Distal Repair After Total Aortic Arch Replacement With Frozen Elephant Trunk in Patients With Chronic Multilevel Thoracic Aortic Disease.

OBJECTIVE: To examine the management of distal aortic disease after total arch replacement with the frozen elephant trunk (TAR + FET) in patients with chronic thoracic aortic disease. METHODS: Two centre retrospective study of consecutive patients treated between January 2010 and December 2019. The primary endpoint was 30 day or in hospital death. The secondary endpoint was midterm survival. Data are presented as median (interquartile range [IQR]). The χ2 or Fisher's exact test was used as appropriate. Estimated survival (standard error) was assessed by calculating the Kaplan-Meier product limit estimator with right censoring of survival data. A p value of < .050 was considered statistically significant. STROBE guidelines were followed. RESULTS: A total of 158 patients (72 men; median age 70 years, IQR 64, 75; median distal aortic diameter 58 mm, IQR 46, 68; 127 aneurysmal disease, 31 chronic dissection) underwent TAR + FET. The peri-operative mortality rate was 10.1% (9/107 elective, 7/51 non-elective). Of 74 (46.8%) patients with a primary distal seal, seven (9.5%) died peri-operatively, the distal seal was maintained during follow up in 51, nine underwent late distal repair (two planned, seven unplanned; one open, eight endovascular; one peri-operative death) with a median interval to unplanned repair of 777 days (IQR 462, 1480), and seven with loss of seal had no intervention. Distal seal failed in 2/28 (7%) patients with a distal seal length > 30 mm and device oversizing > 10%, compared with 12/39 (31%) patients who did not meet these criteria (p = .031). In 84 patients without a primary distal seal, nine (10.7%) died peri-operatively, the distal aorta remained below the size threshold for repair during follow up in 12 patients, 44 had distal repair (median aortic diameter 64 mm, IQR 60, 75; eight open, one hybrid, 35 endovascular repairs; no deaths) at a median of 256 days (IQR 135, 740), and 19 did not have distal repair at the end of the follow up period: six died before planned repair at a median interval of 115 days (IQR 85, 120); eight were considered unfit; one was assessed as fit but declined; and four patients were awaiting assessment. Median follow up was 46 months (IQR 26, 75): no patients were lost to follow up. Estimated ± standard error five year survival was 61.5 ± 4.1%: elective 70.6 ± 4.7%, non-elective 43.2 ± 7.2%. CONCLUSION: TAR + FET achieved primary distal seal in 47% of patients, but late failure occurred in 21%. Distal repair was ultimately indicated in 84% of survivors without a primary distal seal and of these 70% underwent repair, almost 10% died before planned repair, and 13% were considered unfit. Earlier distal endovascular repair and better assessment of patient fitness may improve midterm outcomes.

Perioperative Glycemic Surveillance and Control-Current Practices, Efficacy and Impact on Postoperative Outcomes following Infrainguinal Vascular Intervention.

BACKGROUND: Perioperative glycemic control plays a pivotal role in improving postsurgical outcomes. Hyperglycemia occurs frequently in surgical patients and has been associated with higher rates of mortality and postoperative complications. However, no current guidelines exist regarding intraoperative glycemic monitoring of patients undergoing peripheral vascular procedures and postoperative surveillance is often restricted to diabetic patients. We sought to characterize the current practices around glycemic monitoring and efficacy of perioperative glycemic control at our institution. We also examined the impact of hyperglycemia in our surgical population. METHODS: This was a retrospective cohort study performed at the McGill University Health Centre and Jewish General Hospital in Montreal, Canada. Patients undergoing elective open lower extremity revascularization or major amputation between 2019 and 2022 were included. Data collected from the electronic medical record included standard demographics, clinical, and surgical characteristics. Glycemic measurements and perioperative insulin use were recorded. Outcomes included 30-day mortality and postoperative complications. RESULTS: A total of 303 patients were included in the study. Overall, 38.9% of patients experienced perioperative hyperglycemia defined as glucose ≥180 mg/dL (10 mmol/L) during their hospital admission. Only 12 (3.9%) patients within the cohort underwent any intraoperative glycemic surveillance, while 141 patients (46.5%) had an insulin sliding scale prescribed postoperatively. Despite these efforts, 51 (16.8%) patients remained hyperglycemic for at least 40% of their measurements during their hospitalization. Hyperglycemia in our cohort was significantly associated with an increased risk of 30-day acute kidney injury (11.9% vs. 5.4%, P = 0.042), major adverse cardiac events (16.1% vs. 8.6%, P = 0.048), major adverse limb events (13.6% vs. 6.5%, P = 0.038), any infection (30.5% vs. 20.5%, P = 0.049), intensive care unit admission (11% vs. 3.2%, P = 0.006) and reintervention (22.9% vs. 12.4%, P = 0.017) on univariate analysis. Furthermore, multivariable logistic regression including the covariates of age, sex, hypertension, smoking status, diabetic status, presence of chronic kidney disease, dialysis, Rutherford stage, coronary artery disease and perioperative hyperglycemia demonstrated a significant relationship between perioperative hyperglycemia and 30-day mortality (odds ratio [OR]: 25.00, 95% confidence interval [CI]: 2.469-250.00, P = 0.006), major adverse cardiac events (OR: 2.08, 95% CI: 1.008-4.292, P = 0.048), major adverse limb events (OR: 2.24, 95% CI: 1.020-4.950, P = 0.045), acute kidney injury (OR: 7.58, 95% CI: 3.021-19.231, P < 0.001), reintervention (OR: 2.06, 95% CI: 1.117-3.802, P = 0.021), and intensive care unit admission (OR: 3.38, 95% CI: 1.225-9.345, P = 0.019). CONCLUSIONS: Perioperative hyperglycemia was associated with 30-day mortality and complications in our study. Despite this, intraoperative glycemic surveillance occurred rarely in our cohort and current postoperative glycemic control protocols and management failed to achieve optimal control in a significant percentage of patients. Standardized glycemic monitoring and stricter control in the intraoperative and postoperative period therefore represent an area of opportunity for reducing patient mortality and complications following lower extremity vascular surgery.

Association Between Obesity and Outcomes Following Endovascular Aneurysm Repair.

BACKGROUND: Obesity is prevalent in patients with abdominal aortic aneurysms (AAA). There is an association between increasing body mass index (BMI) and increased overall cardiovascular mortality and morbidity. This study aims to assess the difference in mortality and complication rates between normal weight (NW), overweight (OW), and obese patients undergoing endovascular aneurysm repair (EVAR) for infrarenal AAA. METHODS: This is a retrospective analysis of consecutive patients undergoing EVAR for AAA between January 1998 and December 2019. Weight classes were defined as: BMI<18.5 kg/m2, underweight; BMI 18.5-24.9 kg/m2, NW; BMI 25.0-29.9 kg/m2, OW; BMI 30.0-39.9 kg/m2, obese; BMI>39.9 kg/m2 morbidly obese. Primary outcomes were long-term all-cause mortality and freedom from reintervention. Secondary outcome was aneurysm sac regression (defined as a reduction in sac diameter of 5 mm or more). Kaplan-Meier survival estimates and mixed model analysis of variance were used. RESULTS: The study included 515 patients (83% males, mean age 77 ± 8 years) with a mean follow-up of 3.8 ± 2.8 years. In terms of weight class, 2.1% (n = 11) were underweight, 32.4% (167) were NW, 41.6% (n = 214) were OW, 21.2% (n = 109) were obese, and 2.7% (n = 14) were morbidly obese. Obese patients were younger (mean difference -5.0 years) but had a higher prevalence of diabetes mellitus (33.3% vs. 10.6% for NW) and dyslipidemia (82.4% vs. 60.9% for NW). Obese patients had similar freedom from all-cause mortality (88%) compared to OW (78%) and NW (81%) patients. The same findings were evident for freedom from reintervention where obese (79%) was similar to OW (76%) and NW (79%). At a mean follow-up of 5.1 ± 0.4 years, sac regression was observed similarly across weight classes at 49.6%, 50.6%, and 51.8% for NW, OW, and obese, respectively (P = 0.501). There was a significant difference in mean AAA diameter pre- and post-EVAR [F(2,318) = 24.37, P < 0.001] across weight classes. NW [mean reduction 4.8 mm (2.0-7.6 mm, P < 0.001)], OW [mean reduction 3.9 mm (1.5-6.3 mm, P < 0.001)], and obese [mean reduction 5.7 mm (2.3-9.1 mm, P < 0.001)] achieved similar reductions. CONCLUSIONS: Obesity was not associated with increased mortality or reintervention in patients undergoing EVAR. Obese patients achieved similar rates of sac regression on imaging follow-up.

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.

Outcomes of endovascular treatment of patients with intermittent claudication due to femoropopliteal disease.

OBJECTIVE: Our objective was to evaluate the outcomes of endovascular treatment in patients with moderate and severe claudication due to femoropopliteal disease, that is, disease of the superficial femoral and popliteal arteries. METHODS: A retrospective review of all patients with moderate and severe claudication (Rutherford 2 and 3) undergoing endovascular treatment for FP disease between January 2012 and December 2017 at two university-affiliated hospitals was performed. All procedures were performed by vascular surgeons. Primary outcomes were mortality, freedom from reintervention, major adverse limb events defined as major amputations, open surgical revascularization, or progression to chronic limb-threatening ischemia (CLTI) at 30 days, 1 year, 2 years, and last follow-up. Unadjusted odds ratios were calculated to identify variables associated with adverse outcomes, and Kaplan-Meier survival curves were used to determine mortality and freedom from reintervention. RESULTS: Eighty-five limbs in 74 patients were identified on review. Mean age was 69.6 ± 9.8 years and 74.3% were males. At a median follow-up of 49.0 ± 25.5 months, all-cause mortality rate was 8.1% (6 patients) with 16.7% being due to cardiovascular causes. Reintervention rates were 1.2%, 16.5%, and 21.2% at 30 days, 1 year, and 2 years, respectively. Major adverse limb events occurred in 3 patients and rates were 0%, 1.2%, and 2.4% at 30 days, 1 year, and 2 years, respectively. Progression to CLTI was 0%, 1.2%, and 1.2% at 30 days, 1 year, and 2 years, respectively. Claudication had improved or resolved in 55.6% (n = 34 patients), stable in 38.9% (n = 21 patients), and worse in 5.6% (n = 3 patients) Age ≥ 70 years (OR = 4.09 (1.14-14.66), p = 0.027), TASCII A lesion (OR = 4.67 (1.14-19.17), p = 0.025), and presence of 3-vessel runoff (OR = 3.70 (1.18-11.59), p = 0.022) predicted symptoms' improvement. TASCII A lesions were less likely to require reintervention (OR = 0.23 (0.06-0.86), p = 0.020). Reintervention within 1 year (OR = 11.67 (0.98-138.94), p = 0.017), reintervention with a stent (OR = 14.40 (1.19-173.67), p = 0.008) and more than one reintervention (OR = 39.00 (2.89-526.28), p < 0.001) predicted major adverse limb events. CONCLUSIONS: Careful patient selection is important when planning endovascular treatment in patients with intermittent claudication and FP disease. This could result in symptomatic improvement in more than half of the patients. Adverse outcomes such as major adverse limb events, progression to CLTI, and amputations occur at low rates.

Carotid Endarterectomy Outcomes in the Elderly: A Canadian Institutional Experience.

BACKGROUND: Carotid endarterectomy (CEA) is a well-established surgical intervention for stroke prevention in patients with carotid stenosis of all ages. However, the decision to proceed to operate in the elderly involves a more complicated risk-benefit assessment due in part to increased comorbidities and reduced life expectancy. Some studies suggest that CEA is more risky in the elderly with worse outcomes, whereas others have found no difference. Our objective was to evaluate and compare outcomes of CEA between elderly and younger patients at our institution. METHODS: All hospital charts were reviewed for consecutive patients undergoing CEA from the Jewish General Hospital and the Royal Victoria Hospital from October 2009 to December 2015. Primary outcomes were ipsilateral stroke, death, and restenosis at 30 days and 1 year. Secondary outcomes were cranial nerve injury, myocardial infarction (MI), hematoma, wound infection, cerebral hyperperfusion, and transient ischemic attacks within 30 days. Primary and secondary outcomes were compared between patients aged ≥80 years and <80 years. RESULTS: A total of 361 patients were included in this study with a mean age of 70.2 ± 9.5 years (n = 247 [68.4%] male and n = 272 [75.8%] symptomatic). Elderly patients were more often symptomatic (93.8% vs. 71.6%, P < 0.0001) and had an increased length of stay (2.8 ± 5.3 vs. 1.6 ± 1.8, P = 0.001). There was no statistically significant difference in primary outcomes between patients aged <80 years and ≥80 years, including 30-day stroke (1.7% vs. 0%), death (no deaths in either group), restenosis (8.8% vs. 12.3%), 1-year stroke (1.7% vs. 0%), death (0.7% vs. 0%), or restenosis (14.9% vs. 13.8%). However, elderly patients had significantly increased MI risk postoperatively (4.6% vs. 0.7%, P = 0.01). Other complications, including cranial nerve injury (3.7% in <80 years vs. 4.6% in the elderly group), were similar between the groups. CONCLUSIONS: We found that CEA in the elderly does not have an increased risk of stroke or death up to one year postoperatively. However, the postoperative length of stay is increased and complicated by significantly more MIs, which should weigh into the decision of whether to perform CEA on an elderly patient.