Propensity score analysis in patients with and without previous isolated coronary artery bypass grafting who require proximal aortic and arch surgery.

OBJECTIVE: The risk posed by previous isolated coronary artery bypass grafting (CABG) in patients who require proximal aortic or aortic arch surgery is unclear. We compared outcomes of ascending aortic and arch procedures in patients with and without previous CABG. METHODS: Using propensity scores, we created 2 matched groups of patients who underwent proximal aortic surgery, including total arch repairs, at our institution: 126 patients who underwent isolated CABG before the index operation and 126 without previous CABG. Forty-four percent of aortic operations were emergency procedures. Eighty-six patients had a patent previous left internal mammary graft. We compared outcomes between the 2 groups and calculated Kaplan-Meier survival curves. RESULTS: The following outcomes were recorded for the patients with previous isolated CABG versus no CABG: operative mortality, 15.9% versus 11.1% (P = .3); 30-day mortality, 13.5% versus 7.1% (P = .1); persistent stroke, 6.3% versus 4.8% (P = .6); and renal failure necessitating hemodialysis at discharge, 7.9% versus 4.0% (P = .2). Previous CABG did not independently predict any adverse outcome, even though patients who underwent previous CABG more frequently needed intra-aortic balloon support (P < .01). The P value for the overall intergroup difference in long-term survival was .06. CONCLUSIONS: This is one of the largest studies yet reported to examine the impact of previous isolated CABG on proximal aortic or arch surgery outcomes. Although these results may be specific to aortic centers of excellence, in this complicated patient cohort, previous isolated CABG did not independently predict any adverse outcome. These results could serve as a benchmark for assessing future endovascular therapies.

A 23-year experience with the reversed elephant trunk technique for staged repair of extensive thoracic aortic aneurysm.

OBJECTIVE: The reversed elephant trunk technique permits staged repair of extensive thoracic aortic aneurysm in patients whose distal (ie, descending thoracic and thoracoabdominal) aorta is symptomatic or disproportionately large compared with their proximal aorta (ie, ascending aorta and transverse aortic arch). We present our 23-year experience with the reversed elephant trunk approach. METHODS: Between 1994 and 2017, 94 patients (median age 62 [46-69] years) underwent stage 1 reversed elephant trunk repair of the distal aorta. Fifty-three patients (56%) had aortic dissection, and 31 patients (33%) had heritable thoracic aortic disease. Eighty-eight operations (94%) were Crawford extent I or II thoracoabdominal aortic repairs. Twenty-seven patients (29%) underwent subsequent stage 2 repair of the proximal aorta; 14 patients (52%) required redo median sternotomy. The median time between the stage 1 and 2 operations was 18.8 (4.8-69.3) months. RESULTS: The operative mortality was 10% (9/94) for stage 1 repairs and 4% (1/27) for stage 2 repairs; 1 patient with heritable thoracic aortic disease died after stage 1 repair (1/31, 3%), and 1 patient died after stage 2 repair (1/13, 8%). Two patients (2%) had ruptures after stage 1 repair; 1 resulted in death, and 1 precipitated emergency stage 2 repair. In total, 36 patients (38%) who survived stage 1 repair died before stage 2 reversed elephant trunk completion repair could be performed. CONCLUSIONS: Managing extensive aortic aneurysm with the 2-stage reversed elephant trunk technique yields acceptable short-term outcomes. This technique is useful for the reversed elephant trunk in patients who require distal aortic repair before proximal repair and is particularly effective in patients with heritable thoracic aortic disease. The low number of patients returning for completion repair is concerning. Rigorous surveillance is needed.

Differential presentation in acuity and outcomes based on socioeconomic status in patients who undergo thoracoabdominal aortic aneurysm repair.

OBJECTIVES: Socioeconomic differences can lead to differences in how patients present with surgical conditions. We attempted to determine whether socioeconomic status (SES) affects survival outcomes after thoracoabdominal aortic aneurysm (TAAA) repair. METHODS: We retrospectively reviewed prospectively collected data from 981 TAAA repairs performed on domestic (noninternational) patients between 2006 and 2016. We excluded patients <18 years old (n = 3), those with no available US home address (n = 114), those not within the race and ethnicity categories assessed (n = 30), and those lost to follow-up (n = 6), leaving 832 repairs for analysis. We derived patient SES by using US Census Bureau data to estimate median household income according to patient home address. Patients were grouped into 3 SES groups: high (n = 283), middle (n = 274), and low (n = 275). Multivariable logistic regression modeling was used to identify predictors of operative mortality. Kaplan-Meier curves and Cox proportional hazards regression were used to analyze the association between SES and survival. RESULTS: Operative mortality occurred in 9% (n = 76) of patients. Patients of low SES had greater rates of acute symptoms, dissection, and urgent or emergency TAAA repair. However, lower SES was not an independent predictor of operative death. Kaplan-Meier analysis and Cox proportional hazards modeling did not show a significant difference in mid-term survival by SES. CONCLUSIONS: In our TAAA series from a single, high-volume practice, SES differences did not appear to influence operative mortality rates. In addition, SES was not associated with a difference in mid-term survival. Efforts to understand and ameliorate the greater acuity of presentation in patients of low SES appear worthwhile.

Etiologies of genital inflammation and ulceration in symptomatic Rwandan men and women responding to radio promotions of free screening and treatment services.

INTRODUCTION: The longstanding inadequacies of syndromic management for genital ulceration and inflammation are well-described. The Rwanda National Guidelines for sexually transmitted infection (STI) syndromic management are not yet informed by the local prevalence and correlates of STI etiologies, a component World Health Organization guidelines stress as critical to optimize locally relevant algorithms. METHODS: Radio announcements and pharmacists recruited symptomatic patients to seek free STI services in Kigali. Clients who sought services were asked to refer sexual partners and symptomatic friends. Demographic, behavioral risk factor, medical history, and symptom data were collected. Genital exams were performed by trained research nurses and physicians. We conducted phlebotomy for rapid HIV and rapid plasma reagin (RPR) serologies and vaginal pool swab for microscopy of wet preparation to diagnose Trichomonas vaginalis (TV), bacterial vaginosis (BV), and vaginal Candida albicans (VCA). GeneXpert testing for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) were conducted. Here we assess factors associated with diagnosis of NG and CT in men and women. We also explore factors associated with TV, BV and VCA in women. Finally, we describe genital ulcer and RPR results by HIV status, gender, and circumcision in men. RESULTS: Among 974 men (with 1013 visits), 20% were positive for CT and 74% were positive for NG. Among 569 women (with 579 visits), 17% were positive for CT and 27% were positive for NG. In multivariate analyses, factors associated with CT in men included younger age, responding to radio advertisements, <17 days since suspected exposure, and not having dysuria. Factors associated with NG in men included not having higher education or full-time employment, <17 days since suspected exposure, not reporting a genital ulcer, and having urethral discharge on physical exam. Factors associated with CT in women included younger age and < = 10 days with symptoms. Factors associated with NG in women included younger age, lower education and lack of full-time employment, sometimes using condoms vs. never, using hormonal vs. non-hormonal contraception, not having genital ulcer or itching, having symptoms < = 10 days, HIV+ status, having BV, endocervical discharge noted on speculum exam, and negative vaginal wet mount for VCA. In multivariate analyses, only reporting >1 partner was associated with BV; being single and RPR+ was associated with TV; and having < = 1 partner in the last month, being pregnant, genital itching, discharge, and being HIV and RPR negative were associated with VCA. Genital ulcers and positive RPR were associated with being HIV+ and lack of circumcision among men. HIV+ women were more likely to be RPR+. In HIV+ men and women, ulcers were more likely to be herpetic rather than syphilitic compared with their HIV- counterparts. CONCLUSIONS: Syndromic management guidelines in Rwanda can be improved with consideration of the prevalence of confirmed infections from this study of symptomatic men and women representative of those who would seek care at government health centers. Inclusion of demographic and risk factor measures shown to be predictive of STI and non-STI dysbioses may also increase diagnostic accuracy.

Developing and validating a risk algorithm to diagnose Neisseria gonorrhoeae and Chlamydia trachomatis in symptomatic Rwandan women.

BACKGROUND: Algorithms that bridge the gap between syndromic sexually transmitted infection (STI) management and treatment based in realistic diagnostic options and local epidemiology are urgently needed across Africa. Our objective was to develop and validate a risk algorithm for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) diagnosis among symptomatic Rwandan women and to compare risk algorithm performance to the current Rwandan National Criteria for NG/CT diagnosis. METHODS: The risk algorithm was derived in a cohort (n = 468) comprised of symptomatic women in Kigali who sought free screening and treatment for sexually transmitted infections and vaginal dysbioses at our research site. We used logistic regression to derive a risk algorithm for prediction of NG/CT infection. Ten-fold cross-validation internally validated the risk algorithm. We applied the risk algorithm to an external validation cohort also comprised of symptomatic Rwandan women (n = 305). Measures of calibration, discrimination, and screening performance of our risk algorithm compared to the current Rwandan National Criteria are presented. RESULTS: The prevalence of NG/CT in the derivation cohort was 34.6%. The risk algorithm included: age < =25, having no/primary education, not having full-time employment, using condoms only sometimes, not reporting genital itching, testing negative for vaginal candida, and testing positive for bacterial vaginosis. The model was well calibrated (Hosmer-Lemeshow p = 0.831). Higher risk scores were significantly associated with increased prevalence of NG/CT infection (p < 0.001). Using a cut-point score of > = 5, the risk algorithm had a sensitivity of 81%, specificity of 54%, positive predictive value (PPV) of 48%, and negative predictive value (NPV) of 85%. Internal and external validation showed similar predictive ability of the risk algorithm, which outperformed the Rwandan National Criteria. Applying the Rwandan National Criteria cutoff of > = 2 (the current cutoff) to our derivation cohort had a sensitivity of 26%, specificity of 89%, PPV of 55%, and NPV of 69%. CONCLUSIONS: These data support use of a locally relevant, evidence-based risk algorithm to significantly reduce the number of untreated NG/CT cases in symptomatic Rwandan women. The risk algorithm could be a cost-effective way to target treatment to those at highest NG/CT risk. The algorithm could also aid in sexually transmitted infection risk and prevention communication between providers and clients.

Use of propensity score matching to create counterfactual group to assess potential HIV prevention interventions.

The design of HIV prevention trials in the context of effective HIV preventive methods is a challenge. Alternate designs, including using non-randomised 'observational control arms' have been proposed. We used HIV simulated vaccine efficacy trials (SiVETs) to show pitfalls that may arise from using such observational controls and suggest how to conduct the analysis in the face of the pitfalls. Two SiVETs were nested within previously established observational cohorts of fisherfolk (FF) and female sex workers (FSW) in Uganda. SiVET participants received a licensed Hepatitis B vaccine in a schedule (0, 1 and 6 months) similar to that for a possible HIV vaccine efficacy trial. All participants received HIV counselling and testing every quarter for one year to assess HIV incidence rate ratio (IRR) between SiVET and non-SiVET (observational data). Propensity scores, conditional on baseline characteristics were calculated for SiVET participation and matched between SiVET and non-SiVET in the period before and during the SiVET study. We compared IRR before and after propensity score matching (PSM). In total, 3989 participants were enrolled into observational cohorts prior to SiVET, (1575 FF prior to Jul 2012 and 2414 FSW prior to Aug 2014). SiVET enrolled 572 participants (Jul 2012 to Apr 2014 in FF and Aug 2014 to Apr 2017 in FSW), with 953 non-SiVET participants observed in the SiVET concurrent period and 2928 from the pre-SiVET period (before Jul 2012 in FF or before Apr 2014 in FSW). Imbalances in baseline characteristics were observed between SiVET and non-SiVET participants in both periods before PSM. Similarly, HIV incidence was lower in SiVET than non-SiVET; SiVET-concurrent period, IRR = 0.59, 95% CI 0.31-0.68, p = 0.033 and pre-SiVET period, IRR = 0.77, 95% CI 0.43-1.29, p = 0.161. After PSM, participants baseline characteristics were comparable and there were minimal differences in HIV incidence between SiVET and non-SiVET participants. The process of screening for eligibility for efficacy trial selects participants with baseline characteristics different from the source population, confounding any observed differences in HIV incidence. Propensity score matching can be a useful tool to adjust the imbalance in the measured participants' baseline characteristics creating a counterfactual group to estimate the effect of interventions on HIV incidence.

Correlates of knowledge of family planning among people living in fishing communities of Lake Victoria, Uganda.

BACKGROUND: Knowledge of family planning (FP) is a key determinant of contraceptive use which ultimately plays a role in attainment of good health and in conduct of clinical research. People living in fishing communities (FCs) have limited access to health services including FP and are targeted for future clinical research but their knowledge of FP and its correlates are scantily known. We determined correlates of knowledge of FP among people living in FCs of L. victoria in Uganda to inform future FP education programs in FCs. METHODS: We conducted a comparative cross-sectional survey among participants aged 15-49 years from Kigungu and Nsazi. Participants were asked if they were aware of any FP method. All those who responded in the affirmative were further asked to mention what FP methods they had heard of or knew. Those who reported knowledge of at least one FP method were asked a series of questions about FP methods and their side effects. Knowledge was categorized into good or poor knowledge based on their mean total score. Poor knowledge constituted a score below the mean while good knowledge constituted a score of more than or equal to the mean total score. To further explore attitudes and perceptions of FP, ten in-depth interviews and four focus group discussions were conducted. RESULTS: Of the 1410 screened participants, 94.5% were aware of at least one FP method. Pills and injectable hormonal methods were the most commonly known methods. Slightly over a third (38%) had good knowledge of FP. Correlates of knowledge of FP were; being female (aOR: 1.92 95% CI: 1.39-2.67), residing in Kigungu (aOR: 4.01 95% CI: 2.77-5.81), being married (aOR: 1.59 95% CI: 1.11-2.28) and currently being in a sexual relationship (aOR: 1.75 95% CI: 1.18-2.60). Concerns about safety and effectiveness of some modern FP methods exist. Misconceptions on effects of FP like sterility, cancers and foetal abnormalities were common. CONCLUSION: FP awareness among people living in FCs of L. Victoria in Uganda is high. However, good knowledge about specific methods tends to be low. Correlates of knowledge of FP include gender, residence, marital status and sexual engagement.

Comparison of retention in observational cohorts and nested simulated HIV vaccine efficacy trials in the key populations in Uganda.

BACKGROUND: Outcomes in observational studies may not best estimate those expected in the HIV vaccine efficacy trials. We compared retention in Simulated HIV Vaccine Efficacy Trials (SiVETs) and observational cohorts drawn from two key populations in Uganda. METHODS: Two SiVETs were nested within two observational cohorts, one in Fisherfolk (FF) and another one in Female Sex Workers (FSW). Adult participants in each observational cohort were screened for enrolment into SiVETs. Those screened-out or not screened continued participation in the observational (non-SiVET) cohorts. SiVET participants were administered a licensed hepatitis B vaccine in a schedule that mimicked an actual HIV vaccine efficacy trial. Both cohorts were followed for 12 months and retention was assessed through dropout, defined as lost to follow up, being uncontactable, refusal to continue or missing the last study clinic visit. Dropout rates were compared using Poisson models giving rate ratios and 95% confidence intervals (95%CI). RESULTS: Out of 1525 participants (565 FF and 960 FSW), 572 (38%) were enrolled into SiVETs (282-FF and 290-FSW), and 953 (62%) remained in the non-SiVET cohorts. Overall, 326 (101 SiVET, 225 non-SiVET) dropped out in 1260 Person Years of Observation (PYO), a dropout rate of 25.9 /100 PYO (95%CI: 23.2-28.8); fewer dropped out in the SiVET cohorts (18.4, 95% CI: 15.1-22.4) than in the non-SiVET cohorts (31.6, 95% CI: 27.8-36.1), rate ratio (RR) =0.58, 95% CI: 0.46-0.73. In all cohorts, the dropout was more marked in FSW than in FF population. Duration lived in community was associated with dropout in both SiVETs and religion in both non-SiVET cohorts. CONCLUSION: The rate of dropout was lower in SiVET compared to non-SiVET cohort. Though the difference in dropout between SiVET and non-SiVET was generally similar, the actual dropout rates were higher in the FSW population. Conduct of SiVETs in these key populations could mean that designing HIV Vaccine Efficacy Trials will benefit from lower dropout rate shown in SiVET than non-SiVET observational cohort.

Clinical Characteristics and Long-Term Outcomes of Midaortic Syndrome.

BACKGROUND: Midaortic syndrome (MAS) is a rare congenital or acquired condition marked by segmental or diffuse stenosis of the distal thoracic and/or abdominal aorta and its branches. The optimal approach to medical or interventional management of MAS and long-term outcomes in adults are not well defined. We reviewed MAS cases to characterize the natural history of aortic disease, identify prognostic factors, and evaluate the durability of invasive interventions. METHODS: We conducted a retrospective review of patients with MAS who presented to Memorial Hermann Hospital and Baylor College of Medicine between 1997 and 2018. We categorized cases according to demographic and clinical manifestations, etiologies, the extent of aortic involvement, interventions, and vascular outcomes. RESULTS: We identified a cohort of 13 patients with MAS. The etiology of MAS was identified in 6 cases, including genetic syndromes (neurofibromatosis type 1 (2/13), Williams syndrome (1/13), fibromuscular dysplasia (2/13), and Takayasu arteritis (1/13)). Mean age at first documented clinical event was 25.2 (2-67) years, but cases with genetic etiologies presented significantly younger (18.2 years). The most common primary anatomic site was the suprarenal and infrarenal aorta (zones 5-8). Extra-aortic locations involved the renal (4/13), celiac (3/13), and superior mesenteric (3/13) arteries. Clinical manifestations included hypertension (13/13), claudication (9/13), and postprandial abdominal pain (5/13). All patients with available follow-up data underwent at least one surgical or endovascular intervention (range: 1-8). Postoperative complications included renal failure requiring postdischarge hemodialysis and respiratory failure. There were no deaths in long-term follow-up. CONCLUSIONS: MAS is a complex vasculopathy with substantial variability in clinical presentation and anatomic distribution. Extensive disease frequently requires multiple invasive interventions and results in refractory hypertension, which may predict subsequent clinical events. A multidisciplinary approach with long-term monitoring is essential for preservation of end-organ function and quality of life in this debilitating disease.

Is incidental splenectomy during thoracoabdominal aortic aneurysm repair associated with reduced survival?

OBJECTIVE: The effect of incidental splenectomy during thoracoabdominal aortic aneurysm repair is unknown. We hypothesized incidental splenectomy was associated with decreased late survival. METHODS: We studied 1056 thoracoabdominal aortic aneurysm repairs from 2006 to 2016. Exclusion criteria were age less than 18 years (n = 9), prior splenectomy (n = 2), and intraoperative death (n = 3). This left 1042 thoracoabdominal aortic aneurysm repairs for analysis (median age, 65 years; interquartile range, 56-72), including 221 (21%) that were reoperations. Multivariable modeling identified predictors of operative mortality in the total cohort. Moreover, to adjust for baseline differences, propensity score matching was performed to examine the frequency of these outcomes in the total cohort (n = 132 pairs) and the early survivors (n = 110 pairs). Late survival was estimated by the Kaplan-Meier method, and risk of late mortality was assessed by Cox proportional hazards regression. RESULTS: Incidental splenectomy was performed in 135 patients (13%), 36% of whom underwent reoperation. Operative mortality rates of the incidental splenectomy and nonincidental splenectomy groups were 16% versus 8% in both the overall study (P = .005) and the propensity score-matched (P = .07) cohorts. In multivariable analysis, incidental splenectomy independently predicted operative mortality (odds ratio, 2.2; 95% confidence interval, 1.21-3.94; P = .008). For early survivors, incidental splenectomy did not increase the risk of late mortality. Survival estimates of matched early survivors did not differ between the incidental splenectomy and nonincidental splenectomy groups (P = .29). CONCLUSIONS: Incidental splenectomy during thoracoabdominal aortic aneurysm repair was associated with increased operative mortality but not reduced late survival. Splenic preservation is encouraged when feasible.

Neurologic complications after the frozen elephant trunk procedure: A meta-analysis of more than 3000 patients.

OBJECTIVE: The frozen elephant trunk technique's safety regarding spinal cord ischemia has been questioned. We used a meta-analysis to determine the rates of adverse neurologic events and mortality. METHODS: We searched PubMed/Medline, Embase, Scopus, and Cochrane databases (inception to April 2018) to identify studies of neurologic events after the frozen elephant trunk procedure. Separate meta-analyses were conducted with random-effects models to assess frozen elephant trunk associations with spinal cord ischemia, stroke, operative mortality, and all adverse events combined. Subgroup analyses compared outcomes in patients with acute versus nonacute type A dissection and aneurysm and with different extents of coverage. RESULTS: Thirty-five studies (total N = 3154) met inclusion criteria. The pooled rates of the outcomes of interest were 4.7% (95% confidence interval, 3.5-6.2) for spinal cord ischemia, 7.6% (95% confidence interval, 5.0-11.5) for stroke, and 8.8% (95% confidence interval, 7.0-10.9) for operative mortality. The spinal cord ischemia event rate was higher with stent length 15 cm or greater or coverage to T8 or beyond than with stent length of 10 cm (11.6% vs 2.5%, P < .001). Adverse event rates in patients with acute type A aortic dissection versus nonacute dissection or aneurysm were as follows: mortality 9.2% versus 7.6% (P = .46), stroke 9.3% versus 6.6% (P = .51), and overall adverse events 22.0% versus 16.5% (P = .41). CONCLUSIONS: As the frozen elephant trunk procedure becomes more popular, accurate data regarding outcomes are vital. We associated the frozen elephant trunk technique with (nonsignificantly) more adverse events overall in acute type A dissection cases. Stent length of 10 cm was associated with significantly less risk of spinal cord ischemia. Using a stent 15 cm or greater or coverage extending to T8 or farther should be avoided.

Spinal cord deficit after 1114 extent II open thoracoabdominal aortic aneurysm repairs.

OBJECTIVE: Crawford extent II repairs are the most extensive thoracoabdominal aortic aneurysm operations and pose the greatest risk of postoperative spinal cord deficit. We sought to examine spinal cord deficit after open extent II thoracoabdominal aortic aneurysm repair to identify predictors of the most serious type: persistent paraplegia or paraparesis. METHODS: We included 1114 extent II thoracoabdominal aortic aneurysm repairs performed from 1991 to 2017. Intercostal/lumbar artery reattachment (n = 959, 86.1%) and cerebrospinal fluid drainage (n = 698, 62.7%) were used to mitigate the risk of postoperative spinal cord deficit. We used univariate and multivariable analyses to examine spinal cord deficit and identify predictors of persistent paraplegia or paraparesis, defined as paraplegia or paraparesis present at the time of early death or hospital discharge. RESULTS: Spinal cord deficit developed after 151 (13.6%) repairs: 86 (7.7%) cases of persistent paraplegia or paraparesis (51 paraplegia; 35 paraparesis) and 65 (6.1%) cases of transient paraplegia or paraparesis. Patients with spinal cord deficit were older (median 68 vs 65 years, P < .001) and had more rupture (6.6% vs 2.2%, P = .002) and urgent/emergency repair (25.2% vs 16.9%, P = .01) than those without. Persistent paraplegia or paraparesis developed immediately in 47 patients (4.2%) and was delayed in 39 patients (3.5%). Urgent/emergency repair (relative risk ratio, 2.31; P = .002), coronary artery disease (relative risk ratio, 1.80, P = .01), and chronic symptoms (relative risk ratio, 1.76, P = .02) independently predicted persistent paraplegia or paraparesis. Reattaching intercostal/lumbar arteries (relative risk ratio, 0.38, P < .001) and heritable disease (relative risk ratio, 0.36, P = .01) were protective. Early and late survival were poorer in those with persistent paraplegia or paraparesis than in those without. CONCLUSIONS: Spinal cord deficit after extent II thoracoabdominal aortic aneurysm repairs remains concerning; survival is worse in patients with persistent paraplegia or paraparesis. The complexity of spinal cord deficit and persistent paraplegia or paraparesis warrant further study.

Tracheostomy After Thoracoabdominal Aortic Aneurysm Repair: Risk Factors and Outcomes.

BACKGROUND: Respiratory failure, the most frequent complication after thoracoabdominal aortic aneurysm (TAAA) repair, necessitates tracheostomy in severe cases. We examined risk factors for and outcomes of tracheostomy after TAAA repair. METHODS: We reviewed the records of 1267 consecutive patients who underwent TAAA repair. Patients with a preexisting tracheostomy were excluded. Extensive repairs (Crawford extent I or II) were performed in 716 patients (56.6%). Stepwise logistic regression analysis was used to identify risk factors for postrepair tracheostomy. RESULTS: Tracheostomy was necessary in 140 patients (11.1%). Operative mortality was significantly higher in patients with tracheostomy (27.9%) than in those without (5.8%; p < 0.001). As expected, tracheostomy patients had longer intensive care unit stays (24 vs 4 days, p < 0.001) and hospital stays (57 vs 10 days, p < 0.001) than nontracheostomy patients. Patients with tracheostomy were frequently transferred for additional long-term acute care or hospitalization (107, 76.4%), and many died after transfer (24/107, 22.4%). Kaplan-Meier curves showed markedly poorer late survival in patients with tracheostomy than in those without (47.9% ± 4.3% vs 87.3% ± 1.0% at 1 year; 27.8% ± 4.8% vs 68.6% ± 1.6% at 5 years). Independent predictors of post-TAAA repair tracheostomy included acute aortic dissection, chronic renal insufficiency, underweight body mass index, hypertension, history of stroke, extent II repair, diabetes, age at least 70 years, and greater platelet transfusion volume. CONCLUSIONS: Patients who undergo tracheostomy after TAAA repair have a high risk of early and late mortality as well as prolonged hospitalization. Strategies for improving survival outcomes in tracheostomy patients warrant investigation.

Acute type I aortic dissection with or without antegrade stent delivery: Mid-term outcomes.

OBJECTIVE: We determined the effect of antegrade stent delivery in the descending thoracic aorta on short- and mid-term clinical and imaging outcomes for patients who underwent repair of acute DeBakey type I aortic dissection. METHODS: Outcomes were evaluated for 178 patients who underwent acute type I aortic dissection between 2005 and 2016 (standard repair, n = 115 [64.6%]; antegrade stent delivery, n = 63 [35.4%]). Propensity score match and multivariable analyses were performed to assess outcomes. RESULTS: The stent and standard repair groups had similar rates of operative mortality (30-day or in-hospital) (12.7% vs 17.4%, P = .41), persistent stroke (6.3% vs 5.3%, P = .75), and persistent paraplegia/paraparesis (1.6% vs 0.9%, P = 1.0). Propensity score match analysis indicated that the operative mortality rate was higher in the standard repair group (P = .059), which the multivariable analysis confirmed. The persistent stroke rate was nonsignificantly higher in the stent group (P = .66). Persistent paraplegia/paraparesis rates were similar in both groups (P = 1.0), and the overall rates of spinal cord ischemia were nonsignificantly higher in the stent group (P = .18). During follow-up (mean duration, 4.6 ± 3.6 y), computed tomography showed that stented patients more often had remodeling of the descending thoracic aorta (P = .0002) and somewhat more often had remodeling of the thoracoabdominal aorta (P = .13). Stented patients also had fewer subsequent procedures (P = .25). The 3- and 5-year survivals were 73.3% ± 6.9% and 49.9% ± 7.6% in the matched stented group and 66.3% ± 9.4% and 41.6% ± 7.7% in the matched standard group, respectively (P = .015 for overall survival). CONCLUSIONS: In the short term, antegrade stent delivery was associated with less operative mortality. In the mid-term, promising remodeling of the false lumen was seen in stented patients, as were (nonsignificantly) lower rates of subsequent procedures in the thoracoabdominal aorta. Mid-term survival was also greater in the stented patients.

In the endovascular era, is elective open aortic arch surgery in elderly patients still justified?

OBJECTIVE: The data supporting performing elective aortic arch surgery in patients aged 75 years or older are equivocal. We evaluated short- and long-term outcomes after elective arch surgery in patients aged ≥75 years to determine whether complex arch operations are justified in such patients. METHODS: Over a 10-year period, 805 patients aged 50 to 89 years underwent elective proximal or total arch surgery. Composite adverse outcome was defined as operative mortality, persistent (ie, present at discharge) neurologic event, or persistent hemodialysis. Multivariable logistic regression was performed in the entire group. RESULTS: Multivariable analysis showed that age at admission independently predicted composite adverse outcome, operative mortality, and prolonged (>48 hours) ventilator support (P < .0001 for all), but not stroke. The same results were shown in a subgroup analysis in which older age (80-89 years) was associated with composite adverse outcome, operative mortality, and prolonged ventilator support. In a Cox proportional hazards regression model adjusted for antegrade cerebral perfusion time and prior history of renal disease, patients aged 50 to 74 years had significantly better overall survival than patients aged ≥75 years (P < .001). CONCLUSIONS: As endovascular technology evolves, having benchmark data from likely endovascular-therapy candidates is critical. This study, among the few to focus on elective aortic arch surgery in elderly patients, suggests that surgical intervention carries risk and that novel endovascular therapies are needed.

Incidence and Treatment Outcomes of Vocal Fold Movement Impairment After Total Arch Replacement.

BACKGROUND: Vocal fold movement impairment (VFMI) secondary to neuronal injury is a known risk after aortic surgery. Total arch replacement is technically challenging, and the incidence of vocal fold movement impairment secondary to neuronal injury after this surgery is unknown. This study examined the incidence of VFMI after total arch replacement and medialization treatment outcomes. STUDY DESIGN: Retrospective cohort study. METHODS: All patients who underwent total arch replacement at a tertiary care center over 11 years (2006-2017) were identified through an institutional database. End points included evidence of VFMI on flexible laryngoscopy, time to diagnosis, time to treatment, need for reintubation, and intensive care unit (ICU) and hospital length of stay. RESULTS: Of the 358 patients who underwent total arch replacement, 63 (20%) were diagnosed with VFMI during their initial inpatient stay. Fifty patients (79%) VFMIs were left-sided, nine (14%) were right-sided, and four (6%) were bilateral. Thirty-nine patients (62%) underwent inpatient vocal fold medialization: 28 (72%) by injection laryngoplasty and 11 (28%) by type 1 thyroplasty. Those with unilateral VFMI had longer ICU (8.9 days) and hospital (19.4 days) than those with no VFMI (5.7 and 16.1 days). Among patients with unilateral VFMI, those who underwent inpatient vocal fold medialization trended toward shorter ICU (6.2 vs. 14.4 days, P = .03) and hospital stays (20.1 vs. 23.3 days, P = .4) than patients who did not have a medialization procedure. CONCLUSION: The overall incidence of VFMI after total arch replacement in our series was 20%. Both the right and left vocal folds are potentially at risk from a total arch replacement; consequently, the distribution of injury in our cohort was more heterogeneous than in other series. LEVEL OF EVIDENCE: 3 Laryngoscope, 129:699-703, 2019.

Early-Stage Acute Kidney Injury Adversely Affects Thoracoabdominal Aortic Aneurysm Repair Outcomes.

BACKGROUND: Acute kidney injury (AKI) necessitating renal replacement therapy adversely affects outcomes after thoracoabdominal aortic aneurysm (TAAA) repair. The effects of earlier stages of AKI are less known. We hypothesized that earlier stages of AKI would reduce early survival after TAAA repair. METHODS: We analyzed prospectively collected data from 1,056 consecutive TAAA repairs from our institution (2006 to 2016). We excluded patients less than 18 years of age, those with preexisting renal disease, and three patients who died intraoperatively, resulting in 873 patients. The Kidney Disease Improving Global Outcomes criteria grouped patients into three AKI stages; stage 3 necessitated initiation of renal replacement therapy. Multivariable modeling identified operative mortality predictors. Kaplan-Meier analysis assessed 1-year survival. RESULTS: Of 873 patients, 642 (73.5%) had no AKI and 231 (26.5%) had postoperative AKI (mild/stage 1, n = 92 [10.5%]; moderate/stage 2, n = 44 [5%]; severe/stage 3, n = 95 [10.9%]). Operative death occurred in 65 patients (7.4%): 14 (2.2%) with no AKI, 5 (5.4%) with mild AKI (p = 0.07 versus no AKI), 8 (18.2%) with moderate AKI (p = 0.02 versus mild), and 38 (40%) with severe AKI (p = 0.01 versus moderate). In multivariable analysis, moderate AKI independently predicted death (relative risk ratio: 9.4, 95% confidence interval: 3.4 to 25.9). Kaplan-Meier 1-year survival was 91.1% ± 1.2% for no AKI, 84.6% ± 3.9% for mild AKI (p = 0.07 versus no AKI), 67.4% ± 7.6% for moderate AKI (p = 0.01 versus mild), and 46.6% ± 5.3% for severe AKI (p = 0.02 versus moderate; p < 0.0001 across all groups). CONCLUSIONS: Moderate/stage 2 AKI reduced early survival after TAAA repair. Prevention, earlier detection, and optimal medical management of AKI may improve survival.

Field Performance of PIMA Point-of-Care Machine for CD4 Enumeration Under a Mobile HIV Counseling and Testing Program in Remote Fishing Communities of Lake Victoria, Uganda.

Uganda is among the most HIV/AIDS-afflicted countries, and many HIV-infected persons live in remote areas with poor access to health care. The success of HIV care programs relies in part on patient monitoring using CD4 T cell counts. We conducted an evaluation of the point-of-care PIMA test using BD FACSCount as a gold standard. One hundred fifty-one participants were enrolled, provided venous blood and samples tested at the point of care with the Alere PIMA™ CD4 Analyzer and the BD FACSCount in the UVRI-IAVI main laboratory. Correlation between the methods was assessed, as was the ability of the Pima Analyzer to predict values <200, <350, and ≥500 CD4 cells/mm3 when compared with BD FACSCount as the gold standard. A near-perfect positive Pearson correlation coefficient (r = 0.948; p < .0001) between the two methods was observed. The Alere PIMA Analyzer had a mean bias of -32.5 cells/mm3. The sensitivity and specificity, for PIMA to predict CD4 lymphocyte count less than 200 cells/mm3, were 71.4% and 100%, respectively; less than 350 cells/mm3 were 84.6% and 94.6%, respectively; and at CD4 count less than 500 cells/mm3 were 94.4% and 100%. The Alere Pima Analyzer provides reliable CD4 cell count measurement and is suitable for monitoring and screening eligible HIV patients in hard-to-reach settings.

The impact of preoperative chronic kidney disease on outcomes after Crawford extent II thoracoabdominal aortic aneurysm repairs.

OBJECTIVE: To determine whether preoperative chronic kidney disease (CKD) is predictive of poor outcomes in patients who undergo Crawford extent II thoracoabdominal aortic aneurysm (TAAA) repair. METHODS: Data were collected from patients with CKD (defined as a preoperative estimated glomerular filtration rate <60 mL/min/1.73 m2; n = 399) and without CKD (n = 604) who underwent extent II TAAA repair during 1991 to 2016. We used univariate, multivariable, and propensity score matching analyses to compare outcomes between these 2 groups. RESULTS: Compared with patients without CKD, patients who presented with CKD were older and had greater rates of comorbidities, including coronary artery disease, cerebrovascular disease, and peripheral vascular disease. Patients with CKD had higher rates of operative mortality and adverse events. After propensity analysis, patients with CKD had greater rates of adverse event and renal failure necessitating dialysis, but had comparable rates of operative death to patients without CKD. Multivariable modeling indicated that CKD independently predicted adverse event (relative risk ratio [RRR] = 1.61; P = .01) and renal failure (RRR = 1.86; P = .02) after repair. After adjustment for median age, patients with CKD had substantially worse mid-term survival than those without (23.9 ± 2.4% vs 48.5 ± 2.5% at 10 years; P < .001). CONCLUSIONS: In patients who present with CKD, extent II open TAAA repair carries considerable risks of operative death and adverse events. Further investigation is needed to improve renal protection during such repair.

Chronic Type I and Type III aortic dissections: a propensity analysis of outcomes after open distal repair.

OBJECTIVES: To compare short-term outcomes, long-term survival and reinterventions in patients requiring surgery after chronic Type I and chronic primary Type III aortic dissections. METHODS: Over an 11-year period, 466 patients underwent thoraco-abdominal aortic aneurysm repair for chronic Type III (n = 239) and Type I (n = 227) aortic dissections. Short-term outcomes and reinterventions were evaluated by multivariable regression analysis for the entire group; propensity matching produced 169 pairs. RESULTS: Mortality was 6% (n = 28) in the overall cohort and 6.2% (n = 14) and 5.9% (n = 14) in those with chronic Type I and Type III aortic dissections, respectively. Overall stroke and persistent spinal cord deficit rates were 4.0% and 2.6%, respectively, in the Type I group and 1.3% and 3.8% in the Type III group. In the propensity-matched patients, analysis showed no neurological differences between the 2 groups, but respiratory failure was significantly more frequent in the chronic Type I group (30.2% vs 15.4%; P = 0.001). Multivariable analysis identified chronic Type I dissection as an independent risk factor for postoperative pulmonary complications (odds ratio 1.612; 95% confidence interval 1.060-2.452; P = 0.026) and an association between chronic Type I dissection and stroke (odds ratio 4.013; 95% confidence interval 1.026-15.698; P = 0.046). Six-year survival was 74.4% ± 4.1% and 74.4% ± 4.6% in the chronic Type I and Type III groups, respectively (P = 0.87). CONCLUSIONS: Short- and long-term mortality and reintervention rates were comparable after open repair for chronic Type I and primary chronic Type III aortic dissections. Respiratory failure was more frequent in the chronic Type I aortic dissection group.