraoperative endovascular and open surgical CD repair was associated with whether the access to the true lumen of the carotid artery required additional access attempts or not. This should add qualitative insight among the vascular surgery community regarding intraoperative management of CDs from a TCAR procedure.

Prediction of 2-Year Major Adverse Limb Event-Free Survival After Percutaneous Transluminal Angioplasty and Stenting for Lower Limb Atherosclerosis Obliterans: A Machine Learning-Based Study

Background

The current scoring systems could not predict prognosis after endovascular therapy for peripheral artery disease. Machine learning could make predictions for future events by learning a specific pattern from existing data. This study aimed to demonstrate machine learning could make an accurate prediction for 2-year major adverse limb event-free survival (MFS) after percutaneous transluminal angioplasty (PTA) and stenting for lower limb atherosclerosis obliterans (ASO).

Methods

A lower limb ASO cohort of 392 patients who received PTA and stenting was split to the training set and test set by 4:1 in chronological order. Demographic, medical, and imaging data were used to build machine learning models to predict 2-year MFS. The discrimination and calibration of artificial neural network (ANN) and random forest models were compared with the logistic regression model, using the area under the receiver operating curve (ROCAUC) with DeLong test, and the calibration curve with Hosmer–Lemeshow goodness-of-fit test, respectively.

Results

The ANN model (ROCAUC = 0.80, 95% CI: 0.68–0.89) but not the random forest model (ROCAUC = 0.78, 95% CI: 0.66–0.87) significantly outperformed the logistic regression model (ROCAUC = 0.73, 95% CI: 0.60–0.83, P = 0.01 and P = 0.24). The ANN model the logistic regression model demonstrated good calibration performance (P = 0.73 and P = 0.28), while the random forest model showed poor calibration (P < 0.01). The calibration curve of the ANN model was visually the closest to the perfectly calibrated line.

Conclusion

Machine learning models could accurately predict 2-year MFS after PTA and stenting for lower limb ASO, in which the ANN model had better discrimination and calibration. Machine learning-derived prediction tools might be clinically useful to automatically identify candidates for PTA and stenting.

Vascular Calcification in Chronic Kidney Disease: Diversity in the Vessel Wall

Vascular calcification (VC) is one of the major causes of cardiovascular morbidity and mortality in patients with chronic kidney disease (CKD). VC is a complex process expressing similarity to bone metabolism in onset and progression. VC in CKD is promoted by various factors not limited to hyperphosphatemia, Ca/Pi imbalance, uremic toxins, chronic inflammation, oxidative stress, and activation of multiple signaling pathways in different cell types, including vascular smooth muscle cells (VSMCs), macrophages, and endothelial cells. In the current review, we provide an in-depth analysis of the various kinds of VC, the clinical significance and available therapies, significant contributions from multiple cell types, and the associated cellular and molecular mechanisms for the VC process in the setting of CKD. Thus, we seek to highlight the key factors and cell types driving the pathology of VC in CKD in order to assist in the identification of preventative, diagnostic, and therapeutic strategies for patients burdened with this disease.