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illance is imperative. Encouragingly, reintervention rates have improved over time, with newer devices exhibiting lower rates. Reintervention rate remains an important metric for new devices and registries. Published by Elsevier Inc.OBJECTIVE Recent studies have found that transcarotid artery revascularization (TCAR) is associated with lower risk of stroke or death compared with transfemoral carotid artery stenting but higher risk of bleeding complications, presumably associated with the need for an incision. Heparin anticoagulation is universally used during TCAR, so protamine use may reduce bleeding complications. However, the safety and effectiveness of protamine use in TCAR are unknown. We therefore evaluated the impact of protamine use on perioperative outcomes after TCAR in the Vascular Quality Initiative TCAR Surveillance Project. METHODS We performed a retrospective review of patients undergoing TCAR in the Vascular Quality Initiative TCAR Surveillance Project from September 2016 to April 2019. We assessed in-hospital outcomes using propensity score-matched cohorts of patients who did and did not receive protamine. The primary efficacy end point was access site bleeding complications, and the primary safety end point was in-hospithere was a trend toward lower risk of stroke for patients who received protamine (1.1% vs 2.0%; RR, 0.53; 95% CI, 0.24-1.13; P = .09). There were also no statistically significant differences in the rates of transient ischemic attack (0.4% vs 1.1%; RR, 0.40; 95% CI, 0.13-1.28; P = .11), myocardial infarction (0.4% vs 0.8%; RR, 0.50; 95% CI, 0.15-1.66; P = .25), heart failure exacerbation (0.4% vs 0.3%; RR, 1.33; 95% CI, 0.30-5.96; P = .71), or postoperative hypotensive hemodynamic instability (16% vs 15%; RR, 1.06; 95% CI, 0.83-1.35; P = .50) with protamine use. CONCLUSIONS Protamine can be safely used in TCAR to reduce the risk of perioperative bleeding complications without increasing the risk of thrombotic events. OBJECTIVE An analysis was conducted of early and midterm outcomes of a large series of patients treated with in situ laser fenestration (ISLF) during thoracic endovascular aortic repair (TEVAR) of acute and subacute complex aortic arch diseases, such as Stanford type A aortic dissection (TAAD), type B aortic dissection (TBAD) requiring proximal sealing at zone 2 or more proximal, thoracic aortic aneurysm or pseudoaneurysm, and penetrating aortic ulcer. We present the perioperative and follow-up outcomes and discuss the rate of complications. METHODS This is a retrospective review of prospectively collected data from January 2017 to March 2019 of patients treated with TEVAR and ISLF of aortic arch branches at a large tertiary academic institution in an urban city in China. Preoperative, intraoperative, and follow-up clinical and radiographic data are analyzed and discussed. RESULTS A total of 148 patients presented with symptomatic and acute or subacute TAAD, TBAD, thoracic aortic aneurysm, or penetrating aortntinued investigation of TEVAR and adjunctive ISLF is needed to elucidate the long-term outcomes of this minimally invasive treatment for complex aortic arch disease in an urgent setting. OBJECTIVE Coverage of the left subclavian artery (LSA) origin during thoracic endovascular aortic repair (TEVAR) is associated with increased neurologic complications. Our group is involved in the development of an off-the-shelf (OTS) thoracic endograft incorporating a left common carotid artery (LCCA) scallop and a retrograde inner branch for LSA perfusion. This study aimed to evaluate the arch morphology of patients treated by TEVAR and requiring LSA coverage to determine the applicability of this OTS device. METHODS The preoperative anatomy of consecutive patients from three separate cohorts treated with TEVAR with LSA coverage was studied. High-quality preoperative computed tomography angiography images were analyzed on an imaging workstation. Location of the origin of the supra-aortic trunks and their anatomic relationship were depicted in all patients; the LCCA origin was set as reference point. We determined the proportion of arch morphology in our cohort of patients eligible for this OTS device configuration. RESULTS There were 196 patients included in this study, 132 in the dissection cohort and 64 in the aneurysm cohort. The median length from the lower margin of the LCCA to the proximal aspect of the pathologic process was 25.0 mm (18.2-35.2 mm), with 68.4% (n = 134) of our cohort presenting with a proximal sealing zone length >20 mm. The median LCCA-LSA distance was 20.8 mm (16.6-25.4 mm). The median clock position of the LSA from the LCCA was -10 minutes (-30 to 0 minutes). In total, 127 patients (64.8%) could have been treated with the current OTS branched TEVAR configuration; 59 were excluded for proximal neck length distal to the LCCA  less then 20 mm and 10 because of the clock position of the LCCA, and 9 first required a vertebral artery transposition. CONCLUSIONS The low variability of LSA and LCCA locations in patients with distal aortic arch disease offers wide applicability of a new standardized thoracic branched endograft. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System has been developed to stratify amputation risk on the basis of extent of the wound, level of ischemia, and severity of foot infection (WIfI). However, there are no currently validated metrics to assess, grade, and consider functional status, especially ambulatory status, as a major consideration during limb salvage efforts. Therefore, we propose an adjunct to the current WIfI system to include the patient's ambulatory functional status after initial assessment of limb threat. We propose a functional ambulatory score divided into grade 0, ambulation outside the home with or without an assistive device; grade 1, ambulation within the home with or without an assistive device; grade 2, minimal ambulation, limbs used for transfers; and grade 3, a person who is bed-bound. Adding ambulatory function as a supplementary assessment tool can guide clinical decision making to achieve optimal future functional ambulatory outcome, a patient-centered goal as critical as limb preservation. This adjunct may aid limb preservation teams in rapid, effective communication and clinical decision making after initial WIfI assessment. It may also improve efforts toward patient-centered care and functional ambulatory outcome as a primary objective. We suggest a score of functional ambulatory status should be included in future trials of patients with chronic limb-threatening ischemia. OBJECTIVE The few randomized trials comparing endovascular with open surgical repair of ruptured abdominal aortic aneurysm (rAAA) were poorly designed and heavily criticized. Fasiglifam The short-term and midterm survival advantages of endovascular repair remain unclear. We sought to compare the two treatment modalities using a propensity-matched analysis in a real-world setting. METHODS All ruptured cases of open surgical repair (rOSR) and endovascular aneurysm repair (rEVAR) in the Vascular Quality Initiative were analyzed (2003-2018). Raw and propensity-matched rEVAR and rOSR cohorts were compared. Primary and secondary outcomes included postoperative major adverse events (cardiovascular, pulmonary, renal, bowel or limb ischemia, reoperation) and 30-day and 1-year mortality. Univariate, multivariate, and Kaplan-Meier analyses were performed. RESULTS There were 4929 rAAA repairs performed, 2749 rEVAR and 2180 rOSR. Compared with rEVAR patients, rOSR patients had higher rates of myocardial ischemic events (15% vs 10%; d with rEVAR (odds ratio, 2.0; 95% confidence interval, 1.6-2.7). All-cause 1-year survival was 73% and 59% after rEVAR and rOSR in the propensity-matched cohort, respectively (P  less then .001). CONCLUSIONS This is one of the largest studies of rAAA demonstrating clear short-term and midterm survival benefits of rEVAR over rOSR that persisted after matching on all major demographic, comorbid, and anatomic variables. Furthermore, patients who survived rOSR had twice the length of stay with increased rates of complications compared with rEVAR patients. These data suggest a more aggressive endovascular approach for rAAA in patients with suitable anatomy. BACKGROUND International guidelines recommend carotid revascularization within 14 days for patients with a symptomatic transient ischemic attack (TIA) or stroke event. However, significant delays in care persist, with only 9% of outpatients and 36% of inpatients in Ontario meeting this target. The study objective was to explore the influence of health system factors on carotid revascularization timelines. METHODS We conducted a retrospective chart review of all symptomatic TIA/stroke patients undergoing carotid endarterectomy or stenting at The Ottawa Hospital (2015-2016). The primary outcome was time from TIA/stroke to carotid revascularization. Health system variables of interest included location and timing of patient presentation, timelines to vascular imaging, and same-day collaboration between key services such as emergency, neurology, and surgery. Descriptive statistics and univariate analysis were used to determine statistically significant differences between groups. RESULTS A total of 228 records met the inclusion criteria. The median time from TIA/stroke to carotid revascularization was 10 days, with 58% of patients meeting the 14-day guideline. Prompt patient presentation to emergency demonstrated significantly shorter timelines to surgery (7 days; P  less then .001). Early vascular imaging was strongly correlated with early revascularization (4-5 days; P  less then .001). In addition, collaboration from two or more care services enhanced timelines to surgery ranging from 2.0 to 6.5 days (P  less then .001-.008). CONCLUSIONS Early/emergency response to stroke symptoms was pivotal in achieving best practice recommendations for rapid carotid revascularization, emphasizing the need for ongoing public awareness. Emergency and ambulatory strategies to facilitate urgent vascular imaging, as well as mechanisms for same-day communication between teams require optimization to promote early revascularization. OBJECTIVES Mouth care is increasingly recognized as an important component of care in nursing homes (NHs), yet is known to be deficient. To promote quality improvement and inform research efforts, it is necessary to have valid measures of staff self-efficacy and attitudes to provide mouth care. DESIGN A self-administered questionnaire completed by NH staff, information about the NH obtained from the administrator, and oral hygiene assessments of NH residents. SETTING AND PARTICIPANTS A total of 434 staff in 14 NHs in North Carolina who were participating in a cluster randomized pragmatic trial of Mouth Care Without a Battle (MCWB). METHODS Staff in MCWB homes completed the questionnaire at baseline; staff in control homes completed it at 2-year follow-up. The 35-item questionnaire used new items and those from previous measures, many of which were modified for the NH setting. Factorial, construct, and criterion validity were assessed. RESULTS Exploratory factor analysis identified a 3-factor 11-item self-efficacy scale (promoting oral hygiene, providing mouth care, obtaining cooperation) named "Self-Efficacy for Providing Mouth Care" (SE-PMC), and a 2-factor 11-item attitudes scale (care of residents' teeth, care of own teeth), named Attitudes for Providing Mouth Care (A-PMC).