The Modified Harborview Risk Score Successfully Predicts Mortality After Ruptured Abdominal Aortic Aneurysm Repair.

OBJECTIVE: The traditional Harborview Risk Score (tHRS) uses four criteria to predict mortality after surgical repair of ruptured abdominal aortic aneurysms (rAAA): preoperative minimum systolic blood pressure (SBP <70mm Hg), creatinine (>2.0 mg/dL), age (>76 years) and preoperative arterial pH (<7.2). Difficulties obtaining arterial pH values limit the clinical utility of this score. International normalized ratio (INR >1.8) has been proposed as an acceptable substitution when arterial blood gases are not available preoperatively. Preliminary studies have shown that the accuracy of the score is not compromised when using this modified criterion. The objective of this study is to validate the modified Harborview Risk Score (mHRS). METHODS: We conducted a retrospective analysis of all patients presenting with rAAA at a single tertiary-care center from 2011 to 2022. The Vascular Study Group of New England (VSGNE) score was used for comparison. The primary outcome was 30-day mortality. Logistic regression and receiver operating characteristic (ROC) curves were used to evaluate the predictability of each score. Categorical and continuous data were compared using Chi-squared and Student's t-tests, respectively. RESULTS: Of the 91 patients identified during the study period, 69 patients met inclusion criteria. 50 patients underwent endovascular repairs (rEVAR) and 19 patients received open repairs (rOR). All 69 patient records had documented INR values, and 62 patients (89.8%) had documented arterial pH values. The 30-day mortality rate was 38% overall (30% for rEVAR vs. 58% for rOR, p=0.030). There was a stronger linear relationship between the mHRS and 30-day mortality (R2=0.97) than the VSGNE score (R2=0.94). There was no significant difference in the areas under the ROC curves between the mHRS and VSGNE scores (0.70 [0.56-0.83], p=0.007 vs. 0.69 [0.56-0.82], p=0.01, respectively). Logistic regression analysis showed a significant correlation between creatinine (4.0 [1.2-13.8], p=0.03), SBP (3.8 [1.3-11.1], p=0.02), and age (1.7 [1.1-7.4], p=0.04) and 30-day mortality. CONCLUSIONS: The mHRS accurately predicted 30-day mortality after rAAA repair using INR >1.8. By using easily obtainable preoperative variables, the mHRS has broader clinical utility, making it a superior scoring system to the tHRS and VSGNE scores.

Area Deprivation Index is not predictive of worse outcomes after open lower extremity revascularization.

OBJECTIVE: Prior research has shown that socioeconomic status (SES) is associated with higher rates of diabetes, peripheral vascular disease, and amputation. We sought to determine whether SES or insurance type increases the risk of mortality, major adverse limb events (MALE), or hospital length of stay (LOS) after open lower extremity revascularization. METHODS: We conducted a retrospective analysis of patients who underwent open lower extremity revascularization at a single tertiary care center from January 2011 to March 2017 (n = 542). SES was determined using state Area Deprivation Index (ADI), a validated metric determined by income, education, employment, and housing quality by census block group. Patients undergoing amputation in this same time period (n = 243) were included to compare rates of revascularization to amputation by ADI and insurance status. For patients undergoing revascularization or amputation procedures on both limbs, each limb was treated individually for this analysis. We performed a multivariate analysis of the association between ADI and insurance type with mortality, MALE, and LOS using Cox proportional hazard models, including confounding variables such as age, gender, smoking status, body mass index, hyperlipidemia, hypertension, and diabetes. The cohort with an ADI quintile of 1, meaning least deprived, and the Medicare cohort were used for reference. P values of <.05 were considered statistically significant. RESULTS: We included 246 patients undergoing open lower extremity revascularization and 168 patients undergoing amputation. Controlling for age, gender, smoking status, body mass index, hyperlipidemia, hypertension, and diabetes, ADI was not an independent predictor of mortality (P = .838), MALE (P = .094), or hospital LOS (P = .912). Controlling for the same confounders, uninsured status was independently predictive of mortality (P = .033), but not MALE (P = .088) or hospital LOS (P = .125). There was no difference in the distribution of revascularizations or amputations by ADI (P = .628), but there was higher proportion of uninsured patients undergoing amputation compared with revascularization (P < .001). CONCLUSIONS: This study suggests that ADI is not associated with an increased risk of mortality or MALE in patients undergoing open lower extremity revascularization, but that uninsured patients are at higher risk of mortality after revascularization. These findings indicate that individuals undergoing open lower extremity revascularization at this single tertiary care teaching hospital received similar care, regardless of their ADI. Further study is warranted to understand the specific barriers that uninsured patients face.

Neutrophil-To-Lymphocyte Ratio as a Predictive Tool for Post-Operative Outcomes in Patients Undergoing Open Lower Extremity Revascularization Procedures.

BACKGROUND: Elevated neutrophil-to-lymphocyte ratio (NLR), a marker of systemic inflammation, has been shown to correlate with worse outcomes in patients undergoing vascular surgery. Limited data exists on the association of NLR and outcomes in patients undergoing lower extremity vascular surgery. We sought to investigate whether preoperative NLR correlates with outcomes in patients undergoing open lower extremity revascularization procedures. METHODS: We conducted a retrospective analysis of a prospectively maintained database of patients who underwent open lower extremity revascularization procedures from January 2011 to January 2017 (N = 535). Preoperative NLR was calculated within 6 months of surgery. Primary outcomes were major adverse limb event (MALE) or death. The maximally-ranked statistic method was used to determine the NLR cut-off point. Kaplan-Meier analyses of death and MALE and NLR were used to compare the groups by NLR cut-off point. We conducted a multivariate analysis of the association between NLR and mortality using Cox proportional hazard models, including confounding variables such as age, smoking status, and diabetes. P-values <0.05 were considered statistically significant. RESULTS: Two hundred and fifty four patients undergoing surgery from January 2011 to January 2013 were analyzed. The median NLR was 3.6 interquartile range [IQR 2.5-6.7]. The analysis showed a negative correlation between elevated NLR and mortality (P < 0.001), but not MALE (P = 0.8). Controlling for multiple comorbidities including gender, age, smoking, body mass index (BMI), diabetes, hyperlipidemia, hypertension, and infection, the NLR cut-off point was a significant independent predictor of mortality (P < 0.0001), but not MALE (P = 0.551). Elevated NLR was also correlated with statistically and clinically significant longer hospital stays (6.5 [IQR 3.0-12.8] days vs. 4.0 [IQR 2.0-8.0] days, P = 0.027). CONCLUSIONS: This study suggests that NLR is an independent predictor of mortality and hospital length of stay in patients undergoing open lower extremity revascularizations. Going forward, we plan to expand this study to include more patients and to compare NLR to other risk assessment tools.

A hybrid endovascular and open approach to rare thyrocervical trunk and subclavian pseudoaneurysms complicated by embolic brachial artery occlusion.

Subclavian and thyrocervical trunk pseudoaneurysms are rare pathologies and even more so when they occur simultaneously. Treatment of these vascular injuries can be done endovascularly or with open surgery. We present a novel two-stage, hybrid open and endovascular approach to the management of a healthy 41-year-old man with no personal or family history of connective tissue disorders, who presented with subclavian branch and thyrocervical trunk pseudoaneurysms complicated by brachial artery occlusion. The pseudoaneurysms were treated with microvascular plug deployment, followed by subclavian artery covered stenting, with treatment of the brachial occlusion via open thrombectomy with patch angioplasty. The patient recovered without any complications.