Use of Glycoprotein IIb-IIIa Inhibitors in Patients Undergoing Carotid Artery Stenting in the Vascular Quality Initiative.

BACKGROUND: Antiplatelet therapies with thromboxane inhibitors and adenosine 5'-diphosphate antagonists have been widely used following carotid artery stenting (CAS). However, these therapies may not apply to patients who are intolerant or present acutely. Glycoprotein IIb/IIIa inhibitors (GPI) are a proposed alternative therapy in these patients; however, their use has been limited due to concerns of increased risk for intracranial bleeding. Thus, this study aims to assess the safety profile of GPI in patients undergoing CAS. METHODS: All patients undergoing CAS in the Society of Vascular Surgery - Vascular Quality Initiative database from 2012 to 2021 was included and grouped into GPI versus non-GPI therapy (control). The primary outcome was in-hospital stroke or death, and secondary outcomes included in-hospital stroke/transient ischemic attack (TIA), death, myocardial infarction, and intracranial hemorrhage (ICH)/seizure. Patients were stratified by surgical approach (Transcarotid artery revascularization using flow reversal (TCAR) and transfemoral carotid artery stenting), and stepwise backward logistic regression analysis was conducted to evaluate major primary and secondary outcomes. RESULTS: A total of 50,628 patients underwent carotid revascularization. Of these, 4.4% of the patients received GPI. Mean age was similar between control versus GPI (71.35(9.67) vs. 71.36(10.20) years). Compared to the control group, patients who receive GPI are less likely to be on optimal medical therapy, including aspirin (83.0% vs. 88.1%), P2Y12 inhibitor (73.0% vs. 82.7%), and statin (82.3% vs. 86.0%) (All P < 0.05). In addition, patients in the GPI group were more likely to undergo TCAR for carotid revascularization (52.2% vs. 48.4%) for emergent/urgent (29.4% vs. 16.8%) and symptomatic indications (55.5% vs. 49.7%) (All P < 0.001). After stratifying by surgical approach, if patients underwent TFCAS and received a GPI, they were at increased odds of developing stroke/death (1.77(1.25-2.51)), death (odds ratio (OR) (95% CI): 1.67(1.07-2.61)), stroke/TIA (OR (95% confidence interval (CI)): 1.65(1.09-2.51)), and ICH/seizure (OR (95% CI): 2.13(1.23-3.68)) (All P < 0.05). No difference was seen in outcomes between the 2 groups if undergoing TCAR. CONCLUSIONS: Patients who receive GPI were more likely to be symptomatic at presentation and less likely to be medically optimized before their carotid revascularization. Transfemoral access in patients receiving GPI was associated with increased odds of morbidity and mortality. However, this was not observed if undergoing TCAR. TCAR can be considered for its overall favorable results in high-risk patients who are not medically optimized.

Gender Differences in Aortic Anatomic Severity Grade and Long-Term Survival Following Elective Abdominal Aortic Aneurysm Repair at a Single Tertiary Center.

BACKGROUND: Anatomic severity grade (ASG) score is utilized to assess preoperative abdominal aortic aneurysms (AAA) and provide a quantitative data on its anatomic complexity. The aim of this study is to determine the anatomical differences and long-term survival between male and female patients undergoing elective AAA repair. METHODS: All patients undergoing intact AAA repair from 2007 to 2014 were included. ASG scores were calculated based on preoperative anatomical characteristics including aortic neck, aneurysm, and iliac artery. Standard univariate analysis was used to evaluate patient and anatomical characteristics. Kaplan-Meier survival curves were used to evaluate long-term survival at 1 and 5 years. RESULTS: A total of 379 patients were identified, of which, majority of them were males (80%). Females were on average 3 years older (mean [SD]: 74.32 [8.63] vs. 71.92 [8.64] years) and were more likely to undergo open repair (29.7% vs. 17.5%) (both P < 0.05). Both groups had similar comorbidities. The mean long-term follow-up (S.D.) was 6.21 (3.81) years. No significant difference was seen between males versus females in long-term survival at both 1 year (86.3% vs. 92.8, P = 0.06) and 5 year (68.5% vs. 72.7%, P = 0.38). In regard to the anatomical characteristics, females had shorter aortic neck length (mean in mm [S.D.]: 17.67 [1.41] vs. 27.20 [15.76]), increased tortuosity index [mean (S.D.): 1.11 (0.07) vs. 1.09 (0.07)]) and higher calcification [mean % (S.D.): 17.12 (21.17) vs. 10.59 (16.82)] (All P < 0.05). In contrast, males had larger aortic neck (mean in mm (S.D.): 23.81 (4.17) vs. 22.41 (4.16)] and iliac artery [mean in mm (S.D.): 7.70 (1.91) vs. 6.28 (1.67)] diameter (both P < 0.05). The mean total ASG score was significantly higher among females versus males [mean (S.D.): 17.23 (4.01) vs. 15.67 (3.96), P = 0.003]. After stratifying by ASG score ≥15, females had significantly lower survival at 1 year compared to males (82.6% vs. 92.1%, P = 0.04). However, this difference disappeared at 5 years. CONCLUSIONS: The data demonstrate that females present at an older age with more complex AAA anatomy than males. Based on anatomical complexities, females were more likely to undergo open repair, with a corresponding increase in 1-year mortality, but not at 5 year. The data suggest that care processes for optimization of aortic surgery in females are needed to improve 1-year survival.

Low-volume hospitals are not associated with inferior outcomes after thoracic endovascular aortic repair.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) has been increasingly used to treat complex thoracic aortic pathology. In the present study, we assessed the hospital volume's effects on the outcomes of patients who had undergone TEVAR. METHODS: Patients who had undergone TEVAR from January 2015 to December 2019 were identified from the Vascular Quality Initiative database. The participating centers were stratified by volume as low-volume hospitals (LVHs) and high-volume hospitals (HVHs). We assessed the effects of hospital volume on 30-day mortality and major postoperative complications using multivariable logistic regression analysis. RESULTS: A total of 3584 TEVAR patients (1720 asymptomatic and 1864 symptomatic or ruptured) were identified at 147 centers. The median average annual number of TEVAR cases at the LVHs and HVHs was 6 and 17 cases, respectively. No significant differences were found in 30-day mortality between the LVHs and HVHs (asymptomatic, 3.7% vs 3.7% [P = .98]; symptomatic or ruptured, 9.3% vs 7.3% [P = .13]). After adjusting for multiple clinical and anatomic factors, treatment at a LVH was not associated with increased 30-day mortality (asymptomatic: odds ratio, 0.98; 95% confidence interval, 0.52-1.87; P = .96; symptomatic or ruptured: odds ratio, 1.15; 95% confidence interval, 0.75-1.77; P = .53) nor an increased risk of major complications, including renal, neurologic, cardiac, pulmonary, and femoral artery access complications (P > .05 for all). CONCLUSIONS: Using a large national database, we have demonstrated that treatment at LVHs is not associated with inferior TEVAR outcomes compared with HVHs. The technical aspect of the procedure might play a role in the similarity of outcomes across the different institutional experiences.

Effect of routine intracerebral completion angiography on outcomes after transcarotid artery revascularization.

OBJECTIVE: Completion cerebral angiography (CCA) after transcarotid artery revascularization (TCAR) has been used to identify distal embolization after stenting and serve as a measure of intraoperative quality control. Nevertheless, no general evidence has been reported regarding the benefit of performing routine CCA. The aim of the present study was to evaluate the potential risks and benefits of routine CCA. METHODS: We retrospectively reviewed the Vascular Quality Initiative database for TCAR from 2016 to 2021. The patients were divided into two groups: those with no CCA performed and those with CCA performed. The primary outcome was in-hospital stroke or death. The secondary outcomes included stroke, death, myocardial infarction, and a return to the operating room (RTOR). Clinically relevant and statistically significantly variables on univariable analysis were added to a logistic regression model clustered by center identifier. RESULTS: A total of 18,155 patients who had undergone TCAR were identified, of whom 11,607 (63.7%) had undergone routine CCA. The patients with routine CCA were more likely to have contralateral carotid occlusion and to have received general anesthesia. After adjusting for potential confounders, we found no differences in the risk of stroke/death (adjusted odds ratio [aOR], 1.03; 95% confidence interval [CI], 0.8-1.3; P = .820), stroke/transient ischemic attack (TIA; aOR, 1.00; 95% CI, 0.8-1.3; P = .998), stroke (aOR, 1.1; 95% CI, 0.8-1.4; P = .452), death (aOR, 0.98; 95% CI, 0.6-1.6; P = .953), myocardial infarction (aOR, 0.78; 95% CI, 0.5-1.2; P = .240), or RTOR (aOR, 1.5; 95% CI, 0.6-3.8; P = .412) between patients who had undergone CCA and those who had not. A subanalysis of the patients with new occlusions detected by CCA (69 patients [0.6%]; 19 not treated and 50 treated) indicated a higher risk of stroke/death for the patients with treated new occlusions (aOR, 7.1; 95% CI, 2.9-17.3; P < .001) and stroke/TIA (aOR, 5.8; 95% CI, 2.3-14.7; P < .001) than for the patients who had not undergone CCA. However, no differences were found in stroke/death (aOR, 3.3; 95% CI, 0.37-29.5; P = .283) or stroke/TIA (aOR, 3.1; 95% CI, 0.3-29.4; P = .327) for patients with nontreated new occlusions compared with patients who had not undergone CCA. CONCLUSIONS: In the present retrospective study, routine performance of CCA was not beneficial, with no significant differences in in-hospital stroke or death detected. The detection of new lesions on CCA was rare. Moreover, identifying new occlusions using CCA was associated with higher odds of stroke or death when these new lesions were treated. Further studies are needed to define the etiology of the worse outcomes for patients undergoing intervention for lesions discovered using CCA and delineate the optimal timing for further imaging and intervention.

Frailty as a predictor of outcomes for patients undergoing carotid artery stenting.

OBJECTIVE: The concept of frailty has been proposed to capture the vulnerability resulting from aging and has been implemented for the prediction of perioperative outcomes. Carotid artery stenting (CAS) is considered an appropriate minimally invasive procedure for patients considered to high risk to undergo carotid endarterectomy. Recently, the predictive accuracy for perioperative outcomes using the five-item modified frailty index (5mFI) has been reported to be relatively poor for cardiovascular surgery compared with other surgeries. The effects of functional status and the 5mFI on the outcomes after CAS remain unknown. Thus, in the present study, we investigated the relationship between 5mFI, functional status, and perioperative outcomes. METHODS: All the patients who had undergone CAS in the Vascular Quality Initiative from November 15, 2016 to December 31, 2018 were included. Good functional status was defined as the ability to perform all predisease activities without restriction using a new variable added to the Vascular Quality Initiative from November 15, 2016 onward. The 5mFI was calculated using functional status and a history of diabetes, chronic obstructive pulmonary disease, congestive heart failure, and hypertension. The perioperative outcomes included in-hospital stroke or death within 30 days after CAS, a prolonged postoperative stay (≥2 days), and nonhome discharge. The associations between functional status, 5mFI, and perioperative outcomes were examined using univariate and multivariable logistic regression, adjusting for sex, age, race, degree of stenosis, symptomatic status, and the usage of preoperative medications. An analysis stratified by functional status was also performed. RESULTS: Of the 7836 patients, 188 (2.4%) had experienced perioperative stroke or death, 765 (9.8%) had required a nonhome discharge, and 2584 (33.0%) had required a prolonged postoperative stay. A higher (≥0.6 vs <0.6) 5mFI score was associated with greater odds of perioperative stroke or death (adjusted odds ratio [aOR], 2.75; 95% confidence interval [CI], 1.42-5.28; P = .003), non-home discharge (aOR, 2.70; 95% CI, 1.89-3.85; P < .001), and a prolonged postoperative length of stay (aOR, 1.96; 95% CI, 1.56-2.46; P < .001). For the predictive accuracy of the perioperative outcomes, the 5mFI model had an area under the curve for in-hospital stroke or death, nonhome discharge, and prolonged postoperative length of stay of 0.714, 0.767, and 0.668, respectively. The functional status model was not inferior to the 5mFI model for any of these outcomes. In the subgroup analysis, of the asymptomatic patients, a higher 5mFI score was associated with greater odds of perioperative stroke or death (aOR, 7.08; 95% CI, 2.02-24.48; P = .002), nonhome discharge (aOR, 5.87; 95% CI, 2.45-13.90; P < .001), and a prolonged postoperative stay (aOR, 2.60; 95% CI, 1.82-3.71; P < .001). CONCLUSIONS: Frailty, as measured using the 5mFI, and functional status were independent predictors of perioperative stroke or death, nonhome discharge, and an increased length of stay for patients undergoing CAS. These results were greatly pronounced in asymptomatic patients. The results from the present study, thus, caution against the use of CAS for asymptomatic frail patients.

Outcomes of intact thoracic endovascular aortic repair in octogenarians.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) is a suitable alternative to open aortic surgery especially for older patients with poor general health and functional status. However, data on the benefit of TEVAR in elderly patients are limited. The aim of this study was to use a large national database to compare the outcomes of TEVAR in octogenarians vs nonoctogenarians in the treatment of thoracic aortic aneurysms and dissection. METHODS: All patients who underwent TEVAR for nonruptured thoracic aneurysms or dissection (zones 1-5) between January 2014 and February 2019 were identified in the Vascular Quality Initiative database. The primary outcome was in-hospital mortality. Secondary outcomes included cardiac adverse events; neurologic events; respiratory complications; new-onset dialysis; leg compartment syndrome; postoperative hematoma in addition to spinal, bowel, arm, and leg emboli/ischemia; and return to the operating room. Outcomes were compared between octogenarians (age ≥80 years) and nonoctogenarians (age <80 years) using univariable and multivariable logistic regression models. RESULTS: A total of 2042 patients were identified, including 390 octogenarians (19.1%). Compared with nonoctogenarians, octogenarians had higher percentages of females (49.5% vs 40.4%; P < .01) and White patients (75.9% vs 68.6%; P < .01) and were more likely to present with thoracic aneurysms (86.2% vs 64.3%; P < .001). They also had larger aortic diameters (maximum diameter, 60.3 ± 15.8 mm vs 53.4 ± 17.4 mm), less proximal disease zones (zone 1, 3.3% vs 5.5%; zone 2, 13.9% vs 24.1%; P < .001) and were more likely to undergo the procedure under local/regional anesthesia (5.4% vs 2.4%; P < .01) compared with patients less than 80 years of age. No association was observed between octogenarians and in-hospital mortality after TEVAR for aneurysms (5.1% vs 3.3%; odds ratio [OR], 1.38; 95% confidence interval [CI], 0.72-2.61; P = .33) or dissection (5.6% vs 4.9%; OR, 0.68; 95% CI, 0.14-3.32; P = .63). However, for thoracic aneurysm repair, octogenarians had a 44% higher adjusted odds of in-hospital complications (27.4% vs 20.7%; OR, 1.44; 95% CI, 1.04-1.98; P = .03) compared with their younger counterparts. In-hospital complications (27.8% vs 26.2%; P = .79; OR, 1.02; 95% CI, 0.50-2.11; P = .95) were similar in octogenarians undergoing endovascular repair for dissections of the thoracic aorta. Octogenarians were also associated with 1.74 times the mortality hazard compared with nonoctogenarians (adjusted hazard ratio, 1.74; 95% CI, 1.18-2.58; P = .01). CONCLUSIONS: TEVAR is an acceptable treatment option for octogenarians who have aortic arch and descending aortic aneurysms or dissections (zones 1-5). However, in case of aneurysms, they might be at a higher risk of in-hospital complications. Octogenarians also had increased hazard of 1-year mortality; however, the exact cause of this mortality could not be deciphered. Our findings suggest that elderly patients should not be denied TEVAR based on age if they are medically and anatomically fit for this procedure.

Black patients have a higher burden of comorbidities but a lower risk of 30-day and 1-year mortality after thoracic endovascular aortic repair.

BACKGROUND: Racial disparities in open thoracic aortic aneurysm repair have been well-documented, with Black patients reported to suffer from poor outcomes compared with their White counterparts. It is unclear whether these disparities extend to the less invasive thoracic endovascular aortic repair (TEVAR). This study aims to examine the clinical characteristics, perioperative outcomes, and 1-year survival of Black vs White patients undergoing TEVAR in a national vascular surgery database. METHODS: The Vascular Quality Initiative database was retrospectively queried to identify all patients who underwent TEVAR between January 2011 and December 2019. The primary outcomes were 30-day mortality and 1-year survival after TEVAR. Secondary outcomes included various types of major postoperative complications. Multivariable logistic regression analyses were performed to identify predictors of 30-day mortality and perioperative complications. Multivariable Cox regression analysis was used to determine the predictors of 1-year survival. RESULTS: A total of 2669 patients with TEVAR were identified in the Vascular Quality Initiative, of whom 648 were Black patients (24.3%). Compared with White patients, Black patients were younger and had a higher burden of comorbidities, including hypertension, diabetes, congestive heart failure, dialysis dependence, and anemia. Black patients were more likely to be symptomatic, present with aortic dissection, and undergo urgent or emergent repair. There was no statistically significant difference in 30-day mortality between Black and White patients (3.4% vs 4.9%; P = .1). After adjustment for demographics, comorbidities, and operative factors, Black patients were independently associated with a 56% decrease in 30-day mortality risk compared with their White counterparts (odds ratio, 0.44; 95% confidence interval [CI], 0.22-0.85; P = .01) and not associated with an increased risk of perioperative complications (odds ratio, 0.90; 95% CI, 0.68-1.17; P = .42). Black patients also had a significantly better 1-year overall survival (log-rank, P = .024) and were associated with a significantly decreased 1-year mortality (hazard ratio, 0.65; 95% CI, 0.47-0.91; P = .01) after adjusting for multiple clinical factors. CONCLUSIONS: Although Black patients carried a higher burden of comorbidities, the racial disparities in perioperative outcomes and 1-year survival do not persist in TEVAR.

Incidence and risk factors of sepsis in hemodialysis patients in the United States.

BACKGROUND: Sepsis is one the most serious and life-threatening complication in patients with chronic hemodialysis (HD) access. Arteriovenous fistula (AVF) use is associated with a lower risk of infection. However, several prior studies identified significantly higher number of patients initiating HD using a catheter (HC) or arteriovenous graft (AVG). The aim of this study was to use a large national renal database to report the incidence and risk factors of sepsis in patients with end-stage renal disease (ESRD) initiating HD access using AVF, AVG, or HC in the United States. METHODS: All patients with ESRD initiating HD access (AVF, AVG, HC) between January 1, 2006, and December 31, 2014, in United States Renal Data System were included. International Classification of Diseases, 9th edition-Clinical Modification diagnosis code (038x, 790.7) was used to identify patients who developed first onset of sepsis during follow-up. Standard univariate (Students t-test, χ2, and Kaplan-Meier) and multivariable (logistic/Cox regression) analyses were performed as appropriate. RESULTS: A total of 870,571 patients were identified, of whom, 29.8% (n = 259,686) developed sepsis. HC (31.2%) and AVG (30.6%) were associated with a higher number of septic cases compared with AVF (22.9%; P < .001). The incident rate of sepsis was 12.66 episodes per 100 person-years. It was the highest among HC vs AVG vs AVF (13.86 vs 11.49 vs 8.03 per 100 person-years). Patients with sepsis were slightly older (mean age 65.09 ± 14.49 years vs 63.24 ± 15.17 years) and had higher number of comorbidities including obesity (40.7% vs 37.7%), congestive heart failure (36.6% vs 30.8%), peripheral arterial disease (15.6% vs 12.4%), and diabetes (59.6% vs 53.5%) (all P < .001). After adjusting for potential confounders, compared with AVF, patients with AVG (hazard ratio [HR], 1.35 [95% confidence interval [CI], 1.31-1.40) and HC (HR, 1.80 [95% CI, 1.77-1.84) were more likely to develop sepsis at 3 years (both P < .001). Compared with patients with no sepsis, sepsis was associated with a three-fold increase the odds of mortality (odds ratio, 3.16; 95% CI, 3.11-3.21; P < .001). Additionally, in patients who developed sepsis, AVF use was associated with significantly lower mortality compared with AVG and HC (73.7% vs 78.7% vs 78.0%; P < .001). After adjusting for significant covariates, compared with AVF, mortality at 1 year after sepsis was 21% higher in AVG (HR, 1.21; 95% CI, 1.15-1.28; P < .001) and nearly doubled in HC (HR, 1.94; 95% CI, 1.88-2.00; P < .001). CONCLUSIONS: Sepsis risk in HD patients is clearly related to access type and is associated with dramatic increase in mortality. Initiating HD access with AVF to meet the National Kidney Foundation Kidney Disease Outcomes Quality recommendations should be implemented to reduce the incidence of sepsis and improve survival in patients with ESRD.

Comparison of open- and closed-cell stent design outcomes after carotid artery stenting in the Vascular Quality Initiative.

BACKGROUND: The association between stent design and outcomes after carotid artery stenting (CAS) has remained controversial. The available data are conflicting regarding the superiority of any specific stent design. The present study investigated the association between cell design and outcomes after carotid artery stenting (CAS) in a real world setting. METHODS: Patients who had undergone CAS with distal embolic protection in the Society for Vascular Surgery Vascular Quality Initiative (VQI) database from 2016 to 2018 were included in the present study. Patients undergoing CAS for trauma or dissection or more than two treated lesions were excluded. We also excluded lesions for which more than two carotid stents had been used and lesions confined to the common or external carotid artery. Univariable and multivariable logistic regression analyses were used to compare the outcomes after CAS between the open- and closed-cell stent designs. RESULTS: Of the 2671 CAS procedures included in the present analysis, 1384 (51.8%) had used closed-cell stents and 1287 (48.2%) had used open-cell stents. On univariable analysis, no significant differences were noted between the closed- and open-cell stents in in-hospital mortality (1.8% vs 1.4%; P = .40), stroke (1.8% vs 2.4%; P = .28), and stroke/death (3.3% vs 3.5%; P = .81). After adjusting for potential confounders (ie, age, symptomatic status, previous major amputation, statin and antiplatelet use, American Society of Anesthesiologists class, elective procedures, approach, and post-stent dilatation), no difference was noted in in-hospital stroke/death between the two stent designs (odds ratio [OR], 1.08; 95% confidence interval [CI], 0.68-1.74; P = .74). However, the interaction between stent design (open vs closed) and lesion location (bifurcation vs internal carotid artery [ICA]) was statistically significant (P = .02). Closed-cell stents were associated with five times the odds of in-hospital stroke/death when used in carotid artery bifurcation (OR, 5.5; 95% CI, 1.3-22.2; P = .02). However, when the stent was limited to the ICA, no differences were noted (OR, 0.87; 95% CI, 0.51-1.45; P = .62). One-year follow-up data were available for 19% of patients. No differences in ipsilateral stroke or death at 1 year were noted between the open- and closed-cell stents, except when the lesion was located in the carotid bifurcation (hazard ratio, 6.7; 95% CI, 1.4-31.4; P = .02). CONCLUSIONS: Closed-cell stents were associated with an increased odds of in-hospital stroke/death for carotid bifurcation lesions, which might be related to the relatively lower conformability of closed-cell stents in the tortuous and diameter-mismatched bifurcation anatomy vs the relatively linear uniform diameter of the ICA. Improved follow-up and in-depth analysis of lesion-specific characteristics that might influence the outcomes of these two designs are needed to validate these results.

Midterm outcomes in patients undergoing endovascular repair of thoracic aortic aneurysms and penetrating atherosclerotic ulcers using the RelayPlus stent graft.

BACKGROUND: The Relay Thoracic Stent-Graft with Plus Delivery System (RelayPlus; Terumo Aortic, Sunrise, Fla) was designed to handle the curvature and tortuosity of the thoracic aorta. It was approved by the Food and Drug Administration in 2012; the postapproval study was stopped early because of adequate safety and efficacy data, and no difference was identified in experienced vs first-time users of RelayPlus. The purpose of this study was to report real-world outcomes of patients with thoracic aortic aneurysms and penetrating atherosclerotic ulcers (PAUs) undergoing thoracic endovascular aortic repair (TEVAR) with RelayPlus. METHODS: This is a prospective, multicenter, nonrandomized postapproval study that required the use of novice implanters in the United States. Primary and secondary end points included device-related adverse events (deployment failure, conversion to open repair, endoleaks, migration, rupture, and mortality) and major adverse events (stroke, paraplegia/paraparesis, renal failure, respiratory failure, and myocardial infarction), respectively. Continuous and categorical covariates were reported in means or medians and percentages, respectively. Kaplan-Meier survival estimates were used to report long-term TEVAR-related mortality, all-cause mortality, and reinterventions at 3 years. RESULTS: A total of 45 patients with mean age (standard deviation [SD]) of 73.5 (±7.20) years were treated for descending thoracic fusiform aneurysm (56%) or saccular aneurysm/PAU (44%). The patients were predominantly white (80.0%) and male (68.9%). Mean (SD) proximal neck, distal neck, and lesion lengths were 38.2 (±37) mm, 42.1 (±28) mm, and 103.8 (±74) mm, respectively. Mean (SD) aneurysm, proximal neck, and distal neck diameters were 53.9 (±13) mm, 31.3 (±4) mm, and 31.7 (±6) mm, respectively. Technical success was 100%. TEVAR-related mortality at 30 days was 4.4%; two patients died postoperatively, one of shock and the second of bilateral hemispheric stroke. No patient in the study had any conversion to open repair or post-TEVAR rupture. Two patients experienced three major adverse events, which included stroke (2.2%), paraplegia (2.2%), and respiratory failure (2.2%) at 30 days. Three-year freedom from TEVAR-related mortality, all-cause mortality, and reinterventions was 95.6%, 84.0%, and 97.2%, respectively. There were two type I endoleaks at 3 years: one type IB associated with no migration or aneurysm sac increase and one type IA associated with caudal migration of proximal neck and expansion of the proximal aorta. CONCLUSIONS: The RelayPlus postapproval study reported low operative mortality and morbidity and supported use of the device as a safe and effective thoracic aortic aneurysm and PAU endovascular treatment. Early midterm follow-up showed sustained freedom from TEVAR-related mortality in real-world practice. Follow-up continues to evaluate the durability of this endograft.

Favorable Outcomes in Octogenarians With Hostile Neck Undergoing Endovascular Repair Using EndoAnchors.

OBJECTIVES: Standard endovascular repair (EVAR) is not suitable in patients with hostile aortic anatomy. Open aneurysm repair (OAR) has been the gold-standard approach in managing these patients. EndoAnchors have been introduced as a technique to make EVAR in patients with short and angulated necks possible. The use of EndoAnchors in managing hostile aneurysms in octogenarians has not been studied before. Thus, the purpose of this study is to evaluate both short and long-term outcomes in octogenarians versus nonoctogenarians patients with hostile aortic anatomy undergoing EVAR using EndoAnchors. METHODS: Only patients enrolled in the primary arm of the ANCHOR registry were included and stratified into octogenarians (80-89 years) and nonoctogenarians (<80 years). Standard univariate (chi-square, fisher's exact, student's t-tests) and multivariable (logistic, cox-regression) analysis was used to evaluate patients' characteristics and outcomes between octogenarians versus nonoctogenarians as appropriate. RESULTS: Of 461 patients, 21% (N = 97) were octogenarians. Compared to nonoctogenarians, octogenarians were more likely to have a history of renal (32.0% vs. 18.4%) and genitourinary (30.9% vs. 21.2%) disease (both P < 0.05). They were also more likely to have an AAA diameter greater than 55 mm compared to nonoctogenarians (59% vs. 46%), had increased neck tortuosity index (mean [S.D.] 1.07 [0.08] vs. 1.05 [0.05]), greater proximal neck angulation (mean [S.D.]: 28.2 [17.3] vs. 23.7 [16] degrees) and were more likely to have localized (29.3% vs. 18.7%) and diffuse (25.6% vs. 20.7%) neck calcification (All P < 0.05). The overall procedural success was similar between both groups. However, octogenarians had higher rates of endoleaks at completion (32.0% vs. 21.2%, P = 0.03) and 30-day bleeding (12.4% vs. 5.8%) and cardiac (13.4% vs. 5.2%) complications (All P < 0.05). Additionally, compared to nonoctogenarians, octogenarians had lower freedom from all-cause mortality (87.90% vs. 96.50%) and type II endoleak (73.30% vs. 88.60%) based on Kaplan Meier estimates through one year (Both P < 0.05). In multivariable cox-regression analysis, octogenarians demonstrated a 5-fold increase in all cause mortality (HR [95% CI]: 5.19 [1.92-14], P = 0.001) and a 3-fold increase in type II endoleak (HR [95% CI]: 2.99 [1.54-5.81], P = 0.001) at 1-year. However, no significant difference was seen in aneurysm/device related mortality (HR [95% CI]: 1.42 [0.14-14.7], P = 0.77) and type I endoleak (HR [95% CI]: 1.71 [0.31-9.55], P = 0.54) at 1-year. CONCLUSIONS: Despite a worse aortic neck anatomy, octogenarians undergoing EVAR using EndoAnchors showed acceptable short and long-term outcomes. The results of our study could expand the utilization of EVAR in octogenarians with hostile neck.

Short Duration Catheter-directed Thrombolysis for Acute Pulmonary Embolism Rapidly Improves Acute Cardiac Function.

BACKGROUND: Treatment of massive and submassive pulmonary embolism (PE) has been shown to be a valuable therapeutic modality. However, a paucity of data exists, regarding length and guidelines for treatment and typically these patients are treated by other than vascular surgery specialists. The aim of this study is to evaluate the effectiveness and safety of short duration treatment of massive and submassive PE, exclusively by vascular surgeons, without routine follow-up pulmonary angiography. METHODS: Retrospective analysis of prospectively collected data at a single-institution treating massive and submassive PE with catheter-directed thrombolysis (CDT). Internal review board approval was obtained. Descriptive statistical analysis was performed from the data set. Continuous covariates were presented in mean (SD) or median (IQR) and categorical covariates as number (percentage). For continuous variables, a paired t test was used to measure results against the baseline. P value less than 0.05 was defined as statistically significant. STATA® statistical software was used for analysis. RESULTS: From January of 2013 to December of 2016, 28 consecutive patients were treated for massive and submassive PE with CDT. All patients had evidence of right heart strain on echocardiogram, as evidence by a right ventricular to left ventricular (RV/LV) diameter ratio of >0.9. Of the 28 patients, 19 (68%) had hemodynamic derangement with either systolic blood pressure (SBP) less then 90 or tachycardia (HR > 100). The mean RV/LV ratio before CDT was 1.18. After therapy, RV/LV ratio was reduced to 0.86 at 48 hr (P < 0.0001). In addition, mean right ventricular systolic pressure (RVSP) before CDT treatment was 53 mm Hg, and after treatment, RVSP was reduced to 40 mm Hg at 48-hr (P value = 0.0001). There was complete resolution of hypotension in hemodynamically unstable patients (i.e., SBP <90) after CDT. Mean HR before therapy was 102. After 24 hr of CDT, mean HR reduced to 84 (P < 0.0001). From 2013 to 2016, there was a significant decrease in mean hospital length of stay from 8 days to 4 days (P = 0.05). Mean t-PA dose used decreased, as well, from 2014 (21.7 mg) to 2016 (14.9 mg), but this was not statistically significant (P = 0.13). There was no major bleeding complications or CDT-related death in any of the patients treated during the study period. CONCLUSIONS: CDT treatment of massive and submassive PE is safe and highly efficacious at reducing right heart strain acutely. Significant hemodynamic improvement was shown in our cohort throughout the study period. Improvement in tachycardia and resolution of hypotension were seen within 24 hr of CDT. Tissue plasminogen activator dosage decreased throughout the study period as a more restrictive approach to follow-up angiography was used without adverse safety or patient outcomes.

Intravenous ketorolac is associated with reduced mortality and morbidity after open abdominal aortic aneurysm repair.

OBJECTIVES: The role of non-steroidal anti-inflammatory drugs in aortic aneurysm disease has been debated. Animal studies demonstrated that intrathecal ketorolac reduces the inflammatory response associated with aortic clamping. However, no human-subject study evaluated this association. Therefore, we sought to explore the effects of ketorolac use in open abdominal aortic aneurysm repair. METHODS: The Premier Healthcare Database (June 2009-March 2015) was inquired to capture patients who underwent open abdominal aortic aneurysm repair for non-ruptured abdominal aortic aneurysm, identified via International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Intravenous ketorolac was coded as any or none. Outcomes were in-hospital mortality, cardiac, respiratory, renal, neurological, and hemorrhagic complications. Multivariable logistic regression coarsened exact matching followed by conditional fixed-effect regression modeling were performed. RESULTS: A total of 6394 patients were identified (ketorolac: 806; 12.6%). Patients who received ketorolac were younger and less likely to have hypertension (76.1% vs. 79.3%), diabetes mellitus (12.5% vs. 17.4%), or chronic kidney disease (8.3% vs. 21.4%; all p values ≤ .033). There was no significant difference in medication use including oral non-steroidal anti-inflammatory drugs and malignant or musculoskeletal diseases. Mortality, respiratory, and renal complications were less prevalent with ketorolac (2.5% vs. 4.9%, 25.2% vs. 34.6%, 10.0% vs. 21.1%; p ≤ .002). Ketorolac was associated with lower adjusted odds for those events: 0.58 (0.36-0.93), 0.53 (0.42-0.68), and 0.72 (0.60-0.86), respectively (all p values ≤ .025). There was no association with neurological, cardiac, or hemorrhagic complications. The findings were replicated by coarsened exact matching analysis. CONCLUSION: This study demonstrated 40% mortality reduction with intravenous ketorolac following open abdominal aortic aneurysm repair. The survival benefit could be due to its anti-inflammatory and opioid-sparing properties. This is evident by its protective effect against respiratory outcomes. The lack of association with the classical non-steroidal anti-inflammatory drugs-related cardiac and hemorrhagic complication could be attributable to the short-term use of ketorolac compared with non-steroidal anti-inflammatory drugs chronic use.

Anemia as an independent predictor of adverse outcomes after carotid revascularization.

BACKGROUND: Anemia has been identified as a risk factor for postoperative morbidity and mortality after major vascular procedures. Carotid revascularization carries less cardiac morbidity and physiologic stress compared with other vascular interventions. This study evaluated the association between preoperative anemia and major adverse events after carotid revascularization. METHODS: Patients undergoing carotid endarterectomy (CEA) and carotid artery stenting (CAS) between January 2012 and June 2018 in the Vascular Quality Initiative database were identified. Anemia was defined as a preoperative hemoglobin level of <12 g/dL in women and <13 g/dL in men. Multivariable logistic analysis and 1:1 coarsened exact matching were used to study the association between preoperative anemia and in-hospital major adverse cardiac events (MACEs), defined as a composite of stroke, death, and myocardial infarction, and between anemia and 30-day mortality after CEA and CAS. RESULTS: Of 102,719 patients included in the analysis, 34.8% were anemic (CEA, 34.1%; CAS, 37.8%; P < .001). Anemic patients were older and had more medical comorbidities compared with nonanemic patients. In-hospital MACEs (2.8% vs 1.9%; P < .001) and 30-day mortality (0.9% vs 0.4%; P < .001) were higher among anemic patients. On multivariable analysis, anemia was associated with 18% higher odds of in-hospital MACEs (odds ratio, 1.18; 95% confidence interval, 1.07-1.31, P = .001) and 74% higher odds of 30-day mortality (odds ratio, 1.74; 95% confidence interval, 1.40-2.17, P < .001). Coarsened exact matching showed similar results. The association between preoperative anemia and adverse outcomes was similar in both CAS and CEA and in symptomatic and asymptomatic patients (P interaction > .05). CONCLUSIONS: Anemia is associated with increased odds of adverse events after CEA and CAS. It should be factored into the preoperative risk assessment of patients undergoing carotid revascularization. Prospective studies are needed to study the effectiveness of correcting low preoperative hemoglobin levels in these patients and the association between anemia and long-term outcomes after CEA and CAS.

Predictors of midterm high-grade restenosis after carotid revascularization in a multicenter national database.

BACKGROUND: Restenosis after carotid revascularization is clinically challenging. Several studies have looked into the management of recurrent restenosis; however, studies looking into factors associated with restenosis are limited. This study evaluated the predictors of restenosis after carotid artery stenting (CAS) and carotid endarterectomy (CEA) using a large national database. METHODS: Patients undergoing CEA or CAS in the Vascular Quality Initiative data set (2003-2016) were analyzed. Patients with no follow-up (33%) and those who had prior ipsilateral CEA or CAS were excluded. Significant restenosis was defined as ≥70% diameter-reducing stenosis, target artery occlusion or peak systolic velocity ≥300 cm/s, or repeated revascularization. Kaplan-Meier survival analysis and bootstrapped Cox regression models with stepwise forward and backward selection were used. RESULTS: A total of 35,720 procedures were included (CEA, 31,329; CAS, 4391). No significant difference in restenosis rates was seen between CEA and CAS at 2 years (7.7% vs 9.4% [P = .09]; hazard ratio [HR], 0.99; 95% confidence interval [CI], 0.79-1.25; P = .97). However, after adjustment for age, sex, and symptomatic status at the time of the index operation, CAS patients who had postoperative restenosis were more likely to have a symptomatic presentation (odds ratio, 2.2; 95% CI, 1.2-4.0; P = .01) and to undergo repeated revascularization at 2 years (HR, 1.75; 95% CI, 1.3-2.4; P < .001) compared with patients who had restenosis after CEA. Predictors of restenosis after CAS included a common carotid artery lesion (HR, 1.65; 95% CI,1.06-2.57; P = .03), whereas age (HR, 0.91; 95% CI, 0.84-0.99; P = .03) and dilation after stent placement (HR, 0.53; 95% CI, 0.39-0.72; P < .001) were associated with decreased restenosis at 2 years. Predictors of restenosis after CEA included female sex (HR, 1.55; 95% CI, 1.38-1.74; P < .001), prior neck irradiation (HR, 2.35; 95% CI, 1.66-3.30; P < .001), and prior bypass surgery (HR, 1.29; 95% CI, 1.01-1.65; P = .04). On the other hand, factors associated with decreased restenosis after CEA included age (HR, 0.95; 95% CI, 0.92-0.98; P < .001), black race (HR, 0.57; 95% CI, 0.37-0.89; P = .01), patching (HR, 0.61; 95% CI, 0.47-0.79; P < .001), and completion imaging (HR, 0.70; 95% CI, 0.52-0.95; P = .02). CONCLUSIONS: Our results show no significant difference in restenosis rates at 2 years between CEA and CAS. Restenosis after CAS is more likely to be manifested with symptoms and to undergo repeated revascularization compared with that after CEA. Poststent ballooning after CAS and completion imaging and patching after CEA are associated with decreased hazard of restenosis; however, further research is needed to assess longer term outcomes and to balance the risks vs benefits of certain practices, such as poststent ballooning.

Perioperative blood transfusion in anemic patients undergoing elective endovascular abdominal aneurysm repair.

OBJECTIVE: Although blood transfusion can be lifesaving in active hemorrhage or severe anemia, it is also associated with increased morbidity and mortality. Several trials have established this risk and therefore defined a restrictive standard for transfusion, but this threshold and the risk of transfusions have not been specifically examined in vascular surgery patients. We therefore sought to assess transfusion practices and outcomes of anemic patients undergoing elective endovascular aneurysm repair (EVAR). METHODS: The Vascular Quality Initiative database was queried for patients undergoing EVAR between the years 2008 and 2017. Anemic patients were included in the study and were further stratified into mild anemia, defined by a hemoglobin level of 10 to 13 g/dL in men or 10 to 12 g/dL in women, and moderate to severe anemia, defined by a hemoglobin level <10 g/dL. The primary study outcomes were in-hospital mortality and complications. RESULTS: Among 27,777 EVAR patients, one-third (n = 9232) were anemic and included in the study. One-fifth (n = 1866) of anemic patients received a perioperative transfusion. Transfused patients were more likely to have a history of cardiovascular disease. In-hospital mortality was significantly higher for anemic patients who received transfusions, both in mild anemia (mortality, 3.6% vs 0.4% in no transfusion; P < .001) and in moderate to severe anemia (4.5% vs 1.3%; P < .01). Morbidity was also significantly higher, with anemic patients who received a transfusion having higher rates of myocardial infarction, congestive heart failure, dysrhythmias, renal complications, leg ischemia, respiratory complications, and reoperation compared with anemic patients who did not receive any transfusion. The 30-day mortality was also higher in transfused patients (P < .001). After adjustment for patients' demographics, comorbidities, and operative factors, transfusion in anemic patients was associated with a nearly 4.4-fold increased odds of in-hospital mortality (odds ratio [OR], 4.38; 95% confidence interval [CI], 2.72-7.05; P < .001) and 4.3-fold higher odds of any in-hospital complication (OR, 4.31; 95% CI, 3.47-5.34; P < .001). This was more pronounced among patients with mild anemia, with 5.7 times (OR, 5.7; 95% CI, 1.78-18.0) and 4.3 times (OR, 4.3; 95% CI, 3.46-5.29) the odds of in-hospital mortality and complications, respectively. CONCLUSIONS: Among anemic patients undergoing elective EVAR, transfusion is associated with an increased risk of death and in-hospital complications, even after controlling for patients' comorbidities and operative factors. These data suggest that the restrictive use of blood transfusions might be safer in vascular surgery EVAR patients. Medical management of anemia may be warranted in these patients to reduce morbidity and mortality; however, further studies are needed to evaluate effectiveness.

Impact of suprarenal neck angulation on endovascular aneurysm repair outcomes.

BACKGROUND: Hostile infrarenal proximal neck (ß) anatomy of abdominal aortic aneurysm has been associated with increased risk of aneurysm-related complications after endovascular aneurysm repair (EVAR). However, there is a paucity of literature addressing the suprarenal angle (α). The aim of this study was to evaluate short- and long-term outcomes after EVAR in patients with severe suprarenal neck angulation (α >60 degrees). METHODS: A retrospective review of the medical records of 561 patients who underwent EVAR between January 2005 and December 2017 was performed. The main exclusion criteria were preoperative aneurysm rupture and fenestrated or branched endograft placement. High-resolution computed tomography images of 452 patients were available. Patients were grouped into angulated (α >60 degrees) and nonangulated (α ≤60 degrees) groups. The primary end point was freedom from type IA endoleak. Secondary end points included 30-day mortality, long-term survival, primary clinical success, and freedom from aneurysm rupture and graft migration. Primary clinical success was defined according to Society for Vascular Surgery guidelines as clinical success without the need for an additional or secondary surgical or endovascular procedure. RESULTS: Of 452 patients, 45 (10%) were included in the angulated group (α >60 degrees). Median follow-up time was 34 months (interquartile range, 14-56 months). Compared with patients in the nonangulated group, those in the angulated group had larger neck diameter at the level of the renal arteries (mean [standard deviation], 25.6 [3.8] mm vs 24.6 [3.4] mm; P = .06) and increased ß angle (mean [standard deviation], 50.5 [22.9] degrees vs 41.6 [23.9] degrees; P = .01). The 3-year freedom from type IA endoleak estimate was 80.2% for the angulated group compared with 97.8% for the nonangulated group (P < .001). The angulated group showed significantly higher 30-day mortality (11.1% vs 0.25%; P < .001).The 3-year results showed that patients in the nonangulated group had higher rates of primary clinical success (90.2% vs 67.1%; P < .001), freedom from rupture (99% vs 97.1%; P = .02), freedom from migration (100% vs 92.4%; P < .001), and long-term survival (91.6% vs 75.8%; P = .006) compared with those in the angulated group. After adjustment for age, sex, neck diameter, and ß angle, severe suprarenal neck angulation was associated with higher odds of type IA endoleak (adjusted hazard ratio, 8.9; 95% confidence interval [CI], 2.9-27), loss of primary clinical success (adjusted hazard ratio, 4.8; 95% CI, 2.6-8.9), and 30-day mortality (adjusted odds ratio, 52.5; 95% CI, 5.3-514) compared with α ≤60 degrees (all P < .001). CONCLUSIONS: This is the first report to show a significant increase in operative mortality in patients undergoing EVAR with severely angulated suprarenal neck. Patients who survive the operation are at increased risk of secondary interventions. These findings suggest that EVAR should be used with caution in patients with severe α angulation and underpin the role of close follow-up in this particular population.

Endovascular repair of ruptured abdominal aortic aneurysm is superior to open repair: Propensity-matched analysis in the Vascular Quality Initiative.

OBJECTIVE: The few randomized trials comparing endovascular with open surgical repair of ruptured abdominal aortic aneurysm (rAAA) were poorly designed and heavily criticized. 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%; P < .001), major adverse events (67% vs 37%; P < .001), and 30-day death (34% vs 21%; P < .001). On adjusted analysis, rOSR was predictive of 30-day mortality (odds ratio, 1.8; 95% confidence interval, 1.5-2.2). After 1:1 matching, the study cohort consisted of 724 pairs of rOSR and rEVAR. The rOSR patients had twice the length of stay (median, 10 days [interquartile range, 5-19 days] vs 5 days [interquartile range, 3-10 days]; P < .001). Univariate analysis demonstrated persistent increased 30-day mortality after rOSR (32% vs 18%; P < .001) and higher rates of myocardial infarction (14% rOSR vs 8% rEVAR; P = .002), respiratory complications (38% vs 20%; P < .001), and acute kidney injury (42% vs 26%; P < .001). Overall major adverse event rate was higher after rOSR (68% vs 35%; P < .001). Multivariable regression analysis of the propensity-matched pairs demonstrated that rOSR was associated with double the 30-day mortality compared 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 < .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.

Age-related outcomes of arteriovenous grafts for hemodialysis access.

BACKGROUND: The prevalence of end-stage renal disease spans the spectrum of age. Arteriovenous grafts are viable alternatives for hemodialysis access in patients whose anatomy precludes placement of an arteriovenous fistula. This report describes the age-related outcomes after arteriovenous graft placement in a population-based cohort. METHODS: A retrospective cohort study was conducted of all patients who initiated hemodialysis in the U.S. Renal Data System (2007-2014). The χ2 test, t-test, Kaplan-Meier analysis, log-rank test, and multivariable logistic and Cox regression analyses were employed to evaluate access maturation, interventions, patency, and mortality. RESULTS: Of the 78,341 patients studied, 10,150 (13%) were younger than 50 years, 13,167 (16.8%) were 50 to 59 years, 19,975 (25.5%) were 60 to 69 years, 20,307 (25.9%) were 70 to 79 years, and 14,742 (18.8%) were 80+ years. There was no significant difference in access maturation time for patients in the older age categories compared to patients younger than 50 years. Primary patency at 5 years comparing <50 years vs 50 to 59 years vs 60 to 69 years vs 70 to 79 years vs 80+ years was 12% vs 12% vs 9% vs 9% vs 8% (P < .001). Primary assisted patency at 5 years was 20% vs 21% vs 18% vs 17% vs 14% (P < .001). Secondary patency at 5 years was 36% vs 39% vs 36% vs 30% vs 31% (P < .001). There was no significant difference in primary patency (adjusted hazard ratio [aHR], 1.00; 95% confidence interval [CI], 1.00-1.00; P < .001), primary assisted patency (aHR, 1.00; 95% CI, 1.00-1.00; P < .001), and secondary patency (aHR, 1.00; 95% CI, 1.00-1.00; P = .029) with increasing age. However, there was a decrease in severe prosthetic graft infection requiring graft excision (aHR, 0.99; 95% CI, 0.99-0.99; P < .001) and increase in mortality (aHR, 1.03; 95% CI, 1.03-1.03; P < .001) for the older age categories compared with the younger patients. CONCLUSIONS: In this population-based cohort of hemodialysis patients, there was no significant association between older age and prosthetic graft maturation or patency. However, older age was associated with a decrease in severe graft infection and the expected increase in mortality.

Racial and Gender Disparity in Aortoiliac Disease Open Revascularization Procedures.

BACKGROUND: The impact of race and gender on surgical outcomes has been studied in infrainguinal revascularization for peripheral arterial disease. The aim of this study is to explore how race and gender affect the outcomes of suprainguinal bypass (SIB) for aortoiliac occlusive disease. MATERIALS AND METHODS: Patients who underwent SIB were identified from the procedure-targeted National Surgical Quality Improvement Program data set (2011-2016). Patients were stratified into four groups: nonblack males, black males (BM), nonblack females, and black females (BF). Primary outcomes were 30-d major adverse cardiac events, a composite of myocardial infarction, stroke, or death; postoperative bleeding requiring transfusion or intervention; major amputation and prolonged length of stay (>10 d). Predictors of outcomes were determined by multivariable logistic regression analysis. RESULTS: About 5044 patients were identified. BM were younger, more likely to be smokers, less likely to be on antiplatelet drug or statin, and to receive elective SIB (all P ≤ 0.01). BFs were more likely to be diabetic and functionally dependent (all P ≤ 0.02). Major adverse cardiac events were not significantly different among all groups. BM had a threefold higher risk of amputation (adjusted odds ratio [OR] [95% confidence interval (95% CI)], 3.10 [1.50-6.43]; P < 0.002). Female gender was associated with bleeding in both races, that association was more drastic in BF (OR [95% CI], 2.43 [1.63-3.60]; P < 0.0001), whereas nonblack females (OR [95% CI], 1.46 [1.19-1.80]; P < 0.0001). BF had higher odds of prolonged length of stay (OR [95% CI]: 1.62 [1.08-2.42]; P < 0.019). CONCLUSIONS: In this large retrospective study, we demonstrated the racial and gender disparity in SIB outcomes. BM had more than threefold increase in amputation risk as compared with nonblack males. Severe bleeding risk was more than doubled in BF. Race and gender consideration is warranted in risk assessment when patients are selected for aortoiliac disease revascularization, which in turn necessitate preoperative risk modification and optimization in addition to enhancing their access to primary preventive care measures.