In-hospital complications and long-term outcomes associated with timing of carotid endarterectomy.

OBJECTIVE: Carotid revascularization performed within 2 weeks of symptoms has proven to reduce risk of recurrent stroke in patients with symptomatic carotid artery stenosis. However, the optimal timing of revascularization within the 2-week window has yet to be determined. The objective of this study was to perform a comprehensive analysis of in-hospital and long-term outcomes of carotid endarterectomy (CEA) performed within different time intervals after most recent symptoms. METHODS: We analyzed 2003 to 2016 data from the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network. Only revascularizations performed for symptomatic carotid artery stenosis were included. Procedures were categorized as urgent (0-2 days from latest symptom), early (3-14 days), or late (15-180 days). The primary in-hospital outcome was stroke/death. The primary long-term outcomes of interest were 5-year recurrent ipsilateral stroke/death. Multivariable logistic regression, Kaplan-Meier analysis, and Cox regression were utilized to compare outcomes. RESULTS: A total of 18,970 revascularizations were included: 1130 (6.0%) urgent, 4643 (24.5%) early, and 13,197 (69.6%) late. Earlier CEA had increased odds of in-hospital stroke/death compared with late CEA (urgent: adjusted odds ratio, 1.9; 95% confidence interval [CI], 1.3-2.8; P = .001; early: adjusted odds ratio, 1.7; 95% CI, 1.3-2.2; P < .001). No differences were seen in 5-year risk of stroke/death (urgent: adjusted hazard ratio, 0.95; 95% CI, 0.79-1.15; P = .592; early: adjusted hazard ratio, 0.97; 95% CI, 0.87-1.07; P = .928). CONCLUSIONS: Urgent and early CEA were associated with increased perioperative risk without difference in 5-year outcomes compared with late CEA. Short-term recurrent stroke prevention could not be assessed. Updated population-based studies comparing recurrent stroke prevention with urgent or early revascularization vs best medical management are warranted.

The association of estimated glomerular filtration rate with outcomes following infrainguinal bypass for peripheral arterial disease.

OBJECTIVE: Chronic kidney disease (CKD) is a recognized predictor of long-term survival, frequently coexisting with peripheral arterial disease (PAD). Estimated glomerular filtration rate (eGFR) is a more accurate marker of renal function than creatinine. This study sought to determine the graded impact of CKD, defined by eGFR, on infrainguinal lower extremity bypass (LEB) outcomes. METHODS: This retrospective study examined 44,332 patients from the Vascular Quality Initiative database who underwent LEB between January 2003 and November 2019. The GFR was estimated using the Modification of Diet in Renal Disease equation. Multivariable logistic regression was used to study perioperative mortality and Kaplan-Meier survival estimation and multivariable Cox regression were used to evaluate 5-year mortality, 1-year major amputation, and major amputation/death. RESULTS: The 30-day mortality odds was increased for CKD 3 (odds ratio [OR], 1.58; 95% confidence interval [CI], 1.32-1.91; P < .001) and CKD 5 (OR, 3.08; 95% CI, 2.45-3.87; P < .001) relative to CKD 1 to 2. Comparing CKD stages 3, 4, and 5 with CKD 1 and 2, there was a stepwise increase in the adjusted hazard of 5-year mortality (hazard ratio [HR], 1.18; 95% CI, 1.09-1.27; P < .001), (HR, 1.73; 95% CI; 1.47-2.03; P < .001) and (HR, 2.58; 95% CI, 2.33-3.84; P < .001), respectively. Although the risk of 1-year death or major amputation did not differ for CKD 3 compared with CKD 1, this was 50% higher for CKD 4 (HR, 1.50; 95% CI, 1.26-1.78; P < .001) and doubled for CKD 5 (HR, 2.07; 95% CI, 1.87-2.29; P < .001) compared with CKD 1 and 2. The adjusted HR for major amputation in 1 year was 0.81 (95% CI, 0.71-0.92; P = .002), 1.14 (95% CI, 0.84-1.54; P = .396) and 1.56 (95% CI,1.31-1.84; P < .001) for CKD 3, 4, and 5, respectively, compared with CKD 1 and 2. CONCLUSIONS: The estimated GFR is a useful predictor of postoperative mortality, overall survival, and/or amputation after LEB in patients with PAD. It should be considered in the preoperative risk-benefit analysis process to guide patient selection in the population with concomitant PAD and CKD being considered for LEB.

Plasmacytoma as a cause of small bowel obstruction in a virgin abdomen in a patient with multiple myeloma: a case report.

BACKGROUND: Multiple myeloma is a hematological malignancy that classically results in an abnormal clonal proliferation of plasma cells in the bone marrow. Extramedullary disease in the setting of multiple myeloma, referred to as secondary extramedullary plasmacytoma, is found in 7-17% of cases of multiple myeloma at the time of diagnosis and can involve any organ system. Small bowel obstruction is a rare but important gastrointestinal manifestation of multiple myeloma that should be considered in patients with multiple myeloma who present with concerning abdominal symptoms. CASE PRESENTATION: We present the case of a 52-year-old African-American man with a history of deep venous thrombosis (he is on anticoagulation) and pathologic fracture secondary to multiple myeloma diagnosed 4 months prior to our encounter. He presented with abdominal pain, constipation, nausea, and vomiting. An abdominal X-ray showed distended bowel loops concerning for bowel obstruction and a contrast-enhanced computed tomography scan of his abdomen and pelvis showed a 5.4 cm soft tissue mass involving a loop of distal ileum. He underwent laparoscopic exploration of his abdomen with small bowel resection and primary anastomosis for a small intussusception. He had an uneventful postoperative course and was discharged on postoperative day 6. CONCLUSIONS: Multiple myeloma has myriad presentations. Gastrointestinal involvement, although rare, can manifest as small bowel obstruction for which early recognition and appropriate surgical management are key to improving outcome. Intussusception is the most common mechanism of obstruction from extramedullary plasmacytoma causing small bowel obstruction and this has been seen in five of six case reports, including this case. It is important to recognize and consider the risks of immunosuppression, venous thromboembolism, and malnutrition in the surgical management of gastrointestinal complications of multiple myeloma.