Current Medicare reimbursement for complex endovascular aortic repair is inadequate based on results from a multi-institutional cost analysis.

OBJECTIVE: Complex endovascular juxta-, para- and suprarenal abdominal aortic aneurysm repair (comEVAR) is frequently accomplished with commercially available fenestrated (FEVAR) devices or off-label use of aortoiliac devices with parallel branch stents (chEVAR). We sought to evaluate the implantable vascular device costs incurred with these procedures as compared with standard Medicare reimbursement to determine the financial viability of comEVAR in the modern era. METHODS: Five geographically distinct institutions with high-volume, complex aortic centers were included. Implantable aortoiliac and branch stent device cost data from 25 consecutive, recent, comEVAR in the treatment of juxta-, para-, and suprarenal aortic aneurysms at each center were analyzed. Cases of rupture, thoracic aneurysms, reinterventions, and physician-modified EVAR were excluded, as were ancillary costs from nonimplantable equipment. Data from all institutions were combined and stratified into an overall cost group and two, individual cost groups: FEVAR or chEVAR. These groups were compared, and each respective group was then compared with weighted Medicare reimbursement for Diagnosis-Related Group codes 268/269. Median device costs were obtained from an independent purchasing consortium of >3000 medical centers, yielding true median cost-to-institution data rather than speculative, administrative projections or estimates. RESULTS: A total of 125 cases were analyzed: 70 FEVAR and 53 chEVAR. Two cases of combined FEVAR/chEVAR were included in total cost analysis, but excluded from direct FEVAR vs chEVAR comparison. Median Medicare reimbursement was calculated as $35,755 per case. Combined average implantable device cost for all analyzed cases was $28,470 per case, or 80% of the median reimbursement ($28,470/$35,755). Average FEVAR device cost per case ($26,499) was significantly lower than average chEVAR cost per case ($32,122; P < .002). Device cost was 74% ($26,499/$35,755) of total reimbursement for FEVAR and 90% ($32,122/$35,755) for chEVAR. CONCLUSIONS: Results from this multi-institutional analysis show that implantable device cost alone represents the vast majority of weighted total Medicare reimbursement per case with comEVAR, and that chEVAR is significantly more costly than FEVAR. Inadequate Medicare reimbursement for these cases puts high-volume, high-complexity aortic centers at a distinct financial disadvantage. In the interest of optimizing patient care, these data suggest a reconsideration of previously established, outdated, Diagnosis-Related Group coding and Medicare reimbursement for comEVAR.

Symptomatic carotid webs require aggressive intervention.

OBJECTIVE: Carotid web (CaWeb) is a rare form of fibromuscular dysplasia that can produce embolic stroke. Misdiagnosis of symptomatic CaWeb as "cryptogenic stroke" or "embolic stroke of unknown source" is common and can lead to recurrent, catastrophic neurologic events. Reports of CaWeb in the literature are scarce, and their natural history is poorly understood. Appropriate management remains controversial. METHODS: CaWeb was defined as a single, shelf-like, linear projection in the posterolateral carotid bulb causing a filling defect on computed tomography angiography (CTA) or cerebral angiography. Cases of symptomatic CaWeb at a single institution with a high-volume stroke center were identified through collaborative evaluation by vascular neurologists and vascular surgeons. RESULTS: Fifty-two patients with symptomatic CaWeb were identified during a 6-year period (2016-2022). Average age was 49 years (range, 29-73 years), 35 of 52 (67%) were African American, and 18 of 52 (35%) were African American women under age 50. Patients initially presented with stroke (47/52; 90%) or transient ischemic attack (5/52; 10%). Stenosis was <50% in 49 of 52 patients (94%) based on NASCET criteria, and 0 of 52 (0%) CaWebs were identified with carotid duplex. Definitive diagnosis was made by CTA examined in multiple planes or cerebral angiography examined in a lateral projection to adequately assess the posterolateral carotid bulb, where 52 of 52 (100%) of CaWebs were seen. Early in our institutional experience, 10 of 52 patients (19%) with symptomatic CaWeb were managed initially with dual antiplatelet and statin therapy or systemic anticoagulation; all suffered ipsilateral recurrent stroke at an average interval of 43 months (range, 1-89 months), and five were left with permanent deficits. Definitive treatment included carotid endarterectomy in 27 of 50 (56%) or carotid stenting in 23 of 50 (46%). Two strokes were irrecoverable, and intervention was deferred. Web-associated thrombus was observed in 20 of 50 (40%) on angiography or grossly upon carotid exploration. Average interval from initial stroke to intervention was 39 days. After an average follow-up of 38 months, there was no reported postintervention stroke or mortality. CONCLUSIONS: To our knowledge, this is the largest single-institution analysis of symptomatic CaWeb yet reported. Our series demonstrates that carotid duplex is inadequate for diagnosis, and that medical management is unacceptable for symptomatic CaWeb. Recurrent stroke occurred in all patients managed early in our experience with medical therapy alone. We have since adopted an aggressive interventional approach in cases of symptomatic CaWeb, with no postoperative stroke reported over an average follow-up of 38 months. In younger patients presenting with cryptogenic stroke, especially African American women, detailed review of lateral cerebral angiography or multi-planar, fine-cut CTA images is required to accurately rule out or diagnose CaWeb and avoid recurrent neurologic events.

Severe Increase in Nursing Labor Cost and Effect on Surgical Department Financial Margins at an Academic, Tertiary Medical Center.

BACKGROUND: A pre-existing nationwide nursing shortage drastically worsened during the pandemic, causing a significant increase in nursing labor costs. We examined the financial impact of these changes on department of surgery financial margins. STUDY DESIGN: Operating room, inpatient, and outpatient financial metrics were analyzed. Monthly averages from a 14-month control cohort, January 2019 to February 2020 (pre-COVID-19), were compared with a 21-month cohort, March 2020 to November 2021 (COVID-19). True revenue and cost data from hospital accounting records, not estimates or administrative projections, were analyzed. Statistics were performed with standard Student's t -test and the Anderson-Darling normality test. RESULTS: Monthly surgical nursing costs increased significantly, with concomitant significant decreases in departmental contribution to margin. No significant change was observed in case volume per month, length of stay per case, or surgical acuity, as standardized by the US Centers for Medicare & Medicaid Services Case Mix Index. To obviate insurance payor mix as a variable and standardize cost data, surgical nursing expense per relative value unit was analyzed, demonstrating a significant increase. Hospital-wide agency nursing costs increased from $5.1 to $13.5 million per month (+165%) in 2021. CONCLUSIONS: Our results demonstrate a significant increase in surgical nursing labor costs with a resultant erosion of department of surgery financial margins. Use of real-time accounting data instead of commonly touted administrative approximations or Medicare projections increases both the accuracy and generalizability of the data. The long-term impact of both direct costs from supply chain interruption and indirect costs, such as limited operating room and ICU access, will require further study. Clearly this ominous trend is not viable, and fiscal recovery will require sustained, strategic workforce allocation.

The Surgeon's Risk of SARS-CoV-2 Infection During the Initial Peak of the COVID-19 Pandemic in New Orleans.

Surgeons who care for patients with active SARS-CoV-2 infection represent a unique population of health care providers whose risk of infection has not been elucidated. The objective of this study was to examine SARS-CoV-2 seroprevalence among surgeons who cared for patients with active SARS-CoV-2 infection compared to other employees within our health care system and also the general public of New Orleans. 105 surgeons at our facilities provided direct surgical care to patients with active SARS-CoV-2 infection and underwent voluntary antibody testing. 2/105 (1.9% CI .2%-6.7%) tested positive for SARS-CoV-2 antibodies. 13 343 hospital employees underwent antibody testing and 1066/13 343 (8.0% CI 7.5%-8.5%) tested positive (1.9% vs. 8.0%; P = .03). We saw a significantly lower SARS-CoV-2 seroprevalence among surgeons who directly cared for infected patients versus other hospital employees. When compared to community seroprevalence (6.9% CI 6.0%-8.0%), seroprevalence among our surgeons is also significantly lower (1.9% vs. 6.9%; P = .04).

Successful treatment of a persistent type IA endoleak with endoanchors following chimney endovascular aortic repair.

The chimney endovascular aortic repair technique has become an increasingly used option for the treatment of juxtarenal aortic aneurysms; however, type IA and gutter endoleaks complicate this approach in up to 5.9% of cases. Successful treatment of these leaks is challenging. We report a case of a patient who underwent two-vessel chimney endovascular aortic repair in the treatment of a 5.9-cm juxtarenal aortic aneurysm and developed a type IA endoleak. The endoleak was successfully treated with Heli-FX EndoAnchor placement. Resolution of the endoleak was noted at continued follow-up through 54 months.

Drastic increase in hospital labor costs led to a sustained financial loss for an academic vascular surgery division during the coronavirus disease 2019 pandemic.

OBJECTIVE: The financial effects of the coronavirus disease 2019 (COVID-19) pandemic have fundamentally changed the healthcare environment, with hospitals expected to have lost billions in 2021. A preexisting nationwide nursing shortage became drastically worse during the pandemic amid dramatically increasing labor costs. We examined the evolution and financial effects of these changes during repeated pandemic surges within a vascular surgery division at a tertiary medical center. METHODS: Operating room, inpatient unit, and outpatient clinic financial data were examined retrospectively. The monthly averages for a 14-month control cohort before COVID-19 (January 2019 to February 2020) were compared to the averages for seven interval groups of sequential, 3-month cohorts from March 2020 through November 2021 (groups 1-7). RESULTS: The monthly relative value unit (RVU) generation had returned to the mean before the COVID-19 pandemic (2520 RVUs) after an isolated decrease early in the pandemic (group 1; 1734 RVUs). The RVUs ranged from 2540 to 2863 per month for groups 2 to 5, with a slight decline in groups 6 and 7. The average monthly RVUs in the COVID-19 period (2437 RVUs) were nearly equivalent (P = .93) to those for the pre-COVID-19 cohort. An analysis of payor mix demonstrated an increase in commercial and Medicaid payors, with a respective decrease in Medicare payors, during COVID-19. The contribution to indirect, or profit, from inpatient hospital and outpatient clinical revenue showed a drastic decrease in group 1, followed by a swift rebound when the government restrictions were eased (group 2). The total monthly vascular nursing unit expense demonstrated a marked increase with each sequential group during COVID-19, with an average monthly upsurge of +$82,171 (+47%; P < .001). An increase in the nursing labor expenses of +$884 per vascular case (from $1630 to $2514; +54%; P < .001) was observed in the COVID-19 era. The nursing labor costs per patient day had increased from $580 to $852 (+$272; +53%; P < .001). The nursing labor cost per RVU had increased from $69.5 to $107.7 (+$38.2; +55%; P < .001). On a system-wide level, the agency-related nursing costs had increased from $4.9 million to $13.6 million per month (+178%; P < .001) in 2021 compared with 2020. CONCLUSIONS: The COVID-19 pandemic has had severe, nationwide effects on healthcare delivery, exacerbating the deleterious effects of an existing, critical nursing shortage. To the best of our knowledge, the present study is the first detailed analysis of this phenomenon and its effects on a surgical division. Our results have demonstrated a progressive, drastic increase in nursing labor costs during the pandemic, with a resultant sustained erosion of financial margins despite a level of clinical productivity, as measured in RVUs, equal to the prepandemic standards. This precarious trend is not sustainable and will require increased, targeted government funding.

Financial viability of endovascular aortic repair in the modern era.

BACKGROUND: In the current era of cost containment, the financial impact of high-cost procedures such as endovascular aneurysm repair (EVAR) remains an area of intensive interest. Previous reports suggested slim to negative operating margins with EVAR, prompting widespread initiatives to reduce cost and to improve reimbursement. In 2015, the Centers for Medicare and Medicaid Services (CMS) announced the reclassification of EVAR to more specific diagnosis-related group (DRG) coding and predicted an overall increase in hospital reimbursement. The potential impact of this change has not been described. METHODS: Patients undergoing elective EVAR at a single institution between January 2014 and December 2018 were identified retrospectively, then stratified by date. Group 1 patients underwent EVAR before DRG change in 2015 and were classified with DRG 237/238, major cardiovascular procedure. Group 2 patients underwent EVAR after the change and were classified as DRG 268/269, aortic/heart assist procedures. The total direct cost included implant cost, operating room (OR) labor, room and board, and other supply costs. Net revenue reflected real payer mix values without extrapolation based on standard Medicare rates. Hospital profit was defined as the contribution to indirect (CTI), subtracting total direct cost from net revenue. RESULTS: A total of 188 encounters were included, 67 (36%) in group 1 and 121 (64%) in group 2. Medicare patients composed 84% of group 1 and 81% of group 2. CTI (profit) increased by $4447 (+123%) from $3615 in group 1 to $8062 in group 2. Net revenue per encounter increased by $2054 (+7.1%). In group 1, the higher reimbursement DRG code 237 was applied in 5 of 67 (7.5%) patients, whereas DRG code 268 was assigned in 19 of 121 (15.1%) patients in group 2. Total direct cost per encounter decreased by $2012 (-7.9%). This decrease in cost was driven by a reduction in implant cost, from a mean $16,914 per encounter in group 1 to a mean $15,655 in group 2 (-$1259 or -7.4% per encounter) and by a decrease in OR labor cost, $2838 in group 1 to $2361 in group 2 (-$477 or -17.0% per encounter). CONCLUSIONS: A significant improvement in hospital CTI was observed for elective EVAR during the course of the study. The increased DRG reimbursement after the Centers for Medicare and Medicaid Services coding changes in 2015 was a major driver of this salutary change. Notably, efforts to reduce implant and OR cost as well as to improve coding and documentation accuracy over time had an equally important impact on financial return.

Rapid progression of carotid stenosis was rare in a large integrated healthcare system during an eight-year period.

OBJECTIVE: Few studies have evaluated the rapid progression of carotid stenosis on a large scale. We created a custom software algorithm to analyze an electronic medical record database to examine the natural progression of carotid stenosis, identify a subset of patients with rapid progression, and evaluate the specific patient risk factors associated with this rapid progression. METHODS: Patients in a large integrated healthcare system who had undergone two or more carotid ultrasound scans from August 2010 to August 2018 were identified. We did not distinguish between those with an established carotid stenosis diagnosis and those with a screening ultrasound scan. We used our novel algorithm to extract data from their carotid ultrasound reports. The degrees of carotid stenosis were categorized as follows: level 1, 0% to 39%; level 2, 40% to 59%; level 3, 60% to 79%; level 4, 80% to 99%; and level 5, complete occlusion. The primary endpoint was rapid vs slow progression of carotid stenosis, with rapid progression defined as an increase of two or more levels within any 18-month period of the study, regardless of the date of the initial ultrasound scan. The association of the demographic and clinical characteristics with rapid progression was assessed by univariable and multivariable logistic regression. RESULTS: From a cohort of 4.4 million patients, we identified 4982 patients with two or more carotid ultrasound scans and a median follow-up period of 13.1 months (range, 0.1-93.7 months). Of the 4982 patients, 879 (17.6%) had shown progression of carotid stenosis. Only 116 patients (2.3%) had had progression to level 4 (80%-99% stenosis) from any starting level during a median of 11.5 months. A total of 180 patients (3.6%) were identified as experiencing rapid progression during a median follow-up of 9.9 months. The final multivariable analysis showed that younger age (P < .01), white race (P = .02), lower body mass index (P = .01), a diagnosis of peripheral arterial disease (P = .03), and a diagnosis of transient ischemic attack (P < .01) were associated with rapid progression. CONCLUSIONS: Using a novel algorithm to extract data from >4 million patient records, we found that rapid progression of carotid stenosis appears to be rare. Although 17.6% of patients showed any degree of progression, only 3.6% had experienced rapid progression. Among those with any disease progression, 20.5% had experienced rapid progression. Although the overall incidence of rapid progression was low, patients with any progression might warrant close follow-up, especially if they have the associated risk factors for rapid progression. The custom software algorithm might be a powerful tool for creating and evaluating large datasets.

Safety of urgent carotid endarterectomy following thrombolysis.

INTRODUCTION: Acute ischemic stroke is a leading cause of morbidity and mortality worldwide, and the incidence of ischemic stroke is predicted to increase in coming years. Carotid atherosclerotic occlusive disease accounts for up to 20% of all ischemic strokes, and mounting evidence suggests that, in the setting of an acute ischemic stroke due to carotid disease, earlier treatment with carotid intervention results in better outcomes. In patients with acute ischemic stroke, systemic or intravenous thrombolysis (IVT) has revolutionized ischemic stroke therapy, and intravenous tissue plasminogen activator (tPA) has become the principal treatment for acute ischemic stroke when administered within 3 to 4.5 hours of neurologic symptom onset. Given these trends in acute ischemic stroke therapy, vascular specialists are increasingly asked to perform carotid intervention following IVT, but reports in the literature examining outcomes in this circumstance are scarce, and the data regarding the appropriate interval from IVT to carotid endarterectomy (CEA) remains controversial. EVIDENCE ACQUISITION: Literature searches were performed in PubMed (MEDLINE) and Ovid examining journal articles published between January 1st, 1998 and September 30th, 2019. The search terms used were: "urgent carotid endarterectomy," "carotid endarterectomy" AND "thrombolysis," "acute stroke and thrombolysis," "timing of carotid endarterectomy," and various combinations of these terms. EVIDENCE SYTNHESIS: A total of 21 published reports detailing outcomes in 1165 patients have been published to date, with an average interval from IVT to CEA of 7.1 days, a cumulative 30-day stroke and death rate of 4.1% (0-18%) and a mean frequency of intracranial hemorrhage of 2.6% (0-18%). The aggregate data from the 21 reported series suggest that CEA can be performed safely within the first 14 days after the onset of neurologic symptoms in patients receiving antecedent IVT, however, data regarding the safety of urgent CEA within 48 to 72 hours of thrombolysis is conflicting, with some series reporting excellent results and others showing an increased risk of ICH, stroke, and/or death in these select patients. CONCLUSIONS: Given the trend toward expedited treatment of acute ischemic stroke with subsequent transfer to regional referral centers, vascular specialists will be confronted with an increasing number of patients who may require urgent CEA after antecedent IVT. Further study is warranted to clearly delineate the appropriate interval from IVT to CEA and, specifically, to establish the safety of CEA with 72 hours of tPA administration.

Patients with moderate to severe strokes (NIHSS score >10) undergoing urgent carotid interventions within 48 hours have worse functional outcomes.

OBJECTIVE: Increasing evidence suggests that urgent carotid intervention after a nondisabling stroke is safe. However, the functional outcome of such patients has not been quantified for various degrees of stroke. We aimed to determine whether increased presenting stroke severity and timing to intervention are associated with poor functional outcomes in patients undergoing urgent carotid endarterectomy (CEA) or carotid artery stenting (CAS) after an acute transient ischemic attack or stroke. METHODS: We reviewed all urgent carotid interventions from January 2013 through April 2017 at a single tertiary referral center. Preoperative variables analyzed included admission stroke severity, calculated by National Institutes of Health Stroke Scale (NIHSS). The primary end point was the patient's neurologic functional independence at discharge, quantified by the modified Rankin scale (mRS) score (≤2, functionally independent; ≥3, dependent). Primary complications were defined as new or worsened stroke, intracranial hemorrhage, and death. RESULTS: A total of 120 urgent carotid interventions (CEA, n = 96; CAS, n = 22; 1 CEA with middle cerebral artery aspiration thrombectomy and 1 carotid embolectomy) were performed. Bivariate analysis demonstrated a correlation between admission NIHSS score and mRS score when patients were divided into groups with an admission NIHSS score ≤10 and >10 (P = .0029). Patients presenting with larger strokes (NIHSS score >10) were 3.4 times more likely (95% confidence interval [CI], 1.2-9.6; P = .024) to have functional dependence (mRS score ≥3) at discharge than patients presenting with minor to moderate strokes (NIHSS score ≤10). Patients undergoing CEA or CAS before 48 hours were also associated with a worse discharge mRS score compared with those undergoing carotid interventions after 48 hours (odds ratio, 3.5; 95% CI, 1.4-8.7; P = .007). Even when emergent carotid interventions were excluded from the subgroup of patients undergoing CEA or CAS within 48 hours, discharge mRS correlated with time to procedure (days 1- 2 compared with >2 days). The odds of having discharge functional dependence (mRS score ≥3) were 3.4 times more likely for patients with the procedure performed at 1 to 2 days compared with >2 days (95% CI, 1.3-9.1; P = .014). CONCLUSIONS: Urgent carotid intervention performed in patients with moderate or severe strokes (NIHSS score >10) and before 48 hours is associated with functional dependence (mRS score ≥3) on hospital discharge. By demonstrating a clear correlation between admission NIHSS score and interval time to procedure with independent neurologic functional outcomes, these data aid in clinical decision-making for this high-risk subpopulation of patients who present with acute symptomatic carotid lesions.

Fenestrated endovascular aortic repair and clinical trial devices for complex abdominal aortic aneurysms.

Endovascular aortic repair (EVAR) has revolutionized the treatment of infrarenal abdominal aortic aneurysm (AAA), with consistently low reported perioperative morbidity and mortality. Universal applicability of EVAR to treat AAA is hindered by several specific anatomic constraints, however, and many patients cannot be treated with commercially available stent-grafts within the device specific instructions for use. Treatment of these complex pararenal aneurysms is increasingly accomplished by extension of EVAR into the visceral segment of the abdominal aorta with branches or fenestrations that allow perfusion of the visceral and renal arteries. Fenestrated endovascular aneurysm repair (FEVAR) was initially developed to treat high-risk patients unfit for open surgery and anatomically ineligible for standard infrarenal EVAR, but this technique has evolved over the past decade into a mature treatment option for complex AAA. High-volume, single-center reports, multicenter series and clinical reviews have demonstrated that FEVAR is a safe and effective technique with favorable results at proficient centers. Generalizability of these outcomes to less advanced centers remains unproven, and reintervention rates following FEVAR in the mid- and long-term, even among the most experienced centers, remain a concern. Several off-the-shelf devices that are undergoing clinical trial seek to broaden the anatomic applicability and overall availability of FEVAR. A significant number of patients are not candidates for off-the-shelf or customized stent-grafts, however, stressing the need for continued refinement of existing devices, development of novel devices with broader indications for use, and maintenance of open surgical skills.

Complications after endovascular treatment of hepatic artery stenosis after liver transplantation.

BACKGROUND: Hepatic artery stenosis (HAS) after liver transplantation can progress to hepatic artery thrombosis (HAT) and a subsequent 30% to 50% risk of graft loss. Although endovascular treatment of severe HAS after liver transplantation has emerged as the dominant method of treatment, the potential risks of these interventions are poorly described. METHODS: A retrospective review of all endovascular interventions for HAS after liver transplantation between August 2009 and March 2016 was performed at a single institution, which has the largest volume of liver transplants in the United States. Severe HAS was identified by routine surveillance duplex ultrasound imaging (peak systolic velocity >400 cm/s, resistive index <0.5, and presence of tardus parvus waveforms). RESULTS: In 1129 liver transplant recipients during the study period, 106 angiograms were performed in 79 patients (6.9%) for severe de novo or recurrent HAS. Interventions were performed in 99 of 106 cases (93.4%) with percutaneous transluminal angioplasty alone (34 of 99) or with stent placement (65 of 99). Immediate technical success was 91%. Major complications occurred in eight of 106 cases (7.5%), consisting of target vessel dissection (5 of 8) and rupture (3 of 8). Successful endovascular treatment was possible in six of the eight patients (75%). Ruptures were treated with the use of a covered coronary balloon-expandable stent graft or balloon tamponade. Dissections were treated with placement of bare-metal or drug-eluting stents. No open surgical intervention was required to manage any of these complications. With a median of follow-up of 22 months, four of eight patients (50%) with a major complication progressed to HAT compared with one of 71 patients (1.4%) undergoing a hepatic intervention without a major complication (P < .001). One patient required retransplantation. Severe vessel tortuosity was present in 75% (6 of 8) of interventions with a major complication compared with 34.6% (34 of 98) in those without (P = .05). In the complication cohort, 37.5% (3 of 8) of the patients had received a second liver transplant before intervention compared with 12.6% (9 of 71) of the patients in the noncomplication cohort (P = .097). CONCLUSIONS: Although endovascular treatment of HAS is safe and effective in most patients, target vessel injury is possible. Severe tortuosity of the hepatic artery and prior retransplantation were associated with a twofold to threefold increased risk of a major complication. Acute vessel injury can be managed successfully using endovascular techniques, but these patients have a significant risk of subsequent HAT and need close surveillance.

Retrograde Target Vessel Catheterization as a Salvage Procedure in Fenestrated/Branched Endografting.

PURPOSE: To present retrograde target vessel catheterization as a bailout technique in fenestrated and branched endografting (F/B-EVAR). METHODS: Between November 2003 and November 2014, 11 (1.6%) of 671 consecutive patients with juxtarenal, suprarenal, and thoracoabdominal aortic aneurysms required retrograde target vessel access as a bailout measure during F/B-EVAR due to failure of an antegrade approach. The target vessels involved the left renal artery (LRA) in 6 patients, the celiac artery (CA) in 3 patients, the right renal artery (RRA) in 1 patient, and both renal arteries in 1 patient. RESULTS: The target vessels were successfully catheterized and secured with stent-grafts in 10 patients; a single case was unsuccessful because the fenestration was in the wrong position and blocked against the arterial wall. One (9.1%) patient died within 30 days. Major perioperative complications occurred in 6 patients, including 3 with renal function deterioration, 2 with access-site wound dehiscence, and a case of pneumonia. Median hospital stay was 20 days (range 7-60) and median intensive care unit stay was 2.5 days (range 0-9). Over a mean 26-month follow-up (range 1-60), one unrelated death occurred. Reintervention was required in 1 patient due to progression of an aneurysm of the right iliac artery. CONCLUSION: Retrograde target vessel access in F/B-EVAR is a feasible bailout procedure when antegrade cannulation fails. Secondary technical success is high, but the procedure is associated with higher perioperative morbidity and longer hospital stay.

Augmented mitral valve leaflet area decreases leaflet stress: a finite element simulation.

BACKGROUND: Using human mitral valve (MV) models derived from three-dimensional echocardiography, finite element analysis was used to predict mechanical leaflet and chordal stress. Subsequently, valve geometries were altered to examine the effects on stresses of the following: (1) varying coaptation area; (2) varying noncoapted leaflet tissue area; and (3) varying interleaflet coefficient of friction (µ). METHODS: Three human MV models were loaded with a transvalvular pressure of 80 mm Hg using finite element analysis. Initially leaflet coaptation was set to 10%, 50%, or 100% of actual coaptation length to test the influence of coaptation length on stress distribution. Next, leaflet surface areas were augmented by 1% overall and by 2% in the noncoapted "belly" region to test the influence of increased leaflet billowing without changing the gross geometry of the MV. Finally, the coefficient of friction between the coapted leaflets was set to µ = 0, 0.05, or 0.3, to assess the influence of friction on MV function. RESULTS: Leaflet coaptation length did not affect stress distribution in either the coapted or noncoapted leaflet regions; peak leaflet stress was 0.36 ± 0.17 MPa at 100%, 0.35 ± 0.14 MPa at 50%, and 0.35 ± 0.15 MPa at 10% coaptation lengths (p = 0.85). Similarly, coaptation length did not affect peak chordal tension (p = 0.74). Increasing the noncoapted leaflet area decreased the peak valvular stresses by 5 ± 2% (p = 0.02). Varying the coefficient of friction between leaflets did not alter leaflet or chordal stress distribution (p = 0.18). CONCLUSIONS: Redundant MV leaflet tissue reduces mechanical stress on the noncoapted leaflets; the extent of coaptation or frictional interleaflet interaction does not independently influence leaflet stresses. Repair techniques that increase or preserve noncoapted leaflet area may decrease mechanical stresses and thereby enhance repair durability.

Predictors of decreased short- and long-term survival following open abdominal aortic aneurysm repair.

OBJECTIVES: The purpose of this study was to identify predictors of decreased survival after open abdominal aortic aneurysm (AAA) repair at a single university hospital. METHODS: Patients undergoing open AAA repair from June 2003 to June 2009 were identified. Primary outcomes were 30-day and 5-year survival. Preoperative, intraoperative, and postoperative variables were assessed for their influence on outcomes using univariate and multivariate analysis, as appropriate. One- and 5-year survival were determined by Kaplan-Meier analysis. RESULTS: Four hundred eight patients (289 men; 70.8%) with a mean age of 72.4 ± 8.3 years underwent open AAA repair. Sixty-seven patients (16.4%) underwent nonelective repair. The clamp site was infrarenal in 137 patients (33.6%), suprarenal in 97 patients (23.8%), and supraceliac in 174 patients (42.6%). Thirty-day survival was 95.6%. One- and 5-year survival were 90.0% ± 1.5% and 65.1% ± 3.0%, respectively. Seventy-nine patients (19.4%) had decreased renal function postoperatively compared to preoperatively, 71 patients (17.4%) sustained cardiac complications, and 45 patients (11.0%) sustained pulmonary complications. Patients with chronic obstructive pulmonary disease (91.9% vs 97.2%; P = .004) and chronic renal insufficiency (92.0% vs 98.3%; P = .009) had decreased 30-day survival. Patients with chronic obstructive pulmonary disease (55.8% ± 5.8% vs 67.3% ± 3.6%; P = .013), chronic renal insufficiency (51.2% ± 5.2% vs 72.8% ± 3.7%; P = .043), and cerebrovascular disease (46.8% ± 7.4% vs 67.4% ± 3.4%; P = .003) had decreased 5-year survival. Patients who had decreased postoperative renal function (41.0% ± 7.4% vs 72.2% ± 3.4%; P = .004), and patients who sustained pulmonary complications (45.6% ± 8.8% vs 66.3% ± 3.3%; P = .042) had worse 5-year survival. CONCLUSIONS: Open AAA repair can be done with low morbidity and mortality in the era of endovascular aneurysm repair. Careful consideration should be given to preoperative optimization and perioperative care in patients with chronic obstructive pulmonary disease, chronic renal insufficiency, and cerebrovascular disease. Postoperative decrease in renal function and pulmonary complication portend decreased 5-year survival; strategies to ameliorate these factors should be sought.

Late open conversion and explantation of abdominal aortic stent grafts.

OBJECTIVES: To evaluate indications for, operative strategy during, and outcomes following late open surgical conversion following endovascular aneurysm repair (EVAR). METHODS: Between 2002 and 2009, patients undergoing open abdominal aortic aneurysm repair at a university hospital were entered prospectively into a database which was examined to identify patients undergoing open conversion >30 days after EVAR. RESULTS: Over 7 years, 21 patients required late open conversion of EVAR. The average patient age was 75 years (range, 59-88), and there were 16 male (76%) patients. The mean interval to conversion was 33.4 months (range, 2-73). Eight patients (38%) presented with proximal type I endoleak; 4 patients (19%) presented with type II endoleak and aneurysm expansion; 5 patients (24%) presented with graft migration and aneurysm expansion; and 5 patients (24%) presented with de novo visceral aneurysms. Rupture (1) and infection (1) were also observed. There were five (24%) emergent cases. Most patients (12/21, 57%) had more than one reason for conversion. There were no perioperative deaths; three patients (14%) had major complications. Grafts requiring conversion were AneuRx (6; Medtronic AVE, Santa Rosa, Calif), Zenith (6; Cook Inc, Bloomington, Ind), Talent (3; Medtronic), Excluder (2; W. L. Gore, Flagstaff, Ariz), Anaconda (1; TERUMO Corp, Ann Arbor, Mich), Ancure (1; Guidant, Menlo Park, Calif), Quantum LP (1; Cordis Corp, Miami Lakes, Fla), and Powerlink (1; Endologix, Irvine, Calif). The surgical approach was retroperitoneal in 16 (76%) and transperitoneal in four (19%) patients. Initial proximal aortic control was supraceliac (9/21), suprarenal (7/21), or infrarenal (5/21), with stepwise distal clamping to reduce ischemic time. Complete endograft removal was performed in 17/21 patients; in 4/21 the distal anastomosis was performed to the endograft after proximal segment explantation. Reconstruction was completed with tube (19/21) or aortoiliac (2/21) grafts; in one case, homograft was used. Mean intraoperative blood loss was 1.9 L (range, 0.4-6.5 L), mean intensive care unit (ICU) stay was 3 days (range, 2-6), and the mean hospital stay was 10 days (range, 4-39). CONCLUSIONS: While technically challenging, delayed open conversion of EVAR can be accomplished with low morbidity and mortality in both the elective and emergent settings. These results reinforce the justification for long-term surveillance of endografts following EVAR.

Quantitative mitral valve modeling using real-time three-dimensional echocardiography: technique and repeatability.

BACKGROUND: Real-time three-dimensional (3D) echocardiography has the ability to construct quantitative models of the mitral valve (MV). Imaging and modeling algorithms rely on operator interpretation of raw images and may be subject to observer-dependent variability. We describe a comprehensive analysis technique to generate high-resolution 3D MV models and examine interoperator and intraoperator repeatability in humans. METHODS: Patients with normal MVs were imaged using intraoperative transesophageal real-time 3D echocardiography. The annulus and leaflets were manually segmented using a TomTec Echo-View workstation. The resultant annular and leaflet point cloud was used to generate fully quantitative 3D MV models using custom Matlab algorithms. Eight images were subjected to analysis by two independent observers. Two sequential images were acquired for 6 patients and analyzed by the same observer. Each pair of annular tracings was compared with respect to conventional variables and by calculating the mean absolute distance between paired renderings. To compare leaflets, MV models were aligned so as to minimize their sum of squares difference, and their mean absolute difference was measured. RESULTS: Mean absolute annular and leaflet distance was 2.4±0.8 and 0.6±0.2 mm for the interobserver and 1.5±0.6 and 0.5±0.2 mm for the intraobserver comparisons, respectively. There was less than 10% variation in annular variables between comparisons. CONCLUSIONS: These techniques generate high-resolution, quantitative 3D models of the MV and can be used consistently to image the human MV with very small interoperator and intraoperator variability. These data lay the framework for reliable and comprehensive noninvasive modeling of the normal and diseased MV.

Predictors of early and late mortality following open extent IV thoracoabdominal aortic aneurysm repair in a large contemporary single-center experience.

OBJECTIVE: The primary purpose of this study was to examine outcomes following open repair of extent IV thoracoabdominal aortic aneurysms (TAAAs) at a single university hospital. As a secondary aim, comparison was made to patients who underwent open abdominal aortic aneurysm (AAA) repair with supraceliac clamping but without left renal artery bypass to assess the effect of left renal artery bypass on outcomes. METHODS: Patients undergoing open extent IV TAAA repair from 1998 to 2008 were identified (n = 108). Primary outcomes were 30-day and long-term survival. Secondary outcomes were major complication, renal failure, and postoperative change in renal function. A second analysis was performed, comparing patients undergoing extent IV TAAA repair with patients undergoing AAA repair with supraceliac clamping but without left renal artery bypass (n = 50). RESULTS: Eighty-three men (76.9%) and 25 women (23.1%), with a mean age of 72.9 years, underwent open extent IV TAAA repair. Nine patients (8.3%) were ruptured. Mean aneurysm maximal diameter was 6.5 ± 1.3 cm. Supraceliac and left renal ischemic times were 22.9 ± 9.3 and 40.6 ± 16.2 minutes, respectively. Six patients (5.6%) died at 30 days. The only predictor of 30-day mortality was decreased preoperative estimated glomerular filtration rate (eGFR) (P = .044 by multivariate analysis; and P = .011 by univariate analysis). One-year and 5-year survival rates were 87% and 50%, respectively. Patients with a history of cerebrovascular disease (P = .001) and postoperative renal insufficiency (P = .034) had increased long-term mortality by log-rank test. Twenty-five (25.3%) patients sustained a postoperative decrease in renal function, while 19 (19.2%) patients had an improvement in renal function. There was no difference in 30-day mortality (5.6% vs 6.0%; P = 1.000), 5-year survival (50% vs 48%; P = .886), major complications (37.0% vs 38.0%; P = 1.000), renal failure (6.1% vs 0%; P = .215), or postoperative change in renal function, in patients undergoing extent IV TAAA repair vs AAA repair with supraceliac clamping but without left renal artery bypass. CONCLUSIONS: Open extent IV TAAA repair can be performed with low morbidity and mortality rates. The performance of left renal artery bypass does not appear to contribute to the morbidity and mortality of extent IV TAAA repair. While decreased preoperative eGFR appears to increase the risk of 30-day mortality, a history of cerebrovascular disease and postoperative renal insufficiency appear to increase the risk of long-term mortality. Finally, open extent IV TAAA repair not uncommonly improves renal function.

Endovascular repair of extent I thoracoabdominal aneurysms with landing zone extension into the aortic arch and mesenteric portion of the abdominal aorta.

Thoracic endovascular aortic repair (TEVAR) has emerged as an alternative for patients at prohibitive risk for open thoracic or thoracoabdominal surgery, decreasing perioperative morbidity and mortality. Aneurysms that involve both the left subclavian artery (LSA) proximally and the celiac artery (CA) distally present a unique challenge to the use of TEVAR. We report a series of six high-risk patients presenting with extent I thoracoabdominal aortic aneurysms who were successfully treated with TEVAR including coverage of the LSA and the CA.

Outcomes after 151 extended transcervical thymectomies for myasthenia gravis.

BACKGROUND: The ideal operative technique for thymectomy in myasthenia gravis (MG) remains controversial. We present the largest series of extended transcervical thymectomy to provide outcomes data to compare with transsternal procedures. METHODS: A retrospective chart review/interview was made of 164 patients operated upon from 1992 to 2004. Complete remission (CR) was defined as asymptomatic off medication for 6 months or asymptomatic on low-dose single-drug therapy (< or = 10 mg/d prednisone or < or = 150 mg/d azathioprine). A modified Osserman classification based upon the Myasthenia Gravis Foundation of America quantitative disease severity score was employed. RESULTS: The overall complication rate was 7.3%, and nearly all procedures were outpatient. Mean age at surgery was 43 years, and mean preoperative Osserman class was 2.3 (21% class 1; 39% class 2; 28% class 3; 12% class 4). Mean length of follow-up was 53 months. Mean postoperative Osserman class was 1.0. Nineteen percent of patients failed to improve. The crude cumulative CR rate was 37% (n = 58). Kaplan-Meier estimates of CR were 43% and 45% at 3 and 6 years, respectively. On multivariate analysis, only preoperative disease severity was significantly (inversely) associated with Kaplan-Meier CR rates. Longer-term follow-up (83 months) of only the earlier patients shows preserved CR rates (46%). CONCLUSIONS: This largest series of extended transcervical thymectomy for MG confirms that the 5-year Kaplan-Meier CR rate is comparable with that obtained after transsternal procedures. Patients with less severe disease have higher CR rates. Complete responses are durable, as the CR rate remains stable with extended follow-up.