Outcomes of endovascular intervention for atherosclerotic lesions confined to the popliteal artery.

OBJECTIVE: Most surgeons employ an endovascular-first approach to the treatment of peripheral arterial disease (PAD), but controversy remains regarding the ideal interventions for the management of isolated popliteal artery disease (IPAD). Indeed, there are a paucity of data that compare outcomes of popliteal stents vs other peripheral vascular interventions (PVIs). The goal of this study was to evaluate outcomes of PVIs in IPAD. METHODS: The Vascular Study Group of New England database was queried for all IPAD PVIs performed for atherosclerotic occlusive disease from 2010 to 2021. Those with at least 1 year of follow-up data available were included for analysis. The primary endpoint was 1-year freedom from a composite target lesion (TL) treatment failure that included restenosis >50% on duplex, reintervention, or ipsilateral major amputation. RESULTS: We included 689 procedures performed on 634 patients. Of these, 250 (36.3%) were treated with plain balloons (POBA), 215 (31.2%) had stents, 170 (24.7%) had special balloons (drug-coated, cutting, or lithotripsy), and 54 (7.8%) atherectomies were performed. Stent placement was associated with lower freedom from TL treatment failure (72.6%) than special balloon (81.2%; P = .048) and atherectomy (88.9%; P = .012), but not POBA (76.8%; P = .293). On multivariable logistic regression, stents (odds ratio, 0.637; P = .021) and preoperative P2Y12 inhibitor therapy (odds ratio, 0.683; P = .048) were both associated with lower freedom from intervention failure. CONCLUSIONS: Popliteal stent placement is associated with a higher rate of TL treatment failure at 1 year when compared with other PVIs including special balloon angioplasty and atherectomy, but not POBA, and should therefore be avoided in favor of special balloons or atherectomy whenever feasible.

Characteristics and Outcomes of Patients Undergoing Infrainguinal Bypass in the Endovascular Era.

BACKGROUND: The Society for Vascular Surgery (SVS) developed objective performance goals (OPGs) for lower extremity bypass (LEB) in chronic limb-threatening ischemia (CLTI) based on studies that included patients who were at good risk for open revascularization. In the endovascular era, many LEB patients have had prior interventions, and most would be considered high-risk by the original SVS OPG standards. The goal of this study is to characterize a contemporary patient population undergoing LEB for CLTI and determine if outcomes remain commensurate with the parameters established by the SVS OPG. MATERIALS AND METHODS: All patients who underwent LEB for CLTI over a 10-year period (2012-2021) were identified. Patients were stratified into low- and high-risk categories based upon the clinical, conduit, and anatomic parameters used in the SVS OPG. Limb salvage at 1 year and amputation-free survival, a composite outcome of major amputation and mortality, at 1 year were compared with the SVS OPG cohort. Primary, assisted, and secondary patency at 1 and 3 years were also evaluated using Kaplan-Meier survival analysis. RESULTS: There were 169 LEBs performed for CLTI. One hundred and two (60.36%) males, 101 (59.76%) current or former smokers, 115 (68.05%) with hypertension, 69 (40.83%) with diabetes mellitus, and 40 (23.67%) with coronary artery disease. Median age was 71.84 years, and mean follow-up was 2.17 years. 65 (38.46%) had a prior ipsilateral endovascular intervention, and 18 (10.65%) were redo bypasses. 21 (12.43%) were deemed clinically high-risk, 44 (26.04%) were high-risk conduits, and 118 (69.82%) had high-risk anatomic factors. Freedom from amputation at 1 year was 87.05% in this cohort which was similar to the overall SVS OPG cohort (88.9%). Amputation-free survival at 1 year was 77.78%, which was also similar to the overall SVS OPG cohort (76.5%). Primary patency at one and three years was 46.84% and 37.59%, assisted patency at one and three years was 61.87% and 44.81%, and secondary patency at one and three years was 72.13% and 61.16%. CONCLUSIONS: The majority of patients undergoing LEB in the endovascular era meet the SVS OPG criteria for high risk. Despite this, the 1-year limb salvage and amputation-free survival in this cohort were equivalent to the SVS OPG LEB cohort. This supports the continued use of LEB for limb salvage in high-risk patients and those who have failed endovascular approaches.

Giant Bilobed Hepatic Artery Aneurysm with Occlusion of the Celiac Axis: Repair Using a Bifurcated Graft.

Hepatic artery aneurysms are uncommon, with fewer than 500 cases noted in the literature. Bilobed hepatic artery aneurysms are extremely rare, with no documented cases in the literature. Although often asymptomatic, these visceral aneurysms are at high risk of rupture. We present an interesting case report of a bilobed hepatic artery aneurysm with occlusion of the celiac axis in a 72-year-old woman. She was asymptomatic at the time of presentation, and diagnosis was made on computerized tomography scan. She was not a candidate for endovascular repair due to the anatomy of the aneurysm and a chronically occluded celiac artery origin. Surgical repair using a bifurcated graft with ligation of the gastroduodenal artery was performed.

Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: management of asymptomatic disease and claudication.

Peripheral arterial disease (PAD) continues to grow in global prevalence and consumes an increasing amount of resources in the United States health care system. Overall rates of intervention for PAD have been rising steadily in recent years. Changing demographics, evolution of technologies, and an expanding database of outcomes studies are primary forces influencing clinical decision making in PAD. The management of PAD is multidisciplinary, involving primary care physicians and vascular specialists with varying expertise in diagnostic and treatment modalities. PAD represents a broad spectrum of disease from asymptomatic through severe limb ischemia. The Society for Vascular Surgery Lower Extremity Practice Guidelines committee reviewed the evidence supporting clinical care in the treatment of asymptomatic PAD and intermittent claudication (IC). The committee made specific practice recommendations using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) system. There are limited Level I data available for many of the critical questions in the field, demonstrating the urgent need for comparative effectiveness research in PAD. Emphasis is placed on risk factor modification, medical therapies, and broader use of exercise programs to improve cardiovascular health and functional performance. Screening for PAD appears of unproven benefit at present. Revascularization for IC is an appropriate therapy for selected patients with disabling symptoms, after a careful risk-benefit analysis. Treatment should be individualized based on comorbid conditions, degree of functional impairment, and anatomic factors. Invasive treatments for IC should provide predictable functional improvements with reasonable durability. A minimum threshold of a >50% likelihood of sustained efficacy for at least 2 years is suggested as a benchmark. Anatomic patency (freedom from restenosis) is considered a prerequisite for sustained efficacy of revascularization in IC. Endovascular approaches are favored for most candidates with aortoiliac disease and for selected patients with femoropopliteal disease in whom anatomic durability is expected to meet this minimum threshold. Conversely, caution is warranted in the use of interventions for IC in anatomic settings where durability is limited (extensive calcification, small-caliber arteries, diffuse infrainguinal disease, poor runoff). Surgical bypass may be a preferred strategy in good-risk patients with these disease patterns or in those with prior endovascular failures. Common femoral artery disease should be treated surgically, and saphenous vein is the preferred conduit for infrainguinal bypass grafting. Patients who undergo invasive treatments for IC should be monitored regularly in a surveillance program to record subjective improvements, assess risk factors, optimize compliance with cardioprotective medications, and monitor hemodynamic and patency status.

The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on wound, ischemia, and foot infection (WIfI).

Critical limb ischemia, first defined in 1982, was intended to delineate a subgroup of patients with a threatened lower extremity primarily because of chronic ischemia. It was the intent of the original authors that patients with diabetes be excluded or analyzed separately. The Fontaine and Rutherford Systems have been used to classify risk of amputation and likelihood of benefit from revascularization by subcategorizing patients into two groups: ischemic rest pain and tissue loss. Due to demographic shifts over the last 40 years, especially a dramatic rise in the incidence of diabetes mellitus and rapidly expanding techniques of revascularization, it has become increasingly difficult to perform meaningful outcomes analysis for patients with threatened limbs using these existing classification systems. Particularly in patients with diabetes, limb threat is part of a broad disease spectrum. Perfusion is only one determinant of outcome; wound extent and the presence and severity of infection also greatly impact the threat to a limb. Therefore, the Society for Vascular Surgery Lower Extremity Guidelines Committee undertook the task of creating a new classification of the threatened lower extremity that reflects these important considerations. We term this new framework, the Society for Vascular Surgery Lower Extremity Threatened Limb Classification System. Risk stratification is based on three major factors that impact amputation risk and clinical management: Wound, Ischemia, and foot Infection (WIfI). The implementation of this classification system is intended to permit more meaningful analysis of outcomes for various forms of therapy in this challenging, but heterogeneous population.

Prosthetic graft infections involving the femoral artery.

BACKGROUND: Prosthetic graft infection is a major complication of peripheral vascular surgery. We investigated the experience of a single institution over 10 years with bypass grafts involving the femoral artery to determine the incidence and risk factors for prosthetic graft infection. METHODS: A retrospective cohort single-institution review of prosthetic bypass grafts involving the femoral artery from 2001 to 2010 evaluated patient demographics, body mass index, comorbidities, indications, location of bypass, type of prosthetic material, case urgency, and previous ipsilateral bypass or percutaneous interventions and evaluated the incidence of graft infections, amputations, and mortality. RESULTS: There were 496 prosthetic grafts identified with a graft infection rate of 3.8% (n = 19) at a mean follow-up of 27 months. Multivariable analysis showed that redo bypass (hazard ratio [HR], 5.8; 95% confidence interval [CI], 2.2-15.0), active infection at the time of bypass (HR, 5.2; 95% CI, 1.9-14.2), female gender (HR, 4.5; 95% CI, 1.6-12.7), and diabetes mellitus (HR, 4.6; 95% CI, 1.5-14.3) were significant predictors of graft infection. Graft infection was predictive of major lower extremity amputation (HR, 9.8; 95% CI, 3.5-27.1), as was preoperative tissue loss (HR, 4.7; 95% CI, 1.8-11.9). Graft infection did not predict long-term mortality; however, chronic renal insufficiency (HR, 2.3; 95% CI, 1.6-3.4), tissue loss (HR, 1.4; 95% CI, 1.0-1.9), and active infection (HR, 2.3; 95% CI, 1.6-3.4) did. Infected grafts were removed 79% of the time. Staphylococcus epidermidis (37%) and methicillin-sensitive Staphylococcus aureus (26%) were the most common pathogens isolated. CONCLUSIONS: Redo bypass, female gender, diabetes, and active infection at the time of bypass are associated with a higher risk for prosthetic graft infection and major extremity amputation but do not confer an increased risk of mortality. Autologous vein for lower extremity bypass and endovascular interventions should be considered when feasible in high-risk patients.

Endovascular vs open repair for ruptured abdominal aortic aneurysm.

OBJECTIVE: Endovascular repair (EVAR) of ruptured abdominal aortic aneurysm (rAAA) has become first-line therapy at our institution and is performed under a standardized protocol. We compare perioperative mortality, midterm survival, and morbidity after EVAR and open surgical repair (OSR). METHODS: Records were retrospectively reviewed from May 2000 to September 2010 for repair of infrarenal rAAAs. Primary end points included perioperative mortality and midterm survival. Secondary end points included acute limb ischemia, length of stay, ventilator-dependent respiratory failure, myocardial infarction, renal failure, abdominal compartment syndrome, and secondary intervention. Statistical analysis was performed using the t-test, χ(2) test, the Fisher exact test, and logistic regression calculations. Midterm survival was assessed with Kaplan-Meier analysis and Cox proportional hazard models. RESULTS: Seventy-four infrarenal rAAAs were repaired, 19 by EVAR and 55 by OSR. Despite increased age and comorbidity in the EVAR patients, perioperative mortality was 15.7% for EVAR, which was significantly lower than the 49% for OSR (odds ratio, 0.19; 95% CI, 0.05-0.74; P = .008). Midterm survival also favored EVAR (hazard ratio, 0.40; 95% CI, 0.21-0.77; P = .028, adjusted for age and sex). Mean follow-up was 20 months, and 1-year survival was 60% for EVAR vs 45% for OSR. Mean length of stay for patients surviving >1 day was 10 days for EVAR and 21 days for OSR (P = .004). Ventilator-dependent respiratory failure was 5% in the EVAR group vs 42% for OSR (odds ratio, 0.08; 95% CI, 0.01-0.62; P = .001). CONCLUSIONS: EVAR of rAAA has a superior perioperative survival advantage and decreased morbidity vs OSR. Although not statistically significant, overall survival favors EVAR. We recommend that EVAR be considered as the first-line treatment of rAAAs and practiced as the standard of care.

The impact of endovascular procedures on fellowship training in lower extremity revascularization.

OBJECTIVE: The introduction of endovascular aneurysm repair has resulted in a decline in open abdominal aortic aneurysm repairs performed by vascular residents. The purpose of this study was to evaluate if a similar trend has occurred with open lower extremity revascularization procedures, with increased endovascular procedures producing a decrease in the number of open lower extremity revascularizations. Furthermore, this study evaluates the effect of endovascular procedure volume on the frequency of subtypes of open lower extremity procedures performed. METHODS: The total number of vascular procedures, lower extremity bypasses, and endovascular interventions from 2000 to 2010 were analyzed from case logs of vascular residents as reported by the Accreditation Council for Graduate Medical Education. RESULTS: The average number of cases performed by vascular residents has increased by 150% from 463.9 in 2000 to 1168 in 2009, due to the increased number of endovascular procedures. The average number of endovascular revascularizations has increased by 317% from 40.5 performed in 2000 to 168.9 in 2009. Femoral-popliteal bypasses have increased in frequency by 27% whereas the number of infrapopliteal bypass has remained unchanged. The largest difference is seen in femoral endarterectomies with a 234% increase from 3.2 per resident in 2001 to 10.7 per resident in 2010. Comparison of the proportion of femoral-popliteal and tibioperoneal interventions performed by angioplasty or bypass after 2007 revealed that endovascular interventions comprise 50% of procedures in the femoral-popliteal distribution, whereas 65% of infrapopliteal interventions are still performed using open techniques. CONCLUSIONS: The number of procedures performed during vascular residency has dramatically increased over the last decade secondary to the increased number of endovascular procedures. The average vascular surgery resident's open operative experience has been stable over the last 10 years, despite the increasing endovascular case volume. Residents perform femoral endarterectomy with increasing frequency, perhaps representing an increasing volume of hybrid procedures. Gaps in information available for evaluating resident training remain a significant obstacle. Moving forward, revision of the current reporting system to a format that more accurately reflects resident experience would be beneficial.

Results for primary bypass versus primary angioplasty/stent for intermittent claudication due to superficial femoral artery occlusive disease.

BACKGROUND: Percutaneous transluminal angioplasty ± stent (PTA/S) and surgical bypass are both accepted treatments for claudication due to superficial femoral artery (SFA) occlusive disease. However, long-term results comparing these modalities for primary intervention in patients who have had no prior intervention have not been reported. We report our results with 3-year follow-up. METHODS: We reviewed all lower extremity bypass procedures at Beth Israel Deaconess Medical Center from 2001 through 2009 and all PTA/S performed from 2005 through 2009 for claudication. We excluded all limb salvage procedures and included only those that were undergoing their first intervention for claudication due to SFA disease. We recorded patient demographics, comorbidities, perioperative medications, TASC classification, and runoff. Outcomes included complications, restenosis, symptom recurrence, reinterventions, major amputation, and mortality. RESULTS: We identified 113 bypass grafts and 105 PTA/S of femoral-popliteal lesions without prior interventions. Bypasses were above the knee in 62% (45% vein) and below the knee in 38% (100% vein). Mean age was 63 (bypass) versus 69 (PTA/S; P < .01). Mean length of stay (LOS) was 3.9 versus 1.2 days (P < .01). Bypass grafts were used less for TASC A (17% vs 40%; P < .01) and more for TASC C (36% vs 11%; P < .01) and TASC D (13% vs 3%; P < .01) lesions. There were no differences in perioperative (2% vs 0%; not significant [NS]) or 3-year mortality (9% vs 8%; NS). Wound infection was higher with bypass (16% vs 0%; P < .01). None involved grafts. Bypass showed improved freedom from restenosis (73% vs 42% at 3 years; hazard ratio [HR], 0.4; 95% confidence interval [CI], .23-.71), symptom recurrence (70% and 36% at 3 years; HR, 0.37; 95% CI, .2-.56), and freedom from symptoms at last follow-up (83% vs 49%; HR, 0.18; 95% CI, .08-.40). There was no difference in freedom from reintervention (77% vs 66% at 3 years; NS). Multivariable analysis of all patients showed that restenosis was predicted by PTA/S (HR, 2.5; 95% CI, 1.4-4.4) and TASC D (HR, 3.7; 95% CI, 3.5-9) lesions. Recurrence of symptoms was similarly predicted by PTA/S (HR, 3.0; 95% CI, 1.8-5) and TASC D lesions (HR, 3.1; 95% CI, 1.4-7). Statin use postoperatively was predictive of patency (HR, 0.6; 95% CI, .35-.97) and freedom from recurrent symptoms (HR, 0.6; 95% CI, .36-.93). CONCLUSIONS: Surgical bypass for the primary treatment of claudication showed improved freedom from restenosis and symptom relief despite treatment of more extensive disease, but was associated with increased LOS and wound infection. Statins improved freedom from restenosis and symptom recurrence overall.

Thirty-day mortality and late survival with reinterventions and readmissions after open and endovascular aortic aneurysm repair in Medicare beneficiaries.

OBJECTIVES: Late survival is similar after open and endovascular abdominal aortic aneurysm (AAA) repair (EVAR), despite a perioperative benefit with EVAR. AAA-related reinterventions are more common after EVAR, whereas laparotomy-related reinterventions are more common after open repair. The effect of reinterventions on survival, however, is unknown. We therefore evaluated the rate of reinterventions and readmission after initial AAA repair, 30-day mortality, and the effect on long-term survival. METHODS: We identified AAA-related and laparotomy-related reinterventions for propensity score-matched cohorts of 45,652 Medicare beneficiaries undergoing EVAR and open repair from 2001 to 2004. Follow-up was up to 6 years. Hospitalizations for ruptured AAA without repair and for bowel obstruction or ventral hernia without abdominal surgery were also recorded. Event rates were calculated per year and are presented through 6 years of follow-up as events per 100 person-years. Thirty-day mortality was calculated for each reintervention or readmission. RESULTS: Through 6 years, overall reinterventions or readmissions were similar between repair methods but slightly more common after EVAR (7.6 vs 7.0/100 person-years; relative risk [RR], 1.1; P < .001). Overall 30-day mortality with any reintervention or readmission was 9.1%. EVAR patients had more ruptures (0.50 vs 0.09 [RR, 5.7; P < .001]), with a mortality of 28%, but these were uncommon. EVAR patients also had more AAA-related reinterventions through 6 years (3.7 vs 0.9 [RR, 4.0; P < .001]; mortality, 5.6%), most of which were minor endovascular reinterventions (2.4 vs 0.2 [RR, 11.4; P < .001]), with a 30-day mortality of 3.0%. However, minor open (0.8 vs 0.5 [RR, 1.4; P < .001]; mortality, 6.9%) and major reinterventions (0.4 vs 0.2 [RR, 2.4; P < .001]; mortality, 12.1%) were also more common after EVAR than open repair. Conversely, EVAR patients had fewer laparotomy-related reinterventions than open patients (1.4 vs 3.0 [RR, 0.5; P < .001]; mortality, 8.1%) and readmissions without surgery (2.0 vs 2.7 [RR, 0.7; P < .001]; mortality 10.9%). Overall, reinterventions or readmission accounted for 9.6% of all EVAR deaths and 7.6% of all open repair deaths in the follow-up period (P < .001). CONCLUSIONS: Reintervention and readmission are slightly higher after EVAR. Survival is negatively affected by reintervention or readmission after EVAR and open surgery, which likely contributes to the erosion of the survival benefit of EVAR over time.

A long-term survival score improves preoperative prediction of survival following major vascular surgery.

BACKGROUND: In a previous study it has been shown that a long-term survival score (LTSS), composed of Lee's Revised Cardiac Risk Index (RCRI) criteria supplemented by age, preoperative electrocardiography (EKG) features, and all types of diabetes to the RCRI criteria, predicts long-term (3-15 years) survival after major vascular surgery. The present study aimed to investigate the performance of LTSS in predicting earlier survival (3 months-3 years) as compared with the RCRI. METHODS: Data from 921 consecutive patients undergoing major vascular surgery (624 patients at Hadassah Medical Center [HMC] and 296 patients in Beth Israel Deaconess Medical Center [BIDMC]) were collected retrospectively. The LTSS was seven points that included the five RCRI factors as well as age >65 years and ST-segment depression on preoperative EKG. Logistic regression and receiver operating characteristic curve (ROC) curve analyses were used to compare the 3 months-3 years mortality between the RCRI and LTSS. RESULTS: The Beth Israel Deaconess Medical Center patients were sicker than the Hadassah Medical Center patients, with higher RCRI (1.2 ± 1.0 vs. 0.81 ± 0.83, p < 0.001) and LTSS (2.6 ± 1.4 vs. 1.7 ± 1.2, p < 0.001) and higher 3-years mortality (36.3% vs. 20.7%, p = 0.005). The LTSS predicted mortality better than RCRI as measured by the area under the ROC curves at all time points between 6 months (0.66 ± 0.03 vs. 0.57 ± 0.04, p = 0.02) and 3 years (0.70 ± 0.02 vs. 0.61 ± 0.02, p < 0.0001) in both institutions, but not 3-months mortality. The LTSS also provided better discrimination between each adjacent two-risk score than the RCRI. CONCLUSIONS: Age >65 years, ST-segment depression on preoperative 12-lead EKG, and all types of diabetes added to the RCRI significantly improved the preoperative prediction of mortality after 6 months following major vascular surgery.

The impact of body mass index on perioperative outcomes of open and endovascular abdominal aortic aneurysm repair from the National Surgical Quality Improvement Program, 2005-2007.

OBJECTIVES: Obesity and morbid obesity have been shown to increase wound infections and occasionally mortality after many surgical procedures. Little is known about the relative impact of body mass index (BMI) on these outcomes after open (OAR) and endovascular abdominal aortic aneurysm repair (EVAR). METHODS: The 2005-2007 National Surgical Quality Improvement Program (NSQIP), a multi-institutional risk-adjusted database, was retrospectively queried to compare perioperative mortality (in-hospital or 30-day) and postoperative wound infections after OAR and EVAR. Patient demographics, comorbidities, and operative details were analyzed. Obesity was defined as a BMI >30 kg/m(2) and morbid obesity as a BMI >40 kg/m(2). Outcomes were compared with t test, Wilcoxon rank sum, χ(2), and multivariate logistic regression. RESULTS: There were 2097 OARs and 3358 EVARs. Compared with EVAR, OAR patients were younger, more likely to be women (26% vs 17%, P < .001), and less obese (27% vs 32%, P < .001). Mortality was 3.7% after OAR vs 1.2% after EVAR (risk ratio, 3.1; P < .001), and overall morbidity was 28% vs 12%, respectively (relative risk, 2.3; P < .001). Morbidly obese patients had a higher mortality for both OAR (7.3%) and EVAR (2.4%) than obese patients (3.9% OAR; 1.5% EVAR) or nonobese patients (3.7% OAR; 1.1% EVAR). Obese patients had a higher rate of wound infection vs nonobese after OAR (6.3% vs 2.4%, P < .001) and EVAR (3.3% vs 1.5%, P < .001). Morbid obesity predicted death after OAR but not after EVAR, and obesity was an independent predictor of wound infection after OAR and EVAR. CONCLUSIONS: Morbid obesity confers a worse outcome for death after abdominal aortic aneurysm repair. Obesity is also a risk factor for infectious complications after OAR and EVAR. Obese patients and, particularly, morbidly obese patients should be treated with EVAR when anatomically feasible.

Stroke and death after carotid endarterectomy and carotid artery stenting with and without high risk criteria.

OBJECTIVE: Centers for Medicare and Medicaid Services (CMS) reimbursement criteria for carotid artery stenting (CAS) require that patients be high surgical risk or enrolled in a clinical trial. This may bias comparisons of CAS and carotid endarterectomy (CEA). We evaluate mortality and stroke following CAS and CEA stratified by medical high risk criteria. METHODS: The Nationwide Inpatient Sample (2004-2007) was queried by ICD-9 code for CAS and CEA with diagnosis of carotid artery stenosis. Medical high risk criteria were identified for each patient including patients undergoing a coronary artery bypass and/or valve repair (CABG/V) during the same admission. Symptom status was defined by history of stroke, transient ischemic attack (TIA), and/or amarosis fugax. The primary outcome was postoperative death, stroke (complication code 997.02), and combined stroke or death, stratified by high risk vs non-high risk status and symptom status. RESULTS: Patient totals of 56,564 (10.5%) CAS and 482,394 (89.5%) CEA were identified. Half of the patients in each group were high risk. CABG/V was performed less commonly with CAS than CEA (2.8% vs 4.0%, P < .001). Patients undergoing CAS were more likely symptomatic than those undergoing CEA (13.1% vs 9.4%, P < .001). Mortality was higher after CAS than CEA for both high risk and non-high risk patients. Stroke was also higher after CAS for both high risk and non-high risk patients. Combined stroke or death was higher after CAS again for both high risk (asymptomatic 1.5% vs 1.2%, P < .05, symptomatic 14.4% vs 6.9%, P < .001) and non-high risk (asymptomatic 1.8% vs 0.6%, P < .001, symptomatic 11.8% vs 4.9%, P < .001). Combined stroke or death for patients undergoing CABG/V during the same admission was similar for CAS and CEA (4.8% vs 3.2%, P = .19). Multivariate predictors of combined stroke or death adjusted for age and gender included CAS vs CEA (odds ratio [OR] 2.4, P < .001), symptom status (OR 6.8, P < .001), high risk (OR 1.6, P < .001), and earlier year of procedure (OR 1.1, P < .01). CONCLUSIONS: In the United States from 2004 to 2007, CAS has a higher risk of stroke and death than CEA after adjustment for medical high risk criteria. Further analysis with prospective assessment of risk factors is needed to guide appropriate patient selection for CEA and CAS in the general population.

Body mass index: surgical site infections and mortality after lower extremity bypass from the National Surgical Quality Improvement Program 2005-2007.

BACKGROUND: Patients undergoing lower extremity bypass are at high risk for surgical site infections (SSI). We examined lower extremity bypasses by graft origin and body mass index (BMI) classification to analyze differences in postoperative mortality and SSI occurrence. METHODS: The 2005-2007 National Surgical Quality Improvement Program (NSQIP), a multi-institutional risk-adjusted database, was queried to compare perioperative mortality (30-day), overall morbidity, and SSIs after lower extremity arterial bypass for peripheral arterial disease. Bypass was stratified by graft origin as aortoiliac, femoral, or popliteal. Patient demographics, comorbidities, operative, and postoperative occurrences were analyzed. RESULTS: There were 7,595 bypasses performed (1,596 aortoiliac, 5,483 femoral, and 516 popliteal). Mortality was similar regardless of bypass origin (2.8%, 2.4%, and 2.7%; p = 0.57). SSIs occurred in 11% of overall cases (10%, 11%, and 11%; p = 0.47). Graft failure was significantly associated with postoperative SSI occurrence (odds ratio [OR] = 2.4, 95% confidence interval [CI] 1.9-3.1, p < 0.001), as was postoperative sepsis (OR = 6.5, 95% CI 5.1-8.3, p < 0.001). Independent predictors of mortality were age, aortoiliac bypass origin, underweight, normal weight, morbid obesity (compared to overweight and obese), end-stage renal disease, poor preoperative functional status, preoperative sepsis, chronic obstructive pulmonary disease, hypoalbuminemia, and cardiac disease. Independent predictors of SSI were obesity, diabetes, poor preoperative functional status, a history of smoking, and female gender. CONCLUSION: SSIs occur frequently after lower extremity bypass regardless of bypass origin and are associated with early graft failure and sepsis. Obesity predicts postoperative SSI. Mortality risk was greatest in the underweight, followed by morbidly obese and normal-weight patients, while overweight and mild to moderate obesity were associated with the lowest mortality.

National outcomes after open repair of abdominal aortic aneurysms with visceral or renal bypass.

BACKGROUND: We evaluated national outcomes after open repair of abdominal aortic aneurysms (AAAs) with visceral or renal bypass (VRB). METHODS: Using the National Inpatient Sample database from 1993 through 2006, AAA repairs were identified by ICD9 codes for diagnosis of intact AAA combined with a procedure of open AAA repair. VRB patients also had an aortorenal and/or mesenteric bypass or mesenteric endarterectomy. Dissections as well as thoracic and thoracoabdominal aneurysms were excluded. Demographics and comorbidities were noted. Mortality and complications were compared to infrarenal AAA (IRA) repairs without VRB. Predictors of perioperative mortality were analyzed by multivariate logistic regression. RESULTS: A total of 41,166 VRB and 362,808 IRA repairs were identified. VRB repair volume decreased by 58% and IRA volume decreased by 59% from 1993 to 2006. VRB patients had higher mortality (5.8% vs. 4.4%, p < 0.001) and more complications including acute renal failure (9.5% vs. 6.0%, p < 0.001), acute mesenteric ischemia (2.0% vs. 1.2%), and bowel resection (1.1% vs. 0.8%, p < 0.01). Patients requiring a bowel resection or with acute renal failure were 10 times more likely to die within the hospital stay regardless of repair type. Independent preoperative predictors of mortality were VRB (odds ratio [OR] = 1.3, 95% confidence interval [CI] 1.2-1.5), age (OR = 1.4 per decade, 95% CI 1.4-1.5), chronic renal failure (OR = 5.5, 95% CI 4.9-6.3), congestive heart failure (OR = 7.5, 95% CI 6.1-9.3), and pulmonary disease (OR = 1.2, 95% CI 1.1-1.2). CONCLUSION: VRB repair volume decreased per year similarly to open IRA repair volume and may be related to increasing use of endovascular therapy. Mortality after VRB is high and dependent upon age, renal failure, and congestive heart failure. Overall, VRB repair was associated with worsened outcomes; however, this study cannot conclude that avoiding such a repair will improve outcomes. This should be factored into surgical decision making for these patients.

Predictors of failure after angioplasty of infrainguinal vein bypass grafts.

OBJECTIVE: Percutaneous transluminal angioplasty (PTA) has had an expanding role as primary therapy for vein graft stenosis with variable results. The aim of this study is to identify patient and graft characteristics predictive of failure after PTA of infrainguinal vein grafts. METHODS: Retrospective review from Jan 2004 to Mar 2007 of patients undergoing angioplasty for failing grafts. Demographics, comorbidities, procedural data, and follow-up information were recorded. PTA failure was defined as first significant event including restenosis by duplex scan (>3.5 x velocity ratio), occlusion, redo-PTA, surgical revision, or amputation. Descriptive, logistic regression and life-table analyses were performed. RESULTS: Eighty-seven grafts in 79 patients underwent PTA. Mean age was 70 years (median 70; range, 39-89 years), 71% were male and 52% were symptomatic (40% with limb-threat). Mean follow-up was 17 months (median 17.4; range, 0.03-39.8 months). Freedom from PTA failure was 58% (standard error [SE] 0.0574) at 12 months. Predictors of PTA failure by multivariate analysis were: time from bypass <3 months (hazard ratio [HR] 5.8; 95% confidence interval [CI] 1.91-18.0; P = .002), stenosis length >2 cm (HR 2.7; 95% CI 1.33-5.83; P = .007) and multiple stenoses (HR 2.5; 95% CI 1.29-5.1; P = .007). PTA patency for grafts with favorable lesions (single, less than 2 cm lesions in grafts older than 3 months) was 71% vs 35% for unfavorable lesions at 12 months. Limb-salvage was 95% and 90% and overall survival was 92% and 81% at 12 and 24 months, respectively. CONCLUSION: PTA of failing infrainguinal vein grafts is a reasonable primary therapy for favorable lesions. Early graft stenosis, long, and multiple stenoses are markers for procedural failure and are better served with surgical revision.

Risk prediction for perioperative mortality of endovascular vs open repair of abdominal aortic aneurysms using the Medicare population.

OBJECTIVES: The impact of risk factors upon perioperative mortality might differ for patients undergoing open vs endovascular repair (EVAR) of abdominal aortic aneurysms (AAA). In order to investigate this, we developed a differential predictive model of perioperative mortality after AAA repair. METHODS: A total of 45,660 propensity score matched Medicare beneficiaries undergoing elective open or endovascular AAA repair from 2001 to 2004 were studied. Using half the dataset we developed a multiple logistic regression model for a matched cohort of open and EVAR patients and used this to derive an easily evaluable risk prediction score. The remainder of the dataset formed a validation cohort used to confirm results. RESULTS: The derivation cohort included 11,415 open and 11,415 endovascular repairs. Perioperative mortality was 5.3% and 1.8%, respectively. Independent predictors of mortality (relative risk [RR], 95% confidence interval [CI]) were open repair (3.2, 2.7-3.8); age (71-75 years 1.2, 0.9-1.6; 76-80 years 1.9, 1.4-2.5; >80 years 3.1, 2.4-4.2); female gender (1.5, 1.3-1.8); dialysis (2.6, 1.5-4.6); chronic renal insufficiency (2.0, 1.6-2.6); congestive heart failure (1.7, 1.5-2.1); and vascular disease (1.3, 1.2-1.6). There were no differential predictors of mortality across the two procedures. A simple scoring system was developed from a logistic regression model fit to both endovascular and open patients (area under the receiver operator curve [ROC] curve of 72.6) from which low, medium, and high risk groups were developed. The absolute predicted mortality ranged from 0.7% for an EVAR patient 80 with all the comorbidities considered. Although relative risk was similar among age groups, the absolute difference was greater for older patients (with higher baseline risk). CONCLUSION: Mortality after AAA repair is predicted by comorbidities, gender, and age, and these predictors have similar effects for both methods of AAA repair. This simple scoring system can predict repair mortality for both treatment options and thus may help guide clinical decisions.

Endoluminal intervention for limb salvage after failed lower extremity bypass graft.

BACKGROUND: Lower extremity bypass graft failure in patients with limb-threatening ischemia carries an amputation rate of greater than 50%. Redo bypass is often difficult due to the lack of conduit, adequate target, or increased surgical risk, and resultant limb salvage rates are reduced significantly compared with the index operation. We set forth to investigate whether endovascular treatment in this setting would result in an acceptable limb salvage rate. METHODS: A single-institution, retrospective review from June 2004 to December 2007 of patients with failed grafts who underwent endovascular treatment with percutaneous balloon angioplasty (PTA) of their native circulation was performed. Stents were selectively used in cases of post-PTA residual stenosis or flow-limiting dissection. Technical success was defined as a residual stenosis less than 30%. Percutaneous attempts at bypass graft salvage were excluded. Demographics, comorbidities, procedural data, and follow-up information were recorded. Descriptive, logistic regression and life-table analyses were performed. RESULTS: Twenty-four lower extremities were treated in 23 patients with failed bypass grafts. Average patency of the index graft before failure was 647 days (range 5-2758). Mean age was 68 years (range 51-85), 62% were male and 81% had diabetes mellitus (DM). 87.5% of limbs treated had TransAtlantic InterSociety Consensus (TASC) C and D lesions and 62% had multiple lesions. Technical success was achieved in 100%. Mean follow-up was 25.6 months. At follow-up, there were 17 PTA failures, which resulted in: amputation (4), redo-bypass (3), and redo-PTA (11). Freedom from surgical revision and PTA failure was 89% (+/- 0.07 SE) and 28% (+/- 0.09 SE) respectively. PTA secondary patency was 72% (+/- 0.09 SE) and limb-salvage was 81% (+/- 0.08 SE) at both 12 and 24 months. Overall survival was 83% (+/- 0.07 SE) and 77% (+/- 0.09 SE) at 12 and 24 months, respectively. CONCLUSIONS: Endovascular treatment of patients with previously failed bypass grafts results in a high rate of limb salvage. This is a reasonable option in selected patients and the primary choice in those with poor targets, conduit, or excess surgical risk. Endovascular salvage should be considered before proceeding to primary amputation.

Mesenteric revascularization: management and outcomes in the United States, 1988-2006.

BACKGROUND: Recent reports have suggested that angioplasty, with and without stenting (PTA/S), may have a lower perioperative mortality rate than open surgery for revascularization of acute (AMI) and chronic mesenteric ischemia (CMI). It is unclear if there has been nationwide adoption of this methodology or whether there is actually a mortality benefit. METHODS: We identified all patients undergoing surgical (bypass, endarterectomy, or embolectomy) or PTA/S mesenteric revascularization from the Nationwide Inpatient Sample from 1988 to 2006. A diagnosis by International Classification of Diseases, 9th Revisioncoding of AMI or CMI was required for inclusion. We evaluated trends in management during this period and compared in-hospital death and complications between surgical bypass and PTA/S for the years 2000 to 2006. RESULTS: From 1988 to 2006, there were 6342 PTA/S and 16,071 open surgical repairs overall. PTA/S increased steadily, surpassing all surgery for CMI in 2002. PTA/S for AMI has also increased and surpassed bypass in 2002 but has not surpassed all surgical procedures for AMI even in 2006. The mortality rate was lower after PTA/S than after bypass for CMI (3.7% vs 13%, P < .01) and AMI (16% vs 28%, P < .01). Bowel resection was more common after bypass than PTA/S for CMI (7% vs 3%, P < .01). This subgroup showed an increased in-hospital mortality rate for both repair types (54% and 25%, respectively). CONCLUSION: PTA/S is being used with increasing frequency for revascularization of CMI and AMI. The lower in-hospital mortality rate for patients, as they are currently being selected, shows that PTA/S is appropriate therapy for selected patients with CMI. Longitudinal data are needed to determine the durability of this benefit. The greater proportion of patients undergoing bowel resection with bypass for AMI suggests a more advanced level of ischemia in this group, making comparison with PTA/S difficult. However, PTA/S may be useful in selected patients with AMI and appropriate anatomy. Further data with greater detail regarding symptomatology and anatomy will clarify appropriate patient selection.