Antielastin autoimmunity in tobacco smoking-induced emphysema.

Chronic obstructive pulmonary disease and emphysema are common destructive inflammatory diseases that are leading causes of death worldwide. Here we show that emphysema is an autoimmune disease characterized by the presence of antielastin antibody and T-helper type 1 (T(H)1) responses, which correlate with emphysema severity. These findings link emphysema to adaptive immunity against a specific lung antigen and suggest the potential for autoimmune pathology of other elastin-rich tissues such as the arteries and skin of smokers.

Predicting mortality in high-risk coronary artery bypass: surgeon versus risk model.

BACKGROUND: Risk models are useful in evaluating and comparing surgical outcomes, but surgeons may not always agree with the risk estimates derived from these models, particularly in high-risk cases. We examined the concordance between surgeons' and a risk model's predictions of operative mortality in high-risk coronary artery bypass grafting (CABG) patients, and we attempted to identify the reasons for any discrepancies. METHODS: From the Veterans Affairs Continuous Improvement in Cardiac Surgery Program (CICSP), a prospective database and cardiac surgery risk model, we obtained data regarding 181 high-risk, isolated CABG cases performed at a single institution between April 1998 and April 2008. Cases were considered high risk if the surgeon estimated the patient's operative mortality risk to be ≥ 10%. We compared the mortality predictions made by surgeons and the risk model by using the signed-rank test and investigated cases in which there was a significant discrepancy (at least 2-fold) between the two predictions. RESULTS: The observed 30-d/in-hospital and 180-d mortality rates were 6.1% (11/181) and 11.0% (20/181), respectively. The mean operative mortality prediction made by surgeons (12.0% ± 5.3%) was higher than that made by the risk model (7.5% ± 8.5%) (P < 0.001). There was significant discrepancy between the surgeon and risk model estimates in 62% (113/181) of cases. In 53% (60/113) of these cases, the surgeon reported having considered risk factors not included in the CICSP model, including (most commonly) possible need for an additional procedure (n = 15), compromised mobility (n = 11), liver disease (n = 9), hematologic or immunologic disease (n = 6), and quality of targets (n = 5). CONCLUSIONS: In high-risk CABG cases, surgeon and CICSP risk estimates often disagreed markedly, partly because some disease entities of concern to surgeons are not included in the risk model. The higher mortality risk estimated by the surgeons is a better reflection of the considerable mortality risk that extends up to 180 days after surgery.

Association of Thoracic Aortic Aneurysm Size With Long-term Patient Outcomes: The KP-TAA Study.

Importance: The risk of adverse events from ascending thoracic aorta aneurysm (TAA) is poorly understood but drives clinical decision-making. Objective: To evaluate the association of TAA size with outcomes in nonsyndromic patients in a large non-referral-based health care delivery system. Design, Setting, and Participants: The Kaiser Permanente Thoracic Aortic Aneurysm (KP-TAA) cohort study was a retrospective cohort study at Kaiser Permanente Northern California, a fully integrated health care delivery system insuring and providing care for more than 4.5 million persons. Nonsyndromic patients from a regional TAA safety net tracking system were included. Imaging data including maximum TAA size were merged with electronic health record (EHR) and comprehensive death data to obtain demographic characteristics, comorbidities, medications, laboratory values, vital signs, and subsequent outcomes. Unadjusted rates were calculated and the association of TAA size with outcomes was evaluated in multivariable competing risk models that categorized TAA size as a baseline and time-updated variable and accounted for potential confounders. Data were analyzed from January 2018 to August 2021. Exposures: TAA size. Main Outcomes and Measures: Aortic dissection (AD), all-cause death, and elective aortic surgery. Results: Of 6372 patients with TAA identified between 2000 and 2016 (mean [SD] age, 68.6 [13.0] years; 2050 female individuals [32.2%] and 4322 male individuals [67.8%]), mean (SD) initial TAA size was 4.4 (0.5) cm (828 individuals [13.0% of cohort] had initial TAA size 5.0 cm or larger and 280 [4.4%] 5.5 cm or larger). Rates of AD were low across a mean (SD) 3.7 (2.5) years of follow-up (44 individuals [0.7% of cohort]; incidence 0.22 events per 100 person-years). Larger initial aortic size was associated with higher risk of AD and all-cause death in multivariable models, with an inflection point in risk at 6.0 cm. Estimated adjusted risks of AD within 5 years were 0.3% (95% CI, 0.3-0.7), 0.6% (95% CI, 0.4-1.3), 1.5% (95% CI, 1.2-3.9), 3.6% (95% CI, 1.8-12.8), and 10.5% (95% CI, 2.7-44.3) in patients with TAA size of 4.0 to 4.4 cm, 4.5 to 4.9 cm, 5.0 to 5.4 cm, 5.5 to 5.9 cm, and 6.0 cm or larger, respectively, in time-updated models. Rates of the composite outcome of AD and all-cause death were higher than for AD alone, but a similar inflection point for increased risk was observed at 6.0 cm. Conclusions and Relevance: In a large sociodemographically diverse cohort of patients with TAA, absolute risk of aortic dissection was low but increased with larger aortic sizes after adjustment for potential confounders and competing risks. Our data support current consensus guidelines recommending prophylactic surgery in nonsyndromic individuals with TAA at a 5.5-cm threshold.

Radial artery grafts vs saphenous vein grafts in coronary artery bypass surgery: a randomized trial.

CONTEXT: Arterial grafts are thought to be better conduits than saphenous vein grafts for coronary artery bypass grafting (CABG) based on experience with using the left internal mammary artery to bypass the left anterior descending coronary artery. The efficacy of the radial artery graft is less clear. OBJECTIVE: To compare 1-year angiographic patency of radial artery grafts vs saphenous vein grafts in patients undergoing elective CABG. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, randomized controlled trial conducted from February 2003 to February 2009 at 11 Veterans Affairs medical centers among 757 participants (99% men) undergoing first-time elective CABG. INTERVENTIONS: The left internal mammary artery was used to preferentially graft the left anterior descending coronary artery whenever possible; the best remaining recipient vessel was randomized to radial artery vs saphenous vein graft. MAIN OUTCOME MEASURES: The primary end point was angiographic graft patency at 1 year after CABG. Secondary end points included angiographic graft patency at 1 week after CABG, myocardial infarction, stroke, repeat revascularization, and death. RESULTS: Analysis included 733 patients (366 in the radial artery group, 367 in the saphenous vein group). There was no significant difference in study graft patency at 1 year after CABG (radial artery, 238/266; 89%; 95% confidence interval [CI], 86%-93%; saphenous vein, 239/269; 89%; 95% CI, 85%-93%; adjusted OR, 0.99; 95% CI, 0.56-1.74; P = .98). There were no significant differences in the secondary end points. CONCLUSION: Among Veterans Affairs patients undergoing first-time elective CABG, the use of a radial artery graft compared with saphenous vein graft did not result in greater 1-year patency. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00054847.

The impact of obesity on long-term survival after coronary artery bypass grafting.

BACKGROUND: Obesity is a well-known risk factor for coronary artery disease. The objective of our study was to examine the impact of obesity on long-term survival after coronary artery bypass grafting (CABG). MATERIALS AND METHODS: Using prospectively gathered data, we reviewed records of 1163 consecutive patients who underwent isolated primary CABG between 1997 and 2007. We compared outcomes of obese patients (body mass index [BMI] > or = 30 kg/m(2); n = 472) and non-obese patients (BMI < 30 kg/m(2); n = 691). Long-term survival was assessed by using Kaplan-Meier curves generated by log-rank tests and adjusted for confounding factors with Cox logistic regression analysis. RESULTS: Obese patients were slightly younger (60 +/- 8 versus 63 +/- 9y; P < 0.0001), were less likely to be current tobacco smokers (30% versus 41%; P < 0.0001), had a higher incidence of diabetes (51% versus 33%; P < 0.0001), and had a lower incidence of cerebral vascular disease (18% versus 24%; P = 0.009) than non-obese patients. The two groups of patients had similar 30-d rates of mortality (1.3% versus 1.5%; P = 0.8) and major adverse cardiac events (2.3% versus 2.5%; P = 0.9). Adjusted Cox regression survival curves were also similar between the two groups of patients (adjusted hazard ratio, 1.2; 95% confidence interval, 0.8-1.8; P = 0.28). CONCLUSIONS: Obese patients who underwent CABG had 30-d mortality rates and early outcomes similar to those of non-obese patients. Long-term survival was also similar between these two groups of patients after adjustment for confounding variables.

Impact of ACGME work-hour restrictions on the outcomes of coronary artery bypass grafting in a cohort of 600,000 patients.

BACKGROUND: Since the resident physician 80-h/wk restriction was implemented on July 1, 2003, little has been learned about the impact of this reform on patient outcomes after coronary artery bypass grafting (CABG). METHODS: Using the Nationwide Inpatient Sample database, we identified 614,177 patients who underwent isolated CABG from 1998 through 2007. Of the 374,947 patients who underwent CABG at a teaching hospital, 133,285 (36%) belonged to the post-reform group. Hierarchic logistic and multivariable regression models were used to assess the independent effect of the reform after adjusting for potential confounding factors. Outcomes assessed were operative morbidity and mortality, and length of stay. Outcomes of CABG patients at non-teaching hospitals were used to control for time bias. RESULTS: In teaching hospitals, after risk adjustment, the post-reform era was associated with lower mortality risk (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.56-0.63; P < 0.001) but greater operative morbidity (OR, 1.5; 95% CI, 1.43-1.58; P < 0.001). Although the implementation of work-hour reforms was correlated with shorter lengths of stay, there were fewer routine home discharges (OR, 0.73; 95% CI, 0.73-0.76; P < 0.001). Outcomes at non-teaching hospitals were similar, except that operative morbidity rates were lower during the post-reform era. CONCLUSIONS: The implementation of the resident work-hour reform in teaching hospitals did not affect mortality rates in CABG patients but was associated with increased morbidity. Further studies are needed to identify the reasons for the post-reform increase in postoperative complications at teaching hospitals.

Aortic valve replacement: mortality predictions of surgeons versus risk model.

BACKGROUND: We compared the abilities of surgeons and of an established risk model to predict operative mortality after aortic valve replacement (AVR), and we investigated scenarios that give rise to discrepancies between these predictions. MATERIALS AND METHODS: We reviewed all AVR procedures performed at a Veterans Affairs institution between 1993 and 2008 (n = 317). The abilities of the Continuous Improvement in Cardiac Surgery Program (CICSP) risk model and of the surgeons to predict operative mortality were assessed by computing the area under the receiver operating characteristic curve (AUC). We investigated cases in which there was a significant discrepancy (2-fold or greater) between the surgeons' and the CICSP model's predictions. RESULTS: The predictive abilities of both the surgeons and the CICSP risk model were good-AUC values were 0.73 and 0.75, respectively (P = 0.84)-but the surgeons' mean estimate of mortality risk (8.3% +/- 8.3%) exceeded both the CICSP model's estimate (6.6% +/- 8.3%) (P < 0.0001) and the actual mortality rate (5.4%). There was significant discrepancy between the two sources of prediction in 38% (122/317) of cases. In this subset of cases, the CICSP did not adjust for factors that influenced risk stratification by the surgeon in 33% (40/122) of cases; the most common of these factors were anticipation of a more extensive procedure, severe pulmonary disease other than chronic obstructive pulmonary disease, hepatic disease, and pulmonary hypertension. CONCLUSIONS: Both surgeons and the CICSP model performed well in risk-stratifying AVR patients, but the surgeons tended to overestimate the risk. The CICSP model did not capture some disease entities considered relevant in estimating mortality by surgeons.

The impact of resident work-hour restrictions on outcomes of cardiac operations.

BACKGROUND: The Accreditation Council of Graduate Medical Education mandated an 80-h/wk resident physician work-hour restriction on July 1, 2003. The objective of this study was to evaluate the impact of the resident work-hour restriction on outcomes of cardiac operations. MATERIALS AND METHOD: We reviewed records of 1562 patients who underwent cardiac operations at our institution between 1997 and 2007, and we compared outcomes of operations performed before July 1, 2003 (pre-reform, n=777) and those performed after July 1, 2003 (post-reform, n=785). Multivariate analysis with logistic regression was used to test for the independent effects of the resident work-hour reform by controlling for patient-specific confounding factors. RESULTS: Post-reform patients had a significantly lower 30-d mortality rate (1.8% versus 3.9%; P=0.01) and a slightly lower 6-month mortality rate (4.5% versus 6.3%; P=0.12) than pre-reform patients. Multivariate analysis revealed that the post-reform patients had significantly lower adjusted 30-d mortality (odds ratio, 0.37; 95% CI, 0.18-0.75; P=0.006) and 6-mo mortality (odds ratio, 0.56; 95% CI, 0.34-0.91; P=0.02) than the pre-reform patients. CONCLUSIONS: Cardiac operations performed after the resident work-hour restriction went into effect were associated with significantly lower adjusted 30-d and 6-mo mortality rates than were operations performed before the work-hour restriction became effective.

Outcomes of coronary surgery at a Veterans Affairs hospital versus other hospitals.

BACKGROUND: The aim of this study was to compare outcomes of coronary artery bypass grafting (CABG) operations at a VA hospital and non-VA hospitals. MATERIALS AND METHODS: Using the 2004 Nationwide Inpatient Sample database, we identified 48,669 discharge records of patients who underwent CABG in non-VA hospitals and compared these patients' outcomes with those of 688 patients who underwent CABG at our VA hospital from 2002 to 2006. Student t- tests and chi(2) tests were used to identify significant intergroup differences. RESULTS: The VA patients were slightly younger than the non-VA patients (62 +/- 8 versus 66 +/- 11 y, P < 0.0001). The VA patients also had a higher prevalence of prior myocardial infarction (60.6% versus 34.6%), congestive heart failure (38.2% versus 22.1%), peripheral vascular disease (25.9% versus 7.2%), cerebral vascular disease (23.4% versus 5.9%), chronic obstructive pulmonary disease (32.3% versus 16.6%), and diabetes (41.7% versus 29.7%) (P < 0.0001 for all). Nonetheless, the in-hospital mortality rate was significantly lower in VA patients than in non-VA patients (1.6% versus 3.0%, P = 0.03). CONCLUSIONS: Despite the higher prevalence of comorbidities, patients who underwent CABG at a VA hospital had a significantly lower mortality rate than CABG patients in non-VA hospitals.

Cardiac surgery in patients with major lower extremity amputation: a single institution experience.

BACKGROUND: Cardiac surgery patients with lower-extremity amputations pose a challenge in terms of medical comorbidities and functional recovery. METHODS: A retrospective review of all patients (n=10) with preexisting below-knee amputation (BKA) or more proximal amputation level who underwent cardiac surgery between April 1998 and April 2008. Data were analyzed to evaluate outcomes. RESULTS: The median age was 59 y (range, 51-75 y). One patient had bilateral above-knee amputation (AKA), and 9 had BKAs (two bilateral). Comorbidities included diabetes (n=5), peripheral vascular disease (n=7), cerebrovascular disease (n=2), hypertension (n=9), chronic renal insufficiency (n=2), pulmonary hypertension (n=1), and pulmonary fibrosis (n=1). Nine patients underwent coronary artery bypass grafting and one patient underwent aortic valve replacement. There were no operative deaths. The median length of hospital stay (to home discharge) was 12.5 d (range, 5-562 d). Eight patients were transferred to a rehabilitation unit or a chronic care facility before being discharged to home. At follow-up (median, 1.5 y; range, 0.4-3.8 y), all but one patient were alive and had returned to their preoperative ambulatory status. CONCLUSIONS: In our experience, patients with lower-extremity amputations require prolonged hospitalization after cardiac surgery but can expect good mid-term outcomes and functional recovery.

Outcomes of aortic valve replacement performed by residents in octogenarians.

BACKGROUND: Aortic valve replacement (AVR) traditionally carries a significant risk in elderly patients. We evaluated the outcomes of AVR in octogenarian patients in the context of surgical education. METHODS: A retrospective review of all AVR operations (n=23) performed by residents at a single academic institution between May 1992 and May 2007 on patients who were >/=80 y old. RESULTS: All patients were men (mean age, 83+/-2.5 y). The predominant valve disease was aortic stenosis. Comorbidities included coronary artery disease (n=15), New York Heart Association class III/IV congestive heart failure (n=15), hypertension (n=17), diabetes (n=5), chronic obstructive pulmonary disease (n=5), peripheral vascular disease (n=6), and cerebrovascular disease (n=3). Major postoperative morbidity included cerebrovascular accident (n=1), mediastinitis (n=1), reoperation for bleeding (n=1), and respiratory failure (n=3; 2 required a tracheostomy). There were no operative deaths. The mean length of total hospital stay (to home discharge) after AVR was 36+/-45 d, of which 19+/-14 d were spent in an acute surgical care unit. Follow-up was complete; the 1-, 3-, and 5-y survival rates were 96%, 86%, and 55%, respectively. CONCLUSIONS: Supervised residents can safely perform AVR on octogenarian patients and achieve good outcomes.

Descending thoracic aortic dissection: evaluation and management in the era of endovascular technology.

Acute aortic dissection is a relatively uncommon but highly lethal condition. Without proper treatment, devastating consequences can occur due to aortic rupture, cardiac tamponade, or irreversible ischemia involving the spinal cord or the visceral organs. The treatment strategy of this condition is in part influenced by the location and the severity of aortic dissection as immediate surgical intervention is necessary in acute ascending aortic dissection, whereas medical therapy is the initial treatment approach in uncomplicated descending aortic dissection. Recent advances of endovascular technology have broadened the potential application of this catheter-based therapy in aortic pathologies, including descending thoracic aortic dissection. In this article, the etiology, pathogenesis, and classification of this condition are discussed. The diagnostic benefits of various imaging modalities for descending aortic dissection are also discussed. Current treatment strategies, including medical, surgical, and catheter-based interventions, are reviewed. Lastly, clinical experiences of endovascular treatment for descending aortic dissection and various endovascular devices potentially applicable for this condition are discussed.

Hurricane Katrina: impact on cardiac surgery case volume and outcomes.

Hurricane Katrina produced a surge of patient referrals to our facility for cardiac surgery. We sought to determine the impact of this abrupt volume change on operative outcomes. Using our cardiac surgery database, which is part of the Department of Veterans Affairs' Continuous Improvement in Cardiac Surgery Program, we compared procedural outcomes for all cardiac operations that were performed in the year before the hurricane (Year A, 29 August 2004-28 August 2005) and the year after (Year B, 30 August 2005-29 August 2006). Mortality was examined as unadjusted rates and as risk-adjusted observed-to-expected ratios. We identified 433 cardiac surgery cases: 143 (33%) from Year A and 290 (67%) from Year B. The operative mortality rate was 2.8% during Year A (observed-to-expected ratio, 0.4) and 2.8% during Year B (observed-to-expected ratio, 0.6) (P = 0.9). We identified several factors that enabled our institution to accommodate the increase in surgical volume during the study period. We conclude that, although Hurricane Katrina caused a sudden, dramatic increase in the number of cardiac operations that were performed at our facility, good surgical outcomes were maintained.

An immune basis for lung parenchymal destruction in chronic obstructive pulmonary disease and emphysema.

BACKGROUND: Chronic obstructive pulmonary disease and emphysema are a frequent result of long-term smoking, but the exact mechanisms, specifically which types of cells are associated with the lung destruction, are unclear. METHODS AND FINDINGS: We studied different subsets of lymphocytes taken from portions of human lungs removed surgically to find out which lymphocytes were the most frequent, which cell-surface markers these lymphocytes expressed, and whether the lymphocytes secreted any specific factors that could be associated with disease. We found that loss of lung function in patients with chronic obstructive pulmonary disease and emphysema was associated with a high percentage of CD4+ and CD8+ T lymphocytes that expressed chemokine receptors CCR5 and CXCR3 (both markers of T helper 1 cells), but not CCR3 or CCR4 (markers of T helper 2 cells). Lung lymphocytes in patients with chronic obstructive pulmonary disease and emphysema secrete more interferon gamma--often associated with T helper 1 cells--and interferon-inducible protein 10 and monokine induced by interferon, both of which bind to CXCR3 and are involved in attracting T helper 1 cells. In response to interferon-inducible protein 10 and monokine induced by interferon, but not interferon gamma, lung macrophages secreted macrophage metalloelastase (matrix metalloproteinase-12), a potent elastin-degrading enzyme that causes tissue destruction and which has been linked to emphysema. CONCLUSIONS: These data suggest that Th1 lymphoctytes in the lungs of people with smoking-related damage drive progression of emphysema through CXCR3 ligands, interferon-inducible protein 10, and monokine induced by interferon.

Surgical management of traumatic pulmonary injury.

BACKGROUND: Surgical treatment of traumatic pulmonary injuries requires knowledge of multiple approaches and operative interventions. We present a 15year experience in treatment of traumatic pulmonary injuries. We hypothesize that increased extent of lung resection correlates with higher mortality. METHODS: Surgical registry data of a level 1 trauma center was retrospectively reviewed from 1984 to 1999 for traumatic lung injuries requiring operative intervention. Epidemiologic, operative, and hospital mortality data were obtained. RESULTS: Operative intervention for traumatic pulmonary injuries was required in 397 patients, of whom 352 (89%) were men. Penetrating trauma was seen in 371 (93%) patients. Location of the injuries was noted in the left side of the chest in 197 (50%), right side of the chest in 171 (43%), and bilateral in 29 (7%). Operative interventions included pneumonorraphy (58%), wedge resection or lobectomy in (21%), tractotomy (11%), pneumonectomy (8%), and evacuation of hematoma (2%). Overall mortality was 27%. If concomitant laparotomy was required, mortality increased to 33%. The mortality rate in the pneumonectomy group was 69.7%. CONCLUSIONS: The majority of lung injuries occurred in males due to penetrating trauma. Surgical treatment options ranged from simple oversewing of bleeding injury to rapid pneumonectomy. Mortality increased as the complexity of the operative intervention increased. Rapid intraoperative assessment and appropriate control of the injury is critical to the successful management of traumatic lung injury.

Outcomes of concomitant aortic valve replacement and coronary artery bypass grafting at teaching hospitals versus nonteaching hospitals.

OBJECTIVE: Hospitals with a high volume and academic status produce better patient outcomes than other hospitals after complex surgical procedures. Risk models show that concomitant aortic valve replacement and coronary artery bypass grafting pose a greater risk than isolated coronary artery bypass grafting or aortic valve replacement. We examined the relationship of hospital teaching status and the presence of a thoracic surgery residency program with aortic valve replacement/coronary artery bypass grafting outcomes. METHODS: By using the Nationwide Inpatient Sample database, we identified patients who underwent concomitant aortic valve replacement/coronary artery bypass grafting from 1998 to 2007 at nonteaching hospitals, teaching hospitals without a thoracic surgery residency program, and teaching hospitals with a thoracic surgery residency program. Multivariate analysis was performed to identify intergroup differences. Risk-adjusted multivariable logistic regression analysis was used to assess independent predictors of in-hospital mortality and complication rates. RESULTS: The 3 groups of patients did not differ significantly in their baseline characteristics. Patients who underwent aortic valve replacement/coronary artery bypass grafting had higher overall risk-adjusted complication rates in nonteaching hospitals (odds ratio 1.58; 95% confidence interval, 1.39-1.80; P < .0001) and teaching hospitals without a thoracic surgery residency program (odds ratio 1.42; 95% confidence interval, 1.26-1.60; P < .0001) than in thoracic surgery residency program hospitals. However, no difference was observed in the adjusted mortality rate for nonteaching hospitals (odds ratio 0.95; 95% confidence interval, 0.87-1.04; P = .25) or teaching hospitals without a thoracic surgery residency program (odds ratio 1.00; 95% confidence interval, 0.92-1.08; P = .98) when compared with thoracic surgery residency program hospitals. Robust statistical models were used for analysis, with c-statistics of 0.98 (complications) and 0.82 (mortality). CONCLUSION: Patients who require complex cardiac operations may have better outcomes when treated at teaching hospitals with a thoracic surgery residency program.

Thoracic or thoracoabdominal approaches to endovascular device removal and open aortic repair.

BACKGROUND: Endovascular aortic repair is becoming increasingly common and diverse in its application despite ongoing uncertainty about long-term durability. Recent reports detail late conversion to open surgical repair to treat disease progression and repair failure. We describe our experience with using thoracic or thoracoabdominal approaches to endovascular device removal and open aortic repair after previous endovascular procedures. METHODS: Thirty-five patients underwent open aortic repair through thoracotomy (n=7) or thoracoabdominal incision (n=28) 0.5 to 48 months after undergoing endovascular thoracic (n=27) or abdominal (n=8) aortic procedures. Indications for open repair included expanding aneurysm (n=23), device infection (n=8), fistula (n=5), pseudoaneurysm (n=2), aneurysm rupture (n=2), and restenosis (n=1). Endovascular devices were completely removed in 26 patients and partially removed in 9. Descending thoracic aortic repair was performed in 10 patients, thoracoabdominal aortic repair in 24, and juxtarenal abdominal aortic repair in 1. RESULTS: There were 2 in-hospital deaths (6%), both in patients who presented with endovascular device infection. There were 8 late deaths. Overall 1-year survival was 83%±7%. Among the patients who presented with infected devices, 3 experienced major late complications, including persistent infection, pseudoaneurysm, and recurrent fistula; 2 of these patients succumbed to late deaths. CONCLUSIONS: Open surgical repair after previous endovascular aortic procedures is successful in the majority of patients, particularly in those without device infections. Achieving definitive aortic repair in patients with infected endovascular devices is particularly challenging.

Hypoalbuminemia and long-term survival after coronary artery bypass: a propensity score analysis.

BACKGROUND: Hypoalbuminemia is associated with increased morbidity in surgical patients. The impact of low albumin level on survival in cardiac surgical patients is unknown. We hypothesized that a low preoperative albumin level negatively affects long-term survival after coronary artery bypass graft (CABG) surgery. METHODS: We reviewed prospectively gathered data from the records of 1,164 consecutive patients who underwent primary isolated CABG at our institution between 1997 and 2007. Propensity score analysis of 18 preoperative and intraoperative variables balanced potential confounding factors between the two groups of patients, so that the final study cohort consisted of 588 patients: 294 with a preoperative albumin level less than 3.5 g/dL (ie, hypoalbuminemia) and 294 patients with a preoperative albumin level of 3.5 g/dL or greater. We assessed long-term survival by using Kaplan-Meier curves generated by log rank tests. RESULTS: The two groups of patients were well matched in terms of preoperative and intraoperative covariates. Both groups had similar early outcomes, including 30-day mortality rates (2.0% versus 1.7%; p = 0. 76) and the incidence of major adverse cardiac events (2.7% versus 2.7%; p = 1.0). However, patients with hypoalbuminemia had a significantly worse 8-year survival rate (65% ± 7% versus 86% ± 3%; hazard ratio 2.2; 95% confidence interval: 1.4 to 3.6; p = 0.001) than patients without hypoalbuminemia. CONCLUSIONS: Although preoperative hypoalbuminemia did not predict increased early postoperative mortality or morbidity in CABG patients, it did independently predict poor long-term survival after CABG. Identifying the mechanism that underlies this relationship is essential in improving overall survival among patients with low serum albumin levels who are undergoing surgical myocardial revascularization.