Objectives: There are few data to delineate the risk differences among open aortic procedures. We... more Objectives: There are few data to delineate the risk differences among open aortic procedures. We aimed to investigate the influence of the procedural types on the outcomes of proximal thoracic aortic aneurysm repair. Methods: Among 1900 patients who underwent aortic replacement in our institution between 2005 and 2019, 1132 patients with aortic aneurysm who underwent a graft replacement of proximal thoracic aorta were retrospectively reviewed. Patients were divided into 4 groups based on the extent of the aortic replacement: isolated ascending aortic replacement (n ¼ 52); ascending aortic replacement with distal extension with hemiarch, partial arch, or total arch replacement (n ¼ 126); ascending aortic replacement with proximal extension with aortic valve or root replacement (n ¼ 620); and ascending aortic replacement with distal and proximal extension (n ¼ 334). "Eventful recovery," defined as occurrence of any key complications, was used as the primary end point. Odds ratios for inability to achieve uneventful recovery in each procedure were calculated using ascending aortic replacement as a reference. Results: Overall, in-hospital mortality and stroke occurred in 16 patients (1.4%) and 24 patients (2.1%). Eventful recovery was observed in 19.7% of patients: 11.5% in those with ascending aortic replacement, 36.5% in those with partial arch or total arch replacement, 16.6% in those with proximal extension with aortic valve or root replacement, and 20.4% in those with distal and proximal extension (P < .001). With ascending aortic replacement as the reference, a multivariable logistic regression revealed partial arch or total arch replacement (odds ratio, 10.0; 95% confidence interval, 1.8-189.5) was an independent risk factor of inability to achieve uneventful recovery. Conclusions: Open proximal aneurysm repair in the contemporary era resulted in satisfactory in-hospital outcomes. Distal extension was associated with a higher risk for postoperative complications. (JTCVS Open 2022;12:1-12)
For ascending aortic pseudoaneurysms with a large aortic entry site and thrombus burden, temporar... more For ascending aortic pseudoaneurysms with a large aortic entry site and thrombus burden, temporary stent-graft placement at induction of circulatory arrest can prevent thrombotic complication.
abdominal sarcopenia. Among chronic aortic disease patients, thoracic and abdominal sarcopenia oc... more abdominal sarcopenia. Among chronic aortic disease patients, thoracic and abdominal sarcopenia occurred in 37% and 35% (81% agreement). Sarcopenic patients were older, had lower body mass indices, and were more frequently male and white; comorbidities and procedural characteristics were similar between patient groups. Whereas abdominal sarcopenia did not predict mortality at any time point (Fig 1; 2-year mortality, 16% vs 15%; P ¼ .66), T12 sarcopenia was associated with substantially higher long-term mortality (Fig 2; 2-year mortality 23% vs 10%; P < .05). In contrast, among injured patients, thoracic sarcopenia was less frequent (15%), and was not associated with increased mortality (0% vs 15%; P ¼ .58). Conclusions: Thoracic sarcopenia is common among patients with chronic aortic disease, and is an important and specific predictor of long-term mortality after TEVAR. In contrast, psoas-derived assessment of sarcopenia may not be valid in this patient population. As an objective, reproducible, and patient-specific indicator of frailty, T12 sarcopenia may provide for valuable risk assessment to optimize appropriate patient selection for TEVAR and to identify patients at greater risk for late adverse outcomes.
Objective: Although the effect of body mass index on the treatment of infrainguinal peripheral ar... more Objective: Although the effect of body mass index on the treatment of infrainguinal peripheral arterial disease (PAD) has been analyzed, outcomes of patients on the high end of the spectrum of morbid obesity (MO; body mass index >40) and superobesity (SO) are unclear. Our goal was to analyze perioperative outcomes of infrainguinal PAD after lower extremity bypass (LEB) and peripheral vascular interventions (PVIs) in this population of patients. Methods: The Vascular Quality Initiative was reviewed for all infrainguinal PAD interventions from 2010 to 2017. Patient and case details were recorded. Multivariable analysis was used to analyze outcomes. Results: We identified 30,389 LEB cases (69.8% nonobese, 27.1% obese, 2.8% MO, 0.33% SO) and 84,649 PVI cases (67.9% nonobese, 28.1% obese, 3.5% MO, 0.52% SO). For LEB and PVI, MO and SO patients were younger, more often female, less often with smoking history, more often on Medicaid, and more often ambulatory, with diabetes, end-stage renal disease, congestive heart failure, and fewer previous inflow procedures (P <. 05 for all). LEB and PVIs in MO and SO were less often elective and more often for tissue loss. For LEB, MO and SO patients more often had great saphenous vein used as conduit and had popliteal artery origin grafts (P < .05). In PVI, MO and SO patients more often had tibial interventions (P < .05). Multivariable analysis showed that after LEB, MO and SO were not associated with increased perioperative cardiac complications, return to operating room, primary patency, and mortality. MO was associated with increased surgical site infection. Multivariable analysis showed that after PVI, MO and SO were not associated with periprocedural access site hematoma, access site stenosis or occlusion, and mortality. Conclusions: MO and SO were not independently associated with increased major adverse outcomes after LEB and PVI, aside from surgical site infections after LEB. Overall, MO and SO patients have more comorbidities and have more advanced presentation. MO and SO alone should not deter appropriate revascularization.
Objective: Acute mesenteric ischemia (AMI) is a life-threatening condition associated with dismal... more Objective: Acute mesenteric ischemia (AMI) is a life-threatening condition associated with dismal outcomes. This study sought to evaluate the evolution of presentation, treatment, and outcomes in AMI patients during the past two decades. Methods: Patients who presented with AMI from 1993 to 2015 across three institutions were reviewed. Primary outcome was 30-day mortality. Univariate and multivariate analysis were performed. Results: There were 305 patients identified. AMI mechanisms included embolic (49%), thrombotic (28%), and nonocclusive (22%). The majority were women (55%), 50% had atrial fibrillation, and 41% had a procedure within 30 days of presentation. Mean age was 72 6 13 years. There were 244 patients who underwent operative exploration: 225 open vs 19 hybrid/endovascular. Among patients explored, 32% (n ¼ 77) underwent a second-look procedure; the majority of these patients (n ¼ 49/77 [64%]) required either additional revascularization or bowel resection at time of second-look surgery. The 30-day mortality was 60% (n ¼ 182). In comparing patients who presented before 2004 with those who presented after, 30-day mortality was similar (before 2004, 62%; after 2004, 58%; P ¼ .47), but anticoagulation use was more prevalent in the contemporary cohort (10% vs 34%; P < .001). There was a trend toward embolic events representing fewer AMI cases over time: 52% to 45%. Up to one in three operations had findings of nonsurvivable bowel necrosis before 2004, and this decreased to one in five after 2004. Predictors of 30-day mortality included an admission white blood cell count $23,000/m 3 (odds ratio [OR], 2.8; P ¼ .02) and coronary disease (OR, 2.1; P ¼ .01); anticoagulation use was protective (OR, 0.24; P ¼ .001). Predictors of nonsurvivable bowel necrosis included embolic event (OR, 4.4; P ¼ .001) and chronic kidney disease (OR, 4.9; P ¼ .003); white blood cell count and lactate concentration were not predictive. Conclusions: Despite advances in critical care during the past 25 years, AMI continues to be associated with poor prognosis. Fewer patients with nonsurvivable bowel necrosis are being operated on, suggesting improvement in clinician prognostication. However, contemporary rates of 30-day mortality remain high at 58%. The significant percentage of patients requiring intervention on second-look procedures suggests this practice is prudent. Better guidelines for and compliance with anticoagulation appear to contribute to decreasing embolic events causing AMI.
degenerative), and dialysis (0% postdissection, 3% degenerative). Mean follow-up was 14 6 11 mont... more degenerative), and dialysis (0% postdissection, 3% degenerative). Mean follow-up was 14 6 11 months. At 2 years, there was no difference (P > .05) in patient survival (81% 6 8% vs 73% 6 0.5%), freedom from aortic death (98% 6 2% vs 97% 6 1%), primary (95% 6 2% vs 97% 6 1%) and secondary target artery patency (99% 6 1% vs 99% 6 0.6%), target artery instability (89% 6 3% vs 93% 6 1%), and freedom from secondary interventions (68% 6 8% vs 78% 6 4% at 1 year) for postdissection and degenerative TAAAs, respectively (Table). Conclusions: Despite some differences in demographics, anatomic factors, and stent graft design, fenestrated-branched endovascular aneurysm repair was safe and effective with nearly identical outcomes in patients with postdissection and degenerative TAAAs. Larger clinical experience and longer follow-up are needed to better evaluate differences in mortality, spinal cord injury, target vessel instability, and secondary interventions.
European Journal of Vascular and Endovascular Surgery, 2019
Objectives: Stroke after carotid endarterectomy (CEA) has been assessed widely. However, factors ... more Objectives: Stroke after carotid endarterectomy (CEA) has been assessed widely. However, factors enhancing non-ipsilateral stroke risk are poorly defined. The aim of this study was to identify drivers of 30 day non-ipsilateral stroke after CEA in the Vascular Quality Initiative (VQI) and assess long-term survival based on laterality of post-operative stroke. Methods: The VQI was queried between April 1, 2003, and March 31, 2017, for all CEA. Bilateral carotid procedures within 30 days were excluded. Thirty day non-ipsilateral strokes were identified. Factors were examined to discriminate between patients with and without non-ipsilateral stroke. Univariable analysis followed by multivariable logistic regression was performed. KaplaneMeier and log rank methods were used to estimate and compare survival. Results: During this 14 year period, 80,230 CEA in 74,928 patients met the criteria. The average age was 70.3 6 9.3 years. Most were male (48,506; 60%), Caucasian (73,967; 92%), smokers (60,543; 76%), and asymptomatic (43,074; 54%). Contralateral stenosis $70% was present in 8033 (10%) with 2239 (3%) having contralateral occlusion. In 491 (0.6%) patients, peri-operative non-ipsilateral stroke occurred. After characterising univariable associations, logistic regression identified independent drivers of non-ipsilateral stroke after CEA. Operative urgency (p = .001), symptomatic disease (p < .001) and contralateral occlusion (p = .001) were pre-operative drivers. Operative predictors included shunt use (p = .008), CEA with cardiac surgery (p = .013), and CEA with concomitant proximal ipsilateral endovascular intervention (p = .01). Use of dextran (p = .005) and anti-angiotensin therapy (p = .03) were protective. Reperfusion syndrome (p < .001), re-exploration (p < .001), myocardial infarction (p < .001), and intravenous treatment of hypotension (p < .001) or hypertension (p < .001) were postoperative correlates. Non-ipsilateral stroke 30 day mortality was less than ipsilateral stroke (6.1% vs. 10.3%; p = .007). Five year survival after non-ipsilateral stroke was 73%, and no different from ipsilateral stroke 76% (p = .16). Both were worse than without stroke (88%; p < .001). Conclusion: Non-ipsilateral stroke after CEA is rare. Features driving risk surround global disease burden, combined procedures, and haemodynamic fluctuations. Contralateral occlusion independently increases non-ipsilateral stroke risk. Regardless of laterality or location, effects of stroke after CEA on long-term survival are similar.
or glue (n-butyl cyanoacrylate) and coil embolization were used in 20 of 26 cases; 6 patients wer... more or glue (n-butyl cyanoacrylate) and coil embolization were used in 20 of 26 cases; 6 patients were treated with coiling alone. Total procedure time was 75.9 6 40.7 minutes, contrast material volume was 19.9 6 29 mL, fluoroscopy time was 13.74 6 12.2 minutes, and radiation dose was 121.16 6 167.7 mGy. After embolization, the mean sac diameter decreased by 4.3 mm to 64.6 6 9.3 mm. The average follow-up period was 214 days. In 18 patients, the sac reduced in size from 0.2 to 47.62 mm/100 days; in 3 patients, there was continued AAA expansion (0.6 to 4.31 mm/100 days); there was no change in the sac size in 4 patients after the procedure. Once treated, the recurrence rate of T2L was low (Fig). The patients with sac growth tended to be associated with higher body mass index and baseline estimated glomerular filtration rate levels (P ¼ .09). Conclusions: This initial multicenter evaluation of the effectiveness of fusion image-guided translumbar obliteration of T2L demonstrated that the technique was effective at all three study centers and showed excellent midterm efficacy to reduce AAA sac size. This may become a more effective and efficient method of treating T2L after endovascular aortic repair going forward.
Peripheral Arterial Disease of the Lower Limbs Arterial disease of the lower limbs is often encou... more Peripheral Arterial Disease of the Lower Limbs Arterial disease of the lower limbs is often encountered in general and specialist practice. This video presents the systematic assessment of arterial perfusion of the lower limbs to prevent limb or tissue loss.
compared between the two groups. Long-term follow-up was collected by telephone survey inquiring ... more compared between the two groups. Long-term follow-up was collected by telephone survey inquiring about intensity of symptoms on a numeric rating scale of 0 to 10 before and after treatment. A multivariable analysis was performed to identify predictors of recurrence. Results: There were 362 patients with 529 veins treated. The mean age was 59.2 6 14.4 years (63% women). There were significant differences in history of hypertension (P ¼ .02) and deep venous thrombosis (P ¼ .02) between the two groups (Table I). The clinical success, technical success, and complication rates were 80%, 95.6%, and 11.5%. There were no significant differences between the two groups in outcomes (Table II). After a mean follow-up of 27.5 months, recurrence rate was 22.2%. There was a trend toward higher recurrence in group B that did not reach statistical significance (P ¼ .1). On multivariable analysis, there was no clinical or technical factor that could predict recurrence. Conclusions: The experience with radiofrequency VA does not support difference in outcomes when treatment starts at $3 cm from the deep junction. However, there is a trend toward increased longterm recurrence that warrants further investigation with the newer technology.
Background: Major adverse event (MAE) rates are used as a measure of outcomes assessment after su... more Background: Major adverse event (MAE) rates are used as a measure of outcomes assessment after surgical procedures. Although MAE rates summarize the occurrences of adverse events, they do not reflect differences in severity of these events. We propose that a measure of complication severity could provide a more sensitive assessment about the quality of care. We compare outcomes of elective endovascular aneurysm repair (EVAR) across centers in the Vascular Study Group of New England (VSGNE) using actual MAE rates, predicted MAE rates, complication severity-adjusted MAE rates, and mortality. Methods: Patients undergoing elective EVAR (n ¼ 4731) at 30 VSGNE centers between 2003 and 2016 were studied. The MAE composite end point was defined as the occurrence of any of the following postoperative events: myocardial infarction, dysrhythmia, congestive heart failure, leg ischemia, renal insufficiency, bowel complication, reoperation, surgical site infection, stroke, respiratory complication, and no home discharge. An adjustment factor (complication severity index [CSI]) was calculated as a ratio of length of stay for complicated to uncomplicated cases. Adjusted MAE rates were calculated as the actual rate multiplied by the CSI. Multivariate logistic regression was used to calculate predicted MAE rates. The actual, predicted, and CSI-adjusted MAE rates were compared among centers and across quintiles of center volume. Results: Actual MAE rates varied from 0% to 39%. Multivariate predictors of MAE included abdominal aortic aneurysm diameter >6 cm (odds ratio, 2.1 [95% confidence interval, 2.0-2.3]), female gender (2.0 [1.8-2.2]), chronic renal insufficiency (1.9 [1.7-2.1]), age >75 years (1.9 [1.8-2.1]), congestive heart failure (1.7 [1.5-1.9]), chronic obstructive pulmonary disease (1.5 [1.4-1.6]), diabetes (1.4 [1.1-1.7]), positive stress test result (1.2 [1.1-1.4]), preoperative beta blocker (1.2 [1.1-1.3]), and no preoperative statin (1.2 [1.1-1.3]). Predicted MAE rates ranged from 21% to 29%. Complication severity-adjusted MAE rates ranged from 0% to 100% (Fig). Conclusions: MAE rates after elective EVAR vary widely across centers of the VSGNE. Adjusted MAE rates track similarly to actual rates and provide a more sensitive measure of complication severity.
in preserving pelvic perfusion, such as preventing buttock claudication and sexual dysfunction, i... more in preserving pelvic perfusion, such as preventing buttock claudication and sexual dysfunction, is warranted.
European Journal of Vascular and Endovascular Surgery, 2017
This study compares outcomes following use of suprarenal versus infrarenal fixation devices durin... more This study compares outcomes following use of suprarenal versus infrarenal fixation devices during EVAR, including among surgeons who routinely use one or the other. Background: Previous studies comparing endografts with suprarenal and infrarenal fixation for endovascular abdominal aortic aneurysm repair (EVAR) have found conflicting results and did not account for differences in patient selection. This study aims to evaluate the differences in outcomes among surgeons who routinely use either suprarenal or infrarenal fixation, as well as all surgeons in the Vascular Study Group of New England (VSGNE). Methods: All patients undergoing EVAR in the VSGNE from 2003 to 2014 were identified. All ruptured aneurysms, repairs with concomitant procedures, and infrequently used stent grafts (<50) were excluded. Suprarenal endografts included Talent, Zenith, and Endurant; infrarenal endografts included AneuRx and Excluder. Grafts were compared among surgeons who used only one type of endograft (suprarenal or infrarenal) for >80% of cases, as well as all surgeons. Multivariate regression and Cox hazard models were utilised to account for patient demographics, comorbidities, operative differences, and procedure year. Results: This study identified 2574 patients (suprarenal, 1264; infrarenal, 1310) with 888 endografts placed by routine users (suprarenal, 409; infrarenal, 479). There were no differences in baseline comorbidities, including the estimated glomerular filtration rate, between suprarenal and infrarenal fixation, or between patients with endografts placed by routine and non-routine users. Patients treated with suprarenal endografts received more contrast than all users (102 mL vs. 100 mL, p ¼ .01) and routine users (110 mL vs. 88 mL, p < .01), but other vascular and operative details were similar. Among all users, patients treated with suprarenal grafts had higher rates of creatinine increase >.5 mg/dL (3.7% vs. 2.0%, p ¼ .01), length of stay >2 days (27% vs. 19%, p < .01), and discharge to a skilled nursing facility (9.2% vs. 6.7%, p ¼ .02). There were no differences in 30 day or 1 year mortality. Following adjustment, suprarenal stent grafts remained associated with an increased risk of renal deterioration (OR 2.0; 95% CI 1.2e3.4) and prolonged length of stay (OR 1.8; 95% CI 1.4e2.2). Among routine users, suprarenal fixation was also associated with higher rates of renal dysfunction (3.7% vs. 1.3%, p ¼ .02; OR 2.9; 95% CI 1.1e7.8). Conclusion: Despite potential differences in patient selection, endografts with suprarenal fixation among all users and routine users were associated with higher rates of renal deterioration and longer length of hospital stay. Longer-term data are needed to determine the duration and severity of renal function decline and to identify potential benefits of decreased migration or endoleak.
Conclusions: The 2006 Massachusetts insurance expansion was associated with a decreased probabili... more Conclusions: The 2006 Massachusetts insurance expansion was associated with a decreased probability of patients presenting with severe peripheral arterial disease (PAD) and resolution of measured racial disparities in presentation with severe PAD in Massachusetts. Summary: Lack of insurance coverage with poor access to care and non-white race have been shown to be associated with increased severity of PAD, decreased rates of revascularization and increased rates of amputation (
Objectives: The 1-year results of endovascular exclusion of degenerative descending thoracic aort... more Objectives: The 1-year results of endovascular exclusion of degenerative descending thoracic aortic aneurysms (DTAs) with the Valiant Thoracic Stent Graft (Medtronic Vascular) have been previously reported. With longterm follow-up now complete, this study reports the 5-year results. Methods: The VALOR II trial was a prospective, nonrandomized trial of the Valiant Thoracic Stent Graft system in patients with degenerative DTA. The trial involved 24 sites in the United States and enrolled patients between December 2006 and September 2009. Standard follow-up included physical examination, computed tomography, and chest radiography through 5 years. Results: The study enrolled 160 patients. The average age was 72.2 years (range, 36-85 years), 95 (59%) were men, 150 (94%) had hypertension, and 26 (16%) had renal insufficiency. There were 50 patients (31%) who presented with symptoms; back pain was the most common (34 [68%]). The average aneurysm diameter was 57 mm (range, 32-96 mm). A fusiform aneurysm was present in 103 patients (64%), and a saccular aneurysm or penetrating ulcer was present in 57 (36%). More than two devices were implanted in 126 patients (79%), and the maximum number of grafts implanted was four. There were 54 deaths during the study. The 5-year survival actuarial was 64%. There were eight aneurysm-related deaths (5 were #30 days of implant), and the 5-year freedom from aneurysm-related death was 95%. There was one conversion to open repair at 36 months. Eleven patients underwent 13 secondary procedures (9 for endoleak, 3 for aneurysm expansion, and 1 rupture). Five-year follow-up imaging was available for 56 patients. The average aortic diameter decreased >5 mm in 27 patients (48%), increased >5 mm in 6 patients (11%), and remained unchanged in 23 patients (41%). Conclusions: The VALOR II 5-year results demonstrate that the reintervention and aneurysm-related death rates are low. The Valiant thoracic stent graft is an effective treatment of degenerative DTA.
clinically rich, vascular-specific quality-improvement registry to evaluate the perioperative and... more clinically rich, vascular-specific quality-improvement registry to evaluate the perioperative and midterm safety of these procedures compared with their open counterpart. Methods: The Vascular Study Group of New England patient registry (2003-2013) was queried to identify patients undergoing open and fenestrated endovascular repair (FEVAR) of cAA. Open repair of cAA was limited to those with a suprarenal or supravisceral clamp site. FEVAR was limited to those with proximal seal in zone 6 or more caudally. Univariate and multivariate analyses were completed with primary end points of 30-day mortality, in-hospital myocardial infarction, in-hospital acute renal failure, and 1-year survival. Results: This study included 685 patients who underwent repair of cAA (639 open, 46 FEVAR). FEVAR configurations involved 1 (7%), 2 (27%), 3 (60%), or 4 (7%) vessels. Baseline demographic data shows the two groups were comparable with respect to gender, race, CKD status, and coronary artery disease history. FEVAR patients were significantly older (74 6 8.2 vs 71 6 8.5 years; P < .01) and trended toward higher congestive heart failure (15% vs 8%; P ¼ .09). FEVAR patients experienced lower but nonsignificant improvement in rates of 30-day mortality (0% vs 4%; P ¼ .39) and postoperative myocardial infarction (0% vs 7%; P ¼ .10). FEVAR patients demonstrated lower rates of acute renal failure (7% vs 21%; P ¼ .05) and showed decreased intensive care unit length of stay (0 6 1 vs 5 6 9 days; P < .01) and overall length of stay (3 6 3.0 vs 11 6 12.6 days; P < .01). Multivariate analysis confirmed that fenestrated repair was not a significant predictor of mortality (P ¼ .97). One-year survival was similar: 76% for FEVAR vs 73% for open repair (hazard ratio, 0.88; 95% confidence interval, 0.27-2.83; P ¼ .83). One-year reintervention rates were 4.8% for open repair and 8.7% for FEVAR (P ¼ .29). Conclusions: This early experience with FEVAR demonstrates similar morbidity and mortality compared with open repair of cAA, despite a higher risk profile in the FEVAR cohort (ie, age, congestive heart failure). Comparable 1-year survival and reintervention rates suggest similar utility for the two procedures. Patient age and comorbidity profiles should figure prominently in the application of FEVAR.
Objectives: There are few data to delineate the risk differences among open aortic procedures. We... more Objectives: There are few data to delineate the risk differences among open aortic procedures. We aimed to investigate the influence of the procedural types on the outcomes of proximal thoracic aortic aneurysm repair. Methods: Among 1900 patients who underwent aortic replacement in our institution between 2005 and 2019, 1132 patients with aortic aneurysm who underwent a graft replacement of proximal thoracic aorta were retrospectively reviewed. Patients were divided into 4 groups based on the extent of the aortic replacement: isolated ascending aortic replacement (n ¼ 52); ascending aortic replacement with distal extension with hemiarch, partial arch, or total arch replacement (n ¼ 126); ascending aortic replacement with proximal extension with aortic valve or root replacement (n ¼ 620); and ascending aortic replacement with distal and proximal extension (n ¼ 334). "Eventful recovery," defined as occurrence of any key complications, was used as the primary end point. Odds ratios for inability to achieve uneventful recovery in each procedure were calculated using ascending aortic replacement as a reference. Results: Overall, in-hospital mortality and stroke occurred in 16 patients (1.4%) and 24 patients (2.1%). Eventful recovery was observed in 19.7% of patients: 11.5% in those with ascending aortic replacement, 36.5% in those with partial arch or total arch replacement, 16.6% in those with proximal extension with aortic valve or root replacement, and 20.4% in those with distal and proximal extension (P < .001). With ascending aortic replacement as the reference, a multivariable logistic regression revealed partial arch or total arch replacement (odds ratio, 10.0; 95% confidence interval, 1.8-189.5) was an independent risk factor of inability to achieve uneventful recovery. Conclusions: Open proximal aneurysm repair in the contemporary era resulted in satisfactory in-hospital outcomes. Distal extension was associated with a higher risk for postoperative complications. (JTCVS Open 2022;12:1-12)
For ascending aortic pseudoaneurysms with a large aortic entry site and thrombus burden, temporar... more For ascending aortic pseudoaneurysms with a large aortic entry site and thrombus burden, temporary stent-graft placement at induction of circulatory arrest can prevent thrombotic complication.
abdominal sarcopenia. Among chronic aortic disease patients, thoracic and abdominal sarcopenia oc... more abdominal sarcopenia. Among chronic aortic disease patients, thoracic and abdominal sarcopenia occurred in 37% and 35% (81% agreement). Sarcopenic patients were older, had lower body mass indices, and were more frequently male and white; comorbidities and procedural characteristics were similar between patient groups. Whereas abdominal sarcopenia did not predict mortality at any time point (Fig 1; 2-year mortality, 16% vs 15%; P ¼ .66), T12 sarcopenia was associated with substantially higher long-term mortality (Fig 2; 2-year mortality 23% vs 10%; P < .05). In contrast, among injured patients, thoracic sarcopenia was less frequent (15%), and was not associated with increased mortality (0% vs 15%; P ¼ .58). Conclusions: Thoracic sarcopenia is common among patients with chronic aortic disease, and is an important and specific predictor of long-term mortality after TEVAR. In contrast, psoas-derived assessment of sarcopenia may not be valid in this patient population. As an objective, reproducible, and patient-specific indicator of frailty, T12 sarcopenia may provide for valuable risk assessment to optimize appropriate patient selection for TEVAR and to identify patients at greater risk for late adverse outcomes.
Objective: Although the effect of body mass index on the treatment of infrainguinal peripheral ar... more Objective: Although the effect of body mass index on the treatment of infrainguinal peripheral arterial disease (PAD) has been analyzed, outcomes of patients on the high end of the spectrum of morbid obesity (MO; body mass index >40) and superobesity (SO) are unclear. Our goal was to analyze perioperative outcomes of infrainguinal PAD after lower extremity bypass (LEB) and peripheral vascular interventions (PVIs) in this population of patients. Methods: The Vascular Quality Initiative was reviewed for all infrainguinal PAD interventions from 2010 to 2017. Patient and case details were recorded. Multivariable analysis was used to analyze outcomes. Results: We identified 30,389 LEB cases (69.8% nonobese, 27.1% obese, 2.8% MO, 0.33% SO) and 84,649 PVI cases (67.9% nonobese, 28.1% obese, 3.5% MO, 0.52% SO). For LEB and PVI, MO and SO patients were younger, more often female, less often with smoking history, more often on Medicaid, and more often ambulatory, with diabetes, end-stage renal disease, congestive heart failure, and fewer previous inflow procedures (P <. 05 for all). LEB and PVIs in MO and SO were less often elective and more often for tissue loss. For LEB, MO and SO patients more often had great saphenous vein used as conduit and had popliteal artery origin grafts (P < .05). In PVI, MO and SO patients more often had tibial interventions (P < .05). Multivariable analysis showed that after LEB, MO and SO were not associated with increased perioperative cardiac complications, return to operating room, primary patency, and mortality. MO was associated with increased surgical site infection. Multivariable analysis showed that after PVI, MO and SO were not associated with periprocedural access site hematoma, access site stenosis or occlusion, and mortality. Conclusions: MO and SO were not independently associated with increased major adverse outcomes after LEB and PVI, aside from surgical site infections after LEB. Overall, MO and SO patients have more comorbidities and have more advanced presentation. MO and SO alone should not deter appropriate revascularization.
Objective: Acute mesenteric ischemia (AMI) is a life-threatening condition associated with dismal... more Objective: Acute mesenteric ischemia (AMI) is a life-threatening condition associated with dismal outcomes. This study sought to evaluate the evolution of presentation, treatment, and outcomes in AMI patients during the past two decades. Methods: Patients who presented with AMI from 1993 to 2015 across three institutions were reviewed. Primary outcome was 30-day mortality. Univariate and multivariate analysis were performed. Results: There were 305 patients identified. AMI mechanisms included embolic (49%), thrombotic (28%), and nonocclusive (22%). The majority were women (55%), 50% had atrial fibrillation, and 41% had a procedure within 30 days of presentation. Mean age was 72 6 13 years. There were 244 patients who underwent operative exploration: 225 open vs 19 hybrid/endovascular. Among patients explored, 32% (n ¼ 77) underwent a second-look procedure; the majority of these patients (n ¼ 49/77 [64%]) required either additional revascularization or bowel resection at time of second-look surgery. The 30-day mortality was 60% (n ¼ 182). In comparing patients who presented before 2004 with those who presented after, 30-day mortality was similar (before 2004, 62%; after 2004, 58%; P ¼ .47), but anticoagulation use was more prevalent in the contemporary cohort (10% vs 34%; P < .001). There was a trend toward embolic events representing fewer AMI cases over time: 52% to 45%. Up to one in three operations had findings of nonsurvivable bowel necrosis before 2004, and this decreased to one in five after 2004. Predictors of 30-day mortality included an admission white blood cell count $23,000/m 3 (odds ratio [OR], 2.8; P ¼ .02) and coronary disease (OR, 2.1; P ¼ .01); anticoagulation use was protective (OR, 0.24; P ¼ .001). Predictors of nonsurvivable bowel necrosis included embolic event (OR, 4.4; P ¼ .001) and chronic kidney disease (OR, 4.9; P ¼ .003); white blood cell count and lactate concentration were not predictive. Conclusions: Despite advances in critical care during the past 25 years, AMI continues to be associated with poor prognosis. Fewer patients with nonsurvivable bowel necrosis are being operated on, suggesting improvement in clinician prognostication. However, contemporary rates of 30-day mortality remain high at 58%. The significant percentage of patients requiring intervention on second-look procedures suggests this practice is prudent. Better guidelines for and compliance with anticoagulation appear to contribute to decreasing embolic events causing AMI.
degenerative), and dialysis (0% postdissection, 3% degenerative). Mean follow-up was 14 6 11 mont... more degenerative), and dialysis (0% postdissection, 3% degenerative). Mean follow-up was 14 6 11 months. At 2 years, there was no difference (P > .05) in patient survival (81% 6 8% vs 73% 6 0.5%), freedom from aortic death (98% 6 2% vs 97% 6 1%), primary (95% 6 2% vs 97% 6 1%) and secondary target artery patency (99% 6 1% vs 99% 6 0.6%), target artery instability (89% 6 3% vs 93% 6 1%), and freedom from secondary interventions (68% 6 8% vs 78% 6 4% at 1 year) for postdissection and degenerative TAAAs, respectively (Table). Conclusions: Despite some differences in demographics, anatomic factors, and stent graft design, fenestrated-branched endovascular aneurysm repair was safe and effective with nearly identical outcomes in patients with postdissection and degenerative TAAAs. Larger clinical experience and longer follow-up are needed to better evaluate differences in mortality, spinal cord injury, target vessel instability, and secondary interventions.
European Journal of Vascular and Endovascular Surgery, 2019
Objectives: Stroke after carotid endarterectomy (CEA) has been assessed widely. However, factors ... more Objectives: Stroke after carotid endarterectomy (CEA) has been assessed widely. However, factors enhancing non-ipsilateral stroke risk are poorly defined. The aim of this study was to identify drivers of 30 day non-ipsilateral stroke after CEA in the Vascular Quality Initiative (VQI) and assess long-term survival based on laterality of post-operative stroke. Methods: The VQI was queried between April 1, 2003, and March 31, 2017, for all CEA. Bilateral carotid procedures within 30 days were excluded. Thirty day non-ipsilateral strokes were identified. Factors were examined to discriminate between patients with and without non-ipsilateral stroke. Univariable analysis followed by multivariable logistic regression was performed. KaplaneMeier and log rank methods were used to estimate and compare survival. Results: During this 14 year period, 80,230 CEA in 74,928 patients met the criteria. The average age was 70.3 6 9.3 years. Most were male (48,506; 60%), Caucasian (73,967; 92%), smokers (60,543; 76%), and asymptomatic (43,074; 54%). Contralateral stenosis $70% was present in 8033 (10%) with 2239 (3%) having contralateral occlusion. In 491 (0.6%) patients, peri-operative non-ipsilateral stroke occurred. After characterising univariable associations, logistic regression identified independent drivers of non-ipsilateral stroke after CEA. Operative urgency (p = .001), symptomatic disease (p < .001) and contralateral occlusion (p = .001) were pre-operative drivers. Operative predictors included shunt use (p = .008), CEA with cardiac surgery (p = .013), and CEA with concomitant proximal ipsilateral endovascular intervention (p = .01). Use of dextran (p = .005) and anti-angiotensin therapy (p = .03) were protective. Reperfusion syndrome (p < .001), re-exploration (p < .001), myocardial infarction (p < .001), and intravenous treatment of hypotension (p < .001) or hypertension (p < .001) were postoperative correlates. Non-ipsilateral stroke 30 day mortality was less than ipsilateral stroke (6.1% vs. 10.3%; p = .007). Five year survival after non-ipsilateral stroke was 73%, and no different from ipsilateral stroke 76% (p = .16). Both were worse than without stroke (88%; p < .001). Conclusion: Non-ipsilateral stroke after CEA is rare. Features driving risk surround global disease burden, combined procedures, and haemodynamic fluctuations. Contralateral occlusion independently increases non-ipsilateral stroke risk. Regardless of laterality or location, effects of stroke after CEA on long-term survival are similar.
or glue (n-butyl cyanoacrylate) and coil embolization were used in 20 of 26 cases; 6 patients wer... more or glue (n-butyl cyanoacrylate) and coil embolization were used in 20 of 26 cases; 6 patients were treated with coiling alone. Total procedure time was 75.9 6 40.7 minutes, contrast material volume was 19.9 6 29 mL, fluoroscopy time was 13.74 6 12.2 minutes, and radiation dose was 121.16 6 167.7 mGy. After embolization, the mean sac diameter decreased by 4.3 mm to 64.6 6 9.3 mm. The average follow-up period was 214 days. In 18 patients, the sac reduced in size from 0.2 to 47.62 mm/100 days; in 3 patients, there was continued AAA expansion (0.6 to 4.31 mm/100 days); there was no change in the sac size in 4 patients after the procedure. Once treated, the recurrence rate of T2L was low (Fig). The patients with sac growth tended to be associated with higher body mass index and baseline estimated glomerular filtration rate levels (P ¼ .09). Conclusions: This initial multicenter evaluation of the effectiveness of fusion image-guided translumbar obliteration of T2L demonstrated that the technique was effective at all three study centers and showed excellent midterm efficacy to reduce AAA sac size. This may become a more effective and efficient method of treating T2L after endovascular aortic repair going forward.
Peripheral Arterial Disease of the Lower Limbs Arterial disease of the lower limbs is often encou... more Peripheral Arterial Disease of the Lower Limbs Arterial disease of the lower limbs is often encountered in general and specialist practice. This video presents the systematic assessment of arterial perfusion of the lower limbs to prevent limb or tissue loss.
compared between the two groups. Long-term follow-up was collected by telephone survey inquiring ... more compared between the two groups. Long-term follow-up was collected by telephone survey inquiring about intensity of symptoms on a numeric rating scale of 0 to 10 before and after treatment. A multivariable analysis was performed to identify predictors of recurrence. Results: There were 362 patients with 529 veins treated. The mean age was 59.2 6 14.4 years (63% women). There were significant differences in history of hypertension (P ¼ .02) and deep venous thrombosis (P ¼ .02) between the two groups (Table I). The clinical success, technical success, and complication rates were 80%, 95.6%, and 11.5%. There were no significant differences between the two groups in outcomes (Table II). After a mean follow-up of 27.5 months, recurrence rate was 22.2%. There was a trend toward higher recurrence in group B that did not reach statistical significance (P ¼ .1). On multivariable analysis, there was no clinical or technical factor that could predict recurrence. Conclusions: The experience with radiofrequency VA does not support difference in outcomes when treatment starts at $3 cm from the deep junction. However, there is a trend toward increased longterm recurrence that warrants further investigation with the newer technology.
Background: Major adverse event (MAE) rates are used as a measure of outcomes assessment after su... more Background: Major adverse event (MAE) rates are used as a measure of outcomes assessment after surgical procedures. Although MAE rates summarize the occurrences of adverse events, they do not reflect differences in severity of these events. We propose that a measure of complication severity could provide a more sensitive assessment about the quality of care. We compare outcomes of elective endovascular aneurysm repair (EVAR) across centers in the Vascular Study Group of New England (VSGNE) using actual MAE rates, predicted MAE rates, complication severity-adjusted MAE rates, and mortality. Methods: Patients undergoing elective EVAR (n ¼ 4731) at 30 VSGNE centers between 2003 and 2016 were studied. The MAE composite end point was defined as the occurrence of any of the following postoperative events: myocardial infarction, dysrhythmia, congestive heart failure, leg ischemia, renal insufficiency, bowel complication, reoperation, surgical site infection, stroke, respiratory complication, and no home discharge. An adjustment factor (complication severity index [CSI]) was calculated as a ratio of length of stay for complicated to uncomplicated cases. Adjusted MAE rates were calculated as the actual rate multiplied by the CSI. Multivariate logistic regression was used to calculate predicted MAE rates. The actual, predicted, and CSI-adjusted MAE rates were compared among centers and across quintiles of center volume. Results: Actual MAE rates varied from 0% to 39%. Multivariate predictors of MAE included abdominal aortic aneurysm diameter >6 cm (odds ratio, 2.1 [95% confidence interval, 2.0-2.3]), female gender (2.0 [1.8-2.2]), chronic renal insufficiency (1.9 [1.7-2.1]), age >75 years (1.9 [1.8-2.1]), congestive heart failure (1.7 [1.5-1.9]), chronic obstructive pulmonary disease (1.5 [1.4-1.6]), diabetes (1.4 [1.1-1.7]), positive stress test result (1.2 [1.1-1.4]), preoperative beta blocker (1.2 [1.1-1.3]), and no preoperative statin (1.2 [1.1-1.3]). Predicted MAE rates ranged from 21% to 29%. Complication severity-adjusted MAE rates ranged from 0% to 100% (Fig). Conclusions: MAE rates after elective EVAR vary widely across centers of the VSGNE. Adjusted MAE rates track similarly to actual rates and provide a more sensitive measure of complication severity.
in preserving pelvic perfusion, such as preventing buttock claudication and sexual dysfunction, i... more in preserving pelvic perfusion, such as preventing buttock claudication and sexual dysfunction, is warranted.
European Journal of Vascular and Endovascular Surgery, 2017
This study compares outcomes following use of suprarenal versus infrarenal fixation devices durin... more This study compares outcomes following use of suprarenal versus infrarenal fixation devices during EVAR, including among surgeons who routinely use one or the other. Background: Previous studies comparing endografts with suprarenal and infrarenal fixation for endovascular abdominal aortic aneurysm repair (EVAR) have found conflicting results and did not account for differences in patient selection. This study aims to evaluate the differences in outcomes among surgeons who routinely use either suprarenal or infrarenal fixation, as well as all surgeons in the Vascular Study Group of New England (VSGNE). Methods: All patients undergoing EVAR in the VSGNE from 2003 to 2014 were identified. All ruptured aneurysms, repairs with concomitant procedures, and infrequently used stent grafts (<50) were excluded. Suprarenal endografts included Talent, Zenith, and Endurant; infrarenal endografts included AneuRx and Excluder. Grafts were compared among surgeons who used only one type of endograft (suprarenal or infrarenal) for >80% of cases, as well as all surgeons. Multivariate regression and Cox hazard models were utilised to account for patient demographics, comorbidities, operative differences, and procedure year. Results: This study identified 2574 patients (suprarenal, 1264; infrarenal, 1310) with 888 endografts placed by routine users (suprarenal, 409; infrarenal, 479). There were no differences in baseline comorbidities, including the estimated glomerular filtration rate, between suprarenal and infrarenal fixation, or between patients with endografts placed by routine and non-routine users. Patients treated with suprarenal endografts received more contrast than all users (102 mL vs. 100 mL, p ¼ .01) and routine users (110 mL vs. 88 mL, p < .01), but other vascular and operative details were similar. Among all users, patients treated with suprarenal grafts had higher rates of creatinine increase >.5 mg/dL (3.7% vs. 2.0%, p ¼ .01), length of stay >2 days (27% vs. 19%, p < .01), and discharge to a skilled nursing facility (9.2% vs. 6.7%, p ¼ .02). There were no differences in 30 day or 1 year mortality. Following adjustment, suprarenal stent grafts remained associated with an increased risk of renal deterioration (OR 2.0; 95% CI 1.2e3.4) and prolonged length of stay (OR 1.8; 95% CI 1.4e2.2). Among routine users, suprarenal fixation was also associated with higher rates of renal dysfunction (3.7% vs. 1.3%, p ¼ .02; OR 2.9; 95% CI 1.1e7.8). Conclusion: Despite potential differences in patient selection, endografts with suprarenal fixation among all users and routine users were associated with higher rates of renal deterioration and longer length of hospital stay. Longer-term data are needed to determine the duration and severity of renal function decline and to identify potential benefits of decreased migration or endoleak.
Conclusions: The 2006 Massachusetts insurance expansion was associated with a decreased probabili... more Conclusions: The 2006 Massachusetts insurance expansion was associated with a decreased probability of patients presenting with severe peripheral arterial disease (PAD) and resolution of measured racial disparities in presentation with severe PAD in Massachusetts. Summary: Lack of insurance coverage with poor access to care and non-white race have been shown to be associated with increased severity of PAD, decreased rates of revascularization and increased rates of amputation (
Objectives: The 1-year results of endovascular exclusion of degenerative descending thoracic aort... more Objectives: The 1-year results of endovascular exclusion of degenerative descending thoracic aortic aneurysms (DTAs) with the Valiant Thoracic Stent Graft (Medtronic Vascular) have been previously reported. With longterm follow-up now complete, this study reports the 5-year results. Methods: The VALOR II trial was a prospective, nonrandomized trial of the Valiant Thoracic Stent Graft system in patients with degenerative DTA. The trial involved 24 sites in the United States and enrolled patients between December 2006 and September 2009. Standard follow-up included physical examination, computed tomography, and chest radiography through 5 years. Results: The study enrolled 160 patients. The average age was 72.2 years (range, 36-85 years), 95 (59%) were men, 150 (94%) had hypertension, and 26 (16%) had renal insufficiency. There were 50 patients (31%) who presented with symptoms; back pain was the most common (34 [68%]). The average aneurysm diameter was 57 mm (range, 32-96 mm). A fusiform aneurysm was present in 103 patients (64%), and a saccular aneurysm or penetrating ulcer was present in 57 (36%). More than two devices were implanted in 126 patients (79%), and the maximum number of grafts implanted was four. There were 54 deaths during the study. The 5-year survival actuarial was 64%. There were eight aneurysm-related deaths (5 were #30 days of implant), and the 5-year freedom from aneurysm-related death was 95%. There was one conversion to open repair at 36 months. Eleven patients underwent 13 secondary procedures (9 for endoleak, 3 for aneurysm expansion, and 1 rupture). Five-year follow-up imaging was available for 56 patients. The average aortic diameter decreased >5 mm in 27 patients (48%), increased >5 mm in 6 patients (11%), and remained unchanged in 23 patients (41%). Conclusions: The VALOR II 5-year results demonstrate that the reintervention and aneurysm-related death rates are low. The Valiant thoracic stent graft is an effective treatment of degenerative DTA.
clinically rich, vascular-specific quality-improvement registry to evaluate the perioperative and... more clinically rich, vascular-specific quality-improvement registry to evaluate the perioperative and midterm safety of these procedures compared with their open counterpart. Methods: The Vascular Study Group of New England patient registry (2003-2013) was queried to identify patients undergoing open and fenestrated endovascular repair (FEVAR) of cAA. Open repair of cAA was limited to those with a suprarenal or supravisceral clamp site. FEVAR was limited to those with proximal seal in zone 6 or more caudally. Univariate and multivariate analyses were completed with primary end points of 30-day mortality, in-hospital myocardial infarction, in-hospital acute renal failure, and 1-year survival. Results: This study included 685 patients who underwent repair of cAA (639 open, 46 FEVAR). FEVAR configurations involved 1 (7%), 2 (27%), 3 (60%), or 4 (7%) vessels. Baseline demographic data shows the two groups were comparable with respect to gender, race, CKD status, and coronary artery disease history. FEVAR patients were significantly older (74 6 8.2 vs 71 6 8.5 years; P < .01) and trended toward higher congestive heart failure (15% vs 8%; P ¼ .09). FEVAR patients experienced lower but nonsignificant improvement in rates of 30-day mortality (0% vs 4%; P ¼ .39) and postoperative myocardial infarction (0% vs 7%; P ¼ .10). FEVAR patients demonstrated lower rates of acute renal failure (7% vs 21%; P ¼ .05) and showed decreased intensive care unit length of stay (0 6 1 vs 5 6 9 days; P < .01) and overall length of stay (3 6 3.0 vs 11 6 12.6 days; P < .01). Multivariate analysis confirmed that fenestrated repair was not a significant predictor of mortality (P ¼ .97). One-year survival was similar: 76% for FEVAR vs 73% for open repair (hazard ratio, 0.88; 95% confidence interval, 0.27-2.83; P ¼ .83). One-year reintervention rates were 4.8% for open repair and 8.7% for FEVAR (P ¼ .29). Conclusions: This early experience with FEVAR demonstrates similar morbidity and mortality compared with open repair of cAA, despite a higher risk profile in the FEVAR cohort (ie, age, congestive heart failure). Comparable 1-year survival and reintervention rates suggest similar utility for the two procedures. Patient age and comorbidity profiles should figure prominently in the application of FEVAR.
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Papers by Virendra Patel