Locoregional anesthesia is associated with decreased cardiac complications in symptomatic heart failure patients undergoing carotid endarterectomy.

OBJECTIVE: Although the current literature reports no advantage for locoregional anesthesia (LRA) over general anesthesia (GA) in patients undergoing carotid endarterectomy (CEA), there remains a gap in understanding the impact of LRA on individuals with congestive heart failure (CHF). This study aims to assess whether the choice of anesthesia influences the rates of perioperative complications within this patient population. METHODS: Using the Vascular Quality Initiative CEA module, all patients undergoing CEA between 2013 and 2023 were identified. The subset of patients with CHF was included, and patients were divided based on the type of anesthesia received. Patient characteristics and outcomes were compared using the χ2 or Fischer's exact test as appropriate for categorical variables and the independent t test or Mann-Whitney U test as appropriate for continuous variables. A sensitivity analysis was performed based on the symptomatic status of CHF, and the association between anesthesia modality and postoperative outcomes was studied using multivariable logistic regression analysis. The primary outcomes of this study included perioperative stroke, myocardial infarction (MI), acute HF, and the combination of MI and acute HF defined as major cardiac complications. RESULTS: A total of 21,292 patients (19,730 receiving GA, 1562 receiving LRA) with a diagnosis of CHF undergoing CEA were identified. On multivariable logistic regression analysis, LRA was independently associated with lower MI (odds ratio [OR]; 0.35; 95% confidence interval [CI], 0.13-0.96), acute HF (OR, 0.27; 95% CI, 0.09-0.87), major cardiac complications (OR, 0.30; 95% CI, 0.13-0.67), hemodynamic instability (OR, 0.64; 95% CI, 0.53-0.78), cranial nerve injury (OR, 0.40; 95% CI, 0.19-0.81), shunt use (OR, 0.25; 95% CI, 0.20-0.31), and neuromonitoring device use (OR, 0.20; 95% CI, 0.17-0.24) compared with GA in patients with symptomatic CHF. No difference in MI, acute HF, and major cardiac complications was seen in patients with asymptomatic CHF. CONCLUSIONS: CEA can be performed safely in patients with CHF. Using LRA is associated with a decreased incidence of perioperative cardiac complications in patients with symptomatic HF undergoing CEA.

Single-center experience with the JETi Hydrodynamic Thrombectomy System for acute limb ischemia.

OBJECTIVE: Acute limb ischemia (ALI) remains a vascular emergency with high morbidity and mortality. While the JETi Hydrodynamic Thrombectomy System (Abbott) offers a percutaneous approach to fragment and aspirate the thrombus in patients with arterial occlusions, data on its efficacy and safety are limited. This study reports our early experience using the JETi device to treat ALI at our institution. METHODS: This is a single-center, retrospective review of patients with ALI treated with the JETi device between September 2020 and December 2022. Patients were included if the JETi device was used either as a primary intervention or as an adjunct procedure. The primary endpoint was technical success defined as <50% residual thrombus after intervention. Secondary endpoints included achieving complete resolution of the thrombus on angiogram, acute kidney injury (AKI), major bleeding, 30-day major amputation, and 30-day mortality. RESULTS: A total of 59 JETi procedures for ALI (median age 62 years [interquartile range: 56-71 years]) were performed on 39 male and 20 female patients. The median time from onset of symptoms to hospitalization was 24 hours (interquartile range: 4-168 hours). Rutherford classifications were I (10), IIa (27), IIb (14), and undocumented (8). Etiology of ALI was native vessel thrombosis (27), embolism (16), graft/stent thrombosis (14), and iatrogenic (2). A total of 124 vessels were treated, with an average of 2.1 vessels per procedure. The primary outcome was achieved in 86% (107/124) of the arteries, with 82% (102/124) successfully opened using the JETi device alone without the need for any adjunctive therapy. Complete resolution of the thrombus using JETi was achieved in 81% (101/124) arteries, with or without the use of adjunctive therapy. A total of 6.7% (4/59) patients required a major limb amputation within 30 days despite successful recanalization, and one 30-day mortality was recorded. Complications included distal embolization (5), access site hematoma (2), and AKI (4). No major bleeding, hemolysis-induced AKI, or vessel dissection or perforation was observed. CONCLUSIONS: The JETi device appears to be a safe and effective percutaneous treatment option in the management of ALI. It provides definitive treatment with a high technical success rate of 86% and a good safety profile.

Patients with Acute Lower Limb Ischemia Continue to Have Significant Morbidity and Mortality.

BACKGROUND: The treatment of acute lower limb ischemia (ALLI) has evolved over the last several decades with the availability of several new treatment modalities. This study was undertaken to evaluate the contemporary presentation and outcomes of ALLI patients. METHODS: We retrospectively analyzed data from a prospectively collected database of all patients who presented to our tertiary referral hospital with acute ischemia of the lower extremity between May 2016 and October 2020. The cause of death was obtained from the Michigan State Death Registry. RESULTS: During the study period, 233 patients (251 lower limbs) were evaluated for ALLI. Seventy-three percent had thrombotic occlusion, 24% had embolic occlusion, and 3% due to a low flow state. Rutherford classification of ischemia severity was 7%, 49%, 40%, and 4% for Rutherford grade I, IIA, IIB, and III, respectively. Five percent underwent primary amputations, and 6% received medical therapy only. The mean length of stay was 11 ± 9 days. Nineteen percent of patients were readmitted within 30 days of discharge. At 30 days postoperatively, mortality was 9% and limb loss was 19%. On multivariate analysis, 1 or no vessel runoff to the foot postoperatively was associated with higher 30-day limb loss. Patients with no run-off vessels postoperatively had significantly higher 30-day mortality. Cardiovascular complications accounted for most deaths (48%). At 1-year postoperatively, mortality and limb loss reached 17% and 34%, respectively. CONCLUSIONS: Despite advances in treatment modalities and cardiovascular care, patients presenting with ALLI continue to have high mortality, limb loss, and readmission rates at 30 days.

Quality of Life Predictors in Patients with Acute Lower Limb Ischemia Quality of Life in Acute Limb Ischemia.

OBJECTIVE: While existing literature has established factors associated with improved health-related quality of life (HRQOL) in patients with chronic limb-threatening ischemia, similar work has not been done in individuals with acute lower limb ischemia (ALLI). This study aims to identify the factors associated with HRQOL in patients presenting with ALLI. METHODS: Using a prospectively collected registry, all patients who received treatment for ALLI between May 2016 and July 2023 at a quaternary medical center were identified and invited to complete two HRQOL questionnaires: the VascuQoL-6 and the EQ-5D-5L. Simple linear regression followed by multivariate analysis using multiple linear regression were used to determine the patient variables independently associated with HRQOL. RESULTS: Of the 216 eligible patients treated for ALLI during the study period, 47 (20%) of patients with a mean age of 58 ± 10 years completed the HRQOL questionnaires. Questionnaires were completed at a median time of 16.5 months after the episode of ALLI. On multiple linear regression, higher age was associated with higher VascuQoL-6 (p=0.037) and EQ-5D-5L (p=0.041) scores, while hypertension and non-ambulatory status were significant predictors of lower VascuQoL-6 (p=0.006, p=0.013) and EQ-5D-5L (p=0.009, p=0.026) scores. Any ambulation had a significantly higher HRQOL compared to non-ambulatory status, but no significant HRQOL difference was observed between patients with any type of ambulation (unhindered ambulation, ambulation with pain, and ambulation using a prosthesis). CONCLUSION: This study demonstrates that the ability to ambulate after ALLI, and not amputation per se, is an important predictor of HRQOL. As such, early rehabilitation strategies should be a focus of post-ALLI care. Further exploration of factors that shape HRQOL after ALLI is needed.

Left subclavian artery revascularization is associated with less neurologic injury after endovascular repair of acute type B aortic dissection.

OBJECTIVE: The aim of this study was to analyze patients with acute type B aortic dissection (aTBAD) requiring thoracic endovascular aortic repair (TEVAR) with left subclavian artery (LSA) coverage to determine whether LSA revascularization decreased the risk of neurologic complications. METHODS: The national Vascular Quality Initiative TEVAR module was queried for all procedures performed between 2014 and 2021. Patients presenting with aortic aneurysms or aortic ruptures were excluded from the analysis. Patients were divided into two groups according to whether their LSA was revascularized (prior to or during TEVAR) or not. Univariate followed by multivariate analysis was used to account for possible confounders and evaluate the association of LSA revascularization with the primary outcome of neurologic injury (stroke or spinal cord ischemia). RESULTS: Among patients who had TEVAR for aTBAD, 501 patients had the LSA covered. The LSA was revascularized prior to or concomitant with TEVAR in 28% of these patients (n = 139). Average age was 57 years, and 73% (n = 366) were male. Neurologic injury developed in 88 patients (18%). On univariate analysis, patients who had their LSA revascularized were significantly less likely to develop neurologic injury (10% vs 20%; P < .01). This association persisted after accounting for potential confounders (odds ratio, 0.4; P = .02). No significant difference was seen when comparing 30-day or 1-year mortality between patients who had LSA revascularization and those who did not. Follow-up averaged 1.9 years (range, 0-8.1 years). Long-term survival did not differ between the two groups on Kaplan-Meier analysis. CONCLUSIONS: In this study of patients with aTBAD who underwent LSA coverage during TEVAR, the addition of a LSA revascularization procedure was associated with a significantly lower incidence of neurological injury including spinal cord ischemia and/or stroke.

Impact of Preoperative Anemia on Hospitalization, Death, and Overall Survival in Patients With Peripheral Artery Disease Undergoing Endovascular Therapy: A Retrospective Cohort Study in the United States and Canada.

PURPOSE: Preoperative anemia is associated with adverse outcomes after cardiac and noncardiac surgeries, but outcomes after an endovascular peripheral vascular intervention (PVI) are not well established. We aimed to assess the association of preoperative anemia with 30 day death, hospital length of stay (LOS), and overall (long term) survival in patients undergoing an endovascular PVI for peripheral artery disease. MATERIALS AND METHODS: In this retrospective, cohort study in the United States and Canada, we queried the national Vascular Quality Initiative database for all endovascular PVIs performed between 2010 and 2019, and outcomes were correlated with patients' hemoglobin (Hb) levels. Anemia was classified as mild (Hb=10-13 g/dL for men and 10-12 g/dL for women), moderate (Hb=8-9.9 g/dL), and severe (Hb<8 g/dL). RESULTS: A total of 79 707 adult patients who met study criteria underwent endovascular PVI. The mean age was 68 years, and 59% of patients were male. Anemia was documented in 38 543 patients (48%) and was mild in 27 435 (71%), moderate in 9783 (25%), and severe in 1325 (4%). The median follow-up duration was 4 years (range, 1.25-5.78 years). On univariate analysis, 30 day mortality, total LOS, and overall survival were significantly associated with the level of preoperative anemia. These associations persisted in the multivariate models. Kaplan-Meier survival analysis demonstrated an association of death with degree of anemia (p<0.001). CONCLUSION: The presence and degree of preoperative anemia were independently associated with increased 30 day mortality and LOS and decreased overall survival for patients with peripheral artery disease who had undergone endovascular PVI. CLINICAL IMPACT: The findings from this study have many implications for how to approach vascular surgery in patients with variable hemoglobin levels. Our findings will strengthen our ability to conduct accurate preoperative risk stratification for patients undergoing peripheral vascular interventions. This may also mitigate healthcare expenditures if findings are applied in a way that can lower patient length of postoperative stay while also maintaining quality of care and patient safety. Our results will also serve as guidance for clinical trials, and future prospective trials should evaluate the effect of preoperative optimization of hemoglobin as a potentially modifiable risk factor for outcomes.

Necessity, Role, and Outcomes of Fasciotomy in Patients with Acute Limb Ischemia.

BACKGROUND: The incidence of compartment syndrome in patients with acute lower limb ischemia (ALLI) and the effects of fasciotomy on outcomes are largely undefined. This study aimed to define the incidence of compartment syndrome in patients with ALLI and to examine whether different fasciotomy strategies are associated with specific patient outcomes. METHODS: A single-center retrospective study of patients who had ALLI between April 2016 and October 2020 at a tertiary care center. Patients were categorized into groups as having received early and late therapeutic fasciotomy (TF), early prophylactic fasciotomy (PF), early exploratory fasciotomy, and no fasciotomy. Primary outcome was 30-day amputation rate. Secondary outcomes were 30-day and 1-year mortality, 1-year amputation rate, and length of stay. Groups were compared using descriptive statistics to assess the association of fasciotomy approach with outcomes. RESULTS: During the study period, 266 patients were treated for ALLI, and 62 patients (23%) underwent 66 fasciotomies. A total of 41 TF, 23 PF, and 2 exploratory fasciotomies were done. There were 58 early fasciotomies performed (88% of 66 limbs): 33 (57%) early TF, 23 (40%) PF, and 2 (3%) exploratory. There were 8 patients who developed compartment syndrome after their revascularization operation and received delayed TF (12% of 66 limbs). The total number of TF was 41, which was 15% of all ALLI patients. The mean ± SD time to fasciotomy closure was 6.7 ± 5.7 days, which did not differ between PF and TF groups. Significantly more patients in the TF group had an amputation at 30 days (11 [29%] vs. 1 [5%]; P = 0.03) and at 1 year (6 [18%] vs. 2 [9%]; P = 0.02) than those in the PF group. Length of stay was increased in both TF (16 days) and PF (19 days) patients compared to nonfasciotomy patients (10 days; P < 0.01) but did not differ between the 2 fasciotomy groups (P = 0.4). Thirty-day limb loss was highest in patients who underwent early TF (10/33, 33%), intermediate in those with delayed TF (1/8, 13%), and lowest in PF (1/23, 5%; P = 0.03). CONCLUSIONS: Approximately 15% of patients with ALLI in our cohort required a TF for compartment syndrome. Close postoperative monitoring of ALLI patients who did not undergo early fasciotomy did detect delayed compartment syndrome; however, this approach did not prevent limb loss. To optimize limb salvage, physicians treating patients with ALLI should be experienced in how to recognize and treat compartment syndrome.

Cross-clamp location and perioperative outcomes after open infrarenal abdominal aortic aneurysm repair: A Vascular Quality Initiative® review.

OBJECTIVES: By analyzing national Vascular Quality Initiative (VQI) data for patients undergoing open infrarenal abdominal aortic aneurysms (AAA) repair, we sought to better characterize the effects of different suprarenal clamping positions on postoperative outcomes. METHODS: We performed a retrospective analysis of a prospectively collected national VQI database for all open infrarenal AAA repairs performed between 2003 and 2017. Patients were initially divided into proximal (above 1 renal, above 2 renals, and supraceliac) and infrarenal clamp groups. Patients were then subdivided into those who underwent surgery between 2003-2010 and those who had surgery between 2011-2017. Univariate followed by multivariate analyses were done to compare the baseline characteristics, preoperative, intraoperative, and postoperative outcomes between the two groups. RESULTS: During the study period, 9068 open AAA repairs were recorded in the VQI; of these, 5043 met the inclusion criteria. Aortic clamp level was infrarenal in 59% (N = 2975), above 1 renal in 15% (N = 735), above both renals in 21% (N = 1053), and supraceliac in 5% (N = 280). The average age was 69 years, and males comprised 73% (N = 3701) of the cohort. The overall 30-day mortality for the entire study group was 2.7%. On univariate analysis, patients who underwent proximal clamping had significantly higher 30-day mortality than those undergoing infrarenal clamping (3.7 vs 2.0%, p < 0.001). After adjusting for preoperative and intraoperative variables, this difference became nonsignificant. On multivariate analysis, clamping above both renals or the celiac artery was associated with an increased occurrence of postoperative myocardial infarction (odds ratio = 1.44, p = 0.037 and odds ratio = 1.78, p = 0.023, respectively). All proximal clamp positions were associated with a significant increase in the incidence of AKI and renal failure requiring dialysis. There was no significant difference when looking at overall survival times comparing the suprarenal and infrarenal clamp position groups (p = 0.1). Patients who underwent surgery in the latter half of the study period had longer intraoperative renal ischemia time, increased in estimated blood loss, and longer total procedure time. CONCLUSIONS: Suprarenal clamping, at any level, was associated with an increased risk of AKI and renal replacement therapy. Clamping above both renal and celiac arteries was associated with increased cardiac morbidity. Perioperative and long-term mortality was unaffected by clamp level. Patients operating in the latter half of the study had increased estimated blood loss, renal ischemia time, and operative time, which may reflect decreased training in open AAA repair. During open AAA repair, the proximal clamp site should be chosen based on anatomic considerations and not a perceived perioperative mortality benefit. Proximal aortic clamping should always be performed at the safest, distal-most level to reduce cardiac morbidity and the risk of postoperative dialysis.

Outcomes of patients with acute type A aortic dissection and concomitant lower extremity malperfusion.

OBJECTIVE: The occurrence of acute lower limb ischemia (ALLI) is a serious risk within the context of aortic dissection repair. The aim of the present study was to examine the outcomes of patients with acute type A aortic dissection (ATAD) and concomitant lower extremity malperfusion. METHODS: We performed a retrospective medical record review at our tertiary referral center of patients who underwent ATAD repair from January 2002 to June 2018. We used univariate and multivariate analyses to compare the outcomes of patients with and without lower extremity malperfusion. The primary outcomes were 30-day and 1-year mortality. RESULTS: A total of 378 patients underwent ATAD repair during the study period. Their mean age was 57 years, 68% were men, and 51% were White. A total of 62 patients (16%) presented with concomitant ALLI, including 35 (9%) who presented with isolated ALLI and 27 (7%) who presented with ALLI and concomitant malperfusion of at least one other organ. Of the 62 patients with ALLI, 46 underwent only proximal aortic repair. Of the 378 patients, 6 died within the first 24 hours, and their limb perfusion was not assessed. Among the 40 patients who underwent isolated proximal repair and survived >24 hours, 34 (85%) had resolution of their ALLI. Of the 16 patients who underwent concomitant lower extremity peripheral vascular procedures, 10 had bypass procedures and 1 died within 24 hours due to refractory coagulopathy and hypotension. All six patients with adequate follow-up imaging studies had asymptomatic occlusion of the bypass graft with recanalization of the occluded native arteries. Patients who presented with any organ malperfusion had increased 30-day (odds ratio, 1.8; P = .04) and 1-year (odds ratio, 1.8; P = .04) mortality and decreased overall survival (P < .01). For the patients with isolated ALLI, no significant differences were found in 30-day or 1-year mortality or overall survival (P = .57). CONCLUSIONS: Proximal repair of ATAD resolves most cases of associated ALLI, and isolated ALLI does not affect short- or long-term survival. All patients with follow-up in our study who underwent extra-anatomic bypass developed asymptomatic graft occlusion, which could be attributed to competitive flow from the remodeled native arterial system. We believe that rapid and aggressive restoration of flow to the lower extremity is the best method to treat ALLI malperfusion syndrome. Close monitoring for the development of compartment syndrome is recommended.

Socioeconomic status is not associated with unfavorable outcomes in patients with acute limb ischemia.

OBJECTIVE: Whether socioeconomic status (SES) is associated with health outcomes in patients with acute limb ischemia (ALI) is largely unknown. We aimed to determine whether SES is associated with worse presentations and outcomes for patients with ALI. METHODS: We performed a retrospective medical record review of patients who presented with ALI between April 2016 and October 2020 at a single tertiary care center. SES was quantified using individual variables (median household income, level of education, and employment) and a composite endpoint, the neighborhood deprivation index (NDI). The NDI is a standardized and reproducible index that uses census tract data (higher number indicates lower SES status). The NDI summarizes 8 domains of socioeconomic deprivation. ALI severity was categorized using the Rutherford classification. The association between SES and the severity of ALI at presentation and between SES and other health outcomes were analyzed using bivariate analysis of variance, independent t test, and multivariate logistic regression. RESULTS: During the study period, 278 patients were treated for ALI, of whom 211 had complete SES data available. The mean age was 64 years, 55% were men, and 57% were White. The Rutherford classification of disease severity was grade 1, 2a, 2b, and 3 for 6%, 54%, 32%, and 8% of patients, respectively. Patients with a low SES status per the NDI were more likely to have a history of peripheral arterial disease and chronic kidney disease at presentation. The ALI etiology (thrombotic vs embolic) was not associated with SES. No significant differences were seen between SES and the severity of ALI at presentation (p = 0.96) or the treatment modality (p = 0.80). No associations between SES and 30-day or 1-year mortality were observed (mean NDI, 0.15 vs 0.26, p = 0.58, and 0.20 vs 0.26, p = 0.71, respectively) or between SES and 30-day or 1-year limb loss (mean NDI, 0.06 vs 0.30, p = 0.18, and 0.1 vs 0.32, p = 0.17, respectively). Lower SES (higher NDI) was associated with increased 30-day readmission (mean NDI, 0.49 vs 0.15, p = 0.021). However, this association was not significant on multivariate analysis (odds ratio 1.4, 95% CI 0.9-2.1, p = 0.06). CONCLUSIONS: SES was not associated with the severity of ALI at patient presentation. Although SES was associated with the presence of peripheral arterial disease and chronic kidney disease at presentation, SES was not a predictor of short-term or 1-year limb loss and mortality. Overall, ALI presentation and treatment outcomes were independent of SES.

Outcome benefit of arterial duplex stent imaging after superficial femoral artery stent implantation.

OBJECTIVE: In-stent stenosis is a frequent complication of superficial femoral artery (SFA) endovascular intervention and can lead to stent occlusion or symptom recurrence. Arterial duplex stent imaging (ADSI) can be used in the surveillance for recurrent stenosis; however, its uniform application is controversial. In this study, we aimed to determine, in patients undergoing SFA stent implantation, whether surveillance with ADSI yielded a better outcome than in those with only ankle-brachial index (ABI) follow-up. METHODS: We performed a retrospective analysis of all patients undergoing SFA stent implantation for occlusive disease at a tertiary care referral center between 2009 and 2016. The patients were divided into those with ADSI and those with ABI follow-up only. Life-table analysis comparing stent patency, major adverse limb events (MALEs), limb salvage, and mortality between groups was performed. RESULTS: There were 248 patients with SFA stent implantation included, 160 in the ADSI group and 88 in the ABI group. Groups were homogeneous in clinical indications of claudication and critical limb-threatening ischemia (for ADSI, 39% and 61%; for ABI, 38% and 62%; P = .982) and TransAtlantic Inter-Society Consensus class A, B, C, and D lesions (for ADSI, 17%, 45%, 16%, and 22%; for ABI, 21%, 43%, 16%, and 20%; P = .874). Primary patency was similar between groups at 12, 36, and 56 months (ADSI, 65%, 43%, and 32%; ABI, 69%, 34%, and 34%; P = .770), whereas ADSI patients showed an improved assisted primary patency (84%, 68%, and 54%) vs ABI patients (76%, 38%, and 38%; P = .008) and secondary patency. There was greater freedom from MALEs in the ADSI group (91%, 76%, and 64%) vs the ABI group (79%, 46%, and 46%; P < .001) at 12, 36, and 56 months of follow-up. ADSI patients were more likely to undergo an endovascular procedure as their initial post-SFA stent implantation intervention (P = .001), whereas ABI patients were more likely to undergo an amputation (P < .001). CONCLUSIONS: In SFA stent implantation, patients with ADSI follow-up demonstrate an advantage in assisted primary patency and secondary patency and are more likely to undergo an endovascular reintervention. These factors are likely to have effected a decrease in MALEs, indicating the benefit of a more universal adoption of post-SFA stent implantation follow-up ADSI.

Survival after abdominal aortic aneurysm repair is affected by socioeconomic status.

OBJECTIVE: The association between socioeconomic status (SES) and outcome after abdominal aortic aneurysm (AAA) repair is largely unknown. This study aimed to determine the influence of SES on postoperative survival after AAA repair. METHODS: Patients undergoing surgical treatment of AAA at a tertiary referral center between January 1993 and July 2013 were retrospectively collected. Thirty-day postoperative mortality and long-term mortality were documented through medical record review and the Michigan Social Security Death Index. SES was quantified using the neighborhood deprivation index (NDI), which is a standardized and reproducible index used in research that summarizes eight domains of socioeconomic deprivation and is based on census tracts derived from patients' individual addresses. The association between SES and survival was studied by univariable and multivariable Cox regression analysis. RESULTS: A total of 767 patients were included. The mean age was 73 years; 80% were male, 77% were white, and 20% were African American. There was no difference in SES of patients who underwent open vs endovascular repair of AAA (P = .489). The average NDI was -0.18 (minimum, -1.47; maximum, 2.35). After adjusting for the variables that were significant on univariable analysis (age, medical comorbidities, length of stay, and year of surgery), the association between NDI and long-term mortality was significant (P = .021; hazard ratio, 1.21 [1.05-1.37]). CONCLUSIONS: Long-term mortality after AAA repair is associated with SES. Further studies are required to assess which risk factors (behavioral, psychosocial) are responsible for this decreased long-term survival in low SES patients after AAA repair.

Contrast-induced nephropathy after peripheral vascular intervention: Long-term renal outcome and risk factors for progressive renal dysfunction.

OBJECTIVE: Contrast-induced nephropathy (CIN) is a frequently used quality outcome marker after peripheral vascular interventions (PVIs). Whereas the factors associated with CIN development have been well documented, the long-term renal effects of CIN after PVI are unknown. This study was undertaken to investigate the long-term (1-year) renal consequences of CIN after PVI and to identify factors associated with renal function deterioration at 1-year follow-up. METHODS: From 2008 to 2015, patients who had PVI at our institution (who were part of a statewide Vascular Interventions Collaborative) were queried for those who developed CIN. CIN was defined by the Collaborative as an increase in serum creatinine concentration of at least 0.5 mg/dL within 30 days after intervention. Preprocedural dialysis patients or patients without postprocedural creatinine values were excluded. Preprocedural, postprocedural, and 1-year serum creatinine values were abstracted and used to estimate glomerular filtration rate (GFR). ΔGFR was defined as preprocedural GFR minus 1-year GFR. Univariate and multivariate analyses for ΔGFR were performed to determine factors associated with renal deterioration at 1 year. RESULTS: From 2008 to 2015, there were 1323 PVIs performed; 881 patients met the inclusion criteria. Of these, 57 (6.5%) developed CIN; 47% were male, and 51% had baseline chronic kidney disease. CIN resolved by discharge in 30 patients (53%). Using multivariate linear regression, male sex (P = .027) and congestive heart failure (P = .048) were associated with 1-year GFR decline. Periprocedural variables related to 1-year GFR decline included percentage increase in 30-day postprocedural creatinine concentration (P = .025), whereas CIN resolution by discharge (mean, 13.1 days) was protective for renal function at 1 year (P = .02). A post hoc analysis was performed with 50 PVI patients (randomly selected) who did not develop CIN, comparing their late renal function with that of the CIN group stratified by the periprocedural 30-day variables. Patients with CIN resolution at discharge had similar 1-year renal outcomes to non-CIN patients, whereas the CIN-persistent (at discharge) patients had greater renal deterioration at 1 year compared with non-CIN patients (P = .016). CONCLUSIONS: Male sex and congestive heart failure are risk factors for further renal function decline in patients developing CIN after PVI. The magnitude and duration of increase in creatinine concentration (CIN persistence at discharge) correlated with late progressive renal dysfunction in CIN patients, suggesting that early-resolving CIN is relatively benign.

Cryopreserved Allograft in the Management of Native and Prosthetic Aortic Infections.

BACKGROUND: The management of patients with aortic native and prosthetic infections is associated with significant morbidity and mortality. We describe a single-center experience with the use of cryopreserved allografts for the treatment of aortic infections, and compare outcomes with rifampin-soaked grafts and extra-anatomic bypass. METHODS: We retrospectively reviewed all patients who underwent an operative intervention for aortic infection at our tertiary care center from August 2007 to August 2017. Demographic data, preoperative work-up, procedural details, and outcomes were collected for each treatment modality. RESULTS: Thirty-two patients had aortic revascularization for aortic infection. Seventeen patients had cryopreserved allografts, 10 had rifampin-soaked grafts, and 5 had extra-anatomic bypass. Sixteen patients (50%) had native aortic infection and 16 patients (50%) had prosthetic aortic infection. Eighteen had involvement of the infrarenal abdominal aorta, 12 of the paravisceral aorta, and 2 of the descending thoracic aorta. Early mortality was 5.9% (1/17) for the cryopreserved group, 10% (1/10) for the rifampin-soaked group, and 40% (2/5) for the extra-anatomic bypass group. Early graft-related complications occurred in 1 patient (cryopreserved group). Mean follow-up was 34.8 months. Late death occurred in 4 patients with cryopreserved allografts, 2 with rifampin-soaked grafts and none with extra-anatomic bypass. Late graft-related complications occurred in 4 patients (cryopreserved group). Only 1 patient had recurrence of aortic infection (cryopreserved group) and 2 patients had limb loss (1 from the cryopreserved group and 1 from the rifampin-soaked group). At 1 month, 6 months, 1 year, and 3 years, estimated survival for patients with cryopreserved allografts was 94%, 82%, 75%, and 64%, respectively. CONCLUSIONS: The management of aortic infections is challenging. In patients who do not need immediate intervention, in situ aortic reconstruction with cryopreserved allografts is a viable treatment modality with relatively low morbidity and mortality.

The Clinical Impact of Cardiology Consultation Prior to Major Vascular Surgery.

OBJECTIVE: To understand statewide variation in preoperative cardiology consultation prior to major vascular surgery and to determine whether consultation was associated with differences in perioperative myocardial infarction (poMI). SUMMARY BACKGROUND DATA: Medical consultation prior to major vascular surgery is obtained to reduce perioperative risk. Despite perceived benefit of preoperative consultation, evidence is lacking specifically for major vascular surgery on the effect of preoperative cardiac consultation. METHODS: Patient and clinical data were obtained from a statewide vascular surgery registry between January 2012 and December 2014. Patients were risk stratified by revised cardiac risk index category and compared poMI between patients who did or did not receive a preoperative cardiology consultation. We then used logistic regression analysis to compare the rate of poMI across hospitals grouped into quartiles by rate of preoperative cardiology consultation. RESULTS: Our study population comprised 5191 patients undergoing open peripheral arterial bypass (n = 3037), open abdominal aortic aneurysm repair (n = 332), or endovascular aneurysm repair (n = 1822) at 29 hospitals. At the patient level, after risk-stratification by revised cardiac risk index category, there was no association between cardiac consultation and poMI. At the hospital level, preoperative cardiac consultation varied substantially between hospitals (6.9%-87.5%, P <0.001). High preoperative consulting hospitals (rate >66%) had a reduction in poMI (OR, 0.52; confidence interval: 0.28-0.98; P <0.05) compared with all other hospitals. These hospitals also had a statistically greater consultation rate with a variety of medical specialties. CONCLUSIONS: Preoperative cardiology consultation for vascular surgery varies greatly between institutions, and does not appear to impact poMI at the patient level. However, reduction of poMI was noted at the hospitals with the highest rate of preoperative cardiology consultation as well as a variety of medical services, suggesting that other hospital culture effects play a role.

Long-term decline in renal function is more significant after endovascular repair of infrarenal abdominal aortic aneurysms.

OBJECTIVE: It is not clear whether endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) results in an increase in renal insufficiency during the long term compared with open repair (OR). We reviewed our experience with AAA repair to determine whether there was a significant difference in postoperative and long-term renal outcomes between OR and EVAR. METHODS: A retrospective cohort study was conducted of all patients who underwent AAA repair between January 1993 and July 2013 at a tertiary referral hospital. Demographics, comorbidities, preoperative and postoperative laboratory values, morbidity, and mortality were collected. Patients with ruptured AAAs, preoperative hemodialysis, juxtarenal or suprarenal aneurysm origin, and no follow-up laboratory values were excluded. Preoperative, postoperative, 6-month, and yearly serum creatinine values were collected. Glomerular filtration rate (GFR) was calculated on the basis of the Chronic Kidney Disease Epidemiology Collaboration equation. Acute kidney injury (AKI) was classified using the Kidney Disease: Improving Global Outcomes guidelines. Change in GFR was defined as preoperative GFR minus the GFR at each follow-up interval. Comparison was made between EVAR and OR groups using multivariate logistics for categorical data and linear regression for continuous variables. RESULTS: During the study period, 763 infrarenal AAA repairs were performed at our institution; 675 repairs fit the inclusion criteria (317 ORs and 358 EVARs). Mean age was 73.9 years. Seventy-nine percent were male, 78% were hypertensive, 18% were diabetic, and 31% had preoperative renal dysfunction defined as GFR below 60 mL/min. Using a multivariate logistic model to control for all variables, OR was found to have a 1.6 times greater chance for development of immediate postoperative AKI compared with EVAR (P = .038). Hypertension and aneurysm size were independent risk factors for development of AKI (P = .012 and .022, respectively). Using a linear regression model to look at GFR decline during several years, there was a greater decline in GFR in the EVAR group. This became significant starting at postoperative year 4. AKI and preoperative renal dysfunction were independent risk factors for long-term decline in renal function. CONCLUSIONS: Although AKI is less likely to occur after EVAR, patients undergoing EVAR experience a significant but delayed decline in GFR over time compared with OR. This became apparent after postoperative year 4. Studies comparing EVAR and OR may need longer follow-up to detect clinically significant differences in renal function.

Cerebrovascular injuries found in acute type B aortic dissections are associated with blood pressure derangements and poor outcome.

OBJECTIVE: Cerebrovascular injury (CVI) is a recognized but underappreciated complication of acute type B aortic dissection (ATBAD). This study was performed to determine risk factors for CVI associated with ATBAD and, in particular, the possible contributory role of aggressive anti-impulse therapy. METHODS: A retrospective review of all patients presenting to a tertiary medical center with an ATBAD between January 2003 and October 2012 was conducted. All CVIs were adjudicated by a vascular neurologist and assigned a probable cause. The initial intensity of anti-impulse therapy was defined as the difference in mean arterial pressure (ΔMAP) from presentation to subsequent admission to the intensive care unit. RESULTS: A total of 112 patients were identified. The average age was 61 years; 64% were male, and 59% were African American. Twenty patients required operative intervention (14 thoracic endovascular aortic repairs and 6 open). CVI occurred in 13 patients (11.6%): 9 were hypoperfusion related (6 diffuse hypoxic brain injuries and 3 watershed infarcts), 2 were procedure related (both thoracic endovascular aortic repairs), 1 was an intracranial hemorrhage on presentation, and 1 was a probable embolic stroke on presentation. CVI patients had demographics and comorbidities comparable to those of the non-CVI patients. CVI was associated with operative intervention (54% vs 13%; P = .002). Thirty-day mortality was significantly higher in CVI patients (54% vs 6%; P < .001). Patients who suffered a hypoperfusion brain injury had a higher MAP on presentation to the emergency department (142 mm Hg vs 120 mm Hg; P = .034) and a significantly greater reduction in MAP (ΔMAP 49 mm Hg vs 15 mm Hg; P < .001) by the time they reached the intensive care unit compared with the non-CVI patients. CONCLUSIONS: In our series, CVI in ATBAD is more frequent than previously reported and is associated with increased mortality. The most common causes are related to cerebral hypoperfusion. Higher MAP on presentation and greater decline in MAP are associated risk factors for hypoperfusion-related CVI. A less aggressive approach to lowering MAP in ATBAD warrants further study in an attempt to reduce CVI in ATBAD.

Predictors of surgical site infection after open lower extremity revascularization.

OBJECTIVE: Surgical site infection (SSI) after open lower extremity bypass (LEB) is a serious complication leading to an increased rate of graft failure, hospital readmission, and health care costs. This study sought to identify predictors of SSI after LEB for arterial occlusive disease and also potential modifiable factors to improve outcomes. METHODS: Data from a statewide cardiovascular consortium of 35 hospitals were used to obtain demographic, procedural, and hospital risk factors for patients undergoing elective or urgent open LEB between January 2012 and June 2015. Bivariate comparisons and targeted maximum likelihood estimation were used to identify independent risk factors of SSI. Adjusted odds ratios (ORs) were calculated for patient demographics, comorbidities, operative details, and hospital-level factors. RESULTS: Our study population included 3033 patients who underwent 703 femoral-femoral bypasses, 1431 femoral-popliteal bypasses, and 899 femoral-distal vessel bypasses. An SSI was diagnosed in 320 patients (10.6%) ≤30 days after the index operation. Adjusted patient and procedural predictors of SSI included renal failure currently requiring dialysis (OR, 4.35; 95% confidence interval [CI], 3.45-5.47; P < .001), hypertension (OR, 4.29; 95% CI, 2.74-6.72; P < .001), body mass index ≥25 kg/m2 (OR, 1.78; 95% CI, 1.23-2.57; P = .002), procedural time >240 minutes (OR, 2.95; 95% CI, 1.89-4.62; P < .001), and iodine-only skin preparation (OR, 1.73; 95% CI, 1.02-2.91; P = .04). Hospital factors associated with increased SSI included hospital size <500 beds (OR, 2.22; 95% CI, 1.09-4.55; P = .028) and major teaching hospital (OR, 1.66; 95% CI, 1.07-2.58; P = .024). SSI resulted in increased risk of major amputation and surgical reoperation (P < .01), but did not affect 30-day mortality. CONCLUSIONS: SSI after LEB is associated with an increase in rate of amputation and reoperation. Several patient, operative, and hospital-related risk factors that predict postoperative SSI were identified, suggesting that targeted improvements in perioperative care may decrease complications and improve vascular patient outcomes.

Contrast-induced nephropathy in patients undergoing endovascular peripheral vascular intervention: Incidence, risk factors, and outcomes as observed in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium.

BACKGROUND: The incidence, risk factors, and outcomes associated with Contrast-induced nephropathy (CIN) after Percutaneous Vascular Intervention (PVI) in contemporary medical practice are largely unknown. METHODS: A total of 13 126 patients undergoing PVI were included in the analysis. CIN was defined as an increase in serum creatinine from pre-PVI baseline to post-PVI peak Cr of ≥0.5 mg/dL. RESULTS: CIN occurred in 3% (400 patients) of the cohort, and 26 patients (6.5%) required dialysis. Independent predictors of CIN were high and low body weight, diabetes, heart failure, anemia, baseline renal dysfunction, critical limb ischemia, and a higher acuity of the PVI procedure and a contrast dose that was greater than three times the calculated creatinine clearance (CCC) (adjusted OR 1.4, 95% CI: 1.1-1.8, P = 0.003). CIN was strongly associated with adverse outcome including in-hospital death (adjusted OR 18.1, CI 10.7-30.6, P < 0.001), myocardial infarction (adjusted OR 16.2, CI 8.9-29.5, P < 0.001), transient ischemic attack/stroke (adjusted OR 5.5, CI 3.2-14.9, P = 0.001), vascular access complications (adjusted OR 3.4, CI 2.3-5, P < 0.001), and transfusion (adjusted OR 7, CI 5.4-9, P < 0.001). Hospital stay was longer in patients who developed CIN versus those who did not. CONCLUSIONS: CIN is not an uncommon complication associated with PVI, can be reliably predicted from pre-procedural variables, including a contrast dose of greater than three times the CCC and is strongly associated with the risk of in-hospital death, MI, stroke, transfusion, and increased hospital length of stay.

Socioeconomic disparities affect survival after aortic dissection.

OBJECTIVE: The effect of socioeconomic status (SES) on the course of many disease states has been documented in the literature but has not been studied in aortic dissection. This study evaluated the effect of SES on 30-day and long-term survival of patients after aortic dissection. METHODS: Hospital discharge records were used to identify patients with acute aortic dissection. Patient demographics, insurance status, comorbidities, and 30-day mortality were collected. Home addresses were used to estimate each patient's median household income, and the neighborhood deprivation index, a measure of SES, was determined. Long-term survival was assessed by review of the Social Security Death Index. Associations between demographics, insurance status, comorbidities, and poverty level were investigated to determine their effect on survival. RESULTS: There were 212 aortic dissections; of which, 118 were type A and 94 were type B. Median follow-up was 7.6 years. The neighborhood deprivation index (hazard ratio, 1.43; 95% confidence interval, 1.16-1.78; P = .001) was associated with reduced long-term survival and was also significantly associated with 30-day mortality (hazard ratio, 1.43; 95% confidence interval, 1.05-1.93; P = .02). The mean neighborhood deprivation index score was higher in patients with type B aortic dissections (0.45 ± 0.93) than in those with type A aortic dissections (0.16 ± 0.96; P = .029). CONCLUSIONS: Patients with a lower SES had reduced short-term and long-term survival after aortic dissection. Patients with type B dissection live in lower socioeconomic neighborhoods than patients with type A dissection.