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.

Regional variation in the cost of infrainguinal lower extremity bypass surgery in the United States.

BACKGROUND: Lower extremity bypass (LEB) remains the gold standard revascularization procedure in patients with peripheral arterial disease. The cost of LEB substantially varies based on patient's characteristics and comorbidities. The aim of this study was to assess regional variation in infrainguinal LEB cost and to identify the specific health care expenditures per service that are associated with the highest cost in each region. METHODS: We identified adult patients who underwent infrainguinal LEB in the Premier database between June 2009 and March 2015. Generalized linear regression models were used to report differences between regions in total in-hospital cost and service-specific cost adjusting for patient's demographics, clinical characteristics, and hospital factors. RESULTS: A total of 50,131 patients were identified. The median in-hospital cost was $13,259 (interquartile range, $9308-$19,590). The cost of LEB was significantly higher in West and Northeast regions with a median cost of nearly $16,000. The high cost in the Northeast region was driven by the fixed (indirect) cost, whereas the driver of the high cost in the West region was the variable (direct) cost. The adjusted total in-hospital cost was significantly higher in all regions compared with the South (mean difference, West, $3752 [95% confidence interval (CI), 3477-4027]; Northeast, $2959 [95% CI, 2703-3216]; Midwest, 1586 [95% CI, 1364-1808]). CONCLUSIONS: In this study, we show the marked regional variability in LEB costs. This disparity was independent from patient clinical condition and hospital factors. Cost inequality across the US represents a financial burden on both the patient and the health system.

Complication-Specific In-Hospital Costs After Carotid Endarterectomy vs Carotid Artery Stenting.

PURPOSE: To quantify and compare the incremental cost associated with in-hospital stroke, death, and myocardial infarction (MI) after carotid endarterectomy (CEA) vs carotid artery stenting (CAS). METHODS: A retrospective analysis was performed of 100,185 patients (mean age 70.7±9.5 years; 58.3% men) who underwent CEA (n=86,035) or CAS (n=14,150) between 2009 and 2015 and were entered into the Premier Healthcare Database. Multivariate logistic models and generalized linear models were used to analyze binary outcomes and hospitalization costs, respectively. Outcomes are presented as the adjusted odds ratio (aOR) and 95% confidence interval (CI). RESULTS: CAS was associated with 1.6 times higher adjusted odds of stroke [aOR 1.55 (95% CI 1.36 to 1.77), p<0.001] and with 2.6 times higher odds of death [aOR 2.60 (95% CI 2.14 to 3.17), p<0.001] compared with CEA. There was no significant difference in MI risk between the 2 procedures. The adjusted incremental cost of death and MI were similar between the 2 procedures. However, the adjusted incremental cost of stroke was significantly higher in CEA compared with CAS by an estimated $2000. When stratified with respect to symptomatic status, the increased adjusted incremental cost of stroke in CEA was mainly seen in asymptomatic patients ($5284 vs $2932, p<0.01). CONCLUSION: The incremental cost of in-hospital stroke is relatively higher in CEA compared to CAS. However, CEA remains a more cost-effective carotid intervention due to lower complication rates and baseline costs compared with CAS. Long-term cost-effectiveness studies are needed before definite conclusions are made.

Fixed and variable cost of carotid endarterectomy and stenting in the United States: A comparative study.

OBJECTIVE: Despite multiple landmark clinical trials, little data exists on real-world cost of carotid artery stenting (CAS) and carotid endarterectomy (CEA) to the United States healthcare system. We aim to study differences in actual hospitalization cost between patients who underwent CAS vs CEA in a nationally representative database. METHODS: We studied hospital discharge and billing records of all patients, in the Premier Perspective Database, who underwent CEA or CAS between the third quarter of 2009 and the first quarter of 2015. Nearest-neighbor 1:1 propensity score matching was performed, to account for differences in patient and hospital characteristics as well as clinical comorbidities of patients who underwent both procedures, for both symptomatic and asymptomatic cohorts using 32 variables. Pearson χ2, Student t-test, and nonparametric K-sample equality-of-medians tests were used to analyze the data, as appropriate. The primary outcome was total in-hospital cost, including fixed (administrative, capital and utilities) and variable costs (labor and supply). Cost data were presented as medians, inflation-adjusted for 2015 U.S. dollar and rounded to the nearest dollar. RESULTS: A total of 115,548 procedures were identified. The mean age was 71 and 69 years; 58% and 57% were male patients; and 81% and 77% were white among asymptomatic and symptomatic patients, respectively. After propensity score matching, 25,812 asymptomatic (12,906 CEA and 12,906 CAS) and 3864 symptomatic (1932 CEA and 1932 CAS) patients were included. Total hospitalization cost per CAS was 40% ($11,814 vs $8378; P < .001) and 37% ($19,426 vs $14,190; P < .001) higher than CEA among asymptomatic and symptomatic patients, respectively. Patients who underwent CAS incurred significantly higher total hospitalization cost despite stratifying by type of cost (fixed and variable), U.S. census regions and symptomatic status. Moreover, asymptomatic patients who underwent CAS performed by any surgical specialty incurred an average of $2717 to $4918 higher total hospitalization cost compared with patients who underwent CEA (all P < 001). Among symptomatic patients, those who underwent CAS performed by vascular, cardiac, and neurologic surgeons, incurred $2108 ($16,114 vs $14,006; P = .006), $7055 ($17,351 vs $10,296; P = .023) and $6479 ($27,290 vs $20,811; P = .002) higher total hospitalization cost compared with patients who underwent CEA, respectively. CONCLUSIONS: The total hospitalization cost incurred by patients who underwent CAS was significantly higher than for those who underwent CEA, despite matching cohort based on patient and hospital characteristics, and stratifying by symptomatic status, type of cost, hospital region, and surgeon specialty. Our findings could provide additional important information giving the ongoing controversy regarding the appropriate indication for CAS.

Stenting versus endarterectomy after prior ipsilateral carotid endarterectomy.

BACKGROUND: Restenosis after carotid endarterectomy (CEA) is associated with an increased risk of stroke, and the management of critical or symptomatic restenotic lesions poses a treatment challenge. The superiority of CEA vs carotid angioplasty and stenting (CAS) for restenosis remains debatable because existing studies are few and limited by small sample size or the inability to align interventions with ipsilateral events beyond the periprocedural period. We performed a population-based evaluation of CEA vs CAS in a large contemporary cohort of patients with carotid artery restenosis. METHODS: We studied all patients in the Vascular Quality Initiative (VQI) database who underwent CEA or CAS after prior ipsilateral CEA between January 2003 and April 2015. Univariate methods (χ2 and t-test) were used to compare patients' characteristics and outcomes ≤30 days and up to 1 year. Multivariate logistic and Cox regression analyses, adjusting for patients' demographic and clinical characteristics, were used to compare the procedures with respect to ipsilateral stroke, death, myocardial infarction (MI), stroke/death, and stroke/death/MI. RESULTS: This cohort of patients with prior ipsilateral CEA underwent 2863 carotid interventions, 1047 (37%) CEA, and 1816 (63%) CAS. Characteristics were similar in both groups. The 30-day ipsilateral stroke rate comparing CEA vs CAS was 2.2% vs 1.3% (P = .09) for asymptomatic patients and 1.2% vs 1.6% (P = .604) for symptomatic patients. The 30-day mortality was 1.3% vs 0.6% (P = .04), and MI occurred in 1.4% of CEA vs 1.1% of CAS patients (P = .443). Cranial nerve injury occurred in 4.1% of the redo-CEA cases, and access site complications occurred in 5.3% of the CAS cases. CEA was associated with higher mortality at 30 days (adjusted odds ratio [aOR], 2.83; 95% confidence interval [CI], 1.13-7.14; P = .027) and at 1 year (adjusted hazard ratio, 2.17; 95% CI, 1.03-4.58; P = .042). However, there were no differences in postoperative stroke (aOR, 0.54; 95% CI, 0.20-1.45, P = .22), MI (aOR, 0.98; 95% CI, 0.31-3.10; P = .97), stroke/death (aOR, 1.38; 95% CI, 0.72-2.67; P = .22), and stroke/death/MI (aOR, 1.38; 95% CI, 0.80-2.37; P = .25) between CEA and CAS after adjusting for patient characteristics, and freedom from stroke at 1 year was also similar (CEA: 96.7% vs CAS: 96.4%; P = .78). CONCLUSIONS: In this population-based study, we have shown higher mortality but similar stroke and MI associated with redo CEA compared with CAS after prior ipsilateral CEA. We recommend avoidance of redo CEA in very sick patients. Smoking cessation remains a potent target for improvement of outcomes of carotid revascularization in these patients.

Bovine carotid artery biologic graft outperforms expanded polytetrafluoroethylene for hemodialysis access.

OBJECTIVE: Arteriovenous grafts remain reliable substitutes for permanent hemodialysis access in patients without a suitable autogenous conduit. Advances in conduit design and endovascular management of access-related complications question the preference for synthetic conduits over biologic grafts in contemporary practice. In this study, we compared outcomes between a bovine carotid artery (BCA) biologic graft and expanded polytetrafluoroethylene (ePTFE) grafts for hemodialysis access in a recent cohort of patients. METHODS: This was a single-institution retrospective review of 120 consecutive grafts placed in 98 patients between January 1, 2011, and June 30, 2014. Univariate methods (χ2, analysis of variance, t-test) were used to compare demographic and medical characteristics of patients who received each graft type. Kaplan-Meier, log-rank tests, univariate and multivariate logistic analyses, and Cox regression analyses were used to evaluate patency and graft complications. Outcomes were defined and analyzed according to reporting guidelines published by the Society for Vascular Surgery. RESULTS: Of the 120 grafts studied, 52 (43%) were BCA and 68 (57%) were ePTFE. Successful graft use for dialysis was 96% (95% confidence interval [CI], 90%-100%) for BCA and 84% (95% CI, 74%-93%) for ePTFE (P = .055). Comparing BCA vs ePTFE, estimates for primary patency were 30% vs 43% at 1 year and 16% vs 29% at 2 years (P = .27). Primary assisted patency was 36% vs 45% at 1 year and 24% vs 35% at 2 years (P = .57). Secondary patency was 67% vs 48% at 1 year and 67% vs 38% at 2 years (P = .05). There were no differences in primary (hazard ratio [HR], 0.70; 95% CI, 0.40-1.28; P = .25) and primary assisted (HR, 0.87; 95% CI, 0.46-1.65; P = .67) patency for BCA compared with ePTFE. However, secondary patency was higher for BCA compared with ePTFE (HR, 2.92; 95% CI, 1.29-6.61; P = .01). Graft infection rates during the study period were 15.4% for BCA and 20.6% for ePTFE (P = .47). The significant predictors of graft failure were higher body mass index (HR, 1.06; 95% CI, 1.00-1.11; P = .04) and hyperlipidemia (HR, 2.94; 95% CI, 1.27-6.76; P = .01). CONCLUSIONS: In this study of a recent cohort of patients who received arteriovenous grafts, primary and primary assisted patencies were similar between BCA and ePTFE grafts. However, secondary patency was higher for BCA, indicating better durability for the biologic graft than for ePTFE grafts in patients whose anatomy preclude placement of an arteriovenous fistula.

Endarterectomy versus stenting in patients with prior ipsilateral carotid artery stenting.

OBJECTIVE: In-stent restenosis is a recognized complication of carotid angioplasty and stenting (CAS), and it is associated with an increased risk of stroke. Few case series have reported outcomes separately following carotid endarterectomy (CEA) and CAS for the treatment of in-stent restenosis. In this study, we perform an evaluation of redo-CAS vs CEA in a large contemporary cohort of patients who underwent prior ipsilateral CAS. METHODS: We studied all patients in the Vascular Quality Initiative (VQI) database, who underwent CEA or CAS between January 1, 2003, and April 30, 2016, after prior ipsilateral CAS. Univariate methods (χ2, t-test), Kaplan-Meier, logistic, and Cox regression analyses adjusting for patient characteristics were employed to evaluate stroke, death, myocardial infarction (MI), stroke/death, and stroke/death/MI within 30 days and up to 1 year following the procedure. RESULTS: There were 645 carotid interventions (CEA, 134 [21%] and redo-CAS, 511 [79%]) performed in this cohort of patients with prior ipsilateral CAS. Postoperative stroke within 30 days comparing CEA vs CAS was 0% vs 0.3% (P = .61) for asymptomatic patients and 4.4% vs 3.5% (P = .79) for symptomatic patients for an overall stroke rate of 1.5% vs 1.4%. MI was 2.3% vs 1.2% (P = .35), 30-day mortality was 3.7% vs 0.9% (P = .02) following CEA vs CAS, whereas the composite of perioperative stroke/death was 4.5% vs 1.9% (P = .09). Freedom from stroke/death at 1 year was 91% for CEA and 92% for redo-CAS (P = .76). After risk adjustment, there was no significant difference in 30-day stroke (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.15-4.48; P = .82), mortality (OR, 2.21; 95% CI, 0.54-9.11; P = .27), or stroke/death (OR, 0.99; 95% CI, 0.26-3.84; P = .99) as well as 1-year stroke (hazard ratio [HR], 0.60; 95% CI, 0.13-2.85; P = .52), mortality (HR, 0.83; 95% CI, 0.42-1.65; P = .60), or stroke/death (HR, 0.80; 95% CI, 0.43-1.49; P = .48) comparing CEA with CAS. The significant predictors of perioperative stroke/death were older age, diabetes, active smoking, and preoperative American Society of Anesthesiologists class IV status (all P < .05). CONCLUSIONS: We have reported adverse event rates for CEA and CAS after prior CAS and shown no significant difference in perioperative and 1-year outcomes between both groups. However, CEA is offered to patients who are more severely ill than redo-CAS, resulting in significantly higher absolute mortality. We recommend avoidance of CEA especially in asymptomatic patients with serious systemic disease. Tight management of diabetes and smoking cessation remain potent targets for outcomes improvement in redo-CAS patients.

Predicting failure to rescue after abdominal aortic aneurysm repair in elderly patients.

BACKGROUND: We aim to describe trends in failure to rescue (FTR) among elderly patients undergoing elective open aortic aneurysm repair (OAR) and endovascular aortic aneurysm repair (EVAR). MATERIALS AND METHODS: All patients aged ≥80 y recorded in the Vascular Quality Initiative database (2002-2014) undergoing nonruptured infrarenal AAA repair were included. Primary outcome was FTR, defined as percentage of deaths in patients who had a complication within 30 d of surgery. Univariable and multivariable statistics were used to identify risk factors for FTR following OAR and EVAR procedures. RESULTS: 975 elderly patients underwent AAA repair during the study period (EVAR = 667, OAR = 308). Overall FTR was 10%, most commonly related to acute kidney injury (62%) and respiratory failure (53%). Independent predictors of FTR included female gender (odds ratio [OR] 1.95), multiple comorbidities (OR 1.98), renal insufficiency (OR 1.97), peripheral vascular disease (OR 2.42), and perioperative vasopressor use (OR 4.49) (all, P < 0.02). Obesity was protective (OR 0.58, P = 0.02). FTR was higher following OAR versus EVAR (14% versus 9%; P = 0.02) on univariable analysis, but there was no significant difference between operative approaches after risk adjustment (OR 1.15, P = 0.60). Comparing elderly versus younger patients (n = 2854), FTR was significantly higher for the elderly for both OAR (OR 2.0, 95% CI 1.36-3.01) and EVAR (OR 1.60, 95% CI 1.07-2.40). CONCLUSIONS: FTR after AAA repair is not uncommon among elderly patients and could explain the higher mortality observed in this group compared to the general population. Overall health status should be carefully considered when weighing the risks versus benefits of performing AAA repair in patients aged ≥80 y.

Sartorius Muscle Flaps: Perioperative Outcomes Based on Surgical Specialty.

BACKGROUND: Complicated groin wounds often require repair by sartorius muscle flap (SMF). Operating surgical specialty differs based on SMF indication, hospital, and operating surgeon preference. We aim to assess the effect of operating surgical specialty, indication for SMF, and other patient-level factors on 30-day outcomes. METHODS: We collected data on all patients undergoing SMF performed at our institution from 2005 to 2015, including age, sex, body mass index, comorbidity index (hypertension, diabetes, dyslipidemia, peripheral arterial disease, coronary artery disease), smoking status, history of malignancy, indication for SMF (infection, noninfectious complication, prophylaxis), and operating surgeon's specialty (vascular, plastic, general, other). Primary outcome was any 30-day complications (wound infection, seroma, dehiscence, or bleeding). Secondary outcome included 30-day surgical reintervention rate. Univariate analysis and multivariate logistic regression modeling were used to evaluate primary outcomes. RESULTS: A total of 170 SMFs were performed during the study period (mean patient age 58 years; 49% male). Primary indication for SMF was prophylaxis in 116 cases (68%), followed by infection in 36 cases (21%) and noninfectious complications in 18 cases (11%). General surgeons performed the highest proportion of SMF (45%) followed by vascular surgeons (26%), "other specialties" (15%), and plastic surgeons (14%). Compared with all specialties, vascular surgeons operated on the severely ill patients (77% of vascular patients had ≥3 comorbidities, P < 0.001). Surgical reintervention within 30 days was required in 7 patients (4.1%): 3 by vascular surgeons (6.8% of total cases by vascular surgery) and 4 by plastic surgeons (17.4% of total cases by plastic surgery, P < 0.001). Any 30-day complications occurred in 47 patients (28%): 30 general surgery cases (39%), 7 plastic surgery cases (30%), 7 other specialty cases (27%), and 3 vascular surgery cases (7%) (P < 0.001). Of all vascular disease-related cases (56), plastic surgeons performed 21% of SMF, while vascular surgeons performed 79%. On logistic regression correcting for baseline differences between groups, vascular surgeon SMF outcomes were compared favorably with those done by other specialties. CONCLUSIONS: Overall, SMFs have low perioperative reintervention rates but high complication rates. Vascular surgeons perform SMF on high-risk patients with more comorbidities compared with other specialties. Although overall morbidity associated with this procedure is high, perioperative outcomes for SMF performed by vascular surgeons are favorable.

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.

Carotid Revascularization in Asymptomatic Patients after Renal Transplantation.

BACKGROUND: In multiple studies, chronic renal insufficiency has been associated with increased risk of periprocedural stroke, cardiac complications, and death following carotid revascularization. Renal transplantation has been shown to reduce cardiovascular risk and improve survival; outcomes after carotid revascularization in renal transplant patients however are unknown. In this study, we evaluate periprocedural and long-term risks after carotid endarterectomy (CEA) and carotid artery stenting (CAS) in a cohort of renal transplant patients. METHODS: We studied all renal transplant patients in the United States Renal Data System who underwent CEA or CAS between January 2006 and December 2011. Patient outcomes were determined by linking with the Medicare database. Propensity score matched logistic and cox regression analyses were employed to evaluate perioperative stroke, myocardial infarction (MI), and death and long-term stroke and death. RESULTS: Of the 462 revascularizations for asymptomatic carotid artery stenosis between 2006 and 2011, 387 (84%) were CEA and 75 (16%) were CAS. The 2 groups did not differ in age, gender, sex, race, or baseline medical characteristics. There was no significant difference in perioperative stroke, MI, or death rates in the CEA cohort (4.7%, 4.4%, and 1.3%, respectively) compared with the CAS cohort (5.3%, 2.7%, and 4.0%, respectively). Stroke-free survival for CEA versus CAS was 93% vs. 92% at 1 year, 90% vs. 87% at 2 years, 88% vs. 87% at 3 years, and 84% vs. 82% at 4 years (P = 0.81). Overall patient survival for CEA versus CAS was 89% vs. 88% at 1 year, 77% vs. 75% at 2 years, 66% for both at 3 years, and 53% vs. 48% at 4 years (P = 0.68). In propensity score matched Cox regression analysis, there was no difference in risk of perioperative stroke or MI or in long-term stroke or death for CAS compared with CEA. CONCLUSIONS: This is the first study to evaluate outcomes following CEA and CAS in renal transplant patients. The incidence of perioperative complications in this group is higher than the maximum recommended by the Society of Vascular Surgery, and the benefits of revascularization may be outweighed by the excess periprocedural morbidity and reduced life expectancy of these patients.

Abdominal aortic aneurysm repair in octogenarians is associated with higher mortality compared with nonoctogenarians.

OBJECTIVE: Age is a well-known independent risk factor for death after abdominal aortic aneurysm (AAA) repair. However, there is significant debate about the utility of AAA repair in older patients. In this study, mortality outcomes after endovascular AAA repair (EVAR) and open AAA repair (OAR) in octogenarians (aged ≥80 years) were compared with younger patients (aged <80 years). METHODS: All patients recorded in the Vascular Quality Initiative database (2002-2012) who underwent infrarenal AAA repair were included. Univariable and multivariable statistics were used to compare perioperative (30-day) and 1-year mortality outcomes between octogenarians vs nonoctogenarians for OAR and EVAR. RESULTS: During the study period, 21,874 patients underwent AAA repair (OAR, 5765; EVAR, 16,109), including 4839 octogenarians (OAR, 765; EVAR, 4074) and 17,035 nonoctogenarians (OAR, 5000; EVAR, 12,035). Octogenarians (mean age, 83.0 ± 0.1 years) were less frequently male (66% vs 75%) and had a higher prevalence of congestive heart failure (9.9% vs 7.1%), chronic renal insufficiency (12.2% vs 7.5%), and a history of aortic surgery (14.3% vs 7.7%) compared with nonoctogenarians (P < .01 for all). Intraoperative use of blood transfusions and vasopressors was more common in octogenarians for OAR (blood: 3.3 ± 4.4 vs 1.8 ± 3.7 units; vasopressors: 45.2% vs 32.8%) and EVAR (blood: 0.43 ± 1.7 vs 0.31 ± 1.6 units; vasopressors: 7.6% vs 5.7%; P < .01 for all). Contrast dye volumes used during EVAR were similar in octogenarians and nonoctogenarians (108 ± 71 vs 107 ± 68 mL; P = .18). Perioperative mortality after OAR was 20.1% in octogenarians compared with 7.1% in nonoctogenarians (P < .01). Perioperative mortality after EVAR was 3.8% in the octogenarians compared with 1.6% in nonoctogenarians (P < .01). One-year mortality among octogenarians vs nonoctogenarians was 26% vs 9.7% for OAR and 8.9% vs 4.3% for EVAR (log-rank test, P < .01 for both). Multivariable analysis controlling for baseline and intraoperative differences between groups demonstrated that age ≥80 years increased the risk of 30-day and 1-year mortality after AAA repair by 223% and 187%, respectively (P < .01 for both). CONCLUSIONS: AAA repair should be approached with extreme caution in octogenarians. Perioperative and 1-year mortality rates after OAR are particularly high in the older population, suggesting that the appropriate aneurysm size threshold for OAR might be larger due to the greater operative risk in octogenarian patients.

Outcomes after open infrainguinal bypass in patients with scleroderma.

BACKGROUND: There are limited reports of outcomes after infrainguinal bypass surgery in patients with scleroderma. This study evaluated the long-term outcome after lower extremity bypass in these patients. METHODS: The study included all patients with systemic sclerosis who underwent infrainguinal bypass surgery for severe peripheral arterial disease at our institution from January 1, 2007, to August 31, 2014. Kaplan-Meier and Cox regression analyses were used to evaluate graft failure and limb salvage. These outcomes were compared with those of nonscleroderma patients who underwent infrainguinal bypass surgery during the same period. Outcomes were defined and evaluated by Society for Vascular Surgery standards. RESULTS: There were 18 autogenous grafts (6% femoral-popliteal, 11% femoral-tibial, 72% popliteal-tibial, 11% tibial-tibial) placed in 18 limbs from 12 patients with systemic sclerosis. Mean ± standard deviation age was 71 ± 9.5 years, and most of the patients were women (83%) and white (78%). All patients presented with critical limb ischemia. History of hypertension and coronary artery disease were 94% and 61%, respectively. All grafts used were autogenous, continuous, and harvested from the lower extremity (nonreversed great saphenous in 61% and reversed great saphenous in 39%). Mean follow-up duration was 2.3 ± 1.6 years. Graft failure was significantly higher in scleroderma patients than in nonscleroderma patients who underwent bypass in the same study period (hazard ratio, 7.2; 95% confidence interval, 1.44-41.4; P = .02). The limb salvage rate was 72%. CONCLUSIONS: Long-term outcomes after open infrainguinal bypass surgery in scleroderma patients are significantly worse than those in nonscleroderma patients. Careful consideration of their inherently poor outcomes should be made when reaching a decision for revascularization.

Racial disparities after vascular trauma are age-dependent.

OBJECTIVE: Different racial disparities exist between white and black all-cause trauma patients depending on their age group; however, the effects of race and age on outcomes after vascular trauma are unknown. We assessed whether the previously described age-dependent racial disparities after all-cause trauma persist in the vascular trauma population. METHODS: Vascular trauma patients were identified from the Nationwide Inpatient Sample (January 2005 to December 2012) using International Classification of Diseases-Ninth Edition codes. Univariable and multivariable analyses were used to compare in-hospital mortality and amputation for blacks vs whites for younger (16-64 years) and older (≥65 years) age groups. RESULTS: Black patients (n = 937) were younger, more frequently male, without insurance, and suffered from more penetrating and nonaccidental injuries than white patients (n = 1486; P < .001). On univariable analysis, blacks had a significantly higher risk of death (odds ratio, [OR], 1.78; 95% confidence interval [CI], 1.16-2.74) and a significantly lower risk of amputation (OR, 0.54; 95% CI, 0.38-0.77), but these differences were not sustained after adjusting for baseline differences between groups. When stratified by age, there were significant racial disparities in mortality and amputation on univariable analysis. After risk adjustment, these differences persisted in the older group (mortality: OR, 5.95; 95% CI, 1.42-25.0; amputation: OR, 4.21; 95% CI, 1.28-13.6; P < .001) but not the younger group (mortality: OR, 1.31; 95% CI, 0.71-2.42; amputation: OR, 0.92; 95% CI, 0.58-1.46; P = not significant). Differences in survival and amputation after vascular trauma appear to be related to a higher prevalence of nonaccidental penetrating injuries in the younger black population. Race was the single greatest predictor of poor outcomes in the older population (P ≤ .008). CONCLUSIONS: Older black patients are nearly five-times more likely to experience death or amputation after vascular trauma than their white counterparts. Contrary to reports suggesting that younger white patients have better outcomes after all-cause trauma than younger black patients, racial disparities among patients with traumatic vascular injuries appear to be confined to the older age group after risk adjustment.

Beta-blocker use is associated with lower stroke and death after carotid artery stenting.

BACKGROUND: Proper selection of patients for carotid artery stenting (CAS) remains controversial despite multiple controlled trials. This relates in part to differences in interpretation of the relative importance of myocardial vs stroke complications after the procedure by different specialties and a lack of granular clinical data to analyze outcomes outside the large clinical trials. The objective of this study was to assess the effect of preoperative medications, procedure parameters, and patient characteristics on outcomes of CAS performed in a multispecialty national database. METHODS: We analyzed all patients who underwent CAS between 2005 and 2014 in the Vascular Quality Initiative. A multivariate logistic regression model was built to assess the effects of age, gender, comorbidities, smoking, preprocedure medications, procedure details, and hypotension or hypertension that required intravenous medication on 30-day death or stroke rates. RESULTS: A total of 5263 patients underwent CAS (mean age, 70 years; 63% male). The 30-day stroke/death rate was 3.4% (1.5% minor stroke, 0.9% major stroke, and 1.2% death; 40% of patients who had major strokes died within 30 days), and the myocardial infarction rate was 0.8%. Postprocedural hypertension requiring treatment occurred in 519 cases (9.9%), and it was associated with a 3.4-fold increase in stroke/death (odds ratio, 3.39; 95% confidence interval, 2.30-5.00; P < .0001). Preprocedural beta-blocker use for >30 days was associated with a 34% reduction in the stroke/death risk (odds ratio, 0.66; 95% confidence interval, 0.46-0.95; P = .025) compared with nonuse. Beta-blocker use was not associated with postprocedural hypotension. Other predictors of postoperative stroke and death included age, symptomatic status, diabetes (type 1 or type 2), and postprocedural hypotension, whereas prior carotid endarterectomy and distal embolic protection use were protective. CONCLUSIONS: Postprocedural hypertension and hypotension that require treatment are both strongly associated with periprocedural stroke/death after CAS. Beta blockers significantly reduce the stroke/death risk associated with carotid stenting and should be investigated prospectively for potential use during CAS.

Outcomes after carotid artery stenting in hemodialysis patients.

BACKGROUND: Patients who require hemodialysis are historically excluded from randomized studies of carotid artery stenting (CAS) due to perceived poor outcomes. Observational studies of outcomes after CAS in hemodialysis patients are mostly limited to small, single-institution series. OBJECTIVE: This study evaluated long-term outcomes after CAS in a large nationally representative cohort of hemodialysis patients. METHODS: We studied all patients who underwent CAS in the United States Renal Disease System database between January 2006 and December 2011. Patient outcomes were determined by matching with the Medicare database. Univariable and multivariable logistic and Cox regression were used to compare perioperative (stroke, death, myocardial infarction) and long-term (stroke, death) outcomes after CAS. RESULTS: The cohort included 1109 patients who underwent CAS. Median follow-up was 2.5 years (interquartile range, 1.30-3.71; maximum, 4.97 years). Mean age was 67 (standard deviation, 9.9) years, and 61% of patients were male, 75% were white, and 83% were asymptomatic. Overall, 30-day perioperative stroke, myocardial infarction, and death rates were 5.5%, 5.5%, and 3.1%, respectively. Long-term freedom from stroke was 90% at 1 year, 85% at 2 years, and 76% at 4 years. Patient survival was 73% at 1 year and 29% at 4 years. Symptomatic status was the only significant predictor of stroke in a long-term period of 4 years (hazard ratio, 1.92; 95% confidence interval, 1.12-3.29; P < .05). CONCLUSIONS: This study, which is the largest population-based study of outcomes after CAS in hemodialysis patients, demonstrates relatively poor long-term survival and prohibitive operative stroke and death risk. We recommend avoidance of CAS in asymptomatic dialysis patients and cautious consideration when planning CAS in symptomatic patients.

Contemporary outcomes of open thoracoabdominal aneurysm repair: functional status is the strongest predictor of perioperative mortality.

BACKGROUND: Open repair of thoracoabdominal and descending thoracic aneurysm (TAA) carries significant operative morbidity and mortality. Despite evolving operative techniques patient-level risk factors affecting mortality after open TAA repair, including patient functional status, remain to be fully understood. MATERIALS AND METHODS: We identified all open TAA repair cases in the National Surgical Quality Improvement Program database between 2005 and 2013. Multivariable logistic regression was used to evaluate the effect of patients' age, gender, race, body mass index (BMI), comorbid conditions, functional status, ASA class, smoking, rupture, descending thoracic aneurysm versus Crawford types, dissection, and preoperative: transfusion, creatinine levels, on perioperative (30-d) mortality after open TAA repair. RESULTS: A total of 1048 patients underwent open TAA repair during the 9-y study period. Mean patient age was (mean ± SEM) 67 ± 0.4 y, mean BMI was 27 ± 6 kg m2, and most patients (60%) were male. Perioperative mortality was 14.0% (nonruptured 11.4% versus ruptured 34.2%, P < 0.01) and patients with postoperative renal failure requiring dialysis comprised 12.6%. On multivariable analysis, dependent status had the highest effect on operative mortality, tripling the risk of death (odds ratio [OR] = 3.18, 95% confidence interval [CI] = 1.49-6.81, P < 0.01). Ruptured aneurysms had more than double the operative mortality risk (OR = 2.49, 95% CI = 1.42-4.38, P < 0.01). Preoperative renal insufficiency added 23% mortality risk per unit increase in creatinine (OR = 1.23, 95% CI = 1.01-1.50, P = 0.04), whereas each year in patient age or unit increase in BMI increased the risk of death by 4% (OR = 1.04, 95% CI = 1.02-1.07, P < 0.01, OR = 1.04, 95% CI = 1.00-1.07, P = 0.04, respectively). CONCLUSIONS: Patients' functional status is the strongest independent predictor of perioperative death. Other patient-level factors, including increasing age, BMI, and renal dysfunction, also play a role. Appropriate patient selection for open TAA repair is essential for achieving good outcomes.

Predictors of perioperative outcomes after carotid revascularization.

BACKGROUND: The aim of our study was to compare and identify possible predictors of perioperative outcomes of carotid endarterectomy (CEA) with carotid artery stenting (CAS) using the procedure-targeted American College of Surgeons National Surgical Quality Improvement Program database. METHODS: Patients who underwent CEA or CAS were identified in American College of Surgeons National Surgical Quality Improvement Program (2011-2013). Univariate and multivariable logistic regression analyses were performed to evaluate the predictors of perioperative outcomes (any stroke or death, myocardial infarction [MI], 30-d readmission and reoperation). Final models were constructed based on the lowest Akaike Information Criterion. RESULTS: A total of 10,169 patients underwent carotid revascularization (CEA: 9817 [96.5%] versus CAS: 352 [3.5%]). Most patients were male (61%). Patients who had CAS were younger (mean age [±standard deviation]: 69.1 [±9.7] versus 71.3 [±9.4] y, P < 0.001); however, they showed a greater prevalence of diabetes (38.4% versus 29.2%), congestive heart failure (4.8% versus 1.4%), and chronic obstructive pulmonary disease (17.3% versus 10.2%) (all P < 0.001). The risk of postoperative stroke and/or death was nearly doubled with CAS (adjusted Odds Ratio = 1.84; 95% confidence interval: 1.07-3.18, P = 0.028). The odds of reoperation were higher in nonwhite patients compared with white patients (adjusted Odds Ratio: 1.34, 95% confidence interval: 0.97-1.84, P = 0.078). Perioperative MI and readmission were mostly related to patient's age and comorbidities. CONCLUSIONS: In a national data set representing real-world outcome, CAS is associated with higher odds of postoperative mortality and stroke in comparison to CEA. Carotid revascularization procedure type is not a predictor of postoperative MI or readmission, suggesting that these outcomes are a function of other patient factors. Nonwhite race is a predictor of reoperation.

Contemporary Outcomes for Open Infrainguinal Bypass in the Endovascular Era.

BACKGROUND: The role of infrainguinal bypasses in this era of increasing endovascular interventions remains the subject of significant debate. In this study, we evaluate contemporary long-term outcomes of lower-extremity open revascularization for peripheral arterial disease (PAD). METHODS: We evaluated all patients who underwent infrainguinal bypass with autogenous vein conduits for claudication or critical limb ischemia in our institution between January 1st, 2007 and July 31st, 2014. Kaplan-Meier and Cox regression analyses were used to evaluate graft failure and identify its predictors. Outcomes were defined per the Society for Vascular Surgery standards. RESULTS: There were 428 autogenous vein grafts (femoro-popliteal: 32%, femoro-tibial: 39%, popliteo-tibial: 27%, and tibio-tibial: 2%) placed in 368 patients (mean age of 67 ± 11.4 years). Most patients were male (59%), white (73%), and presented with critical limb ischemia (81%). Sixty-five cases (15%) were redo bypasses. Arm veins and spliced vein conduits were used in 15% and 14% of cases, respectively. Primary patency at 1, 3, and 5 years was 66%, 59%, and 55%, respectively. Primary-assisted patency was 78%, 69%, and 64% at 1, 3, and 5 years, respectively. Secondary patency was 88%, 84%, and 82% at 1, 3, and 5 years, respectively. Patency was higher for grafts harvested from the lower versus upper extremities and for proximal versus distal bypass (all P < 0.05). Limb salvage rate was 88% after a mean follow-up of 2 ± 1.8 years. Significant predictors of graft failure were younger age, diabetes mellitus, and hyperlipidemia (all P < 0.05). CONCLUSIONS: In this contemporary cohort of patients, we have demonstrated that infrainguinal bypass for lower-extremity revascularization has good long-term outcomes in patients with symptomatic PAD. Patency and limb salvage rates are optimized with careful selection of autogenous conduits, close monitoring of high-risk groups and management of comorbidities.

Poststent ballooning is associated with increased periprocedural stroke and death rate in carotid artery stenting.

BACKGROUND: Whereas carotid endarterectomy (CEA) remains the "gold standard" treatment, given its low complication rate, carotid artery stenting (CAS) has emerged as a valid alternative in patients with prohibitive surgical risks. However, the application of CAS has been scrutinized, given its increased perioperative risk in comparison to CEA. Operators follow general guidelines in intraoperative techniques in CAS. However, few of those are evidence based. We believe that a specific outcome-driven examination of the effect of pre- and poststent deployment ballooning is warranted. The objective of this study was to analyze the effect of prestent ballooning (pre-SB) and poststent ballooning (post-SB) on hemodynamic depression (HD) and perioperative stroke or death. METHODS: We performed a retrospective analysis of all patients who had CAS between 2005 and 2014 in the Vascular Quality Initiative database. Logistic regression analyses of the effect of different pre-SB and post-SB combinations on HD and the 30-day stroke and death rate were performed. We excluded patients who had no protection device, those with isolated common carotid artery lesions, and those who had no ballooning at all. The models controlled for patient age, gender, comorbidities, smoking status, symptomatic status, history of previous ipsilateral CEA, preoperative medications, and ipsilateral degree of stenosis. RESULTS: A total of 3772 patients who underwent CAS were included for analysis. Average age of patients was 69.8 ± 9.6 years, with 63% being male. The overall perioperative stroke and death rate was 3.0%. Compared with pre-SB only technique, the combined pre-SB and post-SB technique had a 2.1-fold increase in HD (odds ratio, 2.13; 95% confidence interval, 1.51-3.01; P < .001) and 2.4-fold increase in perioperative stroke and death rate (odds ratio, 2.37; 95% confidence interval, 1.01-5.62; P < .050). CONCLUSIONS: Compared with pre-SB alone, the use of post-SB increases the chances of perioperative HD and stroke and death rate in patients undergoing CAS. Post-SB should be used only in those cases with severe residual stenosis.