Mortality and Major Adverse Events Improve With Increased Institutional Experience for Fenestrated and Branched Endovascular Aortic Repair.

OBJECTIVE: Our objective was to evaluate temporal trends in outcomes at our institution in the context a more heterogenous application of fenestrated/branched endovascular aneurysm repair (F/BEVAR). METHODS: Patient and aneurysm characteristics, procedure details, and postoperative outcomes were collected for consecutive patients undergoing F/BEVAR between 2002 and February 2019 at our institution. Outcomes were compared between tertile 1 (T1, 2002-2010, n=47), T2 (2011-2014, n=47), and T3 (2015-February 2019, n=47). RESULTS: We included 141 patients (74.8 ± 8.1 years, 83% male) with a mean follow-up of 28.0 ± 31.6 months. Proportion of patients with hypertension (63.8% T1, 85.1% T3, p=0.009), diabetes (6.4% T1, 29.7% T3, p=0.005), chronic obstructive pulmonary disease (COPD; 27.6% T1, 42.5% T3, p=0.07), and history of stroke (4.2% T1, 17% T3, p=0.07) increased over time. Aneurysm diameter (65.3±11.4mm) and extent (56.0% juxtarenal/pararenal, 22.0% type IV, 22.0% type I-III) did not differ between groups. Custom made devices were implanted in 96.5% of cases with 3.4 ± 0.7 vessels reimplanted/case. There was a trend toward increased history of aortic surgery (p=0.008) and less custom made devices (p=0.007) in T3.Total procedure time (383.5±119.2 minutes T1, 316.2±88.4 T3, p=0.02), contrast volume (222.8±109.1 mL T1, 139.2±62.7ml T3, p<0.0001), and estimated blood loss (601.3±458.1 mL T1, 413.3±317.7 mL T3, p=0.02) decreased over time. Overall 30-day mortality was 6.3%, 10.6%-T1, 6.3%-T2, and 2.1%-T3 (p=0.09). We noted significant improvement in survival over time; 1- and 3-year survival was 79% and 56%, 89% and 83%, and 90% and 90%, for T1, T2, and T3, respectively (p=0.007). In all, 467 of 480 target vessels were revascularized (97.3% success). Reintervention rate (30-day: 13.5%, follow-up: 34.7%) and reintervention free survival was not significantly different between groups. Any major adverse event (MAE) occurred in 36.9% of patients overall with a significant decrease from early (51.1%), mid (34.9%), to late in our experience (25.5%, p=0.03). In multivariate analyses, increasing institutional experience (T3), procedure time, age, and sex were independent predictors of major adverse events. CONCLUSION: We have shown improvement in F/BEVAR outcomes including mortality, MAEs, and procedural metrics with increasing institutional experience. We postulate that a combination of advancements in technique, surgical team and postoperative care experience, graft design and stent technologies, and patient selection contributed to improvement in outcomes.

Low Psoas Muscle Area is Associated with Increased Mortality and Spinal Cord Injury After Complex Endovascular Aortic Aneurysm Repair.

BACKGROUND: Low psoas muscle area (PMA) is associated with worse post-operative outcomes. Our objective was to evaluate the association of PMA and postoperative outcomes in patients undergoing fenestrated/branched endovascular aneurysm repair (F/BEVAR). METHODS: Patient characteristics, anatomical and clinical information, and post-operative outcomes were collected from patients undergoing F/BEVAR between 2005-February 2019 who were deemed too high-risk for open repair. PMA was measured using a validated web-based software (coreslicer.com). Post-operative outcomes were compared between patients with low PMA (lowest quartiles) and high PMA (highest quartiles). RESULTS: We included 129 patients with a mean age of 74.6 ± 8.1, 81.4% male, and a mean follow-up of 29.4 ± 32.2 months. Patients in the low PMA group were more likely to be female (33.8% vs. 3.1%, P < 0.0001), less likely to have hypertension (72.3% vs. 87.5%, P = 0.03), dyslipidemia (63.1% vs. 78.1%, P = 0.06), and a trend towards a greater history of endovascular aneurysm repair (4.6% vs. 0%, P = 0.08). There were no significant differences in aneurysm or device characteristics between groups. In a multivariate model including age, sex, aneurysm type, and presence of prophylactic spinal drain, the low PMA group had a significantly increased risk of spinal cord injury (odds ratio 12.7, 95% CI 1.1-143.6). There were no significant differences in other 30-day outcomes. When compared to the highest quartile, the lowest PMA quartile patients had a hazard ratio of 4.6 (95% CI 1.2-17.6) for mortality during follow-up in a model with age, sex, and aneurysm type. For each 1 cm2 increase in PMA, the HR was 0.90 (95% CI 0.82-0.99) for mortality during follow-up. CONCLUSIONS: In high-risk patients undergoing F/BEVAR low PMA is associated with spinal cord injury and mortality during follow-up. We found no association between PMA and 30-day mortality. PMA measurement is a simple method to assess for sarcopenia and frailty and may be useful for risk stratification pre-operatively.

Impact of diabetes on carotid artery revascularization.

OBJECTIVE: Diabetes has been suggested as a marker of higher operative risk during carotid artery revascularization. The aim of this study was to summarize the current evidence comparing the effectiveness of carotid revascularization in diabetic vs nondiabetic patients. METHODS: We conducted a systematic search of MEDLINE, Embase, and the Cochrane Library databases (1946 to January 2015) for all studies comparing the clinical outcomes of diabetic vs nondiabetic patients who underwent carotid endarterectomy (CEA) or carotid artery stenting (CAS) in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two authors independently reviewed the studies for inclusion and quality and extracted the data. A third author validated study selection and data extraction. We calculated treatment effects as odds ratios (ORs) and 95% confidence intervals (CIs). We quantified heterogeneity using the I(2) statistic. All pooled analyses were based on random-effects models. The predefined review protocol was registered at the International Prospective Register of Systematic Reviews (PROSPERO 2015:CRD42015015873). RESULTS: Of the 1241 abstracts screened, we included 14 observational studies involving 16,264 patients. There was excellent agreement in study selection between the two reviewers (κ statistic, 0.83; 95% CI, 0.72-0.94). CEA was used in 10 studies, CAS was used in 3 studies, and both CEA and CAS were used in 1 study. All included studies were published after 1984, and 93% were published after 1997. Carotid revascularization in diabetic patients was associated with a higher risk of the following outcomes: perioperative stroke (OR, 1.38; 95% CI, 1.02-1.88; P = .04; I(2) =13%), death (OR, 1.94; 95% CI, 1.36-2.75; P = .0002; I(2) = 0%), composite risk of stroke or death (OR, 1.80; 95% CI, 1.32-2.47; P = .0002; I(2) = 26%), and long-term risk of death (OR, 1.57; 95% CI, 1.22-2.03; P = .0005; I(2) = 0%). No association was found between diabetes and perioperative risk of myocardial infarction (MI); composite risk of MI, stroke, or death; and long-term risk of stroke. Study quality was limited by selection bias, minimal control for confounders, and single-center retrospective design. Sensitivity analyses excluding low-quality studies did not change the effect of diabetes on the risk of stroke, death, or MI. CONCLUSIONS: Diabetic patients are at an increased risk of perioperative stroke, death, and long-term mortality compared with nondiabetic patients who undergo carotid artery revascularization. This knowledge can help further risk stratify patients with carotid artery stenosis before treatment. Future studies should focus on evaluating which mode of revascularization (CEA or CAS) is more effective in diabetic patients with carotid artery stenosis.