Carotid endarterectomy in academic versus community hospitals: the national surgical quality improvement program data.

BACKGROUND: Carotid endarterectomy (CEA) is among the most commonly performed vascular operations in both academic and community hospital settings. The excellent results of the large prospective studies (North American Symptomatic Carotid Endarterectomy Trial, Asymptomatic Carotid Atherosclerosis Study) have been criticized because of a widely held impression that community hospitals could not duplicate the excellent surgical results achieved in high volume university hospitals or clinics. The purpose of this study was to use the National Surgical Quality Improvement Program data to evaluate the outcomes of CEA in academic versus community hospitals. METHODS: All patients undergoing CEA were identified in the National Surgical Quality Improvement Program database conducted between January 1, 2005 and October 30, 2009. The patients were stratified on the basis of the hospital of care: academic hospital or community hospital. All postoperative outcomes were analyzed. RESULTS: A total of 17,388 CEAs met the inclusion criteria, among which 9,649 cases were performed at an academic institution and 7,739 cases were performed at a community hospital. There were more women in the community hospital cohort (42.5% vs. 40.2%, p = 0.0197). Preoperatively, the community hospital cohort had more patients with dyspnea (22.8% vs. 18.1%, p < 0.0001), chronic obstructive pulmonary disease (COPD) (10.7% vs. 9.7%, p = 0.0322), angina (2.6% vs. 1.9%, p = 0.0021), previous stroke with no deficit (9.0% vs. 7.6%, p = 0.0009), and past transient ischemic attacks (28.3% vs. 25.1%, p < 0.0001). The academic hospital cohort had more patients with recent alcohol use (4.5% vs. 3.8%, p = 0.0245), cardiac surgery (24.0% vs. 22.5%, p = 0.0206), and hemiplegia (4.8% vs. 4.1%, p = 0.0288). Postoperatively, there was no difference in the two groups in 30-day stroke rate (1.2% vs. 1.5%, p = 0.1035), 30-day myocardial infarction rate (0.5% vs. 0.6%, p = 0.2149), or 30-day mortality rate (0.5% vs. 0.6%, p = 0.6335). The overall combined 30-day stroke, myocardial infarction, and mortality rates were not different between the two groups (2.2% vs. 2.7%, p = 0.0568). In the asymptomatic patient cohort, there were a total of 9,285 cases, with 5311 cases performed at an academic institution and the remainder at community hospitals. Preoperatively, the community hospitals had more patients with dyspnea (78.3% vs. 82.1%, p < 0.0001). The academic cohort had more patients with acute renal failure (0.3% vs. 0.1%, p = 0.0426). Postoperatively, there was no difference in the two groups in 30-day stroke rate (0.9% vs. 1.1%, p = 0.2899), 30-day myocardial infarction rate (0.4% vs. 0.5%, p = 0.4348), or 30-day mortality rate (0.5% vs. 0.4%, p = 0.6370). The overall combined 30-day stroke, myocardial infarction, and mortality rates were not different between the two groups (1.8% vs. 2.0%, p = 0.4394). CONCLUSION: CEA is widely performed in both academic and community hospital settings. This study demonstrates that the results are equivalent and have equally good 30-day outcomes in both asymptomatic and combined populations.

Vascular complications of exposure for anterior lumbar interbody fusion.

OBJECTIVE: The purpose of this study is to document the incidence of vascular complications during anterior lumbar interbody fusion (ALIF) in 212 consecutive patients treated at the Scripps Clinic and determine what factors adversely affected outcome. METHODS: We reviewed the prospectively maintained database of all ALIF procedures performed at Scripps Clinic between August 2004 and June 2009. All procedures were performed by a spine surgeon in conjunction with a vascular surgeon who performed the exposure portion of the operation, and protected the vessels from injury during the instrumentation phase of the operation. RESULTS: Two hundred twelve ALIF operations were identified. The mean age of the patients was 53.8 years, and 120 (56.6%) were female. The mean body mass index (BMI) was 29.6 (range, 18.1 to 47.8). Twenty-two (10.4%) operations were performed at the L4-5 disc space, 149 (70.3%) at L5-S1, and 41 (19.3%) involved L4-L5 with L5-S1. The mean estimated blood loss (EBL) was 143 milliliters. There was a significant direct correlation between increasing BMI and EBL (P = .018). Thirteen (6.1%) vascular injuries occurred of which five were major (38.5%). One major arterial injury (0.5%) occurred and required arterial thrombectomy and stent placement. Four of the major vascular injuries were venous in nature and required a multi-suture repair. The remaining eight injuries (61.5%) were venous, the majority of which required a suture repair. There were no mortalities. There was an increase risk of vascular injury when both L4-L5 and L5-S1 were exposed (P = .003) and with the male gender (P = .013). Calcification of the aorto-iliac system did not exert an effect on EBL or vascular injury. In four cases, the surgeon was unable to expose the appropriate disc levels. CONCLUSIONS: Anterior exposure of the spine for ALIF can be performed safely with a team approach that includes a vascular surgeon. Preoperative evaluation by a vascular surgeon is advisable. Patients with increased BMI and bi-level exposures should be approached with caution.

Contemporary results of carotid endarterectomy for asymptomatic carotid stenosis.

BACKGROUND AND PURPOSE: The validity of carotid endarterectomy (CEA) for asymptomatic carotid stenosis has been questioned recently due to the increasing effectiveness of medical management. In this study, we evaluated how contemporary outcomes of CEA for asymptomatic carotid stenosis compare with published stroke rates for best medical management. METHODS: We identified all patients who underwent CEA for asymptomatic carotid stenosis from the 2005, 2006, and 2007 National Surgical Quality Improvement Program (NSQIP) database. Pre- and postoperative variables, including 30-day stroke, death, and myocardial infarction, were analyzed. RESULTS: Of 10 423 carotid endarterectomies identified, 5009 were for asymptomatic carotid stenosis. The stroke, death, and myocardial infarction rates of this group were 0.96%, 0.56%, and 0.22%, respectively. If the 0.96% perioperative stroke rate from our contemporary NSQIP analysis is combined with the 5-year stroke risk after CEA of 3.8% from the Asymptomatic Carotid Surgery Trial, the average annual stroke rate is 1%, comparable to the stroke rate of 0.8% for best medical management from the Second Manifestations of Arterial Disease Study trial. CONCLUSIONS: These contemporary results show that stroke rates with CEA and best medical management for asymptomatic stenosis are similar. Despite limitations, our results emphasize the importance of continuing randomized prospective trials comparing CEA and best medical management for asymptomatic carotid stenosis.

Use of a stent graft for bleeding hepatic artery pseudoaneurysm following pancreaticoduodenectomy.

Although uncommon, bleeding following pancreaticoduodenectomy is associated with high mortality. Management generally includes surgical reexploration or, alternatively, transarterial embolization. We report the case of a 62-year-old man who presented with massive upper gastrointestinal bleeding 3 weeks after pancreaticoduodenectomy. Selective coeliac angiography revealed a large pseudoaneurysm involving the proper hepatic artery. This was treated successfully with a stent graft. There was no recurrence of bleeding at the 6-month follow-up. To our knowledge, this is the first report of stent graft repair of bleeding hepatic artery pseudoaneurysm following pancreaticoduodenectomy.

Evidence for ozone formation in human atherosclerotic arteries.

Here, we report evidence for the production of ozone in human disease. Signature products unique to cholesterol ozonolysis are present within atherosclerotic tissue at the time of carotid endarterectomy, suggesting that ozone production occurred during lesion development. Furthermore, advanced atherosclerotic plaques generate ozone when the leukocytes within the diseased arteries are activated in vitro. The steroids produced by cholesterol ozonolysis cause effects that are thought to be critical to the pathogenesis of atherosclerosis, including cytotoxicity, lipid-loading in macrophages, and deformation of the apolipoprotein B-100 secondary structure. We propose the trivial designation "atheronals" for this previously unrecognized class of steroids.