In-situ bypass is associated with superior infection-free survival compared with extra-anatomic bypass for the management of secondary aortic graft infections without enteric involvement.

OBJECTIVE: The optimal revascularization modality following complete resection of aortic graft infection (AGI) without enteric involvement remains unclear. The purpose of this investigation is to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients undergoing complete excision of AGI. METHODS: A retrospective, multi-institutional study of AGI from 2002 to 2014 was performed using a standardized database. Baseline demographics, comorbidities, and perioperative variables were recorded. The primary outcome was infection-free survival. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariable analyses were performed. RESULTS: A total of 241 patients at 34 institutions from seven countries presented with AGI during the study period (median age, 68 years; 75% male). The initial aortic procedures that resulted in AGI were 172 surgical grafts (71%), 66 endografts (27%), and three unknown (2%). Of the patients, 172 (71%) underwent complete excision of infected aortic graft material followed by in situ (in-line) bypass (ISB), including antibiotic-treated prosthetic graft (35%), autogenous femoral vein (neo-aortoiliac surgery) (24%), and cryopreserved allograft (41%). Sixty-nine patients (29%) underwent extra-anatomic bypass (EAB). Overall median Kaplan-Meier estimated survival was 5.8 years. Perioperative mortality was 16%. When stratified by ISB vs EAB, there was a significant difference in Kaplan-Meier estimated infection-free survival (2910 days; interquartile range, 391-3771 days vs 180 days; interquartile range, 27-3750 days; P < .001). There were otherwise no significant differences in presentation, comorbidities, or perioperative variables. Multivariable Cox regression showed lower infection-free survival among patients with EAB (hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.6-3.6; P < .001), polymicrobial infection (HR, 2.2; 95% CI, 1.4-3.5; P = .001), methicillin-resistant Staphylococcus aureus infection (HR, 1.7; 95% CI, 1.1-2.7; P = .02), as well as the protective effect of omental/muscle flap coverage (HR, 0.59; 95% CI, 0.37-0.92; P = .02). CONCLUSIONS: After complete resection of AGI, perioperative mortality is 16% and median overall survival is 5.8 years. EAB is associated with nearly a two and one-half-fold higher reinfection/mortality compared with ISB. Omental and/or muscle flap coverage of the repair appear protective.

Evolution in the Presentation, Treatment, and Outcomes of Patients with Acute Mesenteric Ischemia.

OBJECTIVES: Acute mesenteric ischemia (AMI) is a life-threatening condition associated with dismal outcomes. This study sought to evaluate the evolution of presentation, treatment, and outcomes of AMI over the past two decades. METHODS: AMI patients presenting at a single institution were reviewed (1993-2016). Venous thrombosis patients were excluded. Primary outcome was 30-day mortality. Patients were stratified by etiology and diagnosis date (before 2004 versus 2004 and later). Ordered logistic regression was performed for longitudinal temporal analysis. RESULTS: 303 patients were identified. AMI mechanisms included: embolic (49%), thrombotic (29%), and non-occlusive (NOMI) (22%). The majority were women (55%), 50% had atrial fibrillation, and 23% were on anticoagulation (AC) therapy. Mean age was 72±13 years. 345 procedures were performed in 242 patients: 321 open and 24 hybrid/endovascular. Among the 189 embolic/thrombotic patients who were managed operatively, 45% (n=85) underwent mesenteric revascularization while 39 (21%) had findings of non-survivable bowel necrosis (NSBN). Among the 104 patients who did not undergo revascularization, 64 (62%) died within 30-days compared to 36 out of 85 (42%) patients who were revascularized (P=0.01). 30-day mortality was 61% and stable over time (P=0.91); when stratified by AMI etiology, the thrombotic cohort had worse survival than embolic and NOMI patients (P=0.04). Since 2000, there was a significant decrease in the percentage of embolic AMI events (P=0.04). The percentage of patients who underwent operative management decreased also over time (P=0.01, 81% → 61%), which was correlated with an increasing number of patients being made comfort measures only (CMO) prior to surgical intervention (50% → 70%, P=0.02). The majority of patients (55%) were ultimately made CMO during their hospitalization. Predictors of 30-day mortality included a preoperative white blood cell count (WBC) ≥ 25 K/ µL. (OR 3.0, P=0.002) and lactate ≥ 2.3 mmol/L (OR 2.8, P=0.045). NSBN predictors included WBC ≥ 24 K/ µL. (OR 3.4 P=0.03) and lactate ≥ 3.8 mmol/L (OR 3.6, P=0.04). CONCLUSIONS: Despite advances in critical care over the past 25 years, AMI continues to be associated with poor prognosis. The survival benefit observed in patients who undergo revascularization supports an aggressive approach towards early vascular intervention, although this requires further study. The importance of early diagnosis, prognostication and advanced directives is highlighted given the high morbidity, mortality and use of comfort measures associated with AMI.

Venous mesenteric ischemia carries high procedural burden and elevated mortality in patients with severe presentation.

OBJECTIVE: Venous mesenteric ischemia (VMI) presents with variable severity resulting in a spectrum of outcomes. This study sought to characterize the natural history of VMI and identify drivers of intervention and adverse outcomes. METHODS: All patients who presented to our institution with acute and subacute VMI between 1993 and 2016 were identified. Images were reviewed to determine thrombosis location and charts were reviewed to identify clinical factors and outcomes. Univariate analysis was performed for demographics, comorbidities, and presenting characteristics, with primary outcomes of intervention, readmission, and 30-day mortality. A survival analysis was performed with log-rank difference testing for demographics, comorbidities, and presenting characteristics. RESULTS: We identified 103 patients with acute and subacute VMI. The locations of the thrombosis included the superior mesenteric vein (SMV) (31.1%); SMV and portal vein (35.9%); SMV, portal, and splenic veins (15.5%); and other combinations of portomesenteric veins (17.4%), without correlation between the location and outcomes. Most patients were male (60.6%), 22.3% were actively smoking, and the median Charlson comorbidity score was 4 (interquartile range, 2-7). The mean patient age was 61.3 years. More than one-half had a known hypercoagulability (52.4%), 22.3% had prior bowel resection, and 8.7% had prior mesenteric venous intervention, including transjugular intrahepatic portosystemic shunt procedures. Thirty-five patients underwent 83 procedures during their hospitalization, and 23 patients underwent surgical intervention specifically. Prior mesenteric venous procedure, abdominal tenderness, and lactatemia of more than 1.5 mmol/L were associated with an increased need for surgical intervention (P < .05). Patients with leukocytosis of greater than 10K/µL had increased surgical intervention (P = .10), although without statistical significance. However, symptoms for less than 2 weeks (P < .05) were associated with decreased surgical intervention. The 30-day mortality was low in this cohort (6.8%), but was increased in patients requiring intervention (11.4%). For those undergoing procedures, a shorter time to intervention was associated with an improved 30-day mortality (8.7% for procedures on hospital days 0-1 vs 16.7% for hospital day 2 or later; P = .01). Abdominal tenderness and lactatemia were associated with increased 30-day mortality (6.8% vs 3.6% [P < .01] and 16.0% vs 3.8% [P = .03], respectively). A Kaplan-Meier survival analysis revealed a median survival of 7.1 years, with a 1-year survival rate of 74.9%, a 3-year survival rate of 67.1%, and a 5-year survival rate of 57.9%. Negative predictors of survival included a higher Charlson comorbidity index (hazard ratio, 3.7; P < .01) and malignancy (hazard ratio, 3.1; P < .01). CONCLUSIONS: The 30-day mortality of VMT is low, but more than one-third of patients required an intervention beyond anticoagulation. Comorbidity, a prior mesenteric vessel or intestinal operation, and presentation with tenderness or relevant laboratory abnormalities portend worse outcomes. Early intervention is associated with improved outcomes.

Effect of occult malignancy on femoropopliteal bypass graft thrombosis.

OBJECTIVE: The presence of cancer increases arterial thromboembolic events, specifically myocardial infarction and stroke, before a formal diagnosis of cancer. To the best of our knowledge, this increase in thrombotic risk has not been studied in patients with lower extremity bypass grafts. In the present study, we aimed to determine the effect of occult cancer on femoropopliteal bypass patency. METHODS: A retrospective review of femoropopliteal bypass procedures completed from 2001 to 2018 was performed. International Classification of Diseases, 9th and 10th revision, codes corresponding to breast, lung, prostate, colorectal, skin, brain, and hematologic cancer were used to identify patients who had had occult cancer. Occult cancer was defined as cancer diagnosed within ≤1 year after the bypass procedure. The demographics, comorbidities, bypass configuration and conduit, 1-month, 3-month, 6-month, and 1-year occlusion rates, major adverse limb events, and mortality rates were analyzed. Statistical analysis included t tests, χ2 tests, and Cox regression analysis. RESULTS: A total of 621 procedures in 517 patients met the inclusion criteria. Of the 621 procedures, 36 (5.8%) were classified as procedures in patients with occult cancer. The patients with occult cancer had had higher occlusion rates at 3 months (27.8% vs 8.0%; P < .001), 6 months (30.5% vs 15.1%; P < .01), and 1 year (44.4% vs 19.8%; P < .001). In Cox regression analysis for bypass thrombosis at 1 year, the only significant predictors were occult cancer (hazard ratio [HR], 2.03; P = .01), below-the-knee distal target (HR, 1.88; P < .01), and a compromised conduit (HR, 2.14; P < .001). CONCLUSIONS: We found an increase in bypass graft thrombosis rates in patients who had undergone femoropopliteal bypass who had had occult cancer. Thrombosis of the graft within 1 year postoperatively might be a sign of occult cancer.

Contemporary Endovascular 30-Day Outcomes for Critical Limb Threatening Ischemia Relative to Surgical Bypass Grafting.

OBJECTIVES: Data from 2011-2014 showed lower extremity bypass(LEB) outperforming infrainguinal endovascular intervention(IEI) regarding major adverse limb events(MALE) but noted no significant difference in major adverse cardiac events(MACE) in propensity matched cohorts. This study aimed to determine if more recent(2015-2018) endovascular outcomes data have improved relative to surgical bypass. METHODS: Patients who underwent intervention for chronic limb threatening ischemia (CLTI) from 2015-2018 were identified using the American College of Surgeons National Quality Improvement Program(NSQIP) Vascular Surgery module. The cohort was categorized as undergoing lower extremity bypass(LEB) or infrainguinal endovascular intervention(IEI). Primary 30-day outcomes included major adverse cardiac events(MACE), major adverse limb events(MALE), and major amputation. Inverse probability weighting was used for multivariable analysis. RESULTS: A total of 10,783 patients underwent an infrainguinal intervention for CLTI from 2015-2018. Of these, 6,003(55.7%) underwent LEB and 4,780(44.3%) underwent IEI. Forty percent of the cohort was considered "high anatomic risk" by Objective Performance Goals(OPG) standards, and 13.6% were considered "high clinical risk." The IEI cohort vs. the LEB cohort experienced a Myocardial infarction(MI)/Stroke rate of 1.8% vs. 3.6%(p < .001), and had a mortality rate of 2.0% vs. 1.7%(p = .22), which yielded a composite MACE of 3.4% vs. 4.8%(p = .001). The rate of reintervention for IEI vs LEB was 4.4% vs. 5.3%(p = .04), the loss of patency (without re-intervention) rate was 1.8% vs. 1.8%(p = 1.0), and the major amputation rate was 4.1% vs. 3.5%(p = .15), which resulted in a MALE rate of 9.1% vs. 8.8%(p = .50). Following inverse probability weighting, comparing the IEI to the referent LEB, MALE AOR = 1.17, 95% CI[1.01 -1.36], p = .036, MACE AOR = 0.61, 95% CI[0.49-0.74], p < .001, and major amputation AOR = 1.31, 95% CI[1.05 -1.62], p = .016. CONCLUSION: Endovascular outcomes continue to demonstrate inferiority in major amputation and overall MALE. However, endovascular intervention has a significantly reduced incidence of MACE. Overall, these results demonstrate an improvement in endovascular MACE rates in recent years relative to surgical bypass.

Ensuring equity, diversity, and inclusion in the Society for Vascular Surgery: A report of the Society for Vascular Surgery Task Force on Equity, Diversity, and Inclusion.

Diversity, equity, and inclusion represent interconnected goals meant to ensure that all individuals, regardless of their innate identity characteristics, feel welcomed and valued among their peers. Equity is achieved when all individuals have equal access to leadership and career advancement opportunities as well as fair compensation for their work. It is well-known that the unique backgrounds and perspectives contributed by a diverse workforce strengthen and improve medical organizations overall. The Society for Vascular Surgery (SVS) is committed to supporting the highest quality leadership, patient care, surgical education, and societal recommendations through promoting diversity, equity, and inclusion within the SVS. The overarching goal of this document is to provide specific context and guidance for enhancing diversity, equity, and inclusion within the SVS as well as setting the tone for conduct and processes beyond the SVS, within other national and regional vascular surgery organizations and practice settings.

Adding Supra-Aortic Trunk Surgical Reconstruction to Carotid Endarterectomy: Implications on Risk of Stroke and Death.

BACKGROUND: Additive risks of combining supra-aortic trunk surgical reconstruction (SAT) with carotid endarterectomy (CEA) for associated carotid bifurcation and great vessel disease management are not well defined. This study sought to define risk of combining SAT with CEA. STUDY DESIGN: Isolated CEA (ICEA) and CEA+SAT (from 2005 to 2015) were identified from NSQIP, excluding nonocclusive indications. CEA+SAT were compared with ICEA as well as a propensity-matched ICEA cohort. Primary outcomes included 30-day stroke, death, and composite (SD). Outcomes were then weighted by symptomatic status. Univariate and logistic regression analyses were performed. RESULTS: Patients included 79,477 ICEA and 270 CEA+SAT. SAT reconstructions included 19 (7%) aorto-carotid bypasses, 21 (8%) carotid-subclavian transpositions, 85 (31%) carotid-carotid bypasses, and 145 (54%) carotid-subclavian bypasses. There was no difference in 30-day mortality (vs CEA+SAT 1.5% vs ICEA 0.7% p = 0.12). CEA+SAT had higher rates of stroke (3.7% vs 1.6%, p = 0.005) and stroke and death (SD) (4.8% vs 2.1%, p = 0.001). Predictors of SD included CEA+SAT (odds ratio [OR] 5.2, 95% CI 1.03-26.3, p = 0.046) and symptomatic status (OR 1.9, 95% CI 1.1-3.2, p = 0.02). After propensity matching, CEA+SAT continued to have higher rates of stroke (3.4% vs 0.4%, p = 0.01) and SD (4.5% vs 1.5%, p = 0.04), with similar mortality (1.5% vs 1.1%, p = 0.70). No differences were noted in primary endpoints in asymptomatic patients. In symptomatic patients, CEA+SAT carried significantly higher stroke (5.6% vs 2.1%, p = 0.04) and SD risk (7.0% vs 2.8%, p = 0.03). CONCLUSIONS: CEA+SAT confers increased risk of stroke and SD over ICEA. Symptomatic status and concomitant procedure contribute to this risk. Management should be considered within the context of lesion characteristics, patient longevity, and individual operative risk profile.

Perioperative outcomes for carotid revascularization on asymptomatic dialysis-dependent patients meet Society for Vascular Society guidelines.

OBJECTIVE: The current Society for Vascular Surgery practice guidelines recommend carotid revascularization for asymptomatic disease in patients with at least a 3-year life expectancy and stenosis >60% when the expected perioperative stroke and death rate is <3%. Based on this recommendation, it was previously determined that asymptomatic patients who require dialysis would not meet the perioperative stroke and death thresholds nor the long-term survival benchmarks to justify carotid surgery. To determine whether carotid surgery for patients requiring dialysis is appropriate, the present study compared the perioperative outcomes after carotid revascularization for dialysis-dependent patients relative to nondialysis patients in a contemporary, national cohort. METHODS: The targeted vascular module from the American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients who undergone carotid endarterectomy or carotid artery stenting for asymptomatic carotid disease from 2011 to 2018. The cohort was categorized as requiring or not requiring dialysis. The primary 30-day outcomes included mortality and the composite of stroke/death and stroke/death/myocardial infarction (MI). Univariate analyses were performed using the Fisher exact test and Wilcoxon rank sum test. Multivariable analyses were used to assess the independent associations of the estimated glomerular filtration rate and dialysis dependence with the stroke/death rate. RESULTS: A total of 17,579 patients met the inclusion criteria. Of these patients, 226 (1.3%) required dialysis at revascularization. No difference was found in the degree of severe stenosis (80%-99%) demonstrated by 69% of the dialysis cohort and 72% of the nondialysis cohort (P = .9). Of the dialysis and nondialysis cohorts, 5% and 3.6% underwent carotid artery stenting (P = .3). The dialysis-dependent patients were younger (68 vs 71 years; P < .001) and were more likely to have insulin-dependent diabetes (47% vs 12%; P < .001), congestive heart failure (8.4% vs 1.4%; P < .001), and severe chronic obstructive pulmonary disease (15% vs 10%; P = .03). In the dialysis and nondialysis cohort, 2 (0.9%) and 88 (0.5%) patients died (P = .3); 4 (1.8%) and 247 (1.4%) experienced strokes (P = .6); and 3 (1.3%) and 185 (1.1%) patients experienced MI (P = .5), respectively. The composite outcomes of stroke/death and stroke/death/MI was 2.2% (n = 5) and 1.8% (n = 319; P = .6) and 3.5% (n = 8) and 2.8% (n = 479; P = .4) in the dialysis and nondialysis cohorts, respectively. After multivariable analysis, neither the estimated glomerular filtration rate (adjusted odds ratio, 1.0; 95% confidence interval, 1.00-1.01; P = .26) nor dialysis dependence (adjusted odds ratio, 0.21; 95% confidence interval, 0.03-1.57; P = .13) was independently associated with the composite outcome of stroke/death. CONCLUSIONS: The 30-day carotid revascularization outcomes for asymptomatic disease in dialysis-dependent patients met the Society for Vascular Surgery guidelines in this national cohort and might be better than previously surmised. Hence, vascular surgeons could consider carotid revascularization for select dialysis-dependent patients with the appropriate expected longevity and perioperative risk.

Contemporary Endovascular Outcomes for Critical Limb Ischemia Are Still Failing to Meet Society for Vascular Surgery Objective Performance Goals.

OBJECTIVES: The Society for Vascular Surgery (SVS) created Objective Performance Goals (OPGs) for critical limb ischemia (CLI) in 2009. It was previously shown that endovascular therapy for CLI was not meeting these benchmarks. The OPG for all peripheral interventions is <8% for major adverse cardiac events (MACE), <8% for major adverse limb events (MALE), and <3% for major amputation. The goal of this study is to evaluate if outcomes have improved for CLI in recent years, specifically 2015-2018. METHODS: The Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was queried to identify patients who underwent endovascular intervention for critical limb ischemia from 2011-2018. Cohorts were divided into 2011-2014 and 2015-2018. Primary 30-day outcomes were MACE, MALE, and major amputation. Univariate analyses were performed using the Fisher's exact test and the Wilcoxon rank-sum test. Multivariate analysis comparing groups was performed using inverse probability weights and trend over time analysis was performed using logistic regression with year of intervention as a continuous variable. RESULTS: From 2011 to 2018, 7,168 patients underwent an endovascular intervention for CLI. 28% were classified as "OPG high anatomic risk," and 17% were classified as "OPG high clinical risk." The 2015-2018 cohort vs. the 2011-14 cohort experienced MACE in 3.3% vs. 2.7% (p = .23), MALE in 9.1% vs. 8.9% (p = 0.83), and amputation in 4.0% vs. 4.2% (p = 0.71). When only high anatomic risk patients were considered (n = 1988), MACE was experienced in 2.4% vs. 2.2% (p = 0.87), MALE by 9.5% vs. 10.6% (p = 0.47) and amputation by 5.1% vs. 6.0% (p = 0.40). When only high clinical risk patients were considered (n = 1224), MACE was experienced in 5.2% vs. 3.9% (p = 0.33), MALE by 8.0% vs. 7.4% (p = 0.74) and amputation by 3.9% vs. 3.7% (p = 0.88). Comparing 2015-2018 to the reference 2011-2014, MALE adjusted odds ratio (AOR) = 0.99, 95% CI [0.83-1.18], MACE AOR = 1.19 95% CI [0.88-1.60], and major amputation AOR = 0.91 95% CI [0.70-1.17]. There were no decreases in the trend over time for MALE (AOR per year 0.97, CI [.94-1.02], major amputation (AOR per year: 0.97, CI [0.91-1.03], nor for MACE (AOR per year: 1.05, CI [.98-1.13]). CONCLUSION: Outcomes following endovascular interventions for CLI continue to underperform when compared to OPG benchmarks for MALE and amputations. There is no decrease over time for these target outcomes. Target MACE events remain acceptable despite the increasing clinical complexity of patients being treated.

Female Sex Portends Worse Long-Term Survival after Open Type I-III Thoracoabdominal Aneurysm Repair.

BACKGROUND: Although outcomes after infrarenal abdominal aortic aneurysm surgery are worse in females, sex-specific differences in outcomes after open thoracoabdominal aortic aneurysm (TAAA) repair are less clear. The goal of this study was to identify sex-based disparities in short- and long-term outcomes after open type I-III TAAA surgery. METHODS: All open type I-III TAAA repairs performed from 1987 to 2015 were evaluated using an institutional database. Charts were retrospectively evaluated for perioperative outcomes: major adverse events (MAEs), in-hospital death, and long-term survival. Univariate analysis was performed using the Fisher's exact test for categorical variables and the Wilcoxon rank-sum test for continuous variables. Logistic regression was used for in-hospital end points; survival analyses were performed with Cox proportional hazards modeling and Kaplan-Meier techniques. Sensitivity analyses were performed for relevant multivariable models, one with ruptures removed and another evaluating only repairs performed before 2006 to account for any selection bias due to wider use of complex endovascular technology. RESULTS: Five-hundred sixteen patients underwent open type I-III TAAA repair during the study period. Females accounted for 54.3% (n = 280) of the cohort. Women were older, less likely to have a chronic dissection etiology, more likely to present with a symptomatic/ruptured lesion, and had a lower admission creatinine than men. Perioperative death occurred in 23 men (9.8%) and 19 women (6.8%) (P = 0.26); 133 women (47.3%) and 116 men (49.2%) suffered an MAE (P = 0.72). Multivariable analyses revealed no sex-based difference in perioperative death (Female sex adjusted odds ratio (AOR): 0.72, 95% confidence interval (CI): 0.4-1.4, P = 0.34) or MAE (AOR: 1.0 CI: 0.7-1.5, P = 0.82). Unadjusted survival at five years was 50% for women and 67% for men (log-rank P < 0.001). Female sex was an independent predictor of decreased survival (hazard ratio (HR): 1.5 95% CI: 1.2-1.9, P = 0.001) when adjusted for age, aneurysm extent, creatinine, chronic obstructive pulmonary disease, and ruptures. After removing all ruptures, female sex remained nonpredictive of perioperative death (AOR: 1.1, 95% CI 0.5-2.5, P = 0.75) or MAE (AOR: 1.2, CI: 0.8-1.9, P = 0.31) and predictive of decreased long-term survival (HR: 1.5, 95% CI: 1.2-2.0, P = 0.001). CONCLUSIONS: Those undergoing open type I-III TAAA repair have similar rates of perioperative mortality and MAEs, regardless of sex. However, female sex is an independent risk factor for decreased long-term survival.

Unplanned readmissions after endovascular intervention or surgical bypass for critical limb ischemia.

OBJECTIVE: After surgery or other interventions, unplanned readmissions are associated with poor outcomes and drain health care resources. Patients with critical limb ischemia (CLI) are at particularly high risk of readmission, and readmissions result in increased health care costs. The primary aims of the study were to discover and compare the 30-day readmission rates of patients who underwent lower extremity surgical bypass (LEB) and endovascular infrainguinal endovascular intervention (IEI) for CLI and to evaluate the relationship between unplanned readmissions likely related to the primary procedure for IEI compared with LEB. METHODS: The Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program was queried to identify all infrainguinal LEB or IEI for CLI from 2015 to 2018. Those who were not eligible for the primary outcome of interest were excluded. The primary 30-day outcome was unplanned readmission. Univariate analyses for primary and secondary outcomes were performed using Fisher's exact and Wilcoxon rank-sum testing. Multivariate analysis was performed using inverse probability weighting and independent risk factors for readmission were identified with logistic regression. RESULTS: There were 12,873 patients who met inclusion criteria. In the LEB cohort, there were 7270 (56.5%) patients, and in the IEI cohort, there were 5603 (43.5%) patients. Thirty percent (n = 1696) of the IEI cohort underwent a tibial intervention, and 49% (n = 3547) underwent a distal bypass. The IEI cohort was more likely to be high physiologic risk (P < .001) and to present with tissue loss (P < .001), whereas the LEB cohort was more likely to have high anatomic risk features (P < .001) and be performed under emergent conditions (P < .001). After multivariable analysis, LEB was found to be independently predictive for both unplanned readmissions due to any cause (adjusted odds ratio, 1.35; 95% confidence interval, 1.22-1.51; P < .001) and procedure-related unplanned interventions (adjusted odds ratio, 1.85; 95% confidence interval, 1.63-2.11; P < .001). Independent predictors of readmission were LEB, preoperative sepsis, severe chronic kidney disease, dependent functional status, insulin-dependent diabetes mellitus, high-risk physiologic features, African American race, preoperative steroid use, history of severe chronic obstructive pulmonary disease, and preoperative tissue loss. CONCLUSIONS: LEB is independently associated with unplanned readmission from all causes and from procedure-related causes after adjusting for the measured confounders. More research is required to determine the economic burden of these readmissions.

Comparison of 30 Day Stroke and Death in Hybrid Intervention and Open Surgical Reconstruction for the Treatment of Tandem Carotid Bifurcation and Supra-aortic Trunk Disease.

OBJECTIVE: The optimal approach for the treatment of tandem carotid bifurcation and supra-aortic trunk (SAT) disease remains controversial. The hybrid technique of carotid endarterectomy (CEA) with ipsilateral proximal endovascular intervention (IPE) has provided an attractive alternative to CEA with open SAT reconstruction (SATr). However, no studies have compared cohorts treated by these two approaches. METHODS: Using the National Surgical Quality Improvement Program (2005-2017), patients who underwent CEA + IPE and CEA + SATr were identified. Non-occlusive indications were excluded. Primary outcomes included 30 day stroke, death, and their composite (stroke and/or death [SD]). Univariable and logistic regression analyses were performed. RESULTS: In total, 372 patients were identified: 319 CEA + SATr and 53 CEA + IPE. SATr included 19 (5.9%) aorta to carotid bypasses, 22 (6.9%) carotid subclavian transpositions, 96 (30.1%) carotid carotid bypasses, 179 (56.1%) carotid subclavian bypasses, and three (0.9%) SAT endarterectomies. The mean age was 69 ± 10 years. The majority were men (53%), white (85%), and had a history of hypertension (84%). There were no demographic differences between the operative cohorts except that those having CEA + SATr were more likely to have hypertension (86% vs. 74%; p = .031). CEA + SATr had longer operative times and longer hospital length of stay. There were no differences in outcomes between the cohorts: stroke (CEA + SATr 4.1% vs. CEA + IPE 3.8%; p = .92), death (1.6% vs. 0%; p = .36), or SD (5.3% vs. 3.8%; p = .63). After risk adjustment, predictors of SD included symptomatic status (odds ratio [OR] 3.9, 95% confidence interval [CI] 1.1-13.5; p = .034), congestive heart failure (OR 16.5, 95% CI 2.0-136; p = .011), and return to the operating room (OR 8.5, 95% CI 2.3-30.8; p = .001). Operative method was not predictive (p = .63). CONCLUSION: Outcomes following CEA + SATr and CEA + IPE are similar. Although proposed as a safer, less invasive alternative, the hybrid approach did not reduce the risk of operative stroke or death relative to open reconstruction for the treatment of occlusive, tandem carotid/SAT disease. Based upon lesion and patient factors, both may be considered management options in select patients.

Perioperative and long-term outcomes after thoracoabdominal aortic aneurysm repair of chronic dissection etiology.

OBJECTIVE: Open repair of thoracoabdominal aortic aneurysms (TAAAs) that have developed secondary to chronic dissection (CD) is often more complex than repair of degenerative aneurysms (DAs). However, the literature is conflicted regarding the effect of CD on perioperative and long-term outcomes after open TAAA repair. The goal of this study was to determine whether CD predicts negative outcomes after TAAA repair. METHODS: All open type I to type III TAAA repairs performed from 1987 to 2015 were evaluated using a single institutional database. End points included in-hospital death, spinal cord ischemia (SCI), major adverse events (MAEs), and long-term survival. Repairs performed for rupture or acute dissection were excluded. Univariate analysis was conducted using the Fisher's exact test for categorical variables and the Wilcoxon rank sum test for continuous variables. Logistic multivariable regression was used for the in-hospital end points, and survival analyses were performed with Cox proportional hazards modeling and Kaplan-Meier techniques. RESULTS: During the study period, 453 patients underwent an intact open type I to type III TAAA repair. Ninety (20%) were performed for patients with CD. Those with CD were more likely to be younger (59 years vs 72 years; P < .001), to have an extent II lesion (30% vs 16%; P < .001), and to have Marfan syndrome (18% vs 0.6%; P < .001) and less likely to have coronary artery disease (28% vs 25%; P = .01) or chronic obstructive pulmonary disease (12% vs 27%; P = .004) compared with patients with DA. Twelve percent of patients with CD died perioperatively compared with 6% of those with DA (P = .03). Eighteen percent of CD patients suffered from SCI compared with 12% of DA patients (P = .2). Fifty-nine CD patients suffered a MAE compared with 42% of those with DA (P = .006). Multivariable analysis revealed CD to be an independent predictor of perioperative death (adjusted odds ratio [AOR], 3.1; 95% confidence interval [CI], 1.2-8.0; P = .02) with adjustment for age and Crawford extent. CD was also found to be independently predictive of any MAE (AOR, 2.5; 95% CI, 1.4-4.6; P = .002). CD was not associated with increased risk of SCI (AOR, 1.4; 95% CI, 0.6-3.2; P = .4). There was a long-term survival advantage in the CD cohort in the unadjusted analysis (log-rank, P = .009) but not in the adjusted analysis (CD adjusted hazard ratio, 0.9; 95% CI, 0.6-1.4; P = .7). CONCLUSIONS: When analysis is limited to type I to type III TAAAs, open repair of patients with CD leads to increased perioperative mortality and morbidity compared with patients with DA. However, age-adjusted long-term survival is no different between the two cohorts.

Thoracic aortic remodeling with endografting after a decade of thoracic endovascular aortic repair experience.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) results have been studied in short-term time frames. This study aimed to evaluate midterm and long-term outcomes of TEVAR, emphasizing postoperative aortic remodeling and need for reintervention. METHODS: This is an institutional retrospective review of TEVAR for isolated descending thoracic aortic aneurysms. Data were collected from 2004 to 2018. Primary outcomes studied included aneurysm sac remodeling, freedom from reintervention, and all-cause mortality. Other outcomes studied include endoleak rates, neurologic complication rates, and any overall postoperative complication rates. RESULTS: During the study period, 219 patients underwent TEVAR for descending thoracic aortic aneurysms. The median effect of TEVAR on sac diameter was a 0.7-cm decrease in size (interquartile range, -1.4 to 0.0 cm). During the study period, 80% (n = 147) of patients experienced aneurysm sac regression or stability. Perioperative neurologic complications occurred in 16% (n = 34) of patients. Significant predictors of sac growth were endoleak (odds ratio [OR], 65; P < .001), preoperative carotid-subclavian bypass (OR, 8; P = .003), and graft oversizing <20% (OR, 15; P = .046). Every 1-mm increase in aortic diameter at the proximal TEVAR landing zone led to an increased odds of endoleak (OR, 2; P = .049). Access complications (OR, 8) and subclavian artery coverage (OR, 6) significantly increased the odds of reintervention, whereas every percentage of graft oversizing protected against reintervention (OR, 0.005). Life-table analysis revealed an overall survival of 78% (71%-83%) at median follow-up. At 3 years, survival was 88% (80%-93%) for those with aneurysm sac stability or regression, whereas it was 70% (49%-84%) for those with aneurysm sac growth (P = .0402). Cox proportional hazards model showed that the only protective factor for mortality was percentage oversizing, with every 1% of oversizing having a hazard ratio (HR) of <.001 (P = .032). This was counterbalanced by the fact that patients with graft oversizing >30% had an increased odds of mortality with HR >10 (P = .049). Other significant factors that increased the odds of mortality included endoleak (HR, 3.6; P = .033), diabetes (HR, 4.1; P = .048), age (every 1-year increase in age; HR, 1.2; P = .002), year of surgery (every year subsequent to 2004; HR, 1.3; P = .012), and peripheral artery disease (HR, 5.2; P = .041). CONCLUSIONS: The majority of patients (80%) experience sac stability or regression after TEVAR, which offers a clear survival advantage. Endoleaks are predictive of sac growth, conferring increased mortality. Rigorous surveillance is necessary to prevent future aortic events through reintervention.

Sex-related outcomes after open type IV thoracoabdominal aortic aneurysm repair.

OBJECTIVE: Although outcomes after infrarenal abdominal aortic aneurysm surgery are worse in women, sex-specific differences in outcomes after open type IV thoracoabdominal aortic aneurysm (TAAA) surgery are undefined. The goal of this study was to define sex-based disparities in short- and long-term outcomes after open type IV TAAA surgery. METHODS: All open type IV TAAA repairs performed during 27 years were evaluated using a single institutional database. Charts were retrospectively evaluated for major adverse events (in-hospital death, other major in-hospital complication) and long-term complications (graft- and aortic-related events and death). Univariate analyses were performed using the Fisher's exact test for categorical variables and Wilcoxon rank-sum testing for continuous variables. Logistic multivariable regression was used for the in-hospital end points death and major complication, and survival analyses were performed with Cox proportional hazards modeling and Kaplan-Meier techniques. RESULTS: During the 27-year study period, 234 patients had an open type IV TAAA repair; 85 were female and 149 were male. There were 26 (17.5%) men and 16 (18.8%) women who suffered a major in-hospital complication/death. There were eight (3.4%) in-hospital deaths, all occurring in men. Unadjusted survival at 5 years was 67.9% for women and 58.4% for men. Multivariable analyses revealed no sex-based difference in combined major in-hospital events and death (female: odds ratio [OR], 1.8; confidence interval [CI], 0.83-4.0; P = .13) or any complication (OR, 1.0; CI, 0.55-1.8; P = .99). However, women were less likely than men to be discharged to home (OR, 0.28; CI, 0.13-0.60; P = .001) and had decreased survival compared with men after discharge (hazard ratio, 2.1; CI, 1.2-3.5; P = .008). CONCLUSIONS: No sex-based differences were found for the in-hospital outcomes of death or major complication after open type IV TAAA repair. However, women are less likely than men to be discharged home. Among those who survive the index operation, female sex portends decreased survival following discharge after repair.

Impact of Adding Carotid Endarterectomy to Supra-aortic Trunk Surgical Reconstruction.

BACKGROUND: Up to 20% of patients requiring open supra-aortic trunk (SAT) reconstruction have significant carotid artery stenosis. The addition of carotid endarterectomy (CEA) to SAT has been described. Yet, additive risks are not well defined and controversy remains as to whether concomitant CEA increases stroke risk. This study assessed the perioperative effects of adding CEA to SAT. METHODS: Using the National Surgical Quality Improvement Program (NSQIP), patients who underwent SAT from 2005 to 2015 were evaluated. SAT + CEA were identified. An isolated SAT (ISAT) cohort was created by removing patients who underwent concurrent secondary procedures. Nonocclusive indications were excluded. SAT + CEA were compared with ISAT as well as a propensity-matched ISAT cohort. Primary outcomes were 30-day stroke, death, and composite stroke/death/myocardial infarction (SDM). Univariate and logistic regression analyses were performed. RESULTS: After review, 1,515 patients were identified: 1,245 ISAT (82%) and 270 SAT + CEA (18%). Most were women (56%), 86% were Caucasian, and 24% were symptomatic. Average age was 65 ± 12 years and SAT + CEA were older (69 vs. 64 years, P < 0.001). CEA + SAT were more likely to be men (53% vs. 42%, P < 0.001), have hypertension (86% vs. 75%, P < 0.001) and diabetes (26% vs. 20%, P = 0.04). SAT procedures included the following: carotid-subclavian bypass (68%), carotid-carotid bypass (16%), aorta-great vessel bypass (9%), and carotid-subclavian transposition (7%). ISAT were more likely to undergo carotid-subclavian bypass than SAT + CEA (71% vs. 54%, P < 0.001). Overall stroke was 2.3%, death 1.4%, and SDM 4.6%. There were no differences in 30-day stroke (ISAT 2.0% vs. SAT + CEA 3.7%, P = 0.09) or mortality (1.4% vs. 1.5%, P = 0.88). SAT + CEA had higher rates of SDM (7% vs. 4%, P = 0.03). On logistic regression, urgency was a predictor of SDM (operating room [OR] 3.6, 95% confidence interval [CI] 1.5-8.4, P = 0.003); addition of CEA was not predictive of stroke (OR 1.4, 95% CI 0.5-4.2, P = 0.52) or SDM (OR 1.5, 95% CI 0.6-3.6, P = 0.40). After propensity matching, there were no longer differences in demographics or primary end points between the 2 cohorts. CONCLUSIONS: Addition of CEA does not confer increased perioperative stroke or SDM risk over ISAT. Perioperative outcomes appear to be more affected by disseminated disease risk factors than the addition of CEA. In patients undergoing SAT, it is reasonable to consider performing combined CEA in populations with tandem carotid bifurcation disease and appropriate operative risk profile.

Endovascular Versus Open Repair for Ruptured Complex Abdominal Aortic Aneurysms: A Propensity Weighted Analysis.

BACKGROUND: This study evaluates 30-day mortality after endovascular aneurysm repair (EVAR) versus open repair for ruptured complex abdominal aortic aneurysms (cAAAs), including juxtarenal, pararenal, suprarenal, and extent IV thoracoabdominal aortic aneurysms (TAAA) in a real-world setting. METHODS: The Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients undergoing repair for ruptured cAAA from 2011 to 2017. Primary endpoint was 30-day mortality. Secondary endpoints included renal failure, pulmonary complications, ischemic colitis, cardiac complications, lower extremity ischemia, post-operative rupture, and intensive care unit (ICU) length of stay (LOS). EVAR and open repair were compared using inverse probability weights. RESULTS: Four hundred forty-six patients had a ruptured cAAA repair during the study years; 105 (23.7%) were repaired via EVAR and 338 (76.3%) received open repair. The distribution by aneurysm type was as follows: 253 juxtarenal (57.1%), 59 pararenal (13.3%), and 100 suprarenal (22.6%) AAA with 31 type IV TAAA (7.0%). Juxtarenal aneurysms were more likely to be performed open than EVAR (P < 0.001) and pararenal were more likely to be performed endovascularly (P < 0.001). There was no significant change in the proportion of EVAR versus open repair in the years evaluated (P = 0.16). Hemodynamic stability was nearly identical between the 2 groups, with 49.5% of the EVAR cohort suffering from preoperative hypotension or requiring vasopressors compared to 49.1% in the open surgical cohort (P = 1.0). No significant difference in death existed based on proximal aneurysmal extent (P = 0.42). Death within 30 days occurred in 135 (30.5%) of the total cohort with 25 (23.8%) deaths in the EVAR cohort and 110 (32.5%) deaths in the open cohort. The EVAR group suffered a 20.0% rate of postoperative renal failure requiring dialysis compared to 18.6% of the open cohort (P = 0.78). Pulmonary complications were more common after open repair (40.5% vs. 25.0%, P = 0.004). After propensity weighting and weighted logistic regression, the open cohort had 1.75 times the odds of death compared to the EVAR cohort (AOR: 1.8, 95% CI: 0.9-2.8; P = 0.06). There was no association between repair type and postoperative renal failure. Open repair was associated with greater odds of pulmonary complications, ischemic colitis, and longer ICU stays in survivors. CONCLUSIONS: Mortality after repair for ruptured cAAA is high; and treatment with EVAR may trend toward early survival advantage. Rates of renal failure were similar between each cohort. Open repair is associated with higher rates of pulmonary complications, ischemic colitis, and longer ICU stays.

Endovascular repair of ruptured abdominal aortic aneurysm is superior to open repair: Propensity-matched analysis in the Vascular Quality Initiative.

OBJECTIVE: The few randomized trials comparing endovascular with open surgical repair of ruptured abdominal aortic aneurysm (rAAA) were poorly designed and heavily criticized. The short-term and midterm survival advantages of endovascular repair remain unclear. We sought to compare the two treatment modalities using a propensity-matched analysis in a real-world setting. METHODS: All ruptured cases of open surgical repair (rOSR) and endovascular aneurysm repair (rEVAR) in the Vascular Quality Initiative were analyzed (2003-2018). Raw and propensity-matched rEVAR and rOSR cohorts were compared. Primary and secondary outcomes included postoperative major adverse events (cardiovascular, pulmonary, renal, bowel or limb ischemia, reoperation) and 30-day and 1-year mortality. Univariate, multivariate, and Kaplan-Meier analyses were performed. RESULTS: There were 4929 rAAA repairs performed, 2749 rEVAR and 2180 rOSR. Compared with rEVAR patients, rOSR patients had higher rates of myocardial ischemic events (15% vs 10%; P < .001), major adverse events (67% vs 37%; P < .001), and 30-day death (34% vs 21%; P < .001). On adjusted analysis, rOSR was predictive of 30-day mortality (odds ratio, 1.8; 95% confidence interval, 1.5-2.2). After 1:1 matching, the study cohort consisted of 724 pairs of rOSR and rEVAR. The rOSR patients had twice the length of stay (median, 10 days [interquartile range, 5-19 days] vs 5 days [interquartile range, 3-10 days]; P < .001). Univariate analysis demonstrated persistent increased 30-day mortality after rOSR (32% vs 18%; P < .001) and higher rates of myocardial infarction (14% rOSR vs 8% rEVAR; P = .002), respiratory complications (38% vs 20%; P < .001), and acute kidney injury (42% vs 26%; P < .001). Overall major adverse event rate was higher after rOSR (68% vs 35%; P < .001). Multivariable regression analysis of the propensity-matched pairs demonstrated that rOSR was associated with double the 30-day mortality compared with rEVAR (odds ratio, 2.0; 95% confidence interval, 1.6-2.7). All-cause 1-year survival was 73% and 59% after rEVAR and rOSR in the propensity-matched cohort, respectively (P < .001). CONCLUSIONS: This is one of the largest studies of rAAA demonstrating clear short-term and midterm survival benefits of rEVAR over rOSR that persisted after matching on all major demographic, comorbid, and anatomic variables. Furthermore, patients who survived rOSR had twice the length of stay with increased rates of complications compared with rEVAR patients. These data suggest a more aggressive endovascular approach for rAAA in patients with suitable anatomy.

Gender-based discrimination is prevalent in the integrated vascular trainee experience and serves as a predictor of burnout.

OBJECTIVE: Trainee burnout is on the rise and negative training environments may contribute. In addition, as the proportion of women entering vascular surgery increases, identifying factors that challenge recruitment and retention is vital as we grow our workforce to meet demand. This study sought to characterize the learning environment of vascular residents and to determine how gender-based discrimination and bias (GBDB) affect the clinical experience. METHODS: A survey was developed to evaluate the trainee experience; demographics and a two-item burnout index were also included. The instrument was sent electronically to all integrated (0 + 5) vascular surgery residents in the United States. Univariate analyses were performed and predictors of burnout identified. RESULTS: A total of 284 integrated vascular residents were invited to participate and 212 (75%) completed the survey. Participants were predominantly male (64%) and white (56%), with a median age of 30 years (interquartile range, 28-32 years). Seventy-nine percent of respondents endorsed some form of negative workplace experience and 30% met high-risk criteria for burnout. More than a third (38%) of residents endorsed personally experiencing GBDB, with a significant difference between men and women (14% vs 80%; P < .001). Women were more likely than men to report witnessing GBDB (76% vs 56%; P = .003). Patients and nurses were the most frequently cited sources of GBDB (80% and 64%, respectively), with vascular surgery attendings cited by 41% of trainees. One in four female resident respondents indicated being sexually harassed during the course of training; this was significantly higher than for male residents (25% vs 1%; P < .001). Nearly half (46%) of trainees who witnessed or experienced GBDB thought that quality of patient care, job satisfaction, personal well-being, and personal risk of burnout were directly affected as a result of GBDB. GBDB was predictive of burnout (odds ratio, 1.9; 95% confidence interval, 1.1-3.5; P = .04), as were longer work hours (>80 h/wk; odds ratio, 2.8; 95% confidence interval, 1.1-7.1; P = .03). CONCLUSIONS: GBDB was experienced by 38% of integrated trainees, with women significantly more affected than men. GBDB is predictive of burnout, and this has significant implications for our specialty in the recruitment and retention of female physicians. Resources addressing these issues are needed to maintain a diverse workforce and to promote physician well-being.

Renal Artery Coverage During Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysm.

INTRODUCTION: Coverage of one or both renal arteries may be required to facilitate endovascular aneurysm repair (EVAR) in patients who are not candidates for open surgery in ruptured abdominal aortic aneurysms (rAAAs). We sought to understand the consequences of renal coverage during these emergent procedures. METHODS: Using the VQI data set from 2013 to 2018, we selected patients who had undergone EVAR for rAAA. Patients were distinguished by whether they had none, unilateral, or bilateral renal artery coverage. Patients were excluded if they were previously on dialysis or had an intervention to preserve renal perfusion. Primary endpoints included inhospital mortality, composite permanent dialysis/30-day death, and 1-year survival. RESULTS: Overall, there were 2,278 patients presenting with ruptured aneurysms. Most patients had no renal artery coverage (n = 2,230; 98%), followed by single renal artery coverage (n = 30; 1.2%), and finally bilateral renal artery coverage (n = 18, 0.8%). On multivariate regression, bilateral renal coverage was associated with increased odds of inhospital mortality (odds ratio [OR] = 5.7, ±4; P = 0.030), permanent dialysis/30-day death (OR = 9.5, ±7; P = 0.016), and permanent dialysis (OR = 47.5, ±47; P < 0.001). Two patients with bilateral renal coverage did not suffer permanent dialysis/death. Single renal artery coverage significantly increased the odds of permanent dialysis/30-day death (OR = 2.8, ±1.6; P = 0.044) driven mainly by its effect on the outcome of permanent dialysis (OR = 12.3, ±6; P < 0.001). Unadjusted Kaplan-Meier one-year survival estimates were significantly lower with bilateral renal coverage (hazard ratio [HR] = 3.4, P = 0.0002). Bilateral coverage remained a significant predictor on adjusted analysis (HR = 3.5, P = 0.002); however, single renal coverage did not significantly affect survival in unadjusted or adjusted models. CONCLUSIONS: Bilateral renal coverage in rAAA significantly increases inhospital mortality and lowers long-term survival. While single renal artery coverage increases the risk of permanent dialysis/30-day death driven mainly by its effect on permanent dialysis, it does not significantly affect inhospital mortality or one-year survival and may be a viable option for select patients with rAAAs.