Gender and 30-day outcome in patients undergoing endovascular aneurysm repair (EVAR): an analysis using the ACS NSQIP dataset.

PURPOSE: Prior studies have demonstrated higher in-hospital mortality in women undergoing open abdominal aortic aneurysm repair. The current study evaluates the relationship between gender and 30-day outcomes for endovascular aneurysm repair (EVAR) in a multicenter, contemporary patient population. METHODS: Patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant use file that underwent EVAR of abdominal aortic aneurysm (AAA) from 2005 to 2007 were identified by CPT codes. Outcomes analyzed were 30-day mortality, morbidity (one or more of 21 complications defined by the ACS NSQIP protocol), length of hospital stay, and six complication subgroups. Preoperative risk factors, intraoperative variables, and outcomes were compared across genders using chi(2) (binary and categorical variables) and t tests (continuous variables). The relationship of gender to outcomes was further evaluated using multivariate logistic regressions to adjust for pre- and intraoperative risk variables. RESULTS: In 3662 EVAR patients, 647 (17.7%) were women and 3015 (82.3%) men with mean ages of 75.1 +/- 9.0 and 73.7 +/- 8.5 years (P < .001). Tube graft (360, 9.8%); bifurcated, one docking limb (1624, 44.3%); bifurcated, two docking limbs (1294, 35.3%); unibody (218, 5.9%); and aorto-uni-iliac/femoral (166, 4.4%) repairs were performed. Tube and aorto-uni-iliac/femoral grafts were more common in women (21.4% vs 12.8%, P < .001) than men, as were femoral/femoral crossovers (3.9% vs 1.8%, P = .011) and iliac or brachial exposures (2.8% vs 1.0%, P = .009). Overall morbidity and mortality were 11.9% and 2.1%, respectively. Mortality in women was significantly higher (3.4% vs 2.1%, P = .014), as was morbidity (17.8% vs 10.6%, P < .001). Of thirteen independent preoperative risk factors for mortality or morbidity, women had a higher incidence in five: emergent operation, functional dependence, recent weight loss, underweight status or morbid obesity, and severe chronic obstructive pulmonary disease (COPD). After adjustment for these variables, the odds ratio (OR) for mortality in women vs men was 1.52 (95% confidence interval [CI] 0.85-2.69, P = .157); OR for morbidity was 1.65 (95% CI 1.28-2.14, P < .001). Female gender was also found to be an independent risk factor for length of stay (Beta 0.7 days, 95% CI 0.2-1.2, P = .006), infectious complications (OR 1.49, 95% CI 1.10-2.03, P = .011), wound complications (OR 1.80, 95% CI 1.12-2.90, P = .015) and postoperative transfusion (OR 2.92, 95% CI 1.39-6.13, P = .002). CONCLUSIONS: Mortality and morbidity were higher in women than men undergoing EVAR. Multivariate analysis showed that the increased risk of mortality was related to women presenting more emergently, more debilitated (recent weight loss and functional dependence), and requiring iliac or brachial exposure. After adjustment for multiple preoperative and operative factors, women remained at significantly higher risk for the development of a broad range of complications and increased length of stay.

Endoluminal thermal ablation versus stripping of the saphenous vein: Meta-analysis of recurrence of reflux.

BACKGROUND: Catheter-based minimally invasive techniques developed to treat saphenous vein insufficiency include endovenous laser and radiofrequency ablation. Their long-term results are under evaluation. A meta-analysis of trials was performed, comparing endovenous versus surgical saphenous vein ablation with focus on long-term (greater than 365 days) outcomes of recurrence of varicosities, reflux and symptomatic disease. METHODS: A systematic search of published studies reporting on the treatment of varicose veins was performed. The databases searched included Medline/PubMed, OVID, EMBASE, CINAHL, ClinicalTrials.gov, the Cochrane central register of controlled trials and the Cochrane database of systematic reviews. Search terms included saphenous vein ligation, stripping, radiofrequency ablation, laser ablation and endovenous ablation. Reports in all languages from 1966 to 2009 were considered. The 'related articles' function was used to broaden the search. All article titles, abstracts and subject headings were screened by one reviewer for potential relevance. Abstracts of articles selected by title were read online to reduce the number of articles for full-text examination. Finally, additional titles were sought in the bibliographies of the retrieved articles. Only studies reporting outcomes after more than 365 days were selected. Analyzed outcomes included recurrence of varicosities and reflux, as documented by duplex ultrasound, and recurrence of signs and symptoms. Data extraction was performed from life tables, text or graphs. Statistical analysis was performed using the commercially available software CMA Version 2 (Biostat Inc, USA). The random effects model was used to calculate the ORs and 95% CIs. Statistical heterogeneity was evaluated using the Q value and considered present if P<0.05. RESULTS: Eight randomized controlled trials were included; these reported on 497 patients. Two hundred twenty-six patients underwent ligation and stripping and 271 underwent endoluminal thermal ablation. The mean (± SD) follow-up period was 584±182 days. There was no difference in the age and sex distribution between the groups. There was no difference in the long-term recurrence rate between the two techniques (OR 0.97, 95% CI 0.48 to 1.9, P=0.9). Statistical heterogeneity was not significant (Q value P=0.5) and publication bias was limited. CONCLUSIONS: The analysis indicates that catheter-based treatments and traditional venous stripping with high ligation have similar long-term results. Establishing preoperative criteria for each method may improve outcomes but presently neither technique appears to confer an advantage in terms of mid- to long-term freedom from recurrent symptoms.

Endovascular versus open repair for descending thoracic aortic rupture: institutional experience and meta-analysis.

Rupture of thoracic aneurysm, acute type B dissection, blunt thoracic trauma, and penetrating aortic ulcer can present with a similar clinical profile of thoracic aortic rupture. We report a meta-analysis of comparative studies evaluating endoluminal graft versus open repair of these lesions as well as the early experience from our institution. We searched the following databases for reports of endovascular versus open repair of acute descending thoracic aortic rupture: Medline/PubMed, OVID, EMBASE, CINAHL, ClinicalTrials.gov, the Cochrane central register of controlled trials and the Cochrane database of systematic reviews. We used the random-effects model to calculate the odds ratio (OR) and 95% confidence intervals (CI) for mortality, paraplegia/paraparesis and stroke rates. Also, the medical records of the patients treated in our institution with this technique from 2000 to 2008 were reviewed. Demographics, comorbidities and operative procedure information were retrieved. Outcomes examined were mortality, paraplegia and stroke. Meta-analysis indicates that endoluminal graft repair is accompanied by lower procedure related mortality (OR 0.46, 95% CI 0.26-0.78, p=0.005) and paraplegia rates (OR 0.23, 95% CI 0.08-0.65, p=0.005), as compared to open repair. There was no difference in stroke rate between the two methods (OR 0.86, 95% CI 0.26-2.8, p=0.8). We have treated 13 patients with endoluminal stent-grafts. No conversion to open repair was necessary. Stroke rate was 15%, no patient died as a result of the stent-graft placement, one patient died as a result of massive head injury (overall 30-day mortality: 7.5%). There were no spinal cord ischemic complications. Our experience and meta-analysis indicate that thoracic endograft repair has low mortality and spinal cord complication rates for treatment of acute thoracic aortic rupture. If this method proves to be durable, it could replace open repair as the treatment of choice for these critically ill patients.

Long-term outcome of infrapopliteal catheter-based intervention for critical limb ischemia.

CONTEXT: Percutaneous treatment of tibioperoneal occlusive disease is associated with decreased morbidity compared with bypass surgery. The long-term patency and limb salvage rates are not well documented. AIMS: To evaluate the long-term outcome of endoluminal interventions for tibioperoneal lesions. METHODS: A retrospective study was performed to determine the outcomes of patients undergoing infrapopliteal catheter-based intervention for critical limb ischemia. Collected data included demographics, comorbidities, clinical presentation, pre- and postintervention noninvasive vascular measurements (segmental pressure and waveforms, and ankle-brachial index [ABI]), type of intervention, limb loss rate, patient follow-up and need for surgical revascularization. Statistical analysis was performed with the two-tailed t test. P<0.05 was considered significant; results were reported as mean ± SD. Cox regression analysis and Kaplan-Meier limb survival analysis were performed to demonstrate freedom from amputation over time. RESULTS: Thirty-five patients underwent intervention from 2003 to 2008; technical success was achieved in 26 patients (75%). Arterial segmental pressure studies revealed a significant increase in ABI - preprocedure ABI was 0.62±0.24 versus a postintervention ABI of 0.81±0.29 (P=0.02). The limb salvage rate was 63% during the follow-up period. Limb salvage was better for patients who underwent isolated infrapopliteal intervention versus combined above and below the knee intervention. CONCLUSION: Percutaneous interventions for tibioperoneal occlusive disease offer an acceptable limb salvage rate and may be the preferred initial treatment for critical limb ischemia.