Transplant waitlisting attenuates the association between hemodialysis access type and mortality.

Prior studies have shown that beginning hemodialysis (HD) with a hemodialysis catheter (HC) is associated with worse mortality than with an arteriovenous fistula (AVF) or arteriovenous graft (AVG). We hypothesized that transplant waitlisting would modify the effect of HD access on mortality, given waitlist candidates' more robust health status. Using the US Renal Data System, we studied patients with incident ESRD who initiated HD between 2010 and 2015 with an AVF, AVG, or HC. We used Cox regression including an interaction term for HD access and waitlist status. There were 587,607 patients that initiated HD, of whom 82,379 (14.0%) were waitlisted for transplantation. Only 26,264 (4.5%) were transplanted. Among patients not listed, those with an AVF had a 34% lower mortality compared to HC [adjusted hazard ratio (aHR) 0.66, 95% confidence interval (CI) 0.65-0.67] while those with an AVG had a 21% lower mortality compared to HC (aHR 0.79, 95% CI 0.77-0.81). Transplant waitlisting attenuated the association between hemodialysis access type and mortality (interaction p < 0.001 for both AVF and AVG vs. HC). Among patients on the waitlist, those with an AVF had a 12% lower mortality compared to HC (aHR 0.88, 95% CI 0.84-0.93), while those with an AVG had no difference in mortality (aHR 0.95, 95% CI 0.84-1.08). While all patients benefit from AVF or AVG over HC, the benefit was attenuated in waitlisted patients. Efforts to improve health status and access to healthcare for non-waitlisted ESRD patients might decrease HD-associated mortality and improve rates of AVF and AVG placement.

Trends of 30-day mortality and morbidities in endovascular repair of intact abdominal aortic aneurysm during the last decade.

OBJECTIVE: Significant research efforts have been made to improve the safety and efficacy of endovascular aneurysm repair (EVAR) in treating abdominal aortic aneurysm. This study aimed to examine the trends of perioperative outcomes of EVAR in the recent decade using a national validated database. METHODS: Patients who underwent EVAR for intact abdominal aortic aneurysm between 2006 and 2015 were identified from the National Surgical Quality Improvement Program and divided into early (2006-2010) and late (2011-2015) periods. The primary outcome of the study was 30-day mortality. Secondary outcomes included operative time, length of hospital stay, and 30-day major complications (renal, cardiopulmonary, and wound infection). RESULTS: A total of 30,076 patients were identified, with 11,539 in the early period and 18,537 in the late period. The 30-day mortality was kept at a low level in both periods (1.2% vs 1.2%; P = .98), whereas both the mean operation time (155.5 ± 72.6 minutes vs 141.9 ± 73.7 minutes; P < .001) and length of hospital stay (3.24 ± 5.32 days vs 2.81 ± 4.30 days; P < .001) were decreased in the late period. The 30-day major complication rate was reduced by 19.6% (5.1% vs 4.1%; P < .0001), with decreased renal failure (1.4% vs 1.0%; P = .003), cardiopulmonary complications (2.2% vs 1.7%; P = .006), and wound complications (2.5% vs 1.8%; P < .001). All the decreasing trends of mortality, any 30-day complication, and each type of major complication were statistically significant. Being treated in the late period was independently associated with decreased 30-day major complications (odds ratio, 0.75; 95% confidence interval, 0.65-0.87; P < .001), and this effect was confirmed in the propensity score-matched cohort (odds ratio, 0.76; 95% confidence interval, 0.66-0.90; P < .001). CONCLUSIONS: Although the 30-day mortality remains similar, postoperative complications in EVAR have decreased significantly during the recent decade. The continuous improvement in endograft technology and surgical skills has resulted in decreased operative time, marked reduction in surgical complications, and shorter hospital length of stay after endovascular repair.

Comparison of the Cost of Drug-Eluting Stents versus Bare Metal Stents in the Treatment of Critical Limb Ischemia in the United States.

BACKGROUND: Despite significant technical advancement in the last decade, the durability of endovascular management of critical limb ischemia (CLI) remains highly debatable. Drug-eluting stents (DESs) are being popularized for the management of CLI after its precedent success in coronary intervention. Initial reports on the durability of DES are promising. However, little is known on the additional cost of this relatively newer technology. The aim of this study is to compare the cost of the traditional bare metal stents (BMSs) to the newly introduced DES in a large cohort of CLI patients. METHODS: Using the Premier database (2009-2015), we identified all patients with CLI undergoing DES and BMS. A multivariable generalized linear model was implemented to examine in-hospital cost adjusting for patients' characteristics, comorbidities, and regional characteristics. RESULTS: A total of 20,702 patients with CLI underwent peripheral artery revascularization using BMS (18,924 [91.41%]) or DES (1,778 [8.6%]). Majority of patients were males (53%) and whites (71%). Patients undergoing BMS were slightly younger (median age [interquartile range]: 70 [62-79] versus 71 [63-80]) and were more likely to be smokers (46% vs. 39%) and have a history of cerebrovascular disease (10% vs. 8%) and chronic pulmonary disease (24.5% vs. 20.9%) as compared with those undergoing DES (all P < 0.05). On the other hand, DES patients had a high prevalence of diabetes (4% vs. 3%) and renal disease (25% vs. 22%) (both P < 0.05). There was also a significant increase in the proportion of patients undergoing DES and a corresponding decrease in BMS (P < 0.001) over the study period. Median total in-hospitalization cost (BMS: $13,342 [8,574 to 21,166], DES: $13,243 [8,560-20,232], P = 0.76) was similar for both approaches. After adjusting for potential confounders, DES was associated with $407 higher cost than BMS (adjusted mean difference [95% confidence interval]: 407 [17 to 798], P = 0.04). In addition, the cost was $672 higher in teaching hospitals, $1,153 higher in Rural areas, and increased in all regions compared with the Midwest (adjusted mean difference [95% confidence interval]-South: $293 [31 to 555], Northeast: $2,006 [1,517 to 2,495], West: $3,312 [2,930 to 3,695], all P < 0.05). CONCLUSIONS: In this large cohort of CLI patients, after controlling for potential confounders, we demonstrated that the cost of endovascular revascularization is significantly higher in patients undergoing DES than those undergoing BMS. Regional disparities in cost were also observed. Further studies looking at the long-term durability and costs of DES versus BMS are needed.

Aortic Surgery Outcomes of Marfan Syndrome and Ehlers-Danlos Syndrome Patients at Teaching and Nonteaching Hospitals.

BACKGROUND: Despite improvements in prevention and management, aortic aneurysm repair remains a high-risk operation for patients with Marfan syndrome (MFS) and Ehlers-Danlos syndrome (EDS). The goal of this study was to examine differences in characteristics and outcomes of patients with MFS or EDS undergoing aortic aneurysm repair at teaching versus nonteaching hospitals. METHODS: We used the National Inpatient Sample to study patients with MFS or EDS undergoing open or endovascular aortic aneurysm repair from 2000 to 2014. RESULTS: Of 3487 patients (MFS = 3375, EDS = 112), 2974 (85%) had repair at a teaching hospital. Patients who underwent repair at a teaching hospital were slightly younger than those who underwent repair at a nonteaching hospital (38 vs. 43 years, P < 0.01) but otherwise were similar in gender (29% vs. 28% female), race (70% vs. 78% white), and connective tissue disorder diagnosis (97% vs. 97% MFS, all P ≥ 0.1). There were no differences in anatomy (17% vs. 19% abdominal, 67% vs. 66% thoracic, and 15% vs. 15% thoracoabdominal, all P ≥ 0.1) or type of repair (5% vs. 5% endovascular), but patients at nonteaching hospitals were more likely to have a dissection (49% vs. 38%, P = 0.02). There was no difference in perioperative mortality (4% vs. 6%, P = 0.5) or length of stay (median 8 days vs. 7 days, P = 0.3) between teaching and nonteaching hospitals. There was also no difference in hemorrhagic (47% vs. 43%), pulmonary (9% vs. 16%), renal (12% vs. 14%), or neurologic (5% vs. 6%) complications between teaching and nonteaching hospitals, respectively (all P ≥ 0.05). In analysis stratified by anatomic extent of repair, there was a lower prevalence of pulmonary complications in thoracic aorta repairs at teaching hospitals (8.1% vs. 18.4%, P = 0.01) but a higher prevalence of hemorrhage in abdominal aortic repairs at teaching hospitals (45.6% vs. 20.6%, P = 0.04) as compared with nonteaching hospitals. CONCLUSIONS: Patients with MFS and EDS who undergo aortic aneurysm repair have their operations predominantly at teaching hospitals, but those patients who undergo repair at nonteaching hospitals do not have worse mortality or morbidity despite a higher incidence of dissection.

Use of a primary carotid stenting technique does not affect perioperative outcomes.

BACKGROUND: Primary carotid stenting (PCS) has been shown to be feasible and safe in small series, but real-world outcomes in a large multicenter data set have yet to be explored. We aimed to compare outcomes for PCS (PCS+) vs conventional carotid artery stenting (CAS) with angioplasty (PCS-) using a national database. METHODS: We analyzed all CAS cases in the Vascular Quality Initiative (VQI) database (2005-2016) using univariable and multivariable logistic regression to assess the effect of PCS on outcomes. The primary end point was a composite of stroke/death occurring within 30 days. RESULTS: The study included 10,074 patients (mean age, 69.5 ± 9.9 years; 64% male). The composite end point occurred in 3.5% of cases (stroke, 2.4%; death, 1.5%). PCS was used in 688 (6.8%) patients. On univariable analysis, stroke/death occurred more frequently with PCS+ vs PCS- (5.2% vs 3.4%; P = .01). However, this difference was mitigated after adjusting for baseline group differences (odds ratio [OR], 1.15; 95% confidence interval [CI], 0.72-1.83; P = .55). PCS also had no significant effect on the primary composite end point on adjusted analysis stratified by symptom status (asymptomatic: OR, 0.98 [95% CI, 0.39-2.48]; symptomatic: OR, 1.19 [95% CI 0.66-2.06]) or among patients undergoing CAS with embolic protection (OR, 1.54 [95% CI, 0.92-2.57]). Patients undergoing CAS without embolic protection had a significantly higher risk of stroke/death regardless of the stenting technique used (OR, 3.97 [95% CI, 2.47-6.37]). CONCLUSIONS: PCS is associated with a similar risk of stroke and death compared with conventional CAS with angioplasty. The use of an embolic protection device is essential to good outcomes with both techniques.

Perioperative Outcomes of Open versus Endovascular Repair for Ruptured Thoracoabdominal Aneurysms.

BACKGROUND: Open aneurysm repair (OAR) remains the gold standard for treating ruptured thoracoabdominal aortic aneurysms (TAAAs). The aim of our study is to compare the 30-day postoperative outcomes among patients with ruptured TAAA undergoing OAR versus endovascular aneurysm repair. METHODS: Using the National Surgical Quality Improvement Program database (2006-2015), we identified patients who underwent OAR and endovascular repair for a ruptured TAAA. Postoperative outcomes of interest included mortality, renal failure, stroke, and cardiopulmonary complications. The independent impact of repair type on each of the aforementioned outcomes was examined after robust risk adjustment. RESULTS: A total of 206 ruptured TAAA repairs were performed [OAR 144 (70%) versus endovascular 62 (30%)]. The majority of patients were male (53 %) and white (77%). The comorbidities were similar between the 2 groups. On average, the operative time of OAR was approximately 3 hr longer than endovascular repair (P < 0.001). The mortality was similar between the 2 groups (OAR 38% versus endovascular 26%, P = 0.09). Compared with endovascular repair, OAR was associated with higher rates of renal and pulmonary complications (32% vs. 13%, P = 0.004; 58% vs. 37%, P = 0.007, respectively). After adjusting for high-risk patient characteristics, endovascular repair, in comparison with OAR, was associated with a 66% reduction of pulmonary injury and 70% reduction in renal failure (odds ratio [OR] 0.34, 95% CI 0.16-0.73, P = 0.005; OR 0.30, 95% CI 0.11-0.82, P = 0.02). CONCLUSIONS: Our study reflects the contemporary outcomes following the repair of ruptured TAAA. Despite similar mortality, the endovascular approach was associated with a significant reduction in the risk of renal failure and pulmonary injury.

Perioperative Outcomes of Thoracic Outlet Syndrome Surgical Repair in a Nationally Validated Database.

We evaluated the occurrence of thoracic outlet syndrome (TOS) and 30-day postoperative outcomes. Patients undergoing cervical/first rib resection surgery were identified in the American College of Surgeons National Surgical Quality Improvement Program database (2005-2013). Thoracic outlet syndrome types were then examined. Propensity score matching was performed to account for potential confounders; 1180 patients were explored during the study period, 1007 (85.3%) were of the neurogenic TOS (NTOS), 32 (2.7%) patients had arterial TOS (ATOS), and 141 (12.0%) patients had venous TOS (VTOS). Patients with ATOS were significantly older (median age [interquartile range, IQR]-NTOS: 34 [25-44], ATOS: 49.5 [42.5-57], VTOS: 34 [23-43]; P < .001). Median operating time was significantly longer for patients with ATOS. Median in-hospital stay was also longer for patients with ATOS (median length of in-hospital stay [LOS; IQR]-NTOS: 2 [1-4]; ATOS: 6 [3-7]; and VTOS: 5 [2-7] days; P < .001). Patients with VTOS showed twice longer LOS when compared to NTOS after matching. Presentation and treatment of TOS have been studied extensively at highly experienced centers.