Open surgical revision provides a more durable repair than endovascular treatment for unfavorable vein graft lesions.

OBJECTIVE: Lower extremity bypass grafts that develop stenoses are commonly treated with either open surgical or endovascular revision. Vein graft stenoses with unfavorable lesions (multiple lesions, lesions >2 cm in length, lesions in grafts <3 months old, lesions in grafts <3 mm in diameter) fare worse than those with favorable lesions when treated with endovascular therapy. However, it is not known if unfavorable lesions fare better with surgical revision than with endovascular treatment or than favorable lesions treated with surgery. METHODS: We performed a retrospective review of 175 vein graft revisions performed at a single institution from 2000 to 2010. Characteristics of lesions treated with surgical and endovascular revision were identified. Cox proportional hazard models were used to identify predictors of revision failure (restenosis >75%, revision, or amputation). RESULTS: Ninety-one failing vein grafts (52%) were treated with surgical revision and 84 with endovascular treatment (48%), with a median follow-up of 30 months. Favorable lesions fared better than unfavorable lesions after endovascular treatment, with 12-month freedom from failure of 59% vs 34% (P < .01), but not after surgical revision (66% vs 62%; P = .90). Unfavorable lesions had better freedom from failure after surgery than endovascular treatment (62% vs 34%; P < .01), and results in favorable lesions were similar (66% vs 59%; P = .57). CONCLUSIONS: For the treatment of failing vein grafts, endovascular therapy appears adequate for favorable lesions and surgical revision is more durable for unfavorable lesions.

National trends in utilization and outcome of thoracic endovascular aortic repair for traumatic thoracic aortic injuries.

BACKGROUND: Endovascular repair of traumatic thoracic aortic injuries (TTAI) is an alternative to conventional open surgical repair. Single-institution studies have shown a survival benefit with thoracic endovascular aortic repair (TEVAR), but whether this is being realized nationally is not clear. The purpose of our study was to document trends in the increase in use of TEVAR and its effect on outcomes of TTAI nationally. METHODS: Patients admitted with a TTAI between 2005 and 2011 were identified in the National Inpatient Sample. Patients were grouped by treatment into TEVAR, open repair, or nonoperative management. Primary outcomes were relative use over time and in-hospital mortality. Secondary outcomes included postoperative complications and length of stay. Multivariable logistic regression was performed to identify independent predictors of mortality. RESULTS: Included were 8384 patients, with 2492 (29.7%) undergoing TEVAR, 848 (10.1%) open repair, and 5044 (60.2%) managed nonoperatively. TEVAR became the dominant treatment option for TTAI during the study period, starting at 6.5% of interventions in 2005 and accounting for 86.5% of interventions in 2011 (P < .001). Nonoperative management declined concurrently with the widespread of adoption TEVAR (79.8% to 53.7%; P < .001). In-hospital mortality after TEVAR decreased during the study period from 33.3% in 2005 to 4.9% in 2011 (P < .001), and an increase in mortality was observed for open repair from 13.9% to 19.2% (P < .001). Procedural mortality (TEVAR or open repair) decreased from 14.9% to 6.7% (P < .001), and mortality after any TTAI admission declined from 24.5% to 13.3% during the study period (P < .001). In addition to lower mortality, TEVAR was followed by fewer cardiac complications (4.1% vs 8.5%; P < .001), respiratory complications (47.5% vs 54.8%; P < .001), and shorter length of stay (18.4 vs 20.2 days; P = .012) compared with open repair. In adjusted mortality analyses, open repair proved to be associated with twice the mortality risk compared with TEVAR (odds ratio, 2.1; 95% confidence interval, 1.6-2.7), and nonoperative management was associated with more than a fourfold increase in mortality (odds ratio, 4.5; 95% confidence interval, 3.8-5.3). CONCLUSIONS: TEVAR is now the dominant surgical approach in TTAI, with substantial perioperative morbidity and mortality benefits over open aortic repair. Overall mortality after admission for TTAI has declined, which is most likely the result of the replacement of open repair by TEVAR as well as the broadened eligibility for operative repair.

The effect of endovascular treatment on isolated iliac artery aneurysm treatment and mortality.

OBJECTIVE: Isolated iliac artery aneurysms are rare, but potentially fatal. The effect of recent trends in the use of endovascular iliac aneurysm repair (EVIR) on isolated iliac artery aneurysm-associated mortality is unknown. METHODS: We identified all patients with a primary diagnosis of iliac artery aneurysm in the National Inpatient Sample from 1988 to 2011. We examined trends in management (open vs EVIR, elective and urgent) and overall isolated iliac artery aneurysm-related deaths (with or without repair). We compared in-hospital mortality and complications for the subgroup of patients undergoing elective open and EVIR from 2000 to 2011. RESULTS: We identified 33,161 patients undergoing isolated iliac artery aneurysm repair from 1988 to 2011, of which there were 9016 EVIR and 4933 open elective repairs from 2000 to 2011. Total repairs increased after the introduction of EVIR, from 28 to 71 per 10 million United States (U.S.) population (P < .001). EVIR surpassed open repair in 2003. Total isolated iliac artery aneurysm-related deaths, due to rupture or elective repair, decreased after the introduction of EVIR from 4.4 to 2.3 per 10 million U.S. population (P < .001). However, urgent admissions did not decrease during this time period (15 to 15 procedures per 10 million U.S. population; P = .30). Among elective repairs after 2000, EVIR patients were older (72.4 vs 69.4 years; P = .002) and were more likely to have a history of prior myocardial infarction (14.0% vs 11.3%; P < .001) and renal failure (7.2% vs 3.6%; P < .001). Open repair had significantly higher rate of in-hospital mortality (1.8% vs 0.5%; P < .001) and complications (17.9% vs 6.7%; P < .001) and a longer length of stay (6.7 vs 2.3 days; P < .001). CONCLUSIONS: Treatment of isolated iliac artery aneurysms has increased since the introduction of EVIR and is associated with lower perioperative mortality, despite a higher burden of comorbid illness. Decreasing iliac artery aneurysm-attributable in-hospital deaths are likely related primarily to lower elective mortality with EVIR rather than rupture prevention.

Presentation, treatment, and outcome differences between men and women undergoing revascularization or amputation for lower extremity peripheral arterial disease.

OBJECTIVE: Prior studies have suggested treatment and outcome disparities between men and women for lower extremity peripheral arterial disease after surgical bypass. Given the recent shift toward endovascular therapy, which has increasingly been used to treat claudication, we sought to analyze sex disparities in presentation, revascularization, amputation, and inpatient mortality. METHODS: We identified individuals with intermittent claudication and critical limb ischemia (CLI) using International Classification of Diseases, Ninth Revision codes in the Nationwide Inpatient Sample from 1998 to 2009. We compared presentation at time of intervention (intermittent claudication vs CLI), procedure (open surgery vs percutaneous transluminal angioplasty or stenting vs major amputation), and in-hospital mortality for men and women. Regional and ambulatory trends were evaluated by performing a separate analysis of the State Inpatient and Ambulatory Surgery Databases from four geographically diverse states: California, Florida, Maryland, and New Jersey. RESULTS: From the Nationwide Inpatient Sample, we identified 1,797,885 patients (56% male) with intermittent claudication (26%) and CLI (74%), who underwent 1,865,999 procedures (41% open surgery, 20% percutaneous transluminal angioplasty or stenting, and 24% amputation). Women were older at the time of intervention by 3.5 years on average and more likely to present with CLI (75.9% vs 72.3%; odds ratio [OR], 1.21; 95% confidence interval [CI], 1.21-1.23; P < .01). Women were more likely to undergo endovascular procedures for both intermittent claudication (47% vs 41%; OR, 1.27; 95% CI, 1.25-1.28; P < .01) and CLI (21% vs 19%; OR, 1.14; 95% CI, 1.13-1.15; P < .01). From 1998 to 2009, major amputations declined from 18 to 11 per 100,000 in men and 16 to 7 per 100,000 in women, predating an increase in total CLI revascularization procedures that was seen starting in 2005 for both men and women. In-hospital mortality was higher in women regardless of disease severity or procedure performed even after adjusting for age and baseline comorbidities (.5% vs .2% after percutaneous transluminal angioplasty or stenting for intermittent claudication; 1.0% vs .7% after open surgery for intermittent claudication; 2.3% vs 1.6% after percutaneous transluminal angioplasty or stenting for CLI; 2.7% vs 2.2% after open surgery for CLI; P < .01 for all comparisons). CONCLUSIONS: There appears to be a preference to perform endovascular over surgical revascularization among women, who are older and have more advanced disease at presentation. Percutaneous transluminal angioplasty or stenting continues to be popular and is increasingly being performed in the outpatient setting. Amputation and in-hospital mortality rates have been declining, and women now have lower amputation but higher mortality rates than men. Recent improvements in outcomes are likely the result of a combination of improved medical management and risk factor reduction.

The impact of the present on admission indicator on the accuracy of administrative data for carotid endarterectomy and stenting.

BACKGROUND: Administrative data are often hampered by coding errors, absent data, and the difficulty of distinguishing pre-existing conditions from perioperative complications. We evaluated whether the introduction of the present on admission (POA) indicator improved outcome analysis of carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS) using administrative data. METHODS: State inpatient databases from California (2005-2008), New York (2008), and New Jersey (2008) were used to identify patients undergoing CAS and CEA. We first analyzed morbidity data without the POA indicator, using International Classification of Diseases, Ninth Revision complication codes (eg, 997.02, iatrogenic cerebrovascular infarction or hemorrhage, postoperative stroke) and diagnosis codes (eg, 433.11, occlusion and stenosis of the carotid artery with cerebral infarction). Then, we applied the POA indicator to both diagnosis and complication codes and calculated the proportion of events that were labeled POA. Symptom status and perioperative stroke rate were compared using these coding approaches. RESULTS: We identified 21,639 patients who underwent CEA and 3688 patients who underwent CAS. Without the POA indicator, the complication code for stroke indicated a postoperative stroke rate of 1.4% for CEA and 2.4% for CAS. After applying the POA indicator, 54% (CEA) and 62% (CAS) of these strokes were labeled POA. These POA strokes were either preoperative or intraoperative events. Proportion of symptomatic patients ranged from 7% to 16% for CEA and from 5% to 22% for CAS. Perioperative stroke rate was the lowest in the POA method (1.1% CEA, 1.8% CAS) compared with two other methods without POA information (1.4% and 9.5% CEA and 2.4% and 16.4% CAS). Kappa indicated a poor (0.2) to fair (0.7) agreement between these approaches. CONCLUSIONS: Administrative data has known limitations for assignment of symptom status and nonfatal perioperative outcomes. Given the uncertain timing of POA events as preoperative vs intraoperative and its apparent underestimation of the perioperative stroke rate, the use of administrative data even with the POA indicator for symptom status and non-fatal outcomes after CEA and CAS is hazardous.

Comparative effectiveness of endovascular versus open repair of ruptured abdominal aortic aneurysm in the Medicare population.

OBJECTIVE: Endovascular aortic repair (EVAR) for abdominal aortic aneurysm (AAA) is increasingly used for emergent treatment of ruptured AAA (rAAA). We sought to compare the perioperative and long-term mortality, procedure-related complications, and rates of reintervention of EVAR vs open aortic repair of rAAA in Medicare beneficiaries. METHODS: We examined perioperative and long-term mortality and complications after EVAR or open aortic repair performed for rAAA in all traditional Medicare beneficiaries discharged from a United States hospital from 2001 to 2008. Patients were matched by propensity score on baseline demographics, coexisting conditions, admission source, and hospital volume of rAAA repair. Sensitivity analyses were performed to evaluate the effect of bias that might have resulted from unmeasured confounders. RESULTS: Of 10,998 patients with repaired rAAA, 1126 underwent EVAR and 9872 underwent open repair. Propensity score matching yielded 1099 patient pairs. The average age was 78 years, and 72.4% were male. Perioperative mortality was 33.8% for EVAR and 47.7% for open repair (P < .001), and this difference persisted for >4 years. At 36 months, EVAR patients had higher rates of AAA-related reinterventions than open repair patients (endovascular reintervention, 10.9% vs 1.5%; P < .001), whereas open patients had more laparotomy-related complications (incisional hernia repair, 1.8% vs 6.2%; P < .001; all surgical complications, 4.4% vs 9.1%; P < .001). Use of EVAR for rAAA increased from 6% of cases in 2001 to 31% in 2008, whereas during the same interval, overall 30-day mortality for admission for rAAA, regardless of treatment, decreased from 55.8% to 50.9%. CONCLUSIONS: EVAR for rAAA is associated with lower perioperative and long-term mortality in Medicare beneficiaries. Increasing adoption of EVAR for rAAA is associated with an overall decrease in mortality of patients hospitalized for rAAA during the last decade.

The rise and fall of renal artery angioplasty and stenting in the United States, 1988-2009.

OBJECTIVE: Optimal management of renal artery stenosis (RAS) remains unclear. Recent randomized controlled trials have shown no clear benefit with percutaneous transluminal angioplasty with or without stenting (PTRA/S) over medical management. We hypothesize that interventions for RAS are decreasing nationally. METHODS: The Nationwide Inpatient Sample, 1988-2009, was used to identify patients with a diagnosis of renal artery atherosclerosis undergoing open surgical repair (bypass or endarterectomy) or PTRA/S. The rate of interventions, in-hospital death, and perioperative outcomes were analyzed over time. Additionally, we used individual state inpatient and ambulatory databases to better understand the influence of outpatient procedures on current volume and trends. RESULTS: We identified 308,549 PTRA/S and 33,147 open surgical repairs. PTRA/S increased from 1.9/100K adults in 1988 to 13.7 in 2006 followed by a decrease to 6.7 in 2009. Open surgical repair steadily decreased from 1.3/100K adults in 1988 to 0.3 in 2009. In 2009, PTRA/S procedures (6.4/100K adults) greatly outnumbered procedures done by open repair alone (0.1/100K), combined open renal and aortic repair (0.2/100K), and combined PTRA/S and endovascular aneurysm repair (0.3/100K). From 2005 to 2009 33,953 patients underwent PTRA/S in the states of New Jersey Maryland, Florida, and California combined. The total number of PTRA/S performed in the outpatient setting remained stable from 2005 (3.8/100K) to 2009 (3.7/100K), whereas the total number of inpatient procedures mirrored the national trend, declining from 2006 (7.9/100K) to 2009 (4.2/100K). PTRA/S had lower in-hospital mortality (0.9% vs 4.1%; P < .001) compared with open repair. PTRA/S patients were more likely to be discharged home (86.2% vs 76.3%; P < .001) and had a shorter length of stay (4.4 vs 12.3 days; P < .001). Mortality was higher after combined open renal and open aortic surgery compared to open repair alone (6.5% vs 4.1%; P < .001). Mortality was similar for combined PTRA/S and endovascular aneurysm repair compared with PTRA/S alone (1.2% vs 0.9%; P = .04). CONCLUSIONS: The performance of PTRA/S procedures for the management of RAS has decreased significantly after 2006. An increasing proportion of these procedures are performed in the outpatient setting. PTRA/S remains the dominant revascularization procedure for RAS with lower in-hospital mortality and morbidity than surgery.

In-hospital versus postdischarge adverse events following carotid endarterectomy.

OBJECTIVE: Most studies based on state and nationwide registries evaluating perioperative outcome after carotid endarterectomy (CEA) rely on hospital discharge data only. Therefore, the true 30-day complication risk after carotid revascularization may be underestimated. METHODS: We used the National Surgical Quality Improvement Program database 2005-2010 to assess the in-hospital and postdischarge rate of any stroke, death, cardiac event (new Q-wave myocardial infarction or cardiac arrest), and combined stroke/death and combined adverse outcome (S/D/CE) at 30 days following CEA. Multivariable analyses were used to identify predictors for in-hospital and postdischarge events separately, and in particular, those that predict postdischarge events distinctly. RESULTS: A total of 35,916 patients who underwent CEA during 2005-2010 were identified in the National Surgical Quality Improvement Program database; 59% were male, median age was 72 years, and 44% had a previous neurologic event. Thirty-day stroke rate was 1.6% (n = 591), death rate was 0.8% (n = 272), cardiac event rate was 1.0% (n = 350), stroke or death rate was 2.2% (n = 794), and combined S/D/CE rate was 2.9% (n = 1043); 33% of strokes, 53% of deaths, 32% of cardiac events, 40% of combined stroke/death, and 38% of combined S/D/CE took place after hospital discharge. Patients with a prior stroke or transient ischemic attack had similar proportions of postdischarge events compared with patients without prior symptoms. Independent predictors for postdischarge events, but not for in-hospital events were female sex (stroke [odds ratio (OR), 1.6; 95% confidence interval (CI), 1.2-2.1] and stroke/death [OR, 1.4; 95% CI, 1.1-1.7]), renal failure (stroke [OR, 3.0; 95% CI, 1.4-6.2]) and chronic obstructive pulmonary disease (death [OR, 2.5; 95% CI, 1.6-3.7], stroke/death [OR, 1.8; 95% CI, 1.4-2.4], and S/D/CE [OR 1.8, 95% CI 1.4-2.3]). CONCLUSIONS: With 38% of perioperative adverse events after CEA happening posthospitalization, regardless of symptoms status, we need to be alert to the ongoing risks after discharge particularly in women, patients with renal failure, or chronic obstructive pulmonary disease. This emphasizes the need for reporting and comparing 30-day adverse event rates when evaluating outcomes for CEA, or comparing carotid stenting to CEA.

Outcomes following infrapopliteal angioplasty for critical limb ischemia.

OBJECTIVE: Infrapopliteal angioplasty (percutaneous transluminal angioplasty [PTA]) is routinely used to treat critical limb ischemia (CLI) despite limited data on long-term outcomes. METHODS: We reviewed all patients undergoing infrapopliteal PTA for CLI from 2004 to 2012 stratified by TransAtlantic Inter-Society Consensus (TASC) class. Outcomes included restenosis, primary patency, reintervention (w/PTA or bypass), amputation, procedural complications, wound healing, and survival. RESULTS: Infrapopliteal PTA (stenting 14%, multilevel intervention 50%) was performed in 459 limbs of 413 patients (59% male) with a technical success of 93% and perioperative complications in 11%. TASC class was 16% A, 22% B, 27% C, and 34% D. Multilevel interventions were performed in 50% of limbs and were evenly distributed among all TASC classes. All technical failures were TASC D lesions. Mean follow-up was 15 months; 5-year survival was 49%. One- and 5-year primary patency was 57% and 38% and limb salvage was 84% and 81%, respectively. Restenosis was associated with TASC C (hazard ratio [HR], 2.2; 95% CI, 1.2-3.9; P = .010) and TASC D (HR, 2.4; 95% CI, 1.3-4.4; P = .004) lesions. Amputation rates were higher in patients who were not candidates for bypass (HR, 4.4; 95% CI, 2.6-7.5; P < .001) and with TASC D lesions (HR, 3.8; 95% CI, 1.1-12.5; P = .03). Unsuitability for bypass was also predictive of repeat PTA (HR, 1.8; 95% CI, 1.0-3.4; P = .047). Postoperative clopidogrel use was associated with lower rates of any revascularization (HR, 0.46; 95% CI, 0.25-0.83; P = .011). CONCLUSIONS: Infrapopliteal PTA is effective primary therapy for TASC A, B, and C lesions. Surgical bypass should be offered to patients with TASC D disease who are suitable candidates. Multilevel intervention does not adversely affect outcome.

Gender differences in abdominal aortic aneurysm presentation, repair, and mortality in the Vascular Study Group of New England.

OBJECTIVE: Prior studies of gender differences in abdominal aortic aneurysm (AAA) repair suggest there may be differences in presentation, suitability for endovascular aneurysm repair (EVAR), and outcomes between men and women. METHODS: We used the Vascular Study Group of New England database to identify all patients undergoing EVAR or open AAA repair. We analyzed demographics, comorbidities, and procedural, and perioperative data. Results were compared using the Fisher exact test and the Student t-test. Multivariable logistic regression and Cox proportional hazards modeling were performed to identify predictors of mortality. RESULTS: We identified 4026 patients (78% men) who underwent AAA repair (54% EVAR). Women were less likely than men to undergo EVAR for intact aneurysms (50% vs 60% of intact AAA repair; P < .001) but not for ruptured aneurysms (26% vs 20%; P = .23). Women were older (median age, 75 vs 72 years for intact; P < .001; 78 vs 73 years for rupture; P < .001) with smaller aortic diameters (57 vs 59 mm for elective; P < .001; 71 vs 79 mm for rupture; P < .001). Arterial injury was more common in women (5.4% vs 2.7%; P = .013) among patients undergoing EVAR for intact aneurysms. Women stayed in the hospital longer (4.3 vs 2.7 days; P = .018) and had lower odds of being discharged home, even after adjusting for age. Among patients undergoing open repair for intact aneurysms, women more frequently experienced leg ischemia/emboli (4% vs 1%; P = .001) and bowel ischemia (5% vs 3%; P = .044). Women had higher 30-day mortality after OAR for intact (4% vs 2%; P = .03) and rupture (48% vs 34%; P = .03) repairs. However, 30-day mortality after EVAR was similar for intact (1% in men vs 1% in women; P = .57) and rupture (29% in men vs 27% in women; P > .99) repairs. Late survival was worse in women than men only for patients undergoing open repair of ruptured aneurysms (hazard ratio, 1.8; 95% confidence interval, 1.0-3.1; P = .04). After controlling for age, type of repair, urgency at presentation (ie, elective/intact vs ruptured), comorbidities, and other relevant risk factors, gender was not predictive of 30-day or 1-year mortality. CONCLUSIONS: Women with AAAs are being treated at older ages and smaller AAA diameters and are undergoing rupture repair at smaller diameters than men. Women are more likely to experience perioperative complications as a result of less favorable vascular anatomy. Age >80 years, comorbidity, presentation, and type of repair are more important predictors of mortality than gender.

Accuracy of administrative data versus clinical data to evaluate carotid endarterectomy and carotid stenting.

OBJECTIVE: Administrative data have been used to compare carotid endarterectomy (CEA) and carotid artery stenting (CAS). However, there are limitations in defining symptom status, Centers for Medicare and Medicaid Services high-risk status, as well as complications. Therefore, we did a direct comparison between administrative data and physician chart review as well as between data collected for the National Surgical Quality Improvement Program (NSQIP) and physician chart review for CEA and CAS. METHODS: We performed an outcomes analysis on all CEA and CAS procedures from 2005 to 2011. We obtained International Classification of Diseases, Ninth Revision diagnosis codes from hospital discharge records regarding symptom status, high-risk status, and perioperative stroke. We also obtained data on all CEA patients submitted to NSQIP over the same time period. One of the study authors (R.B.) then performed a chart review of the same patients to determine symptom status, high-risk status, and perioperative strokes and the results were compared. RESULTS: We identified 1342 patients who underwent CEA or CAS between 2005 and 2011 and 392 patients who underwent CEA that were submitted to NSQIP. Administrative data identified fewer symptomatic patients (17.0% vs 34.0%), physiologic high-risk patients (9.3% vs 23.0%), and anatomic high-risk patients (0% vs 15.2%). Although administrative data identified a similar proportion of perioperative strokes (1.9% vs 2.0%), this was due to the fact that these data identified eight false positive and nine false negative perioperative strokes. NSQIP data identified more symptomatic patients compared with chart review (44.1% vs 30.3%), fewer physiologic high-risk patients (13.0% vs 18.6%), fewer anatomic high-risk patients (0% vs 6.6%), and a similar proportion of perioperative strokes (1.5% vs 1.8%, only one false negative stroke and no false positives). CONCLUSIONS: Administrative data are unreliable for determining symptom status, high-risk status, and perioperative stroke and should not be used to analyze CEA and CAS. NSQIP data do not adequately identify high-risk patients, but do accurately identify perioperative strokes and to a lesser degree, symptom status.

Fate of the contralateral limb after lower extremity amputation.

OBJECTIVE: Lower extremity amputation is often performed in patients where both lower extremities are at risk due to peripheral arterial disease or diabetes, yet the proportion of patients who progress to amputation of their contralateral limb is not well defined. We sought to determine the rate of subsequent amputation on both the ipsilateral and contralateral lower extremities following initial amputation. METHODS: We conducted a retrospective review of all patients undergoing lower extremity amputation (exclusive of trauma or tumor) at our institution from 1998 to 2010. We used International Classification of Diseases-Ninth Revision codes to identify patients and procedures as well as comorbidities. Outcomes included the proportion of patients at 1 and 5 years undergoing contralateral and ipsilateral major and minor amputation stratified by initial major vs minor amputation. Cox proportional hazards regression analysis was performed to determine predictors of major contralateral amputation. RESULTS: We identified 1715 patients. Mean age was 67.2 years, 63% were male, 77% were diabetic, and 34% underwent an initial major amputation. After major amputation, 5.7% and 11.5% have a contralateral major amputation at 1 and 5 years, respectively. After minor amputation, 3.2% and 8.4% have a contralateral major amputation at 1 and 5 years while 10.5% and 14.2% have an ipsilateral major amputation at 1 and 5 years, respectively. Cox proportional hazards regression analysis revealed end-stage renal disease (hazard ratio [HR], 3.9; 95% confidence interval [CI], 2.3-6.5), chronic renal insufficiency (HR, 2.2; 95% CI, 1.5-3.3), atherosclerosis without diabetic neuropathy (HR, 2.9; 95% CI, 1.5-5.7), atherosclerosis with diabetic neuropathy (HR, 9.1; 95% CI, 3.7-22.5), and initial major amputation (HR, 1.8; 95% CI, 1.3-2.6) were independently predictive of subsequent contralateral major amputation. CONCLUSIONS: Rates of contralateral limb amputation are high and predicted by renal disease, atherosclerosis, and atherosclerosis with diabetic neuropathy. Physicians and patients should be alert to the high risk of subsequent amputation in the contralateral leg. All patients, but particularly those at increased risk, should undergo close surveillance and counseling to help prevent subsequent amputations in their contralateral lower extremity.

Open repair of intact thoracoabdominal aortic aneurysms in the American College of Surgeons National Surgical Quality Improvement Program.

OBJECTIVE: Open surgical repair of thoracoabdominal aortic aneurysms (TAAAs) is uncommon. Mortality rates of 20% are reported in studies using national data and are 5% to 8% in single-institution studies. Clinical trials are currently evaluating branched and fenestrated endografts. The purpose of this study is to establish a benchmark for future comparisons with endovascular trials using open repair of TAAAs in the National Surgical Quality Improvement Program (NSQIP) database. METHODS: We identified all patients undergoing open elective and emergency surgical repair of intact TAAAs in NSQIP (2005 to 2010) using Current Procedural Terminology (American Medical Association, Chicago, Ill) and International Classification of Diseases, 9th Edition codes. We analyzed demographics, comorbidities, 30-day mortality, postoperative complications, and length of stay. Multivariable logistic regression was used to identify predictors of mortality. RESULTS: We identified 450 patients who underwent open surgical repair (418 elective, 32 emergent) of an intact TAAA. Mean age was 69.4 years, 60.7% were male, and 85.6% were white. Comorbidities included hypertension (87.1%), chronic obstructive pulmonary disease (27.3%), prior stroke or transient ischemic attack (16.7%), diabetes (11.6%), and peripheral vascular disease (9.6%). Thirty-day mortality was 10.0%. Pulmonary complications were the most common: failure to wean from ventilator (39.1%), pneumonia (23.1%), and reintubation (13.8%). Acute renal failure requiring dialysis occurred in 10.7% of patients. Multivariable analysis (odds ratio [95% confidence interval]) showed predictors of mortality were emergent repair (3.3 [1.03-10.83]; P = .04), age >70 years (3.5 [1.03-7.56], P = .001), preoperative dialysis (8.4 [1.90-37.29], P = .005), cardiac complication (2.9 [1.05-8.21], P = .04), and renal complications (8.4 [3.41-20.56], P < .001). CONCLUSIONS: In this study of NSQIP hospitals, the first to analyze open surgical repair of TAAAs, the 30-day mortality rate of 10.0% is similar to single-institution reports. However, morbidity and mortality after open TAAA repair remain high, confirming the need for less invasive procedures.

The current national criteria for carotid artery stenting overestimate its efficacy in patients who are symptomatic and at high risk.

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) have established guidelines that outline patients who are considered "high risk" for complications after carotid endarterectomy (CEA) for which carotid artery stenting (CAS) may provide benefit. The validity of these high-risk criteria are yet unproven. In this study, we stratified patients who underwent CAS or CEA by CMS high-risk criteria and symptom status and examined their 30-day outcomes. METHODS: A nonrandomized, retrospective cohort study was performed by chart review of all patients undergoing CEA or CAS from January 1, 2005, to December 31, 2010, at our institution. Demographic data and data pertaining to the presence or absence of high-risk factors were collected. Patients were stratified using symptom status and high-risk status as variables, and 30-day adverse events (stroke, death, myocardial infarction [MI]) were compared. RESULTS: A total of 271 patients underwent CAS, with 30-day complication rates of stroke (3.0%), death (1.1%), MI (1.5%), stroke/death (3.7%), and stroke/death/MI (5.2%). A total of 830 patients underwent CEA with 30-day complication rates of stroke (2.0%), death (0.1%), MI (0.6%), stroke/death (1.9%), and stroke/death/MI (2.7%). Among symptomatic patients, physiologic high-risk status was associated with increased stroke/death (6 of 42 [14.3%] vs 2 of 74 [2.7%]; P < .01), and anatomic high-risk status was associated with a trend toward increased stroke/death (5 of 31 [16.1%] vs 0 of 20 [0.0%]; P = .14) in patients who underwent CAS vs CEA. Analysis of asymptomatic patients showed no differences between the two groups overall, except for a trend toward a higher rate of MI after CAS than after CEA (3 of 71 [4.2%] vs 0 of 108 [0.0%]; P = .06) in those who were physiologically at high risk. Among symptomatic patients who underwent CAS, patients with physiologic and anatomic high-risk factors had a higher rate of stroke/death than non-high-risk patients (6 of 42 [14.3%] vs 0 of 24 [0.0%] and 5 of 31 [16.1%] vs 0 of 24 [0.0%], respectively; both P ≤ .05). CONCLUSIONS: Physiologic high-risk status was associated with increased stroke/death, whereas anatomic high-risk status showed a trend toward increased stroke/death in symptomatic patients undergoing CAS compared with non-high-risk patients undergoing CAS or physiologically high-risk patients undergoing CEA. Our results suggest that the current national criteria for CAS overestimate its efficacy in patients who are symptomatic and at high risk.

Changes in abdominal aortic aneurysm rupture and short-term mortality, 1995-2008: a retrospective observational study.

OBJECTIVE: To examine the modern epidemiology of abdominal aortic aneurysm (AAA) rupture and short-term AAA-related mortality after the introduction of endovascular aneurysm repair (EVAR). BACKGROUND: Previous epidemiologic studies have demonstrated stable rates of AAA repair, repair mortality, and AAA rupture. Recently, EVAR has been introduced as a less invasive treatment method, and its use has expanded to more than 75% of elective AAA repairs. METHODS: We identified Medicare beneficiaries undergoing AAA repair and those hospitalized with a ruptured AAA during the period 1995 to 2008 and calculated standardized annual rates of AAA-related deaths due to either elective repair or rupture. RESULTS: A total of 338,278 patients underwent intact AAA repair during the study period. There were 69,653 patients with AAA rupture, of whom 47,524 underwent repair. Intact repair rates increased substantially in those older than 80 years (57.7-92.3 per 100,000, P < 0.001) but decreased in those 65 to 74 years old (81.8-68.9, P < 0.001). A decline in ruptures with and without repair was seen in all age groups. By 2008, 77% of all intact repairs and 31% of all rupture repairs were performed with EVAR (P < 0.001). Operative mortality declined during the study period for both intact (4.9%-2.4%, P < 0.001) and ruptured (44.1%-36.3%, P < 0.001) AAA repair. Short-term AAA-related deaths decreased by more than half (26.1-12.1 per 100,000, P < 0.001), with the greatest decline occurring in those older than 80 years (53.7-27.3, P < 0.001). CONCLUSIONS: A recent decline in AAA rupture and short-term AAA-related mortality is demonstrated and likely related in part to the introduction and expansion of EVAR. This is due to decreased deaths from ruptures (with and without repair) and decreased mortality with intact repairs, particularly in patients older than 80 years.

Ultrasound-guided percutaneous endovascular aneurysm repair success is predicted by access vessel diameter.

OBJECTIVE: Ultrasound scan-guided access allows for direct visualization of the access artery during percutaneous endovascular aortic aneurysm repair. We hypothesized that the use of ultrasound scan guidance allowed us to safely increase the utilization of percutaneous endovascular aortic aneurysm repair to almost all patients and decrease access complications. METHODS: A retrospective chart review of all elective endovascular aortic aneurysm repairs, both abdominal and descending thoracic, from 2005 to 2010 was performed. Patients were identified using International Classification of Disease, 9th Revision, Clinical Modification Codes and stratified based on access type: percutaneous vs cut-down. We examined the success rate of percutaneous access and the cause of failure. Sheath size was large (18-24 F) or small (12-16 F). Minimum access vessel diameter was also measured. Outcomes were wound complications (infections or clinically significant hematomas that delayed discharge or required transfusion), operative and incision time, length of stay, and discharge disposition. Predictors of percutaneous failure were identified. RESULTS: One hundred sixty-eight patients (296 arteries) had percutaneous access endovascular aneurysm repair (P-EVAR) whereas 131 patients (226 arteries) had femoral cutdown access EVAR. Ultrasound scan-guided access was introduced in 2007. P-EVAR increased from zero cases in 2005 to 92.3% of all elective cases in 2010. The success rate with percutaneous access was 96%. Failures requiring open surgical repair of the artery included seven for hemorrhage and six for flow-limiting stenosis or occlusion of the femoral artery. P-EVAR had fewer wound complications (0.7% vs 7.4%; P = .001), shorter operative time (153.3 vs 201.5 minutes; P < .001), and larger minimal access vessel diameter (6.7 mm vs 6.1 mm; P < .01). Patients with failed percutaneous access had smaller minimal access vessel diameters when compared to successful P-EVAR (4.9 mm vs 6.8 mm; P < .001). More failures occurred in small sheaths than large ones (7.4% vs 1.9%; P = .02). Access vessel diameter <5 mm is predictive of percutaneous failure (16.7% of vessels <5 mm failed vs 2.4% of vessels ≥ 5 mm failed; P < .001; odds ratio, 7.3; 95% confidence interval, 1.58-33.8; P = .01). CONCLUSIONS: Ultrasound scan-guided P-EVAR can be performed in the vast majority of patients with a high success rate, shorter operative times, and fewer wound complications. Access vessel diameters <5 mm are at greater risk for percutaneous failure and should be treated selectively.

Novel use of a Sengstaken-Blakemore tube during a neck exploration of a carotid injury: A case report.

Penetrating neck trauma can injure the major blood vessels, airway, gastrointestinal system, and neurological system. We present a case where a Sengstaken-Blakemore tube was emergently placed during surgical exploration of a stab wound to the neck to tamponade bleeding until surgical control was obtained and the vascular injuries were managed.

Using the Vascular Quality Initiative to improve quality of care and patient outcomes for vascular surgery patients.

The Society for Vascular Surgery Vascular Quality Initiative (VQI) is a collaborative network of vascular specialists from various specialties that seeks to improve the quality and safety of vascular care by sharing data among physicians, medical centers, and regions. Working under a Patient Safety Organization designation by the Agency for Healthcare Research and Quality, the VQI provides a protected environment where data can be pooled and evaluated for trends that might provide opportunities to improve the care we provide our patients. Since its inception in 2011, this national organization has grown rapidly and now involves >300 medical centers that are separated into 18 active regional groups who meet twice yearly to discuss quality improvement. The structure of the VQI provides a powerful platform for data collection and analysis, and has allowed the development of a large body of literature that demonstrates the importance and benefits of participation. Here we provide a brief overview of the VQI to date.

Risk of late-onset adhesions and incisional hernia repairs after surgery.

BACKGROUND: Long-term adhesion-related complications and incisional hernias after abdominal surgery are common and costly. There are few data on the risk of these complications after different abdominal operations. STUDY DESIGN: We identified Medicare beneficiaries who underwent endovascular repair of an abdominal aortic aneurysm from 2001-2008 who presumably are not at risk for laparotomy-related complications. We identified all laparoscopic and open operations involving the abdomen, pelvis, or retroperitoneum and categorized them into 5 groups according to invasiveness. We then identified laparotomy-related complications for up to 5 years after the index operation and compared these with the baseline rate of complications in a control group of patients who did not undergo an abdominal operation. RESULTS: We studied 85,663 patients, 7,513 (8.8%) of which underwent a laparotomy, including 2,783 major abdominal operations, 709 minor abdominal operations, 963 ventral hernia repairs, 493 retroperitoneal/pelvic operations, and 2,565 laparoscopic operations. Mean age was 76.7 years and 82.0% were male. Major abdominal operations carried the highest risk for adhesion-related complications (14.3% and 25.0% at 2 and 5 years compared with 4.0% and 7.8% for the control group; p < 0.001) and incisional hernias (7.8% and 12.0% compared with 0.6% and 1.2% for the control group; p < 0.001). Laparoscopic operations (4.6% and 10.7% for adhesions, 1.9% and 3.2% for incisional hernias) carried the lowest risk. CONCLUSIONS: Late-onset laparotomy-related complications are frequent and their risk extends through 5 years beyond the perioperative period. With the advancement and expansion of laparoscopic techniques and its attendant lower risk for long-term complications, these results can alter the risk-to-benefit profile of various types of abdominal operations and can also strengthen the rationale for additional development of laparoscopic approaches to abdominal operations.

Defining perioperative mortality after open and endovascular aortic aneurysm repair in the US Medicare population.

BACKGROUND: Perioperative mortality is reported after abdominal aortic aneurysm (AAA) repair, but there is no agreed upon standard definition. Often, 30-day mortality is reported because in-hospital mortality may be biased in favor of endovascular repair given the shorter length of stay. However, the duration of increased risk of death after aneurysm repair is unknown. STUDY DESIGN: We used propensity score modeling to create matched cohorts of US Medicare beneficiaries undergoing endovascular (n = 22,830) and open (n = 22,830) AAA repair from 2001 to 2004. We calculated perioperative mortality using several definitions including in-hospital, 30-day, and combined 30-day and in-hospital mortality. We determined the relative risk (RR) of death after open compared with endovascular repair as well as the absolute mortality difference. To define the duration of increased risk we calculated biweekly interval death rates for 12 months. RESULTS: In-hospital, 30-day, and combined 30-day and in-hospital mortality for open and endovascular repair were 4.6% versus 1.1%, 4.8% versus 1.6%, and 5.3% versus 1.7%, respectively. The absolute differences in mortality were similar, at 3.5%, 3.2%, and 3.7%. The RRs of death (95% confidence interval) were 4.2 (3.6 to 4.8), 3.1 (2.7 to 3.4), and 3.2 (2.8 to 3.5). Biweekly interval death rates were highest during the first month after endovascular repair (0.6%) and during the first 2.5 months (0.5% to 2.1%) after open repair. After 2.5 months, rates were similar for both repairs (<0.5%) and stabilized after 3 months. The 90-day mortality rates for open and endovascular repair were 7.0% and 3.2%, respectively. CONCLUSIONS: In-hospital mortality comparisons overestimate the benefit of endovascular repair compared with 30-day or combined 30-day and in-hospital mortality. The total mortality impact of AAA repair is not realized until 3 months after repair and the duration of highest mortality risk extends longer for open repair.