Elective endovascular aneurysm repair in the elderly: trends and outcomes from the Nationwide Inpatient Sample.

OBJECTIVES: This study attempted to identify trends in the use of endovascular aneurysm repair (EVAR) and outcomes in elective abdominal aortic aneurysm (AAA) repair over a 5-year period in a nationwide dataset, with specific attention to patients older than 80 years. METHODS: The Nationwide Inpatient Sample database was queried for elective AAA repair during 2005 to 2009. Number of EVAR cases, ratio of EVAR/open aneurysm repair (OAR), major clinical outcomes, and discharge status were analyzed by decade. Interval data were compared with analysis of variance (ANOVA) and proportions via chi-squared tests. RESULTS: A total of 174,714 AAA repairs (124,869 EVARs) were identified. The ratio of EVAR/OAR increased with increasing age. Between 2005 and 2009, the total number of AAA repairs increased by 21% (7,179 vs. 8,554) and EVARs increased by 50% (5,057 vs. 7,650; P < 0.05) in patients older than 80 years. In 2009, 85% of AAA repairs in patients older than 80 years were EVARs. Patients older than 80 years constituted 25% of the total EVAR cohort. Although the in-hospital mortality rate remained acceptable in all age groups, EVAR-associated mortality, length of stay, and discharge to a skilled nursing facility increased with each successive decade of life (P < 0.05). Rates of postoperative myocardial infarction and acute renal failure also increased with increasing age (P < 0.05). EVAR results are presented by decade. CONCLUSIONS: EVAR is being performed with increasing frequency in patients older than 80 years, with one-quarter of EVAR performed in patients aged 80 years and older in the current sample. Although mortality rates remain acceptable in this elderly population, EVAR and OAR are associated with an age-dependent increase in death, complications, and discharge to extended care facilities. These factors, in addition to long-term risk of aneurysm rupture, should be considered when evaluating the appropriateness of elective aneurysm repair in the elderly.

Oxidized low-density lipoprotein induces apoptosis in endothelial progenitor cells by inactivating the phosphoinositide 3-kinase/Akt pathway.

We tested the hypothesis that oxidized low-density lipoprotein (oxLDL)-induced inactivation of Akt within endothelial progenitor cells (EPCs) is mediated at the level of phosphoinositide 3-kinase (PI3K), specifically by nitrosylation of the p85 subunit of PI3K, and that this action is critical in provoking oxLDL-induced EPC apoptosis. Hypercholesterolemic ApoE null mice had a significant reduction of the phosphorylated Akt (p-Akt)/Akt ratio in EPCs, as well as a greater percentage of apoptosis in these cells than EPCs isolated from wild-type (WT) C57Bl/6 mice. EPCs were isolated from WT spleen and exposed to oxLDL in vitro. oxLDL increased O2⁻ and H2O2 in these cells and induced a dose- and time-dependent reduction in the p-Akt/Akt ratio and increase in EPC apoptosis. These effects were significantly reduced by the antioxidants superoxide dismutase, L-NAME, epicatechin and FeTPPs. oxLDL also induced nitrosylation of the p85 subunit of PI3K and subsequent dissociation of the p85 and p110 subunits, an effect significantly reduced by all the antioxidant agents tested. EPC transfection with a constitutively active Akt isoform (Ad-myrAkt) significantly reduced oxLDL-induced apoptosis of WT EPCs. The present findings indicate that oxLDL disrupts the PI3K/Akt signaling pathway at the level of p85 in EPCs. This dysfunction can be reversed by ex vivo antioxidant therapy.

Predictors of clinically significant postprocedural hypotension after carotid endarterectomy and carotid angioplasty with stenting.

OBJECTIVES: Significant hypotension after carotid endarterectomy (CEA) and carotid angioplasty with stenting (CAS) has been correlated with adverse outcomes. The objective of this study was to determine risk factors that predict hypotension after patients undergo CEA and CAS. METHODS: The review included 1474 CEA patients and 157 CAS patients who underwent procedures from 2002 to 2008. Specific patient characteristics, such as comorbid diseases, degree of carotid stenosis, presence of neurologic symptoms, and preprocedure medications, were assessed. Also reviewed were specific postprocedural clinical outcomes, including hypotension requiring pressors, myocardial infarction, stroke, death, and hospital length of stay. RESULTS: The incidence of clinically significant hypotension was 12.6% in CEA patients and 35% in CAS patients (P < .001). Clinically significant hypotension was correlated with increased postprocedural myocardial infarction (2.1% vs 0.5%, P = .022), increased mortality (2.1% vs 0.1%, P < .001), and length of stay >2 days (46.3% vs 27.4%, P = .01). Hypotension was not associated with increased postprocedural strokes (0.8% vs 0.6%, P = .75) or recurrent neurologic symptoms (0.4% vs 0.3%, P = .55). Preoperative nitrate use predicted a greater incidence of postprocedural hypotension (P = .043). A history of tobacco use was correlated with postprocedure hypotension (P = .033). Preprocedural strokes, the use of calcium channel blockers, beta-blockers, angiotensin-converting enzyme inhibitors, prior myocardial infarction, degree of preprocedural carotid stenosis, type of stent, previous ipsilateral and contralateral interventions, and female gender did not correlate with postprocedural hypotension (P >.05). CONCLUSIONS: Postprocedural hypotension occurs more commonly with CAS than CEA and is associated with increased postprocedural myocardial infarction and length of stay, and death. Nitrates and tobacco use predict a higher incidence of postprocedural hypotension. High-risk patients should be aggressively managed to prevent the increased morbidity and mortality due to postprocedural hypotension.

Staphylococcus hominis carotid artery infection with septic embolization.

We present the case report of a Staphylococcus hominis carotid artery plaque infection, without mycotic aneurysm formation, that provided the nidus for septic embolization. The patient presented with transient neurologic symptoms, with no clinical signs or symptoms of sepsis. Multiple preoperative imaging modalities revealed critical carotid stenosis but no indication of an infection. Secondary carotid infection was discovered incidentally intraoperatively, and carotid reconstruction was completed with autogenous tissue. The patient transiently manifested sepsis only after the carotid reconstruction and recovered with the institution of parenteral antibiotics.

Trends in treatment of ruptured abdominal aortic aneurysm: impact of endovascular repair and implications for future care.

OBJECTIVE: Our aim was to determine national trends in treatment of ruptured abdominal aortic aneurysm (RAAA), with specific emphasis on open surgical repair (OSR) and endovascular aneurysm repair (EVAR) and its impact on mortality and complications. METHODS: Data from the Nationwide Inpatient Sample (NIS) from 2005 to 2009 were queried to identify patients older than 59 years with RAAA. Three groups were studied: nonoperative (NO), EVAR, and OSR. Chi-square analysis was used to determine the relationship between treatment type and patient demographics, clinical characteristics, and hospital type. The impact of EVAR compared with OSR on mortality and overall complications was examined using logistic regression analysis. RESULTS: We identified 21,206 patients with RAAA from 2005 to 2009, of which 16,558 (78.1%) underwent operative repair and 21.8% received no operative treatment. In the operative group, 12,761 (77.1%) underwent OSR and 3,796 (22.9%) underwent EVAR. Endovascular aneurysm repair was more common in teaching hospitals (29.1% vs 15.2%, p < .0001) and in urban versus rural settings. Nonoperative approach was twice as common in rural versus urban hospitals. Reduced mortality was seen in patients transferred from another institutions (31.2% vs 39.4%, p = 0.014). Logistic regression analysis demonstrated a benefit of EVAR on both complication rate (OR = 0.492; CI, 0.380-0.636) and mortality (OR=0.535; CI, 0.395-0.724). CONCLUSIONS: Endovascular aneurysm repair use is increasing for RAAA and is more common in urban teaching hospitals while NO therapy is more common in rural hospitals. Endovascular aneurysm repair is associated with reduced mortality and complications across all age groups. Efforts to reduce mortality from RAAA should concentrate on reducing NO and OSR in patients who are suitable for EVAR.

Cerebral intolerance during flow arrested carotid angioplasty.

INTRODUCTION: The use of flow arrest as a means of providing cerebral protection during carotid angioplasty offers the advantages of improved efficiency of debris removal and the ability to provide protection under unfavorable (tortuous) anatomic circumstances. However, in contrast to the filtration methods of cerebral protection, this modality requires complete interruption of antegrade carotid artery flow during balloon angioplasty and stent deployment. METHODS: We report our experience with 9 patients undergoing carotid angioplasty with the Mo.Ma device, which utilizes common and external carotid artery balloon occlusion during the angioplasty procedure. We assessed the clinical outcomes and intraprocedural hemodynamic data. RESULTS: The average duration of carotid occlusion was 8.3 minutes. Of the 9 patients, 2 patients (22%) experienced cerebral intolerance. No stroke occurred in this patient cohort. There appeared to be a poor relationship between procedure intolerance and the presence of significant contralateral stenosis or low carotid back pressure. Furthermore, the incidence of postangioplasty hypotension was not clearly related to cerebral intolerance. CONCLUSION: Carotid angioplasty with stenting can be safely conducted with flow arrest as an alternative to filter-type cerebral protection devices. However, because cerebral intolerance is not an infrequent occurrence with this approach, clinicians must be cognizant of management strategies for transient cerebral intolerance.