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OBJECTIVE: With the recent expansion of the Centers for Medicare and Medicaid Services coverage, transfemoral carotid artery stenting (tfCAS) is expected to play a larger role in the management of carotid disease. Existing research on the tfCAS learning curve, primarily conducted over a decade ago, may not adequately describe the current effect of physician experience on outcomes. Because approximately 30% of perioperative strokes/deaths post-CAS occur after discharge, appropriate thresholds for in-hospital event rates have been suggested to be <4% for symptomatic and <2% for asymptomatic patients. This study evaluates the tfCAS learning curve using Vascular Quality Initiative (VQI) data. METHODS: We identified VQI patients who underwent tfCAS between 2005 and 2023. Each physician's procedures were chronologically grouped into 12 categories, from procedure counts 1-25 to 351+. The primary outcome was in-hospital stroke/death rate; secondary outcomes were in-hospital stroke/death/myocardial infarction (MI), 30-day mortality, in-hospital stroke/transient ischemic attack (stroke/TIA), and access site complications. The relationship between outcomes and procedure counts was analyzed using the Cochran-Armitage test and a generalized linear model with restricted cubic splines. Our results were then validated using a generalized estimating equations model to account for the variability between physicians. RESULTS: We analyzed 43,147 procedures by 2476 physicians. In symptomatic patients, there was a decrease in rates of in-hospital stroke/death (procedure counts 1-25 to 351+: 5.2%-1.7%), in-hospital stroke/death/MI (5.8%-1.7%), 30-day mortality (4.6%-2.8%), in-hospital stroke/TIA (5.0%-1.1%), and access site complications (4.1%-1.1%) as physician experience increased (all P values < .05). The in-hospital stroke/death rate remained above 4% until 235 procedures. Similarly, in asymptomatic patients, there was a decrease in rates of in-hospital stroke/death (2.1%-1.6%), in-hospital stroke/death/MI (2.6%-1.6%), 30-day mortality (1.7%-0.4%), and in-hospital stroke/TIA (2.8%-1.6%) with increasing physician experience (all P values <.05). The in-hospital stroke/death rate remained above 2% until 13 procedures. CONCLUSIONS: In-hospital stroke/death and 30-day mortality rates after tfCAS decreased with increasing physician experience, showing a lengthy learning curve consistent with previous reports. Given that physicians' early cases may not be included in the VQI, the learning curve was likely underestimated. Nevertheless, a substantially high rate of in-hospital stroke/death was found in physicians' first 25 procedures. With the recent Centers for Medicare and Medicaid Services coverage expansion for tfCAS, a significant number of physicians would enter the early stage of the learning curve, potentially leading to increased postoperative complications.
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Competencia Clínica , Arteria Femoral , Mortalidad Hospitalaria , Curva de Aprendizaje , Sistema de Registros , Stents , Accidente Cerebrovascular , Humanos , Femenino , Masculino , Anciano , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/mortalidad , Estados Unidos , Factores de Tiempo , Factores de Riesgo , Resultado del Tratamiento , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Estudios Retrospectivos , Anciano de 80 o más Años , Cateterismo Periférico/efectos adversos , Cateterismo Periférico/mortalidad , Indicadores de Calidad de la Atención de Salud , Persona de Mediana Edad , Punciones , Estenosis Carotídea/mortalidad , Estenosis Carotídea/cirugía , Estenosis Carotídea/terapia , Estenosis Carotídea/diagnóstico por imagen , Infarto del Miocardio/mortalidad , Infarto del Miocardio/etiología , Medición de Riesgo , Enfermedades de las Arterias Carótidas/mortalidad , Enfermedades de las Arterias Carótidas/cirugía , Enfermedades de las Arterias Carótidas/terapia , Ataque Isquémico Transitorio/etiologíaRESUMEN
OBJECTIVE: The vast majority of patients with abdominal aortic aneurysms (AAAs) undergoing repairs receive endovascular interventions (EVARs) instead of open operations (OARs). Although EVARs have better short-term outcomes, OARs have improved longer-term durability and require less radiographic follow-up and monitoring, which may have significant implications on health care economics surrounding provision of AAA care nationally. Herein, we compared costs associated with EVAR and OAR of both infrarenal and complex AAAs. METHODS: We examined patients undergoing index elective EVARs or OARs of infrarenal and complex AAAs in the 2014-2019 Vascular Quality Initiative-Vascular Implant Surveillance and Interventional Outcomes Network (VQI-VISION) dataset. We defined overall costs as the aggregated longitudinal costs associated with: (1) the index surgery; (2) reinterventions; and (3) imaging tests. We evaluated overall costs up to 5 years after infrarenal AAA repair and 3 years for complex AAA repair. Multivariable regressions adjusted for case-mix when evaluating cost differences between EVARs vs OARs. RESULTS: We identified 23,746 infrarenal AAA repairs (8.7% OAR, 91% EVAR) and 2279 complex AAA repairs (69% OAR, 31% EVAR). In both cohorts, patients undergoing EVARs were more likely to be older and have more comorbidities. The cost for the index procedure for EVARs relative to OARs was lower for infrarenal AAAs ($32,440 vs $37,488; P < .01) but higher among complex AAAs ($48,870 vs $44,530; P < .01). EVARs had higher annual imaging and reintervention costs during each of the 5 postoperative years for infrarenal aneurysms and the 3 postoperative years for complex aneurysms. Among patients undergoing infrarenal AAA repairs who survived 5 years, the total 5-year cost of EVARs was similar to that of OARs ($35,858 vs $34,212; -$223 [95% confidence interval (CI), -$3042 to $2596]). For complex AAA repairs, the total cost at 3 years of EVARs was greater than OARs ($64,492 vs $42,212; +$9860 [95% CI, $5835-$13,885]). For patients receiving EVARs for complex aneurysms, physician-modified endovascular grafts had higher index procedure costs ($55,835 vs $47,064; P < .01) although similar total costs on adjusted analyses (+$1856 [95% CI, -$7997 to $11,710]; P = .70) relative to Zenith fenestrated endovascular grafts among those that were alive at 3 years. CONCLUSIONS: Longer-term costs associated with EVARs are lower for infrarenal AAAs but higher for complex AAAs relative to OARs, driven by reintervention and imaging costs. Further analyses to characterize the financial viability of EVARs for both infrarenal and complex AAAs should evaluate hospital margins and anticipated changes in costs of devices.
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Aneurisma de la Aorta Abdominal , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Medicare , Humanos , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/economía , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Procedimientos Endovasculares/economía , Procedimientos Endovasculares/efectos adversos , Masculino , Anciano , Estados Unidos , Femenino , Factores de Tiempo , Medicare/economía , Implantación de Prótesis Vascular/economía , Implantación de Prótesis Vascular/efectos adversos , Resultado del Tratamiento , Anciano de 80 o más Años , Estudios Retrospectivos , Bases de Datos Factuales , Costos de la Atención en Salud , Análisis Costo-Beneficio , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/etiologíaRESUMEN
OBJECTIVE: One-year aneurysm sac changes have previously been found to be associated with mortality and may have the potential to guide personalized follow-up following endovascular aneurysm repair (EVAR). In this study, we examined the association of these early sac changes with long-term reintervention and rupture. METHODS: We identified all patients undergoing first-time EVAR for intact abdominal aortic aneurysm between 2003 and 2018 in the Vascular Quality Initiative with linkage to Medicare claims for long-term outcomes. We included patients with an imaging study at 1 year postoperatively. Aneurysm sac behavior was defined as per the Society for Vascular Surgery guidelines: stable sac (<5 mm change), sac regression (≥5 mm), and sac expansion (≥5 mm). Outcomes included mortality, reintervention, and rupture within 8 years, which were assessed with Kaplan-Meier methods and multivariable Cox regression analysis. Secondarily, we utilized polynomial spline interpolation to demonstrate the continuous relationship of diameter change to 8-year hazard of reintervention, rupture, or mortality as a composite outcome. RESULTS: Of 31,185 EVAR patients, 16,102 (52%) had an imaging study at 1 year and were included in this study. At 1 year, 44% of sacs remained stable, 49% regressed, and 6.2% displayed expansion. Following risk adjustment, compared with a stable sac at 1 year, sac regression was associated with lower 8-year mortality (49% vs 53%; hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.85-0.99; P = .036), reintervention rate (8.9% vs 15%; HR, 0.58; 95% CI, 0.50-0.68; P < .001), and rupture rate (2.0% vs 4.0%; HR, 0.45; 95%CI, 0.29-0.69; P < .001). Conversely, compared with a stable sac, sac expansion was associated with higher 8-year mortality (64% vs 53%; HR, 1.31; 95% CI, 1.14-1.51; P < .001) and reintervention rate (27% vs 15%; HR, 1.98; 95% CI, 1.57-2.51; P < .001), but similar risk of rupture (7.2% vs 4.0%; HR, 1.61; 95% CI, 0.88-2.96; P = .12). Polynomial spline interpolation demonstrated that, compared with no diameter change at 1 year, increased sac regression was associated with an incrementally lower risk of late outcomes, whereas increased sac expansion was associated with an incrementally higher risk of late outcomes. CONCLUSIONS: Following EVAR, compared with a stable sac at 1-year imaging, sac regression and expansion are associated with a lower and higher risk respectively of long-term mortality, reinterventions, and ruptures. Moreover, the amount of regression or expansion seems to be incrementally associated with these late outcomes, too. Future studies are needed to determine how to improve 1-year sac regression, and whether it is safe to extend follow-up intervals for patients with regressing sacs.
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Aneurisma de la Aorta Abdominal , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Humanos , Anciano , Estados Unidos , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/complicaciones , Reparación Endovascular de Aneurismas , Resultado del Tratamiento , Medicare , Factores de Riesgo , Estudios RetrospectivosRESUMEN
OBJECTIVE: Prior literature has found worse outcomes for female patients after endovascular repair of abdominal aortic aneurysm and mixed findings after thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysm. However, the influence of sex on outcomes after TEVAR for acute type B aortic dissection (aTBAD) is not fully elucidated. METHODS: We identified patients who underwent TEVAR for aTBAD (<30 days) in the Vascular Quality Initiative from 2014 to 2022. We excluded patients with an entry tear or stent seal within the ascending aorta or aortic arch and patients with an unknown proximal tear location. Included patients were stratified by biological sex, and we analyzed perioperative outcomes and 5-year mortality with multivariable logistic regression and Cox regression analysis, respectively. Furthermore, we analyzed adjusted variables for interaction with female sex. RESULTS: We included 1626 patients, 33% of whom were female. At presentation, female patients were significantly older (65 [interquartile range: 54, 75] years vs 56 [interquartile range: 49, 68] years; P = .01). Regarding indications for repair, female patients had higher rates of pain (85% vs 80%; P = .02) and lower rates of malperfusion (23% vs 35%; P < .001), specifically mesenteric, renal, and lower limb malperfusion. Female patients had a lower proportion of proximal repairs in zone 2 (39% vs 48%; P < .01). After TEVAR for aTBAD, female sex was associated with comparable odds of perioperative mortality to males (8.1 vs 9.2%; adjusted odds ratio [aOR]: 0.79 [95% confidence interval (CI): 0.51-1.20]). Regarding perioperative complications, female sex was associated with lower odds for cardiac complications (2.3% vs 4.7%; aOR: 0.52 [95% CI: 0.26-0.97]), but all other complications were comparable between sexes. Compared with male sex, female sex was associated with similar risk for 5-year mortality (26% vs 23%; adjusted hazard ratio: 1.01 [95% CI: 0.77-1.32]). On testing variables for interaction with sex, female sex was associated with lower perioperative and 5-year mortality at older ages relative to males (aOR: 0.96 [0.93-0.99] | adjusted hazard ratio: 0.97 [0.95-0.99]) and higher odds of perioperative mortality when mesenteric malperfusion was present (OR: 2.71 [1.04-6.96]). CONCLUSIONS: Female patients were older, less likely to have complicated dissection, and had more distal proximal landing zones. After TEVAR for aTBAD, female sex was associated with similar perioperative and 5-year mortality to male sex, but lower odds of in-hospital cardiac complications. Interaction analysis showed that females were at additional risk for perioperative mortality when mesenteric ischemia was present. These data suggest that TEVAR for aTBAD overall has a similar safety profile in females as it does for males.
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OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) at high-volume hospitals has previously been associated with lower perioperative mortality, but the impact of annual surgeon volume on outcomes following TEVAR for BTAI remains unknown. METHODS: We analyzed Vascular Quality Initiative (VQI) data from patients with BTAI that underwent TEVAR between 2013 and 2023. Annual surgeon volumes were computed as the number of TEVARs (for any pathology) performed over a 1-year period preceding each procedure and were further categorized into quintiles. Surgeons in the first volume quintile were categorized as low volume (LV), the highest quintile as high volume (HV), and the middle three quintiles as medium volume (MV). TEVAR procedures performed by surgeons with less than 1-year enrollment in the VQI were excluded. Using multilevel logistic regression models, we evaluated associations between surgeon volume and perioperative outcomes, accounting for annual center volumes and adjusting for potential confounders, including aortic injury grade and severity of coexisting injuries. Multilevel models accounted for the nested clustering of patients and surgeons within the same center. Sensitivity analysis excluding patients with grade IV BTAI was performed. RESULTS: We studied 1321 patients who underwent TEVAR for BTAI (28% by LV surgeons [0-1 procedures per year], 52% by MV surgeons [2-8 procedures per year], 20% by HV surgeons [≥9 procedures per year]). With higher surgeon volume, TEVAR was delayed more (in <4 hours: LV: 68%, MV: 54%, HV: 46%; P < .001; elective (>24 hours): LV: 5.1%; MV: 8.9%: HV: 14%), heparin administered more (LV: 80%, MV: 81%, HV: 87%; P = .007), perioperative mortality appears lower (LV: 11%, MV: 7.3%, HV: 6.5%; P = .095), and ischemic/hemorrhagic stroke was lower (LV: 6.5%, MV: 3.6%, HV: 1.5%; P = .006). After adjustment, compared with LV surgeons, higher volume surgeons had lower odds of perioperative mortality (MV: 0.49; 95% confidence interval [CI], 0.25-0.97; P = .039; HV: 0.45; 95% CI, 0.16-1.22; P = .12; MV/HV: 0.50; 95% CI, 0.26-0.96; P = .038) and ischemic/hemorrhagic stroke (MV: 0.38; 95% CI, 0.18-0.81; P = .011; HV: 0.16; 95% CI, 0.04-0.61; P = .008). Sensitivity analysis found lower adjusted odds for perioperative mortality (although not significant) and ischemic/hemorrhagic stroke for higher volume surgeons. CONCLUSIONS: In patients undergoing TEVAR for BTAI, higher surgeon volume is independently associated with lower perioperative mortality and postoperative stroke, regardless of hospital volume. Future studies could elucidate if TEVAR for non-ruptured BTAI might be delayed and allow stabilization, heparinization, and involvement of a higher TEVAR volume surgeon.
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Aorta Torácica , Competencia Clínica , Reparación Endovascular de Aneurismas , Hospitales de Alto Volumen , Cirujanos , Lesiones del Sistema Vascular , Heridas no Penetrantes , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Aorta Torácica/cirugía , Aorta Torácica/lesiones , Aorta Torácica/diagnóstico por imagen , Bases de Datos Factuales , Reparación Endovascular de Aneurismas/efectos adversos , Reparación Endovascular de Aneurismas/mortalidad , Hospitales de Bajo Volumen , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/cirugía , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Traumatismos Torácicos/cirugía , Traumatismos Torácicos/mortalidad , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos , Lesiones del Sistema Vascular/cirugía , Lesiones del Sistema Vascular/mortalidad , Lesiones del Sistema Vascular/diagnóstico por imagen , Heridas no Penetrantes/cirugía , Heridas no Penetrantes/mortalidadRESUMEN
OBJECTIVE: Current literature reports conflicting findings regarding the effect of diabetes mellitus (DM) on outcomes of AAA repair. In this study we examined the effect of DM and its management on outcomes following open (OAR) and endovascular (EVAR) AAA repair. METHODS: We identified all patients undergoing OAR or EVAR for infrarenal AAA between 2003-2018 in the Vascular Quality Initiative (VQI) registry data linked with Medicare claims. We excluded patients with missing DM status. Patients were stratified by their preoperative DM status, and then further stratified by DM management: dietary, non-insulin anti-diabetic medications (NIM), or insulin. Outcomes of interest included one-year aneurysm sac dynamics, 8-year aneurysm rupture, reintervention, and all-cause mortality. These outcomes were analyzed with chi-square, Kaplan-Meier methods, and multivariable cox regression analyses. RESULTS: We identified 34,021 EVAR patients and 4,127 OAR patients of which 20% and 16% had DM, respectively. Of all DM patients, 22% were managed by dietary management, 59% by NIM, and 19% by insulin. Following EVAR, DM patients were more likely to have stable sacs while non-DM patients were more likely to have sac regression at 1 year. Compared with non-DM, DM was associated with a significantly lower risk for 8-year rupture in EVAR (EVAR HR: 0.68 [0.51-0.92]). Compared with non-DM, NIM was associated with lower risk of rupture within 8-years for both EVAR and OAR (EVAR HR: 0.64 [0.44-0.94]; OAR HR: 0.29 [0.41-0.80]), while dietary and insulin had similar rupture risk compared with non-DM. However, compared with non-DM, DM was associated with higher risk of 8-year all-cause mortality following EVAR and OAR (DM vs. non-DM: EVAR HR: 1.17 [1.11-1.23]; OAR HR: 1.16 [1.00-1.36]). Following further DM management sub-stratification, compared with non-DM, management with NIM and insulin were associated with higher 8-year mortality in EVAR and OAR (EVAR: NIM HR: 1.12 [1.05-1.20] & insulin HR: 1.40 [1.26-1.55]; OAR: NIM HR: 1.27 [1.06-1.54] & insulin HR: 1.57 [1.15-2.13]). Finally, there was a similar risk of reintervention across the DM and non-DM populations in EVAR and OAR. CONCLUSION: DM was associated with lower adjusted risk of rupture following EVAR as well as OAR in patients managed with NIM. Nevertheless, just as in patients without AAA, preoperative DM was associated with a higher adjusted risk of all-cause mortality. Further study is needed to evaluate for differences in aneurysm-related mortality between DM and non-DM, and studies are planned to evaluate the independent effect of NIM on aneurysm-related outcomes.
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OBJECTIVES: The outcomes of carotid revascularization in patients with prior carotid artery stenting remain understudied. Prior research has not reported the outcomes after Transcarotid artery revascularization (TCAR) in patients with previous carotid artery stenting. In this study, we compared the peri-operative outcomes of TCAR, tfCAS and CEA in patients with prior ipsilateral CAS using the VQI. METHODS: Using the Vascular Quality Initiative data from 2016 to 2023, we identified patients who underwent TCAR, tfCAS, or CEA following prior ipsilateral carotid artery stenting. We included covariates such as age, race, sex, BMI, comorbidities (hypertension, diabetes, prior CAD, prior CABG/PCI, CHF, renal dysfunction, smoking, COPD, anemia), symptom status, urgency, ipsilateral stenosis, and contralateral occlusion into a regression model to compute propensity scores for treatment assignment. We then used the propensity scores for inverse probability-weighting and weighted logistic regression to compare in-hospital stroke, in-hospital death, stroke/death, postoperative myocardial infarction (MI), stroke/death/MI, 30-day mortality and cranial nerve injury (CNI) following TCAR, tfCAS, and CEA. We also analyzed trends in the proportions of patients undergoing the three revascularization procedures over time using Cochrane-Armitage trend testing. RESULTS: We identified 2,137 patients undergoing revascularization following prior ipsilateral carotid stenting: 668 TCAR patients (31%), 1128 tfCAS patients (53%) and 341 CEA patients (16%). In asymptomatic patients, TCAR was associated with a lower yet not statistically significant in-hospital stroke/death than tfCAS (TCAR vs tfCAS: 0.7% vs 2.0%,aOR:0.33[0.11-1.05]; p=0.06), and similar odds of stroke/death with CEA (TCAR vs CEA: 0.7% vs 0.9%,aOR:0.80[0.16-3.98]; p=0.8). Compared with CEA, TCAR was associated with lower odds of post-operative MI (0.1% vs 14%,aOR:0.02[0.00-0.10]; p<0.001), stroke/death/MI (0.8% vs 15%,aOR:0.05[0.01-0.25]; p<0.001), and CNI (0.1% vs 3.8%,aOR:0.04[0.00-0.30]; p=0.002) in this patient population. In symptomatic patients, TCAR had an unacceptably elevated in-hospital stroke/death rate of 5.1% with lower rates of CNI than CEA. We also found an increasing trend in the proportion of patients undergoing TCAR following prior ipsilateral carotid stenting (2016 to 2023: 14% to 41%), with a relative decrease in proportions of tfCAS (61% to 45%) and CEA (25% to 14%) (p<.001). CONCLUSIONS: In asymptomatic patients with prior ipsilateral carotid artery stenting, TCAR was associated with lower odds of in-hospital stroke/death compared with tfCAS, with comparable stroke/death but lower postoperative MI and CNI rates compared with CEA. In symptomatic patients, TCAR was associated with unacceptably elevated in-hospital stroke/death rates. In line with the post-procedure outcomes, there has been a steady increase in the proportion of patients with prior ipsilateral stenting undergoing TCAR over time.
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OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) in patients with genetic aortopathies (GA) is controversial, given concerns of durability. We describe characteristics and outcomes after TEVAR in patients with GA. METHODS: All patients undergoing TEVAR between 2010 and 2023 in the Vascular Quality Iniatitive were identified and categorized as having a GA or not. Demographics, baseline, and procedural characteristics were compared among groups. Multivariable logistic regression was used to evaluate the independent association of GA with postoperative outcomes. Kaplan-Meier methods and multivariable Cox regression analyses were used to evaluate 5-year survival and 2-year reinterventions. RESULTS: Of 19,340 patients, 304 (1.6%) had GA (87% Marfan syndrome, 9% Loeys-Dietz syndrome, and 4% vascular Ehlers-Danlos syndrome). Compared with patients without GA, patients with GA were younger (50 years [interquartile range, 37-72 years] vs 70 years [interquartile range, 61-77 years]), more often presented with acute dissection (28% vs 18%), postdissection aneurysm (48% vs 17%), had a symptomatic presentation (50% vs 39%), and were less likely to have degenerative aneurysms (18% vs 47%) or penetrating aortic ulcer (and intramural hematoma) (3% vs 13%) (all P < .001). Patients with GA were more likely to have prior repair of the ascending aorta/arch (open, 56% vs 11% [P < .001]; endovascular, 5.6% vs 2.1% [P = .017]) or the descending thoracic aorta (open, 12% vs 2% [P = .007]; endovascular, 8.2% vs 3.6% [P = .011]). No significant differences were found in prior abdominal suprarenal repairs; however, patients with GA had more prior open infrarenal repairs (5.3% vs 3.2%), but fewer prior endovascular infrarenal repairs (3.3% vs 5.5%) (all P < .05). After adjusting for demographics, comorbidities, and disease characteristics, patients with GA had similar odds of perioperative mortality (4.6% vs 7.0%; adjusted odds ratio [aOR], 1.1; 95% confidence interval [CI], 0.57-1.9; P = .75), any in-hospital complication (26% vs 23%; aOR, 1.24; 95% CI, 0.92-1.6; P = .14), or in-hospital reintervention (13% vs 8.3%; aOR, 1.25; 95% CI, 0.84-1.80; P = .25) compared with patients without GA. However, patients with GA had a higher likelihood of postoperative vasopressors (33% vs 27%; aOR, 1.44; 95% CI, 1.1-1.9; P = .006) and transfusion (25% vs 23%; aOR, 1.39; 95% CI, 1.03-1.9; P = .006). The 2-year reintervention rates were higher in patients with GA (25% vs 13%; adjusted hazard ratio, 1.99; 95% CI, 1.4-2.9; P < .001), but 5-year survival was similar (81% vs 74%; adjusted hazard ratio, 1.02; 95% CI, 0.70-1.50; P = .1). CONCLUSIONS: TEVAR for patients with GA seemed to be safe initially, with similar odds for in-hospital complications, in-hospital reinterventions, and perioperative mortality, as well as similar hazards for 5-year mortality compared with patients without GA. However, patients with GA had higher 2-year reintervention rates. Future studies should assess long-term durability after TEVAR compared with the recommended open repair to appropriately weigh the risks and benefits of endovascular treatment in patients with GA.
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OBJECTIVE: Respiratory adverse events (RAEs) after thoracic endovascular aortic repair (TEVAR) remain poorly characterized due to the lack of comprehensive studies that identify individuals prone to these complications. This study aims to determine the incidence, factors associated with, and outcomes of RAEs after TEVAR. METHODS: We identified Vascular Quality Initiative patients undergoing TEVAR isolated to zones 0-5 from 2010 to 2023 for non-traumatic pathologies. After determining the incidence of post-operative RAEs, we assessed baseline characteristics, pathology, procedural details, and postoperative complications stratified by respiratory complication status: none, pneumonia only, reintubation only, or both. We then examined pre- and intra-operative variables independently associated with the development of postoperative RAEs using multivariable modified Poisson regression. Kaplan-Meier analysis and Cox proportional hazards regression model were used to determine associations between postoperative RAEs and 5-year survival adjusting for preoperative variables and other non-respiratory post-operative complications in a separate model. RESULTS: Of 10,708 patients, 8.3% had any RAE (pneumonia only: 2.1%, reintubation only: 4.8%, both: 1.4%). Patients with any RAE were more likely to present with aortic dissection (any respiratory complication: 46% vs no respiratory complication: 35%; p<.001), and be symptomatic (58% vs 48%;p<.001). Developing RAEs post-TEVAR was associated with male sex (aRR: 1.19 [95% CI: 1.01-1.41]; p=0.037), obesity (1.31[1.07-1.61]; p=0.009), morbid obesity (1.68[1.20-2.32]; p=0.002), renal dysfunction (eGFR 30-45: 1.45[1.15-1.82]; p=0.002; eGFR <30/hemodialysis: 1.7[1.37-2.11]; p<0.001), anemia (1.31[1.09-1.58]; p=0.003), aortic diameter >65mm (1.54[1.25-1.89]; p<0.001), proximal disease in the aortic arch (1.23[1.03-1.48]; p=0.025) or ascending aorta (1.61[1.19-2.14]; p=0.002), acute aortic dissection (2.13[1.72-2.63]; p<0.001), ruptured presentation (3.07[2.43-3.87]; p<0.001), same-day surgical thoracic branch treatment (1.51[1.25-1.82]; p<0.001), COPD on home oxygen (1.58[1.08-2.25]; p=0.014), limited self-care or bed-bound status (2.12[1.45-3.03]; p<0.001), and intraoperative transfusion (1.88[1.47-2.40]; p<0.001). Patients who developed post-operative RAEs had higher 30-day mortality (27% vs 4%; p<.001) and 5-year mortality than patients without respiratory complications (46% vs 20%; p<0.001). After adjusting for pre-operative and post-operative variables, 5-year mortality was higher in patients who developed any post-operative RAE (aHR: 1.8[1.6, 2.1]; p<.001), post-operative pneumonia only (1.4[1.0, 1.8];p=.046), reintubation only (2.2[1.8, 2.6]; p<.001) or both (1.5[1.1, 2.0]; p=.008). CONCLUSIONS: RAEs after TEVAR are common, more likely to occur in male patients with obesity, renal dysfunction, anemia, COPD on home oxygen, acute aortic dissection, ruptured presentation, same-day surgical thoracic branch treatment, who received intra-operative transfusion, and are associated with a two-fold increase in 5-year mortality regardless of the development of other post-operative complications. Considering these factors in assessing risks and benefits of TEVAR procedures, along with implementing customized post-operative care, can potentially improve clinical outcomes.
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BACKGROUND: Given changes in intervention guidelines and the growing popularity of endovascular treatment for aortic aneurysms, we examined the trends in admissions and repairs of abdominal aortic aneurysms (AAAs), thoracoabdominal aortic aneurysms (TAAAs), and thoracic aortic aneurysms (TAAs). METHODS: We identified all patients admitted with ruptured aortic aneurysms and intact aortic aneurysms repaired in the Nationwide Inpatient Sample between 2004 and 2019. We then examined the use of open, endovascular, and complex endovascular repair (OAR, EVAR, and cEVAR) for each aortic aneurysm location (AAA, TAAA, and TAA), alongside their resulting in-hospital mortality, over time. cEVAR included branched, fenestrated, and physician-modified endografts. RESULTS: 715,570 patients were identified with AAA (87% intact repairs and 13% rupture admissions). Both intact AAA repairs and ruptured AAA admissions decreased significantly between 2004 and 2019 (intact 41,060-34,215, P < .01; ruptured 7175-4625, P = .02). Of all AAA repairs performed in a given year, the use of EVAR increased (2004-2019: intact 45%-66%, P < .01; ruptured 10%-55%, P < .01) as well as cEVAR (2010-2019: intact 0%-23%, P < .01; ruptured 0%-14%, P < .01). Mortality after EVAR of intact AAAs decreased significantly by 29% (2004-2019, 0.73%-0.52%, P < .01), whereas mortality after OAR increased significantly by 16% (2004-2019, 4.4%-5.1%, P < .01). In the study, 27,443 patients were identified with TAAA (80% intact and 20% ruptured). In the same period, intact TAAA repairs trended upward (2004-2019, 1435-1640, P = .055), and cEVAR became the most common approach (2004-2019, 3.8%-72%, P = .055). A total of 141,651 patients were identified with ascending, arch, or descending TAAs (90% intact and 10% ruptured). Intact TAA repairs increased significantly (2004-2019, 4380-10,855, P < .01). From 2017 to 2019, the mortality after OAR of descending TAAs increased and mortality after thoracic endovascular aneurysm repair decreased (2017-2019, OAR 1.6%-3.1%; thoracic endovascular aneurysm repair 5.2%-3.8%). CONCLUSIONS: Both intact AAA repairs and ruptured AAA admissions significantly decreased between 2004 and 2019. The use of endovascular techniques for the repair of all aortic aneurysm locations, both intact and ruptured, increased over the past two decades. Most recently in 2019, 89% of intact AAA repairs, infrarenal through suprarenal, were endovascular (EVAR or cEVAR, respectively). cEVAR alone increased to 23% of intact AAA repairs in 2019, from 0% a decade earlier. In this period of innovation, with many new options to repair aortic aneurysms while maintaining arterial branches, endovascular repair is now used for the majority of all intact aortic aneurysm repairs. Long-term data are needed to evaluate the durability of these procedures.
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OBJECTIVE: Current societal recommendations regarding the timing of thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) vary. Prior studies have shown that elective repair was associated with lower mortality after TEVAR for BTAI. However, these studies lacked data such as Society for Vascular Surgery (SVS) aortic injury grades and TEVAR-related postoperative outcomes. Therefore, we used the Vascular Quality Initiative registry, which includes relevant anatomic and outcome data, to examine the outcomes following urgent/emergent (≤ 24 hours) vs elective TEVAR for BTAI. METHODS: Patients undergoing TEVAR for BTAI between 2013 and 2022 were included, excluding those with SVS grade 4 aortic injuries. We included covariates such as age, sex, race, transfer status, body mass index, preoperative hemoglobin, comorbidities, medication use, SVS aortic injury grade, coexisting injuries, Glasgow Coma Scale, and prior aortic surgery in a regression model to compute propensity scores for assignment to urgent/emergent or elective TEVAR. Perioperative outcomes and 5-year mortality were evaluated using inverse probability-weighted logistic regression and Cox regression, also adjusting for left subclavian artery revascularization/occlusion and annual center and physician volumes. RESULTS: Of 1016 patients, 102 (10%) underwent elective TEVAR. Patients who underwent elective repair were more likely to undergo revascularization of the left subclavian artery (31% vs 7.5%; P < .001) and receive intraoperative heparin (94% vs 82%; P = .002). After inverse probability weighting, there was no association between TEVAR timing and perioperative mortality (elective vs urgent/emergent: 3.9% vs 6.6%; odds ratio [OR], 1.1; 95% confidence interval [CI], 0.27-4.7; P = .90) and 5-year mortality (5.8% vs 12%; hazard ratio [HR], 0.95; 95% CI, 0.21-4.3; P > .9).Compared with urgent/emergent TEVAR, elective repair was associated with lower postoperative stroke (1.0% vs 2.1%; adjusted OR [aOR], 0.12; 95% CI, 0.02-0.94; P = .044), even after adjusting for intraoperative heparin use (aOR, 0.12; 95% CI, 0.02-0.92; P = .042). Elective TEVAR was also associated with lower odds of failure of extubation immediately after surgery (39% vs 65%; aOR, 0.18; 95% CI, 0.09-0.35; P < .001) and postoperative pneumonia (4.9% vs 11%; aOR, 0.34; 95% CI, 0.13-0.91; P = .031), but comparable odds of any postoperative complication as a composite outcome and reintervention during index admission. CONCLUSIONS: Patients with BTAI who underwent elective TEVAR were more likely to receive intraoperative heparin. Perioperative mortality and 5-year mortality rates were similar between the elective and emergent/urgent TEVAR groups. Postoperatively, elective TEVAR was associated with lower ischemic stroke, pulmonary complications, and prolonged hospitalization. Future modifications in society guidelines should incorporate the current evidence supporting the use of elective TEVAR for BTAI. The optimal timing of TEVAR in patients with BTAI and the factors determining it should be the subject of future study to facilitate personalized decision-making.
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Implantación de Prótesis Vascular , Procedimientos Endovasculares , Traumatismos Torácicos , Lesiones del Sistema Vascular , Heridas no Penetrantes , Humanos , Reparación Endovascular de Aneurismas , Procedimientos Endovasculares/efectos adversos , Factores de Riesgo , Aorta/cirugía , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/cirugía , Aorta Torácica/lesiones , Heparina , Heridas no Penetrantes/diagnóstico por imagen , Heridas no Penetrantes/cirugía , Traumatismos Torácicos/cirugía , Lesiones del Sistema Vascular/diagnóstico por imagen , Lesiones del Sistema Vascular/cirugía , Resultado del Tratamiento , Estudios Retrospectivos , Implantación de Prótesis Vascular/efectos adversosRESUMEN
OBJECTIVES: The relationship between baseline Modified Rankin Scale (mRS) in patients with prior stroke and optimal timing of carotid revascularization is unclear. Therefore, we evaluated the timing of transfemoral carotid artery stenting (tfCAS), transcarotid artery revascularization (TCAR), and carotid endarterectomy (CEA) after prior stroke, stratified by preoperative mRS. METHODS: We identified patients with recent stroke who underwent tfCAS, TCAR, or CEA between 2012 and 2021. Patients were stratified by preoperative mRS (0-1, 2, 3-4, or 5) and days from symptom onset to intervention (time to intervention; ≤2 days, 3-14 days, 15-90 days, and 91-180 days). First, we performed univariate analyses comparing in-hospital outcomes between separate mRS or time-to-intervention cohorts for all carotid intervention methods. Afterward, multivariable logistic regression was used to adjust for demographics and comorbidities across groups, and outcomes between the various intervention methods were compared. Primary outcome was the in-hospital stroke/death rate. RESULTS: We identified 4260 patients who underwent tfCAS, 3130 patients who underwent TCAR, and 20,012 patients who underwent CEA. Patients were most likely to have minimal disability (mRS, 0-1 [61%]) and least likely to have severe disability (mRS, 5 [1.5%]). Patients most often underwent revascularization in 3 to 14 days (45%). Across all intervention methods, increasing preoperative mRS was associated with higher procedural in-hospital stroke/death (all P < .03), whereas increasing time to intervention was associated with lower stroke/death rates (all P < .01). After adjustment for demographics and comorbidities, undergoing tfCAS was associated with higher stroke/death compared with undergoing CEA (adjusted odds ratio, 1.6; 95% confidence interval, 1.3-1.9; P < .01) or undergoing TCAR (adjusted odds ratio, 1.3; 95% confidence interval, 1.0-1.8; P = .03). CONCLUSIONS: In patients with preoperative stroke, optimal timing for carotid revascularization varies with stroke severity. Increasing preoperative mRS was associated with higher procedural in-hospital stroke/death rates, whereas increasing time to-intervention was associated with lower stroke/death rates. Overall, patients undergoing CEA were associated with lower in-hospital stroke/deaths. To determine benefit for delayed intervention, these results should be weighed against the risk of recurrent stroke during the interval before intervention.
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Estenosis Carotídea , Endarterectomía Carotidea , Procedimientos Endovasculares , Accidente Cerebrovascular , Humanos , Estenosis Carotídea/complicaciones , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/cirugía , Procedimientos Endovasculares/efectos adversos , Factores de Riesgo , Medición de Riesgo , Factores de Tiempo , Stents , Accidente Cerebrovascular/diagnóstico , Endarterectomía Carotidea/efectos adversos , Arterias Carótidas , Resultado del Tratamiento , Estudios RetrospectivosRESUMEN
PURPOSE: Metformin, widely used for the treatment of diabetes mellitus (DM), has shown potential for inhibiting abdominal aortic aneurysm (AAA) growth by reducing extracellular matrix remodeling and inflammation. However, its influence on clinical outcomes and aneurysm sac dynamics after endovascular aneurysm repair (EVAR) remains uncertain. This retrospective study aims to explore the effects of metformin on long-term outcomes following EVAR. MATERIALS AND METHODS: Patients who underwent elective standard EVAR for infrarenal AAA at a single academic Dutch hospital from 2000 to 2022 were included. We collected baseline patient demographics, comorbid conditions, anatomical and operative characteristics, and 30-day postoperative events. Metformin use was defined as using it preceding EVAR. The primary outcome, the postoperative aneurysm sac volume over time, was investigated using linear mixed-effects modeling. The secondary outcomes, 8-year all-cause mortality and freedom from graft-related events, were evaluated using Kaplan-Meier methods. RESULTS: We analyzed 685 patients, including 634 (93%) non-metformin users and 51 (7%) metformin users. The median follow-up period was similar (4.0 years [IQR=1.5, 6.5] vs 5.0 years [IQR=2.0, 8.0]; p=0.091). Patients on metformin had a preoperative aneurysm sac volume of 153 cc (IQR=114, 195) compared with 178 cc (IQR=133, 240) for non-metformin patients (p=0.054). At 30 days post-EVAR, metformin patients had a comparable mean aneurysm sac volume compared with non-metformin patients (metformin: -19.4 cc [95% confidence interval [CI]: -47.4, 8.5]; p=0.173). The effect of metformin on aneurysm growth over time was not significant (-3.9 cc/year; [95% CI: -22.7, 14.9]; p=0.685). Following risk-adjusted analysis, metformin use was associated with similar rates of all-cause mortality (metformin vs no metformin: 50% vs 44%; hazard ratio [HR]=1.11, 95% CI: 0.66, 1.88; p=0.688) and freedom from graft-related events (metformin vs no metformin: 63% vs 66%; HR=1.82, 95% CI: 0.98, 3.38; p=0.059). CONCLUSION: Although metformin use may reduce preoperative AAA growth, it does not seem to influence overall/long-term post-EVAR AAA sac dynamics, all-cause mortality, or freedom from graft-related events. These findings suggest that the potential protective effect of metformin on AAA may not be sustained after EVAR. Further prospective studies are needed to investigate the mechanisms underlying the potential role of metformin in AAA management following EVAR. CLINICAL IMPACT: There is currently no approved pharmacological treatment available to slow the abdominal aortic aneurysm (AAA) growth rate and reduce the related risk of rupture. In our retrospective analysis including 685 patients undergoing EVAR for infrarenal AAA, we found that metformin use was not associated with improved post-EVAR outcomes, such as a reduction of aneurysm sac volume over time, eight-year all-cause mortality, or freedom of graft-related events. These findings suggest that the potential protective effect of metformin on AAA may not be sustained after EVAR and underscore the need for ongoing research into this area.
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OBJECTIVE: Surveillance after endovascular aneurysm repair (EVAR) is suboptimal due to limited compliance and relatively large variability in measurement methods of abdominal aortic aneurysm (AAA) sac size after treatment. Measuring volume offers a more sensitive early indicator of aneurysm sac growth or regression/stability, but is more time consuming and thus less practical than measuring maximum diameter. This study evaluated the accuracy and consistency of the artificial intelligence (AI) driven software PRAEVAorta 2 and compared it with an established semi-automated segmentation method. METHODS: Post-EVAR aneurysm sac volumes measured by AI were compared with a semi-automated segmentation method (3mensio software) in patients with infrarenal AAA, focusing on absolute aneurysm volume and volume evolution over time. The clinical impact of both methods was evaluated by categorising patients as showing either AAA sac regression, stabilisation, or growth comparing the 30 day and one year post-EVAR computed tomography angiography (CTA) images. Intermethod and intramethod agreement were assessed using Bland-Altman analysis, the intraclass correlation coefficient (ICC) and Cohen's κ statistic. RESULTS: Forty nine patients (98 CTA images) were analysed, after excluding 15 patients due to segmentation errors by AI owing to low quality CT scans. Aneurysm sac volume measurements showed excellent correlation (ICC = 0.94, 95% confidence interval [CI] 0.88 - 0.99) with good to excellent correlation for volume evolution over time (ICC = 0.85, 95% CI 0.75 - 0.91). Categorisation of AAA sac evolution showed fair correlation (Cohen's κ = 0.33), with 12 discrepancies (24%) between methods. The intramethod agreement for the AI software demonstrated perfect consistency (bias = -0.01 cc), indicating that it is more reliable compared with the semi-automated method. CONCLUSION: Despite some differences in AAA sac volume measurements, the highly consistent AI driven software accurately measured AAA sac volume evolution. AAA sac evolution classification appears to be more reliable than existing methods and may therefore improve risk stratification post-EVAR. It could facilitate AI driven personalised surveillance programmes. While high quality CTA images are crucial, considering radiation exposure is important, validating the software with non-contrast CT scans might reduce the radiation burden.
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OBJECTIVE: Age stratified mortality was examined following fenestrated endovascular aneurysm repair (F-EVAR) vs. open repair of juxtarenal abdominal aortic aneurysms (AAAs) METHODS: All patients undergoing first time elective F-EVAR and complex open aneurysm repair (c-OAR) for juxtarenal AAA in the Vascular Quality Initiative between 2014 and 2021 were identified. Open repairs were compared with commercially available fenestrated endovascular aneurysm repair and physician modified endografts (PMEGs). Patients were stratified into three age groups (< 65, 65 - 75, > 75 years). Primary outcomes were peri-operative and five year mortality, and inverse probability weighted risk adjustment was performed to account for baseline differences. RESULTS: Overall, 1 961 patients underwent F-EVAR (82% commercial F-EVAR, 18% PMEG) and 3 385 patients underwent c-OAR. Across age groups, the distribution of F-EVAR (vs. c-OAR) was: < 65 years: 23%, 65 - 75 years: 33%, > 75 years: 52%. After adjustment, among patients < 65 years, compared with c-OAR, F-EVAR was associated with similar peri-operative mortality (0.9% vs. 2.1%; hazard ratio [HR] 0.40, 95% confidence interval [CI] 0.07 - 1.44], p = .22), and five year mortality (13% vs. 9.5%; HR 1.44, 95% CI 0.71 - 2.90, p = .31). Among patients aged 65 - 75 years, between juxtarenal AAA repair modalities, compared with c-OAR, F-EVAR was associated with a significantly lower risk of peri-operative mortality (2.2% vs. 5.0%; HR 0.50, 95% CI 0.30 - 0.79, p = .004), and five year mortality (13% vs. 13%; HR 0.94, 95% CI 0.65 - 1.36, p = .74). Similarly, among patients > 75 years, compared with c-OAR, F-EVAR was associated with lower peri-operative mortality (2.2% vs. 6.5%; HR 0.26, 95% CI 0.13 - 0.47, p < .001), but with similar five year mortality (18% vs. 21%; HR 0.83, 95% CI 0.57 - 1.20, p = .31). CONCLUSION: Among patients with a juxtarenal AAA, F-EVAR was associated with a lower peri-operative mortality compared with c-OAR in patients ≥ 65 years, but was similar in those < 65 years. At five years, F-EVAR was associated with similar mortality in all age groups, though there was a non-significant trend for a higher mortality rate in younger patients.
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OBJECTIVE: One year aneurysm sac dynamics after endovascular abdominal aortic aneurysm repair (EVAR) were independently associated with a greater all cause mortality risk in prior registry studies but were limited in completeness and granularity. This retrospective analysis aimed to study the impact of sac dynamics on survival within the Endurant Stent Graft Global Registry (ENGAGE) with five year follow up. METHODS: A total of 1 263 subjects were enrolled in the ENGAGE Registry between March 2009 and April 2011. One year aneurysm sac changes were calculated between the one month post-operative imaging scans and the scan closest to the time of one year follow up. Sac regression was defined as a sac decrease of ≥ 5 mm and sac expansion as aneurysm sac growth ≥ 5 mm. The primary outcome was the five year all cause mortality rate. Kaplan-Meier estimates for freedom from all cause death were calculated. Multivariable Cox regression was used to determine the association between sac dynamics and all cause death. RESULTS: At one year, 441 of the 949 study participants with appropriate imaging (46%) had abdominal aortic aneurysm sac regression, 462 (49%) remained stable, and 46 (4.8%) had sac expansion. For patients with sac regression, the five year all cause mortality rate was 20%, compared with 28% for stable sac (p = .007) and 37% for the sac expansion (p = .010) cohorts. After adjustment, the sac expansion and stable sac cohorts were associated with a greater all cause mortality rate (expansion: hazard ratio [HR] 1.8; 95% CI 1.1 - 3.2; p = .032; stable: HR 1.4; 95% CI 1.1 - 1.9; p = .019). CONCLUSION: In the ENGAGE Global Registry, the one year rate of sac regression was 46%, and one year sac regression was observed to be associated with greater five year survival, corroborating prior findings using data from vascular registries. Sac regression could become the new standard for success after EVAR.
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OBJECTIVE: Fenestrated endovascular aneurysm repair (FEVAR) is a feasible option for aortic repair after endovascular aneurysm repair (EVAR), due to improved peri-operative outcomes compared with open conversion. However, little is known regarding the durability of FEVAR as a treatment for failed EVAR. Since aneurysm sac evolution is an important marker for success after aneurysm repair, the aim of the study was to examine midterm outcomes and aneurysm sac dynamics of FEVAR after prior EVAR. METHODS: Patients undergoing FEVAR for complex abdominal aortic aneurysms from 2008 to 2021 at two hospitals in The Netherlands were included. Patients were categorised into primary FEVAR and FEVAR after EVAR. Outcomes included five year mortality rate, one year aneurysm sac dynamics (regression, stable, expansion), sac dynamics over time, and five year aortic related procedures. Analyses were done using Kaplan-Meier methods, multivariable Cox regression analysis, chi square tests, and linear mixed effect models. RESULTS: One hundred and ninety-six patients with FEVAR were identified, of whom 27% (n = 53) had had a prior EVAR. Patients with prior EVAR were significantly older (78 ± 6.7 years vs. 73 ± 5.9 years, p < .001). There were no significant differences in mortality rate. FEVAR after EVAR was associated with a higher risk of aortic related procedures within five years (hazard ratio [HR] 2.6; 95% confidence interval [CI] 1.1 - 6.5, p = .037). Sac dynamics were assessed in 154 patients with available imaging. Patients with a prior EVAR showed lower rates of sac regression and higher rates of sac expansion at one year compared with primary FEVAR (sac expansion 48%, n = 21/44, vs. 8%, n = 9/110, p < .001). Sac dynamics over time showed similar results, sac growth for FEVAR after EVAR, and sac shrinkage for primary FEVAR (p < .001). CONCLUSION: There were high rates of sac expansion and a need for more secondary procedures in FEVAR after EVAR than primary FEVAR patients, although this did not affect midterm survival. Future studies will have to assess whether FEVAR after EVAR is a valid intervention, and the underlying process that drives aneurysm sac growth following successful FEVAR after EVAR.
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Aneurisma de la Aorta Abdominal , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Humanos , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/mortalidad , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Anciano , Femenino , Masculino , Anciano de 80 o más Años , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Implantación de Prótesis Vascular/métodos , Países Bajos/epidemiología , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Factores de Riesgo , Prótesis Vascular , Reoperación/estadística & datos numéricos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/epidemiología , Diseño de Prótesis , Reparación Endovascular de AneurismasRESUMEN
OBJECTIVE: To evaluate the association between sex and outcomes following TEVAR for intact isolated descending thoracic aortic aneurysms (iiDTAA). SUMMARY BACKGROUND DATA: Data regarding sex-related long-term outcomes after TEVAR for iiDTAA are limited and conflicting results regarding perioperative outcomes have been reported. METHODS: We included all TEVAR for iiDTAA between 2014-2019 in the Vascular Quality Initiative linked to Medicare claims, allowing reliable assessment of long-term outcome data. Primary outcomes included 5-year mortality, reinterventions, and ruptures of the thoracic aorta. Secondarily we assessed perioperative outcomes. RESULTS: We identified 685 patients, of which 54% were females. Females had higher aortic size index (females vs. males: 3.31 [IQR, 2.81-3.85] cm/m2 vs. 2.93 [IQR, 2.42-3.36] cm/m2; P<.001), were more frequently symptomatic (31% vs. 20%; P=.001), had longer procedure time (111 [IQR, 72-165] min vs. 97 [IQR, 70-146] min) and more iliac procedures (16% vs. 7.6%; P=.001). Compared with males, females had similar rates of 5-year mortality (58% vs. 53%; HR, 0.93; 95%CI 0.71-1.22; P=.61), reinterventions (39% vs. 30%; HR, 1.12; 95%CI 0.73-1.73; P=.60) and late ruptures (0.6% vs. 1.2%; HR, 0.87; 95%CI 0.12-6.18; P=.89). After adjustment, these outcomes remained similar through 5-years. Furthermore, perioperative mortality was not significantly different between sexes (4.1% vs. 2.2%; P=.25), as were rates of any complication as a composite outcome (16% vs. 21%; P=.16), as well as of individual complications (all P>.05). CONCLUSIONS: Our findings suggest that females who undergo TEVAR for iiDTAA have similar 5-year and perioperative outcomes as compared with males.
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OBJECTIVE: We examined early (≤24 h) versus delayed (>24 h) thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI), taking the aortic injury severity into consideration. BACKGROUND: Current trauma surgery guidelines recommend delayed TEVAR following BTAI. However, this recommendation was based on small studies, and specifics regarding recommendation strategies based on aortic injury grades are lacking. METHODS: Patients undergoing TEVAR for BTAI in the American College of Surgeons Trauma Quality Improvement Program between 2016 and 2019 were included and then stratified into 2 groups (early: ≤24 h vs. delayed: >24 h). In-hospital outcomes were compared after creating 1:1 propensity score-matched cohorts, matching for demographics, comorbidities, concomitant injuries, additional procedures, and aortic injury severity based on the acute aortic syndrome (AAS) classification. RESULTS: Overall, 1339 patients were included, of whom 1054(79%) underwent early TEVAR. Compared with the delayed group, the early group had significantly less severe head injuries (early vs delayed; 25% vs 32%; P =0.014), fewer early interventions for AAS grade 1 occurred, and AAS grade 3 aortic injuries often were intervened upon within 24 hours (grade 1: 28% vs 47%; grade 3: 49% vs 23%; P <0.001). After matching, the final sample included 548 matched patients. Compared with the delayed group, the early group had a significantly higher in-hospital mortality (8.8% vs 4.4%, relative risk: 2.2, 95% CI: 1.1-4.4; P =0.028), alongside a shorter length of hospital stay (5.0 vs 10 days; P =0.028), a shorter intensive care unit length of stay (4.0 vs 11 days; P <0.001) and fewer days on the ventilator (4.0 vs 6.5 days; P =0.036). Furthermore, regardless of the higher risk of acute kidney injury in the delayed group (3.3% vs 7.7%, relative risk: 0.43, 95% CI: 0.20-0.92; P =0.029), no other differences in in-hospital complications were observed between the early and delayed group. CONCLUSION: In this propensity score-matched analysis, delayed TEVAR was associated with lower mortality risk, even after adjusting for aortic injury grade.
Asunto(s)
Procedimientos Endovasculares , Traumatismos Torácicos , Lesiones del Sistema Vascular , Heridas no Penetrantes , Humanos , Reparación Endovascular de Aneurismas , Aorta Torácica/cirugía , Aorta Torácica/lesiones , Puntaje de Propensión , Procedimientos Endovasculares/métodos , Aorta/lesiones , Aorta/cirugía , Heridas no Penetrantes/cirugía , Traumatismos Torácicos/cirugía , Lesiones del Sistema Vascular/cirugía , Resultado del Tratamiento , Estudios Retrospectivos , Factores de RiesgoRESUMEN
OBJECTIVE: Statin therapy is the standard of care for patients with carotid artery stenosis given its proven cardiovascular benefits. However, the impact of statin therapy on outcomes in patients undergoing carotid revascularization in the Vascular Quality Initiative has not yet been evaluated. Therefore, our aim was to investigate the association of statin therapy with outcomes following carotid endarterectomy (CEA), transfemoral carotid artery stenting (tfCAS), and transcarotid artery revascularization (TCAR). METHODS: We identified all patients who underwent CEA, tfCAS, or TCAR in the Vascular Quality Initiative registry from January 2016 to September 2021. To compare outcomes, we stratified patients by procedure type and created 1:1 propensity score-matched cohorts of patients who received no preoperative statin therapy (within 36 hours of procedure) versus those who received preoperative statin therapy. Propensity scores incorporated demographic characteristics, comorbidities, carotid symptom status, preoperative medications, and physician and hospital procedural experience. The primary outcome was a composite end point of in-hospital stroke and/or death. As a secondary analysis, we performed repeat propensity score-matching by postoperative statin use (prescribed at discharge) and assessed 5-year mortality. Relative risks (RR) and hazard ratios (HR) were calculated using log binomial regression and Cox regression, respectively. RESULTS: Among 97,835 CEA, 20,303 tfCAS, and 22,371 TCAR patients, 15%, 17%, and 10% of patients did not receive preoperative statin therapy, respectively. Compared with statin use, no statin use was associated with a higher risk of in-hospital stroke or death among 13,434 matched CEA patients (no statin, 1.7% vs statin, 1.4%; RR, 1.2; 95% confidence interval [CI], 1.02-1.5) and among 2707 matched tfCAS patients (4.8% vs 2.8%; RR, 1.7; 95% CI, 1.3-2.3). However, there was no difference for this outcome by statin use among 2089 matched TCAR patients (1.8% vs 1.6%; RR, 1.1; 95% CI, 0.7-1.8). At 5 years, no statin therapy at discharge was associated with higher 5-year mortality after CEA (15% vs 10%; HR, 1.8; 95% CI, 1.6-2) and tfCAS (18% vs 14%; HR, 1.5; 95% CI, 1.2-1.8), but there was no difference after TCAR (14% vs 11%; HR, 1.3; 95% CI, 0.9-1.8). CONCLUSIONS: Compared with statin use, no statin use was associated with a higher risk of in-hospital stroke or death and 5-year mortality among CEA and tfCAS patients. Although there was no significant difference in outcomes among TCAR patients, this may in part be due to lower statistical power in this cohort. Overall, statin therapy is essential in the short- and long-term management of patients undergoing carotid revascularization. Our findings not only support current Society for Vascular Surgery recommendations for statin therapy in patients undergoing carotid revascularization, but they also highlight an important opportunity for quality improvement.