Long-term outcomes of great saphenous vein harvest techniques for infrainguinal arterial bypass in a Medicare-matched registry database.

OBJECTIVE: Long-term outcomes for harvesting techniques for great saphenous vein (GSV) and its impact on the outcomes of infrainguinal arterial bypass remains largely unknown. Endoscopic GSV harvesting (EVH) has emerged as a less invasive alternative to conventional open techniques. Using the Vascular Quality initiative Vascular Implant Surveillance & Interventional Outcomes Network (VQI-VISION) database, we compared the long-term outcomes of infrainguinal arterial bypass using open and endoscopic GSV harvest techniques. METHODS: Patients who underwent infrainguinal GSV bypass between 2010 and 2019 were identified in the VQI-VISION Medicare linked database. Long-term outcomes of major/minor amputations, and reinterventions up to 5 years of follow-up were compared between continuous incisions, skip incision, and EVH, with continuous incisions being the reference group. Secondary outcomes included 30- and 90-day readmission, in addition to surgical site infections and patency rates at 6 months to 2 years postoperatively. Survival analysis using Kaplan-Meier curves and Cox regression hazard models were utilized to compare outcomes between groups. To adjust for multiple comparisons between the study groups, a P value of 2.5% was considered significant. RESULTS: Among the 8915 patients included in the study, continuous and skip vein harvest techniques were used in 44.4% and 43.4% of cases each, whereas 12.3% underwent EVH. The utilization of EVH remained relatively stable at around 12% throughout the study period. Compared with GSV harvest using continuous incisions, EVH was associated with higher rates of reintervention at 1 year (46.5% vs 41.3%; adjusted hazard ratio [aHR], 1.22; 95% confidence interval [CI], 1.06-1.41; P = .01]. However, no significant difference was observed between EVH and continuous incisions, and between skip and continuous incisions in terms of long-term reintervention or major and minor amputations on adjusted analysis. Compared with continuous incision vein harvest, both EVH and skip incisions were associated with lower surgical site infection rates within the first 6 months post-bypass (aHR, 0.53; 95% CI, 0.35-0.82 and aHR, 0.68; 95% CI, 0.53-0.87, respectively). Loss of primary, primary-assisted, and secondary patency was higher after EVH compared with continuous incision vein harvest. Among surgeons performing EVH, comparable long-term outcomes were observed regardless of low (<4 cases/year), medium (4-7 cases/year), or high procedural volumes (>7 cases/year). CONCLUSIONS: Despite higher 1-year reintervention rates, EVH for infrainguinal arterial bypass is not associated with a significant difference in long-term reintervention or amputation rates compared with other harvesting techniques. These outcomes are not influenced by procedural volumes for EVH technique.

Predictors of prolonged length of stay after elective carotid revascularization.

OBJECTIVE: Postoperative day-one discharge is used as a quality-of-care indicator after carotid revascularization. This study identifies predictors of prolonged length of stay (pLOS), defined as a postprocedural LOS of >1 day, after elective carotid revascularization. METHODS: Patients undergoing carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TFCAS) in the Vascular Quality Initiative between 2016 and 2022 were included in this analysis. Multivariable logistic regression analysis was used to identify predictors of pLOS, defined as a postprocedural LOS of >1 day, after each procedure. RESULTS: A total of 118,625 elective cases were included. pLOS was observed in nearly 23.2% of patients undergoing carotid revascularization. Major adverse events, including neurological, cardiac, infectious, and bleeding complications, occurred in 5.2% of patients and were the most significant contributor to pLOS after the three procedures. Age, female sex, non-White race, insurance status, high comorbidity index, prior ipsilateral CEA, non-ambulatory status, symptomatic presentation, surgeries occurring on Friday, and postoperative hypo- or hypertension were significantly associated with pLOS across all three procedures. For CEA, additional predictors included contralateral carotid artery occlusion, preoperative use of dual antiplatelets and anticoagulation, low physician volume (<11 cases/year), and drain use. For TCAR, preoperative anticoagulation use, low physician case volume (<6 cases/year), no protamine use, and post-stent dilatation intraoperatively were associated with pLOS. One-year analysis showed a significant association between pLOS and increased mortality for all three procedures; CEA (hazard ratio [HR],1.64; 95% confidence interval [CI], 1.49-1.82), TCAR (HR,1.56; 95% CI, 1.35-1.80), and TFCAS (HR, 1.33; 95%CI, 1.08-1.64) (all P < .05). CONCLUSIONS: A postoperative LOS of more than 1 day is not uncommon after carotid revascularization. Procedure-related complications are the most common drivers of pLOS. Identifying patients who are risk for pLOS highlights quality improvement strategies that can optimize short and 1-year outcomes of patients undergoing carotid revascularization.

Racial and Gender Disparity in Aortoiliac Disease Open Revascularization Procedures.

BACKGROUND: The impact of race and gender on surgical outcomes has been studied in infrainguinal revascularization for peripheral arterial disease. The aim of this study is to explore how race and gender affect the outcomes of suprainguinal bypass (SIB) for aortoiliac occlusive disease. MATERIALS AND METHODS: Patients who underwent SIB were identified from the procedure-targeted National Surgical Quality Improvement Program data set (2011-2016). Patients were stratified into four groups: nonblack males, black males (BM), nonblack females, and black females (BF). Primary outcomes were 30-d major adverse cardiac events, a composite of myocardial infarction, stroke, or death; postoperative bleeding requiring transfusion or intervention; major amputation and prolonged length of stay (>10 d). Predictors of outcomes were determined by multivariable logistic regression analysis. RESULTS: About 5044 patients were identified. BM were younger, more likely to be smokers, less likely to be on antiplatelet drug or statin, and to receive elective SIB (all P ≤ 0.01). BFs were more likely to be diabetic and functionally dependent (all P ≤ 0.02). Major adverse cardiac events were not significantly different among all groups. BM had a threefold higher risk of amputation (adjusted odds ratio [OR] [95% confidence interval (95% CI)], 3.10 [1.50-6.43]; P < 0.002). Female gender was associated with bleeding in both races, that association was more drastic in BF (OR [95% CI], 2.43 [1.63-3.60]; P < 0.0001), whereas nonblack females (OR [95% CI], 1.46 [1.19-1.80]; P < 0.0001). BF had higher odds of prolonged length of stay (OR [95% CI]: 1.62 [1.08-2.42]; P < 0.019). CONCLUSIONS: In this large retrospective study, we demonstrated the racial and gender disparity in SIB outcomes. BM had more than threefold increase in amputation risk as compared with nonblack males. Severe bleeding risk was more than doubled in BF. Race and gender consideration is warranted in risk assessment when patients are selected for aortoiliac disease revascularization, which in turn necessitate preoperative risk modification and optimization in addition to enhancing their access to primary preventive care measures.

Transfemoral Carotid Artery Stents Should Be Used with Caution in Patients with Asymptomatic Carotid Artery Stenosis.

BACKGROUND: Significant national variation exists in defining the degree of stenosis that requires intervention in patients with asymptomatic carotid artery stenosis (ACAS). We aimed to evaluate the risk of perioperative and 2-year stroke and death in ACAS patients undergoing carotid endarterectomy (CEA) and carotid artery stenting (CAS) for severe versus very severe stenosis in a contemporary population. METHODS: All patients undergoing CEA or transfemoral CAS for ACAS in the Vascular Quality Initiative (2005-2017) were included. Degree of stenosis was defined as the highest recorded on any imaging method. Univariable and multivariate logistic regression analyses were performed to assess risk of stroke, stroke/death, and major adverse cardiac events (MACE) at 30 days; and Cox proportional hazard, life tables, and Kaplan-Meier estimates were implemented to evaluate ipsilateral stroke and stroke/death at 2 years postoperatively in patients undergoing CEA versus CAS for severe (60-79%) and very severe (≥80%) stenosis adjusting for baseline characteristics. RESULTS: A total of 53,337 ACAS patients were examined (severe stenosis = 17,586; 33.%), of which 11.5% (n = 6,127) underwent CAS. The crude incidence of 30-day stroke/death was significantly higher for CAS versus CEA in the very severe stenosis group (2.0% vs. 1.2%, P < 0.001), but not in the severe stenosis group (1.7% vs. 1.3%, P = 0.17). MACE was not significantly different for CAS versus CEA in either group (P ≥ 0.64). On multivariable analysis, CAS was associated with a persistently higher risk of 30-day stroke or death compared to CEA in patients with very severe stenosis (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.26-2.13). The 30-day composite stroke/death risk for patients undergoing CEA was similar for severe versus very severe stenosis (OR 1.07, 95% CI 0.89-1.28), but there was a trend toward higher risk of perioperative stroke in the severe stenosis group (OR 1.23, 95% CI 0.97-1.56). Two-year outcomes were similar; the crude annualized incidence rates of stroke and stroke/death were higher for CAS versus CEA in both the severe (stroke: incidence rate ratio [IRR] 1.62, 95% CI 1.00-2.55; stroke/death: IRR 1.53, 95% CI 1.11-1.64) and very severe stenosis (stroke: IRR 1.97, 95% CI 1.44-2.65; stroke/death: IRR 1.51, 95% CI 1.34-1.68) groups (all, P ≤ 0.04). On multivariable Cox proportional hazards analysis, CAS was associated with a higher risk of stroke or death compared to CEA in patients with both severe (hazard ratio [HR] 1.40, 95% CI 1.15-1.70) and very severe stenosis (HR 1.62, 95% CI 1.37-1.90). CONCLUSIONS: More than one-third of patients undergoing carotid revascularization for ACAS had 60-79% stenosis. Having lower degree of stenosis is not protective against stroke and death for either CEA or CAS at either 30 days or 2 years postoperatively. We believe that optimal medical management should be the first line in stroke prevention for asymptomatic patients with severe (60-79%) carotid stenosis.

Endoscopic ultrasound-guided entero-enterostomy for the treatment of afferent loop syndrome: a multicenter experience.

BACKGROUND: Afferent loop syndrome (ALS) is traditionally managed surgically and, more recently, endoscopically. The role of endoscopic ultrasound-guided entero-enterostomy (EUS-EE) has not been well described. The aim of this study was to assess the technical and clinical success and safety of EUS-EE. METHODS: This was a multicenter, retrospective series at six centers in patients with ALS treated by EUS-EE. Data on patients treated with enteroscopy-assisted luminal stenting (EALS) at a single center were also collected. RESULTS: 18 patients (mean age 64.2 years, 72 % post-pancreaticoduodenectomy, 10 female) underwent EUS-EE. The most common symptoms were vomiting (27.8 %) and jaundice (33.3 %). Clinical success included resolution of symptoms in 88.9 % and improvement to allow hospital discharge in 11.1 %. Technical success was achieved in 100 % of cases, with a mean procedure time of 29.7 minutes. The most common procedure was a gastro-jejunostomy (72.2 %). Three adverse events (16.7 %) occurred (two mild, one moderate). When compared with data on EALS, patients treated with EUS-EE needed fewer re-interventions (16.6 % vs. 76.5 %; P < 0.001). CONCLUSION: EUS-EE seems to be safe and effective in the treatment of ALS. Indirect comparison with EALS suggested that EUS-EE is associated with a reduced need for re-intervention.

Association between Medicare high-risk criteria and outcomes after carotid revascularization procedures.

BACKGROUND: The U.S. Centers for Medicare and Medicaid Services (CMS) has defined a set of high-risk criteria to help define patients who are appropriate for carotid artery stenting (CAS), but these criteria have never been validated. We aimed to validate the CMS high-risk criteria in a nationally representative cohort of patients undergoing CAS and carotid endarterectomy (CEA). METHODS: All patients undergoing CAS (with embolic protection) or CEA in the Vascular Quality Initiative (VQI) database (2013-2016) were included. Patients were stratified as being at normal risk (Nr) or high risk (Hr) for undergoing CEA on the basis of CMS criteria. Thirty-day and 2-year stroke outcomes were compared for CAS vs CEA in both the Nr and Hr groups using 1:1 coarsened exact matching and multivariable Cox proportional hazards modeling. RESULTS: A total of 51,942 patients (CAS, 7030; CEA, 44,912) underwent carotid revascularization during the study period. Thirty-day (Nr, 1.7% vs 1.0%; Hr, 2.5% vs 1.4%) and 2-year (Nr, 1.9% vs 1.0%; Hr, 2.4% vs 1.3%) stroke occurred more frequently after CAS vs CEA on crude analysis (P < .001). After matching 2920 pairs of patients on 18 preoperative variables, the risk of 30-day and 2-year stroke remained higher after CAS in the Hr group (30-day risk: hazard ratio [HR], 1.90; 95% confidence interval [CI], 1.26-2.85; 2-year risk: HR, 1.65; 95% CI, 1.05-2.60) but was similar for CAS vs CEA in the Nr group (30-day risk: HR, 0.97; 95% CI, 0.48-1.95; 2-year risk: HR, 1.49; 95% CI, 0.76-2.90). CONCLUSIONS: These data suggest that the utility of CAS in Nr patients may be underappreciated, whereas the potential benefit of CAS in Hr patients may be overestimated. Re-evaluation of the criteria for identifying patients at high risk for CEA and the national guidelines on the indications for CAS is strongly indicated.

Efficacy and Safety of Digital Single-Operator Cholangioscopy for Difficult Biliary Stones.

BACKGROUND & AIMS: It is not clear whether digital single-operator cholangioscopy (D-SOC) with electrohydraulic and laser lithotripsy is effective in removal of difficult biliary stones. We investigated the safety and efficacy of D-SOC with electrohydraulic and laser lithotripsy in an international, multicenter study of patients with difficult biliary stones. METHODS: We performed a retrospective analysis of 407 patients (60.4% female; mean age, 64.2 years) who underwent D-SOC for difficult biliary stones at 22 tertiary centers in the United States, United Kingdom, or Korea from February 2015 through December 2016; 306 patients underwent electrohydraulic lithotripsy and 101 (24.8%) underwent laser lithotripsy. Univariate and multivariable analyses were performed to identify factors associated with technical failure and the need for more than 1 D-SOC electrohydraulic or laser lithotripsy session to clear the bile duct. RESULTS: The mean procedure time was longer in the electrohydraulic lithotripsy group (73.9 minutes) than in the laser lithotripsy group (49.9 minutes; P < .001). Ducts were completely cleared (technical success) in 97.3% of patients (96.7% of patients with electrohydraulic lithotripsy vs 99% patients with laser lithotripsy; P = .31). Ducts were cleared in a single session in 77.4% of patients (74.5% by electrohydraulic lithotripsy and 86.1% by laser lithotripsy; P = .20). Electrohydraulic or laser lithotripsy failed in 11 patients (2.7%); 8 patients were treated by surgery. Adverse events occurred in 3.7% patients and the stone was incompletely removed from 6.6% of patients. On multivariable analysis, difficult anatomy or cannulation (duodenal diverticula or altered anatomy) correlated with technical failure (odds ratio, 5.18; 95% confidence interval, 1.26-21.2; P = .02). Procedure time increased odds of more than 1 session of D-SOC electrohydraulic or laser lithotripsy (odds ratio, 1.02; 95% confidence interval, 1.01-1.03; P < .001). CONCLUSIONS: In a multicenter, international, retrospective analysis, we found D-SOC with electrohydraulic or laser lithotripsy to be effective and safe in more than 95% of patients with difficult biliary stones. Fewer than 5% of patients require additional treatment with surgery and/or extracorporeal shockwave lithotripsy to clear the duct.

Sartorius Muscle Flaps: Perioperative Outcomes Based on Surgical Specialty.

BACKGROUND: Complicated groin wounds often require repair by sartorius muscle flap (SMF). Operating surgical specialty differs based on SMF indication, hospital, and operating surgeon preference. We aim to assess the effect of operating surgical specialty, indication for SMF, and other patient-level factors on 30-day outcomes. METHODS: We collected data on all patients undergoing SMF performed at our institution from 2005 to 2015, including age, sex, body mass index, comorbidity index (hypertension, diabetes, dyslipidemia, peripheral arterial disease, coronary artery disease), smoking status, history of malignancy, indication for SMF (infection, noninfectious complication, prophylaxis), and operating surgeon's specialty (vascular, plastic, general, other). Primary outcome was any 30-day complications (wound infection, seroma, dehiscence, or bleeding). Secondary outcome included 30-day surgical reintervention rate. Univariate analysis and multivariate logistic regression modeling were used to evaluate primary outcomes. RESULTS: A total of 170 SMFs were performed during the study period (mean patient age 58 years; 49% male). Primary indication for SMF was prophylaxis in 116 cases (68%), followed by infection in 36 cases (21%) and noninfectious complications in 18 cases (11%). General surgeons performed the highest proportion of SMF (45%) followed by vascular surgeons (26%), "other specialties" (15%), and plastic surgeons (14%). Compared with all specialties, vascular surgeons operated on the severely ill patients (77% of vascular patients had ≥3 comorbidities, P < 0.001). Surgical reintervention within 30 days was required in 7 patients (4.1%): 3 by vascular surgeons (6.8% of total cases by vascular surgery) and 4 by plastic surgeons (17.4% of total cases by plastic surgery, P < 0.001). Any 30-day complications occurred in 47 patients (28%): 30 general surgery cases (39%), 7 plastic surgery cases (30%), 7 other specialty cases (27%), and 3 vascular surgery cases (7%) (P < 0.001). Of all vascular disease-related cases (56), plastic surgeons performed 21% of SMF, while vascular surgeons performed 79%. On logistic regression correcting for baseline differences between groups, vascular surgeon SMF outcomes were compared favorably with those done by other specialties. CONCLUSIONS: Overall, SMFs have low perioperative reintervention rates but high complication rates. Vascular surgeons perform SMF on high-risk patients with more comorbidities compared with other specialties. Although overall morbidity associated with this procedure is high, perioperative outcomes for SMF performed by vascular surgeons are favorable.