A comparison of endovascular repair to medical management for acute vs subacute uncomplicated type B aortic dissections.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) has emerged as a viable option of treatment for uncomplicated type B aortic dissection (UTBAD) due to the potential for inducing favorable aortic remodeling. The aim of this study is to compare outcomes of UTBAD treated medically or with TEVAR in either the acute (1 to 14 days) or subacute period (2 weeks to 3 months). METHODS: Patients with UTBAD between 2007 and 2019 were identified using the TriNetX Network. The cohort was stratified by treatment type (medical management; TEVAR during the acute period; TEVAR during the subacute period). Outcomes including mortality, endovascular reintervention, and rupture were analyzed after propensity matching. RESULTS: Among 20,376 patients with UTBAD, 18,840 were medically managed (92.5%), 1099 patients were in the acute TEVAR group (5.4%), and 437 patients were in the subacute TEVAR group (2.1%). The acute TEVAR group had higher rates of 30-day and 3-year rupture (4.1% vs 1.5%; P < .001; 9.9% vs 3.6%; P < .001) and 3-year endovascular reintervention (7.6% vs 1.6%; P < .001), similar 30-day mortality (4.4% vs 2.9%; P < .068), and lower 3-year survival compared with medical management (86.6% vs 83.3%; P = .041). The subacute TEVAR group had similar rates of 30-day mortality (2.3% vs 2.3%; P = 1), 3-year survival (87.0% vs 88.8%; P = .377) and 30-day and 3-year rupture (2.3% vs 2.3%; P = 1; 4.6% vs 3.4%; P = .388), with significantly higher rates of 3-year endovascular reintervention (12.6% vs 7.8%; P = .019) compared with medical management. The acute TEVAR group had similar rates of 30-day mortality (4.2% vs 2.5%; P = .171), rupture (3.0% vs 2.5%; P = .666), significantly higher rates of 3-year rupture (8.7% vs 3.5%; P = .002), and similar rates of 3-year endovascular reintervention (12.6% vs 10.6%; P = .380) compared with the subacute TEVAR group. There was significantly higher 3-year survival (88.5% vs 84.0%; P = .039) in the subacute TEVAR group compared with the acute TEVAR group. CONCLUSIONS: Our results found lower 3-year survival in the acute TEVAR group compared with the medical management group. There was no 3-year survival benefit found in patients with UTBAD who underwent subacute TEVAR compared with medical management. This suggests the need for further studies looking at the necessity for TEVAR when compared with medical management for UTBAD as it is non-inferior to medical management. Higher rates of 3-year survival and lower rates of 3-year rupture in the subacute TEVAR group compared with the acute TEVAR group suggest superiority of subacute TEVAR. Further investigations are needed to determine the long-term benefit and optimal timing of TEVAR for acute UTBAD.

Safety and Efficacy of Percutaneous Translumbar Inferior Vena Cava Catheters: A Systematic Review and Meta-Analysis.

PURPOSE: To examine the reported adverse events associated with inferior vena cava (IVC) catheterization and investigate the reasons for discrepancies between reports. MATERIALS AND METHODS: Cochrane Library trials register, PubMed, Embase, and Scopus databases were systematically searched for studies that included any terms of IVC and phrases related to catheters or central access. Of the 5,075 searched studies, 137 were included in the full-text evaluation. Of these, 37 studies were included in the systematic review, and the adverse events reported in 16 of these 37 identified studies were analyzed. An inverse-variance random-effects model was used to conduct the meta-analysis. Outcomes were summarized by the incidence rate (IR) and 95% CI. RESULTS: Compared with that of catheters <10 F in size (IR, 0.08; 95% CI, 0.03-0.12), the incidence of catheter-related infections per 100 catheter days was 0.2 more for catheters ≥10 F in size (IR, 0.28; 95% CI, 0.25-0.31). In addition, dual-lumen catheters showed 0.13 more malfunction per 100 catheter days (IR, 0.27; 95% CI, 0.16-0.37) than that shown by single-lumen catheters (IR, 0.14; 95% CI, 0.09-0.19). Both differences were statistically significant. Other adverse events were malposition (IR, 0.04; 95% CI, 0.04-0.05), fracture (IR, 0.01; 95% CI, 0.00-0.02), kinking (IR, 0.01; 95% CI, 0.00-0.01), replaced catheter (IR, 0.2; 95% CI, 0.1-0.31), removal (IR, 0.13; 95% CI, 0.1-0.16), IVC thrombosis (IR, 0.01; 95% CI, 0.00-0.03), and retroperitoneal hematoma (IR, 0.01; 95% CI, 0.00-0.01), all per 100 catheter days. CONCLUSIONS: Translumbar IVC access is an option for patients with exhausted central veins. Small-caliber catheters cause fewer catheter-related infections, and single-lumen catheters function longer.

Early experience with arterial thromboembolic complications in patients with COVID-19.

BACKGROUND: Little is known about the arterial complications and hypercoagulability associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We sought to characterize our experience with arterial thromboembolic complications in patients with hospitalized for coronavirus disease 2019 (COVID-19). METHODS: All patients admitted from March 1 to April 20, 2020, and who underwent carotid, upper, lower and aortoiliac arterial duplex, computed tomography angiogram or magnetic resonance angiography for suspected arterial thrombosis were included. A retrospective case control study design was used to identify, characterize and evaluate potential risk factors for arterial thromboembolic disease in SARS-CoV-2 positive patients. Demographics, characteristics, and laboratory values were abstracted and analyzed. RESULTS: During the study period, 424 patients underwent 499 arterial duplex, computed tomography angiogram, or magnetic resonance angiography imaging studies with an overall 9.4% positive rate for arterial thromboembolism. Of the 40 patients with arterial thromboembolism, 25 (62.5%) were SARS-CoV-2 negative or admitted for unrelated reasons and 15 (37.5%) were SARS-CoV-2 positive. The odds ratio for arterial thrombosis in COVID-19 was 3.37 (95% confidence interval, 1.68-6.78; P = .001). Although not statistically significant, in patients with arterial thromboembolism, patients who were SARS-CoV-2 positive compared with those testing negative or not tested tended to be male (66.7% vs 40.0%; P = .191), have a less frequent history of former or active smoking (42.9% vs 68.0%; P = .233) and have a higher white blood cell count (14.5 vs 9.9; P = .208). Although the SARS-CoV-2 positive patients trended toward a higher the neutrophil-to-lymphocyte ratio (8.9 vs 4.1; P = .134), creatinine phosphokinase level (359.0 vs 144.5; P = .667), C-reactive protein level (24.2 vs 13.8; P = .627), lactate dehydrogenase level (576.5 vs 338.0; P = .313), and ferritin level (974.0 vs 412.0; P = .47), these differences did not reach statistical significance. Patients with arterial thromboembolic complications and SARS-CoV-2 positive when compared with SARS-CoV-2 negative or admitted for unrelated reasons were younger (64 vs 70 years; P = .027), had a significantly higher body mass index (32.6 vs 25.5; P = .012), a higher d-dimer at the time of imaging (17.3 vs 1.8; P = .038), a higher average in hospital d-dimer (8.5 vs 2.0; P = .038), a greater distribution of patients with clot in the aortoiliac location (5 vs 1; P = .040), less prior use of any antiplatelet medication (21.4% vs 62.5%; P = .035), and a higher mortality rate (40.0% vs 8.0%; P = .041). Treatment of arterial thromboembolic disease in COVID-19 positive patients included open thromboembolectomy in six patients (40%), anticoagulation alone in four (26.7%), and five (33.3%) did not require or their overall illness severity precluded additional treatment. CONCLUSIONS: Patients with SARS-CoV-2 are at risk for acute arterial thromboembolic complications despite a lack of conventional risk factors. A hyperinflammatory state may be responsible for this phenomenon with a preponderance for aortoiliac involvement. These findings provide an early characterization of arterial thromboembolic disease in SARS-CoV-2 patients.

Extended screening guidelines for the diagnosis of abdominal aortic aneurysm.

BACKGROUND: The U.S. Preventive Services Task Force (USPSTF) guidelines are the most widely used criteria for screening for abdominal aortic aneurysms (AAA). However, when the USPSTF criteria are applied retrospectively to a group of patients who have undergone treatment for AAA, there are many patients who satisfy none of the AAA screening criteria. The more sensitive Society for Vascular Surgery (SVS) guidelines have expanded the criteria for screening for AAA with the hope of capturing a greater fraction of those individuals who can undergo treatment for their AAA before presenting with AAA rupture. We sought to identify the number of patients who would have been identified as having criteria for screening for AAA by both the USPSTF and SVS criteria, in a cohort of patients who have undergone treatment for AAA. METHODS: We assessed demographic, comorbidity, and perioperative complication data for all patients undergoing endovascular and open AAA repair in the Vascular Quality Initiative. Patients meeting each of the screening criteria were identified. Clinical factors and demographic variables were collected. RESULTS: We identified 55,197 patients undergoing AAA repair in the Vascular Quality Initiative, including 44,602 patients who underwent endovascular aneurysm repair (EVAR) and 10,595 patients undergoing open repair. Of these, the USPTF guidelines would have identified fewer than one-third of patients (32% EVAR and 33% open repair). Applying the SVS guidelines increased the number meeting criteria for screening by 6% and 12% for the EVAR and open repair cohorts, respectively. Finally, adoption of the expanded SVS guidelines (including the "weak recommendations") would have identified an additional 34% of EVAR patients and 21% of open AAA repair patients. Use of the expanded criteria would have resulted in 27% of patients undergoing EVAR and 33% of patients undergoing open AAA repair who would not have met any screening criteria. In EVAR patients not meeting the criteria, 52% were younger than 65 years had a history of heavy smoking. Of all those who did not meet screening criteria, ruptured AAA was twice as prevalent as those who met screening criteria (8.5% vs 4.4%; P ≤ .0001). CONCLUSIONS: Expanding established USPSTF screening guidelines to include the expanded SVS criteria may potentially double the number of patients identified with AAA. Smokers under the age of 65, and elderly patients 70 and older with no smoking history, represent two groups with AAA and potentially twice the risk of presenting with rupture.

Digital Footprint of Vascular Surgery Training Programs in the United States and Canada.

BACKGROUND: The digital footprint of vascular residency and fellowship programs may have an impact on an applicant's likelihood of selecting a given program. This may include content and accessibility of a particular program's website as well as its social media presence. The goal of this study is to evaluate the online presence of all accredited vascular surgery training programs in the United States and Canada. METHODS: A list of accredited vascular surgery training programs in the United States was obtained from the Accreditation Council for Graduate Medical Education and the Society for Vascular Surgery websites. Canadian program websites were sourced from the Canadian Society for Vascular Surgery website. Each program website was individually queried. A systematic Google search of each program was carried out to determine website accessibility. Thirty-one individual content and quality metrics were used to appraise the websites. Three major social media platforms (Twitter, Facebook, and Instagram) were individually searched for program profiles. RESULTS: A total of 105 independent vascular surgery fellowship programs in the 5 + 2 paradigm and 55 integrated vascular surgery residency programs in the 0 + 5 paradigm were identified in the United States. An additional 10 Canadian programs were also identified, including 10 integrated residency programs and 4 independent fellowships. Ninety-nine percent of integrated residency and fellowship programs were accessible through Google search. Program description was also almost universally available. Significant differences between US and Canadian programs were observed including the mention of salary information (43% vs. 10%, P = 0.039), clinic responsibilities (38% vs. 90%, P = 0.001), teaching responsibilities (34% vs. 100%, P < 0.0001), program director contact information (47% vs. 80%, P = 0.045), mention of journal club (52% vs. 100%, P = 0.003), research requirements (50% vs. 90%, P = 0.014), and past and current research (30% vs. 70%, P = 0.009 and 37% vs. 80%, P = 0.008, respectively). Additionally, there were significant differences in mention of institutions from which trainees came from (48% vs. 10%, P = 0.021), mention of hybrid operating room (42% vs. 100%, P = 0.0003), advertised medical student rotations (25% vs. 90%, P < 0.0001), and finally social media presence (13% vs. 70%, P < 0.0001). CONCLUSIONS: The overall digital footprint of the majority of training programs in the United States was small, unlike their Canadian counterparts. Although the vast majority of websites for vascular surgery training programs were accessible via simple internet searches, they lacked information that could have been important to applicants. Additionally, the significant underuse of social media platforms by American vascular surgery programs indicated a potential missed opportunity to target the millennials who make up most of the applicant pool to these programs.

Trends in open abdominal exposure among vascular surgery trainees.

BACKGROUND: This retrospective study evaluates the trends in open abdominal surgery cases among integrated vascular surgery residents compared with their 5 + 2 counterparts. METHODS: The Accreditation Council for Graduate Medical Education (ACGME) case logs between 2007 and 2016 were collected from a pool of 9861 residents and fellows from 371 institutions. Trainees were grouped into three categories: general surgery residency (GSR), integrated vascular surgery residency (IVSR), and vascular surgery fellowship in the United States. Inclusion criteria were specific to open abdominal cases of or including the anatomy adjacent to the aorta performed by the surgeon chief. RESULTS: The 5 + 2 graduates have obtained significantly more open vascular surgery training experience than their IVSR graduate counterparts (P < .01). GSR chief residents performed significantly more open abdomen cases than IVSR chief residents (P < .01). IVSR chiefs performed significantly more open vascular procedures than GSR chiefs (P < .01). On the completion of vascular surgery fellowship, 5 + 2 graduates had significantly more open abdominal aortic aneurysm (AAA) exposure during training than IVSR graduates did (P < .01); however, IVSR trainees had performed significantly more open AAA procedures than their GSR counterparts (P < .01). CONCLUSIONS: Up to 2016, graduates of the 5 + 2 vascular training pathway had significantly higher open abdominal exposure than those of the IVSR track. However, graduates of the IVSR track had significantly higher open AAA exposure than GSR graduates.

Percutaneous endovascular aneurysm repair in morbidly obese patients.

OBJECTIVE: Endovascular aneurysm repair (EVAR) with percutaneous femoral access (PEVAR) has several potential advantages. Morbidly obese (MO) patients present unique anatomical challenges and have not been specifically studied. This study examines the trends in the use of PEVAR and its surgical outcomes compared with open femoral cutdown (CEVAR) in MO patients. METHODS: The American College of Surgeons National Surgical Quality Improvement Program files for the years 2005 to 2013 were reviewed. The study included all MO patients (body mass index [BMI] ≥40 kg/m2) undergoing EVAR. Patients were categorized as having CEVAR if they had any one of 11 selected Current Procedural Terminology (American Medical Association, Chicago, Ill) codes describing an open femoral procedure. The PEVAR group included any remaining patients who had only codes for EVAR and endovascular procedures. Linear correlation was used to evaluate temporal trends in the use of PEVAR among MO patients. Baseline comorbidities and surgical outcomes were compared between the PEVAR and CEVAR groups using χ2 tests or t-tests. RESULTS: There were 833 MO patients (470 CEVAR and 363 PEVAR) constituting 3.0% of all patients undergoing EVAR. The use of PEVAR in MO patients significantly increased from 27.3% of total EVARs in the years 2005 to 2006 to 48.6% in 2013 (P = .039). The two groups had similar baseline characteristics, including age, BMI, comorbidities, and emergency procedures, except for history of severe chronic obstructive pulmonary disease (29.6% CEVAR vs 22.6% PEVAR; P = .024). PEVAR patients had shorter duration of anesthesia (244 vs 260 minutes; P = .048) and shorter total operation time (158 vs 174 minutes; P = .002). PEVAR patients had significantly decreased wound complications (5.5% vs 9.4%; P = .039). There was a trend towards PEVAR patients being more likely to be discharged home than to a facility (93.6% vs 87.8%; P = .060). There was no difference in any other complication or mortality. A subgroup analysis of 109 superobese patients with BMI ≥50 kg/mg2 (59 CEVAR and 50 PEVAR) demonstrated no significant differences in outcomes between groups. CONCLUSIONS: PEVAR is increasingly used in MO patients and decreases operating time and rates of wound infection compared with CEVAR. The advantages of PEVAR seem to be lost in the superobese patients.

Contemporary outcomes of open complex abdominal aortic aneurysm repair.

OBJECTIVE: The recent commercial availability of fenestrated stent grafts is likely to result in increasing endovascular repair of complex (juxtarenal and suprarenal) abdominal aortic aneurysms (cAAAs). Whereas most studies providing benchmarking for outcomes after open repair have been from high-volume centers, we sought to evaluate outcomes after elective open cAAA repair vs infrarenal AAA repair at a regional level. METHODS: We used the Vascular Study Group of New England registry, which recorded 1875 open AAA repairs in New England from 2003 to 2011. Data from 14 hospitals performing both AAA and cAAA repair were used to assess the impact of clinical and technical factors on outcomes of cAAA repair. RESULTS: There were 443 patients who had elective cAAA repair as defined by use of a suprarenal (n = 340; 77%) or supraceliac (n = 103; 23%) clamp, with median survival follow-up of 35 months (interquartile range, 47 months). Compared with AAA repair, patients undergoing cAAA repair were more likely to be female; to have hypertension, congestive heart failure, or chronic obstructive pulmonary disease; and to have a higher baseline creatinine concentration. cAAA cases were repaired through a retroperitoneal incision in 40% of cases, with hypothermic renal perfusion use in 15%, mannitol in 73%, and renal bypass in 13%, with wide variability in the application of these adjuncts. Complex aneurysm repair vs routine AAA repair was associated with a higher independent risk of 30-day mortality (3.6% vs 1.2%; P = .002), respiratory complications (19% vs 10%; P < .001), and renal complications (21% vs 8.7%; P < .001). Among all patients, the only independent clinical or technical predictors of 30-day mortality were preoperative coronary artery disease (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.1-5.4; P = .02) and amount of intraoperative blood transfusion (OR, 2.8; 95% CI, 1.3-6.2; P = .01). In the subgroup undergoing cAAA repair, there were no predictors of operative mortality. Renal or visceral ischemia time was the only technical factor during cAAA repair that independently predicted cardiac (OR, 1.01; 95% CI, 1.00-1.03; P = .04), respiratory (OR, 1.03; 95% CI, 1.01-1.04; P < .001), and renal (OR, 1.03; 95% CI, 1.02-1.05; P < .001) complications. Long-term survival for cAAA patients was 91% ± 1% at 1 year and 71% ± 3% at 5 years and not different from that of patients undergoing infrarenal AAA repair. Risk-adjusted predictors of late mortality after cAAA repair included age (hazard ratio [HR], 1.08; 95% CI, 1.04-1.11; P < .001), chronic obstructive pulmonary disease (HR, 1.9; 95% CI, 1.2-3.0; P = .008), and preoperative creatinine concentration (per mg/dL; HR, 1.8; 95% CI, 1.05-2.9; P = .03). CONCLUSIONS: These data highlight excellent operative outcomes for open cAAA repair across the New England region despite significant variation in operative conduct across hospitals. Patients tolerating cAAA repair have durable long-term survival.

Successful treatment of a proximal type I endoleak with HeliFX EndoAnchors.

We report the use of Aptus HeliFX EndoAnchors for endovascular treatment of a proximal type I endoleak after previous endovascular aneurysm repair (EVAR) of a ruptured abdominal aortic aneurysm. An 81-year-old man had been treated with EVAR after a ruptured 12 × 11 cm abdominal aortic aneurysm. Standard computed tomographic angiography follow-up demonstrated a proximal type I endoleak. Because of the highly angulated neck and close position of the endograft to the renal arteries, placement of a proximal extension cuff was prohibited; therefore, the endoleak was treated with an alternative approach using the Aptus HeliFX EndoAnchors. Nine EndoAnchors were successfully placed circumferentially on the proximal site of the endograft. This successfully treated the endoleak by excluding the aneurysm sac from the circulation. Computed tomographic angiography follow-up after 3 months showed no residual type I endoleak. This case shows that placement of EndoAnchors can serve as a viable treatment option for proximal type I endoleaks after failed EVAR.

Social media in vascular surgery.

There has been a tremendous growth in the use of social media to expand the visibility of various specialties in medicine. The purpose of this paper is to describe the latest updates on some current applications of social media in the practice of vascular surgery as well as existing limitations of use. This investigation demonstrates that the use of social networking sites appears to have a positive impact on vascular practice, as is evident through the incorporation of this technology at the Cleveland Clinic and by the Society for Vascular Surgery into their approach to patient care and physician communication. Overall, integration of social networking technology has current and future potential to be used to promote goals, patient awareness, recruitment for clinical trials, and professionalism within the specialty of vascular surgery.

Race as a predictor of morbidity, mortality, and neurologic events after carotid endarterectomy.

OBJECTIVE: Racial disparities in the outcomes of patients undergoing carotid endarterectomy (CEA) have been reported. We sought to examine the contemporary relationship between race and outcomes and to report postdischarge events after CEA. METHODS: The American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files were reviewed to identify all CEAs performed from 2005 to 2010 by vascular surgeons. The influence of race on outcomes was examined. Multivariate analysis was performed using variables found to be significant on bivariate analysis. The primary outcomes were stroke and mortality. Secondary outcomes were other 30-day complications, including postdischarge events. RESULTS: CEA was performed on 29,114 white patients (95.7%) and on 1316 black patients (4.3%); the overall stroke and mortality rates were 1.65% and 0.7%, respectively. The stroke rate was 1.6% for whites and 2.5% blacks (P = .009). The 30-day mortality rate was 0.7% for whites and 1.4% for blacks (P = .002). There was a longer operating time (P < .001) and total length of stay (P < .001), more postoperative pneumonias (P = .049), unplanned intubations (P < .001), ventilator dependence (P < .001), cardiac arrests (P < .001), bleeding requiring transfusions (P = .024), and reoperations within 30 days (P = .021) among black patients. Multivariate logistic regression modeling identified black race as an independent risk factor for 30-day mortality (odds ratio, 1.9; P = .007). Black patients also had a greater proportion of in-hospital deaths than white patients (73.7% vs 43.1%; P = .01). There was no between-group difference in the rate of postdischarge strokes. Thirty-six percent of all strokes occurred after discharge at a mean of 8.3 days, and 54.3% of deaths occurred after discharge at a mean of 11 days. CONCLUSIONS: Black race is an independent risk factor for 30-day mortality after CEA. A significant proportion of strokes and deaths occur after discharge in both racial groups evaluated.

Clinical outcomes of 5358 patients undergoing direct open bypass or endovascular treatment for aortoiliac occlusive disease: a systematic review and meta-analysis.

PURPOSE: To examine clinical outcomes of endovascular and open bypass treatment for aortoiliac occlusive disease (AIOD). METHODS: Multiple databases were systematically searched to identify studies on open and endovascular treatment for AIOD published from 1989 to 2010. Studies were independently reviewed for eligibility criteria. Study selection and assessment of methodological quality were performed by two independent reviewers. Assuming between-study heterogeneity due to biases inherent to observational studies, a random effects model (DerSimonian-Laird method) was used for calculation of weighted proportions. Pooled weighted proportions or weighted means are reported. Twenty-nine open bypass studies (3733 patients) and 28 endovascular treatment studies (1625 patients) were analyzed. RESULTS: Weighted mean patient age was 60.4 years for open bypass and 60.8 years for endovascular treatment. Poor preoperative runoff was greater in the open bypass group (50.0% vs. 24.6%, p<0.001). Mean length of hospital stay (LOS) was 13 days for open bypass vs. 4 days for endovascular treatment procedures (p<0.001). The open bypass group experienced more complications (18.0% vs. 13.4%, p<0.001) and greater 30-day mortality (2.6% vs. 0.7%, p<0.001). At 1, 3, and 5 years, pooled primary patency rates were greater in the open bypass group vs. the endovascular cohort (94.8% vs. 86.0%, 86.0% vs. 80.0%, 82.7% vs. 71.4%, respectively; all p<0.001); the same was true for secondary patency [95.7% vs. 90.0% (p=0.002), 91.5 vs. 86.5% (p<0.001), and 91.0% vs. 82.5% (p<0.001), respectively]. CONCLUSION: Although this study was limited by a paucity of randomized control trials, these results demonstrate superior durability for open bypass, although with longer LOS and increased risk for complications and mortality, when compared to the endovascular approach.

Endovascular repair is associated with superior clinical outcomes in patients transferred for treatment of ruptured abdominal aortic aneurysms.

PURPOSE: To compare in a population-based analysis the in-hospital mortality and complications following endovascular aneurysm repair (EVAR) vs. open repair in patients transferred for the management of ruptured abdominal aortic aneurysm (RAAA). METHODS: Interrogation of the 2003-2007 Nationwide Inpatient Sample database identified 271 patients (205 men; mean age 71.7 years) who were transferred for RAAA treatment. Demographic, patient, and hospital characteristics were analyzed. Hierarchical multivariate logistic regression analyses were employed to identify predictors of in-hospital mortality and complications; results are presented as the odds ratio (OR) and 95% confidence interval (CI). RESULTS: In comparison to open repair (n=207), endovascular repair (n=64) was associated with lower in-hospital mortality (36% vs. <18%, p<0.01) and a lower complication rate (78% vs. 66%, p<0.05). Transferred RAAA patients undergoing EVAR had lower in-hospital mortality (OR 0.21, 95% CI 0.09 to 0.49, p<0.01) and fewer complications (OR 0.49, 95% CI 0.26 to 0.95, p<0.05) than transferred patients having open repair. CONCLUSION: Compared to open repair, EVAR led to superior short-term clinical outcomes in transferred RAAA patients. In this clinical situation, transfer of stable RAAA patients to institutions capable of performing EVAR is recommended.

Predicting functional status following amputation after lower extremity bypass.

BACKGROUND: Some patients who undergo lower extremity bypass (LEB) for critical limb ischemia ultimately require amputation. The functional outcome achieved by these patients after amputation is not well known. Therefore, we sought to characterize the functional outcome of patients who undergo amputation after LEB, and to describe the pre- and perioperative factors associated with independent ambulation at home after lower extremity amputation. METHODS: Within a cohort of 3,198 patients who underwent an LEB between January, 2003 and December, 2008, we studied 436 patients who subsequently received an above-knee (AK), below-knee (BK), or minor (forefoot or toe) ipsilateral or contralateral amputation. Our main outcome measure consisted of a "good functional outcome," defined as living at home and ambulating independently. We calculated univariate and multivariate associations among patient characteristics and our main outcome measure, as well as overall survival. RESULTS: Of the 436 patients who underwent amputation within the first year following LEB, 224 of 436 (51.4%) had a minor amputation, 105 of 436 (24.1%) had a BK amputation, and 107 of 436 (24.5%) had an AK amputation. The majority of AK (75 of 107, 72.8%) and BK amputations (72 of 105, 70.6%) occurred in the setting of bypass graft thrombosis, whereas nearly all minor amputations (200 of 224, 89.7%) occurred with a patent bypass graft. By life-table analysis at 1 year, we found that the proportion of surviving patients with a good functional outcome varied by the presence and extent of amputation (proportion surviving with good functional outcome = 88% no amputation, 81% minor amputation, 55% BK amputation, and 45% AK amputation, p = 0.001). Among those analyzed at long-term follow-up, survival was slightly lower for those who had a minor amputation when compared with those who did not receive an amputation after LEB (81 vs. 88%, p = 0.02). Survival among major amputation patients did not significantly differ compared with no amputation (BK amputation 87%, p = 0.14, AK amputation 89%, p = 0.27); however, this part of the analysis was limited by its sample size (n = 212). In multivariable analysis, we found that the patients most likely to remain ambulatory and live independently despite undergoing a lower extremity amputation were those living at home preoperatively (hazard ratio [HR]: 6.8, 95% confidence interval [CI]: 0.94-49, p = 0.058) and those with preoperative statin use (HR: 1.6, 95% CI: 1.2-2.1, p = 0.003), whereas the presence of several comorbidities identified patients less likely to achieve a good functional outcome: coronary disease (HR: 0.6, 95% CI: 0.5-0.9, p = 0.003), dialysis (HR: 0.5, 95% CI: 0.3-0.9, p = 0.02), and congestive heart failure (HR: 0.5, 95% CI: 0.3-0.8, p = 0.005). CONCLUSIONS: A postoperative amputation at any level impacts functional outcomes following LEB surgery, and the extent of amputation is directly related to the effect on functional outcome. It is possible, based on preoperative patient characteristics, to identify patients undergoing LEB who are most or least likely to achieve good functional outcomes even if a major amputation is ultimately required. These findings may assist in patient education and surgical decision making in patients who are poor candidates for lower extremity bypass.

Thoracic aortic pulsatility decreases during hypovolemic shock: implications for stent-graft sizing.

PURPOSE: To investigate the thoracic aortic pulsatility during hypovolemic shock in an experimental porcine model. METHODS: The circulating blood volume of 7 healthy Yorkshire pigs was gradually lowered until the subjects had lost 40% of their normal blood volume. Intravascular ultrasound was used to assess the aortic pulsatility in normovolemic and hypovolemic state at the level of the ascending and descending thoracic aorta. RESULTS: The mean aortic pulsatility at the level of the ascending aorta decreased from 15.9% ± 7.2% (range 6.3%-25.7%) in normovolemia to 6.2% ± 2.8% (range 2.9%-10.7%, p = 0.018) in hypovolemia. At the level of the descending thoracic aorta, the mean aortic pulsatility decreased from 8.7% ± 2.8% (range 4.4%-12.2%) at baseline to 5.6% ± 2.5% (range 1.5%-9.5%, p = 0.028) in hypovolemia. The maximum mean aortic diameter, obtained in cardiac systole, was significantly smaller as well at both evaluated levels during hypovolemic shock compared with the mean diameter in normovolemia. CONCLUSION: The thoracic aortic diameter and pulsatility decreased significantly during hypovolemic shock in this porcine model, most impressively at the level of the ascending aorta. Electrocardiographically-gated imaging may not be necessary for hypovolemic patients with acute aortic disease requiring endovascular repair because of the minimal aortic pulsatility.

Endovascular procedures for aorto-iliac occlusive disease are associated with superior short-term clinical and economic outcomes compared with open surgery in the inpatient population.

OBJECTIVES: There has been a rapid increase in the number of endovascular procedures performed for peripheral artery disease, and especially aorto-iliac occlusive disease (AIOD). Results from single-center reports suggest a benefit for endovascular procedures; however, these benefits may not reflect general practice. We used a population-based analysis to determine predictors of clinical and economic outcomes following open and endovascular procedures for inpatients with AIOD. METHODS: All patients with AIOD who underwent open and endovascular procedures in the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, 2004 to 2007, were identified. Independent patient- and provider-related characteristics were analyzed. Clinical outcomes included complications and mortality; economic outcomes included length of stay (LOS) and cost (2007 dollars). Outcomes were compared using χ2, ANOVA, and multivariate regression analysis. RESULTS: Four thousand, one hundred nineteen patients with AIOD were identified. Endovascular procedures increased by 18%. Patients who underwent endovascular procedures were more likely to be ≥65 years of age (46% vs 37%), female (54% vs 49%), and in the highest quartile of household income (20% vs 16%), all P<.05. Endovascular patients were more likely to be non-elective (41% vs 20%), in the highest comorbidity index group (8% vs 5%), and with iliac artery disease (67% vs 33%), all P≤.05. In bivariate analysis, endovascular procedures were associated with lower complication rates (16% vs 25%), shorter LOS (2.2 vs 5.8 days), and lower hospital costs ($13,661 vs $17,161), all P<.001. In multivariate analysis, endovascular procedures had significantly lower complication rates and cost, and shorter LOS. CONCLUSIONS: Endovascular procedures have superior short-term clinical and economic outcomes compared with open procedures for the treatment of AIOD in the inpatient setting. Further studies are needed to examine long-term outcomes and access-related issues.

Trends and outcomes of endovascular and open treatment for traumatic thoracic aortic injury.

OBJECTIVES: Traumatic thoracic aortic injury (TTAI) is associated with high mortality rates. Data supporting thoracic endovascular aortic repair (TEVAR) to reduce mortality and morbidity for TTAI is limited to small series and meta-analyses. In this study, we evaluated the trends and outcomes of open surgery and TEVAR for TTAI in New York State. METHODS: All cases of TTAI in New York State between 2000 and 2007 were extracted from the New York Statewide Planning and Research Cooperative System (SPARCS) database. A diagnosis by International Classification of Diseases, 9th Revision coding of TTAI was required for inclusion. RESULTS: We identified 328 patients with TTAI who underwent surgical repair in New York State between 2000 and 2007; mean age of the cohort was 39.3 years +/- 18 years; 80% were male. Open repair of TTAI was performed in 79.6% and 20.4% underwent TEVAR. Open repair was performed for all cases of TTAI until the introduction of TEVAR in 2005; TEVAR exceeded the use of open repair for TTAI in 2006 and 2007. Additional major injuries were present in 71.7% in the open repair group vs 91.0% of the TEVAR group (P = .001). The overall in-hospital mortality rate for the 8-year period was significantly increased after open repair of TTAI compared with TEVAR: 17% vs 6%, (odds ratio [OR] 3.19, 95% confidence interval [CI], 1.11-9.23; P = .024). After controlling for the significant covariates, TEVAR independently reduced the risk of death following surgical intervention for TTAI compared with the open procedure (OR 3.8, 95% CI, 1.28-10.99; P = .010). Respiratory complications were the most common postoperative morbidity, and were significantly increased after open repair: 38% vs 24% (OR 1.95; 95% CI, 1.05-3.60; P = .032). There were no significant differences in cardiac complications, acute renal failure (ARF), paraplegia, or stroke. Endoleak and distal embolization each occurred in 9% of patients after TEVAR. CONCLUSIONS: There has been a shift toward endovascular management of patients with TTAI. This change in surgical strategy has been associated with less postoperative mortality and fewer pulmonary complications in patients suffering from TTAI. TEVAR is associated with significant device-related complications.

Subintimal angioplasty is superior to SilverHawk atherectomy for the treatment of occlusive lesions of the lower extremities.

PURPOSE: To evaluate the outcomes of atherectomy versus subintimal angioplasty (SIA) in patients with lower extremity arterial occlusive disease. METHODS: From September 2005 through July 2006, 27 patients (17 women; mean age 65 years, range 37-85) underwent atherectomy of 46 lesions (11 TASC C/D occlusions) with the SilverHawk device. Results were compared to 67 patients (34 men; mean age 69 years, range 46-92) undergoing SIA for 67 lower extremity arterial occlusions from July 1999 through June 2004. RESULTS: Technical success in the atherectomy cohort was 100%. In the 11 patients with occlusions, symptoms improved in 10 and worsened in 1, but 9 (82.0%) of the 11 patients required reintervention, and 8 (72.7%) patients with occlusive lesions re-occluded. Endovascular reintervention was required to maintain primary patency in only 2 (12.5%) of 16 patients treated for stenotic lesions. At 1 year, the assisted primary patency was 37.7% in the atherectomy group. In the 11 patients with occlusive lesions, the patency rates were 36.8% and 12.3% at 6 and 9 months, respectively, versus 100% and 83.3% at the same time intervals in patients with stenotic lesions. SIA was technically successful in 56 (83.6%) of 67 occlusions. The assisted primary patency and limb salvage rates of the entire group (intention-to-treat) at 12 and 24 months were 59.2% and 45.0%, respectively, while the assisted primary patency of the 56 technically successful SIAs at 12 and 24 months were 70.7% and 53.8%, respectively. Limb salvage for the entire group (intention-to-treat) was 90.6% and 87.9% at 12 and 24 months, respectively. CONCLUSION: Atherectomy may yield acceptable primary patency and limb salvage in patients with stenotic lesions. Many of the patients treated for occlusive lesions require reintervention. Based on patency and limb salvage, SIA appears superior to atherectomy for the treatment of lower extremity occlusive disease.

Outcomes of endovascular and open treatment for chronic mesenteric ischemia.

PURPOSE: To measure contemporary practice patterns and compare outcomes of open and endovascular repair for chronic mesenteric ischemia (CMI). METHODS: The New York State Health Department Statewide Planning and Research Cooperative System database was queried for the ICD-9-CM codes for CMI for the years 2000 to 2006. In this time period, 6549 patients were evaluated for CMI in New York State. Of these patients, 666 received an intervention and underwent either open (n = 280) or endovascular (n = 347) repair; 39 patients underwent both treatments and were excluded. Trends in operative management and short-term outcomes were analyzed. RESULTS: Over the 7-year study period, there was a steady increase in the number of endovascular procedures from 28% in 2000 to 75% in 2006. The overall mortality rate for the 7-year period was significantly lower for endovascular versus open repair (11.0% versus 20.4%, respectively; p = 0.0011). Endovascular repair was associated with a significantly lower rate of mesenteric ischemic complications compared to open repair (6.92% versus 17.1%, respectively; p<0.0001). Moreover, compared with open surgery, endovascular repair resulted in significantly lower rates of cardiac, pulmonary, and infectious complications (p<0.05). Only 37% of patients having open repair were discharged home compared to 55% of patients treated with endovascular procedures (p<0.0001). CONCLUSION: The number of patients treated for CMI continues to increase and correlates with the increasing utilization of endovascular procedures. The patients undergoing endovascular treatment had fewer complications, lower in-hospital mortality, and a greater likelihood of being discharged home.