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Bloch RA, Caron E, Pomposelli FB, Prushik SG, Shean KE, Conrad MF. Outcomes of endovascular intervention for atherosclerotic lesions confined to the popliteal artery. J Vasc Surg 2024:S0741-5214(24)00955-8. [PMID: 38599292 DOI: 10.1016/j.jvs.2024.03.454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 03/20/2024] [Accepted: 03/31/2024] [Indexed: 04/12/2024]
Abstract
OBJECTIVE Most surgeons employ an endovascular-first approach to the treatment of peripheral arterial disease (PAD), but controversy remains regarding the ideal interventions for the management of isolated popliteal artery disease (IPAD). Indeed, there are a paucity of data that compare outcomes of popliteal stents vs other peripheral vascular interventions (PVIs). The goal of this study was to evaluate outcomes of PVIs in IPAD. METHODS The Vascular Study Group of New England database was queried for all IPAD PVIs performed for atherosclerotic occlusive disease from 2010 to 2021. Those with at least 1 year of follow-up data available were included for analysis. The primary endpoint was 1-year freedom from a composite target lesion (TL) treatment failure that included restenosis >50% on duplex, reintervention, or ipsilateral major amputation. RESULTS We included 689 procedures performed on 634 patients. Of these, 250 (36.3%) were treated with plain balloons (POBA), 215 (31.2%) had stents, 170 (24.7%) had special balloons (drug-coated, cutting, or lithotripsy), and 54 (7.8%) atherectomies were performed. Stent placement was associated with lower freedom from TL treatment failure (72.6%) than special balloon (81.2%; P = .048) and atherectomy (88.9%; P = .012), but not POBA (76.8%; P = .293). On multivariable logistic regression, stents (odds ratio, 0.637; P = .021) and preoperative P2Y12 inhibitor therapy (odds ratio, 0.683; P = .048) were both associated with lower freedom from intervention failure. CONCLUSIONS Popliteal stent placement is associated with a higher rate of TL treatment failure at 1 year when compared with other PVIs including special balloon angioplasty and atherectomy, but not POBA, and should therefore be avoided in favor of special balloons or atherectomy whenever feasible.
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Affiliation(s)
- Randall A Bloch
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA
| | - Elisa Caron
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA
| | - Frank B Pomposelli
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA
| | - Scott G Prushik
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA
| | - Katie E Shean
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA.
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Kolde G, Penton A, Li R, Weise L, Potluri V, Conrad MF, Blecha M. Carotid Endarterectomy With Simultaneous Proximal Common Carotid Endovascular Intervention is Beneficial for Symptomatic Stenosis and Likely Confers No Advantage for Asymptomatic Lesions. Vasc Endovascular Surg 2024; 58:263-279. [PMID: 37846944 DOI: 10.1177/15385744231207014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
INTRODUCTION Carotid bifurcation stenosis may co-exist simultaneously with more proximal common carotid artery (CCA) atherosclerotic plaquing, primarily at the vessel origin in the aortic arch. This scenario is relatively infrequent and its' management does not have quality randomized data to support medical vs surgical treatment. It is logical to treat any high grade common carotid lesions proximal to a carotid bifurcation endarterectomy (CEA) site both to prevent perioperative emboli or thrombosis as well as future embolization. Prior long-term investigations of the combined treatment paradigm have been low volume analysis. Further, prior studies focus on perioperative outcomes with respect to stroke prevention. The only prior VQI study investigating mid-term outcomes following simultaneous CEA with proximal CCA endovascular therapy provided data on less than 10 patients beyond 1.5 years. The long-term follow-up (LFTU) component initiative within VQI has been emphasized in recent years, now allowing for much more robust LTFU analysis. METHODS Four cohorts were created for perioperative outcome analysis and Kaplan Meier freedom from event analysis: CEA in isolation for asymptomatic disease; CEA in isolation for symptomatic patients; CEA with proximal CCA endovascular intervention for asymptomatic; and, CEA with proximal CCA intervention for symptomatic patients. Binary logistic multivariable regression was performed for perioperative neurological event and 90-day mortality risk determination and Cox multivariable regression analysis was performed for long term freedom from cumulative ischemic neurological event and long-term mortality analysis. Symptomatology and type of surgery (CEA with or without CCA intervention) were individual variables in the multivariable analysis. Neurological ischemic event in this study encompassed transient ischemic attack (TIA) and stroke combined. RESULTS We noted a statistically significant (P < .001) escalation in rates of perioperative neurological event, myocardial infarction (MI), carotid re-exploration, 90 day mortality and combined neurological event and 90 day mortality moving from: A) asymptomatic CEA in isolation to B) symptomatic CEA in isolation to C) asymptomatic CEA combined with proximal CCA intervention to D) symptomatic CEA in combination with proximal CCA intervention. The positivity rate for the combined outcome of perioperative ischemic neurological event and 90 day mortality was 2.2% amongst asymptomatic CEA in isolation, 4.1% amongst symptomatic CEA in isolation, 4.4% amongst asymptomatic CEA in combination with proximal CCA intervention; and 8.8% in patients with symptomatic lesions undergoing combined CEA with proximal CCA intervention. On multivariable analysis patients undergoing CEA with proximal CCA endovascular intervention experienced greater risk for perioperative neurological ischemic event (aOR 2.03, 1.43-2.90, P < .001), combined perioperative neurological ischemic event and 90 day mortality (aOR 2.13, 1.62-2.80, P < .001), long term mortality (HR 1.62, 1.12-2.29, P < .001), and cumulative neurological ischemic event in long term follow up (HR 1.62, 1.12-2.29, P = .007). Amongst 4395 cumulative ischemic neurological events in all study patients, 34% were TIA. CONCLUSIONS Carotid bifurcation endarterectomy in combination with proximal endovascular common carotid artery intervention caries an over two fold higher perioperative risk of neurologic ischemic event and 90 day mortality relative to CEA in isolation for asymptomatic and symptomatic cohorts respectively. After surgery, freedom from cerebral ischemia and mortality for patients undergoing dual intervention is closely aligned with patients undergoing CEA in isolation. Despite high adverse perioperative event rates for the combined CEA and CCA treatment, there is likely long term stroke reduction and mortality benefit to this approach in symptomatic patients based on the event free rates seen herein after initial hospital discharge. The benefit of treating asymptomatic tandem ICA and CCA lesions remains vague but the 4.4% perioperative neurologic event and death rate suggests that these patients would be better managed with medical therapy.
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Affiliation(s)
- Grant Kolde
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
- Loyola University Medical Center, Maywood, IL, USA
| | - Ashley Penton
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
- Loyola University Medical Center, Maywood, IL, USA
| | - Ruojia Li
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
- Loyola University Medical Center, Maywood, IL, USA
| | - Lorela Weise
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
- Loyola University Medical Center, Maywood, IL, USA
| | - Vamsi Potluri
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
- Loyola University Medical Center, Maywood, IL, USA
| | | | - Matthew Blecha
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
- Loyola University Medical Center, Maywood, IL, USA
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Paraskevas KI, Conrad MF, Schneider PA, Cambria RP. Best Medical Treatment Alone Is Adequate for the Management of All Patients With Asymptomatic Carotid Stenosis, or "Alice in Wonderland". Angiology 2024; 75:295-296. [PMID: 37165801 DOI: 10.1177/00033197231174724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Affiliation(s)
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, St Elizabeth's Medical Center, Boston, MA, USA
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA, USA
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, St Elizabeth's Medical Center, Boston, MA, USA
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Bloch RA, McIntosh EE, Pomposelli FB, Prushik SG, Shean KE, Conrad MF. Characteristics and Outcomes of Patients Undergoing Infrainguinal Bypass in the Endovascular Era. Ann Vasc Surg 2023; 97:59-65. [PMID: 37169246 DOI: 10.1016/j.avsg.2023.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/22/2023] [Accepted: 04/29/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND The Society for Vascular Surgery (SVS) developed objective performance goals (OPGs) for lower extremity bypass (LEB) in chronic limb-threatening ischemia (CLTI) based on studies that included patients who were at good risk for open revascularization. In the endovascular era, many LEB patients have had prior interventions, and most would be considered high-risk by the original SVS OPG standards. The goal of this study is to characterize a contemporary patient population undergoing LEB for CLTI and determine if outcomes remain commensurate with the parameters established by the SVS OPG. MATERIALS AND METHODS All patients who underwent LEB for CLTI over a 10-year period (2012-2021) were identified. Patients were stratified into low- and high-risk categories based upon the clinical, conduit, and anatomic parameters used in the SVS OPG. Limb salvage at 1 year and amputation-free survival, a composite outcome of major amputation and mortality, at 1 year were compared with the SVS OPG cohort. Primary, assisted, and secondary patency at 1 and 3 years were also evaluated using Kaplan-Meier survival analysis. RESULTS There were 169 LEBs performed for CLTI. One hundred and two (60.36%) males, 101 (59.76%) current or former smokers, 115 (68.05%) with hypertension, 69 (40.83%) with diabetes mellitus, and 40 (23.67%) with coronary artery disease. Median age was 71.84 years, and mean follow-up was 2.17 years. 65 (38.46%) had a prior ipsilateral endovascular intervention, and 18 (10.65%) were redo bypasses. 21 (12.43%) were deemed clinically high-risk, 44 (26.04%) were high-risk conduits, and 118 (69.82%) had high-risk anatomic factors. Freedom from amputation at 1 year was 87.05% in this cohort which was similar to the overall SVS OPG cohort (88.9%). Amputation-free survival at 1 year was 77.78%, which was also similar to the overall SVS OPG cohort (76.5%). Primary patency at one and three years was 46.84% and 37.59%, assisted patency at one and three years was 61.87% and 44.81%, and secondary patency at one and three years was 72.13% and 61.16%. CONCLUSIONS The majority of patients undergoing LEB in the endovascular era meet the SVS OPG criteria for high risk. Despite this, the 1-year limb salvage and amputation-free survival in this cohort were equivalent to the SVS OPG LEB cohort. This supports the continued use of LEB for limb salvage in high-risk patients and those who have failed endovascular approaches.
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Affiliation(s)
- Randall A Bloch
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA
| | - Erin E McIntosh
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA
| | - Frank B Pomposelli
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA
| | - Scott G Prushik
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA
| | - Katie E Shean
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA.
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DeCarlo C, Mohebali J, Dua A, Conrad MF, Mohapatra A. Preoperative Anemia Is Associated With Postoperative Renal Failure After Elective Open Aortic Repair. J Surg Res 2023; 291:187-194. [PMID: 37442045 DOI: 10.1016/j.jss.2023.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 03/23/2023] [Accepted: 05/15/2023] [Indexed: 07/15/2023]
Abstract
INTRODUCTION Preoperative anemia has been consistently shown to be a risk factor for acute kidney injury (AKI) after cardiac surgery. However, this association has not been examined in the open abdominal aortic aneurysm repair (OAR) population and is the subject of this analysis. METHODS Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program was queried for patients undergoing OAR from 2013 to 2019. Anemia was defined according to World Health Organization Guidelines: Hematocrit<36% for women or <39% for men. Primary endpoint was 30-day AKI. Anemia's effect on AKI was determined using inverse probability weighted logistic regression. RESULTS There were 2275 OAR; mean age was 70.9 ± 8.2 y; 24.0% were women. Anemia was present in 498 (26.3%) patients; 165 (7.6%) had a hematocrit<33% and 8 (0.35%) had a hematocrit<24%. Differences in patient factor were nonsignificant after weighting. Any degree of postoperative AKI was more common in the anemia group (11.2% vs 5.1%; unweighted P < 0.001), as was AKI requiring hemodialysis (7.7% vs 3.2%; unweighted P < 0.001). In the weighted multivariable analysis, anemia was independently associated with postoperative AKI (odds ratio 1.51; 95% confidence interval: 1.01-2.26; P = 0.042) while controlling for age and operative factors. Patients with postoperative AKI were significantly more likely to die postoperatively than those without (26.1% vs 1.9%; <0.001). CONCLUSIONS Preoperative anemia was independently associated with post-OAR AKI after propensity weighting and controlling for operative factors. AKI is a major source of morbidity and mortality in these patients, and, if time permits, preoperative correction of anemia or its underlying cause should be considered in high-risk patients.
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Affiliation(s)
- Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Jahan Mohebali
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mark F Conrad
- Division of Vascular Surgery, St Elizabeth's Hospital, Brighton, Massachusetts
| | - Abhisekh Mohapatra
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Feldman ZM, Zheng X, Mao J, Sumpio BJ, Mohebali J, Chang DC, Goodney PP, Srivastava SD, Conrad MF. Greater Patient Travel Distance is Associated with Perioperative and One-Year Cost Increases After Complex Aortic Surgery. Ann Vasc Surg 2023; 97:289-301. [PMID: 37355014 PMCID: PMC10739569 DOI: 10.1016/j.avsg.2023.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/23/2023] [Accepted: 05/25/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND With increasing regionalization of complex aortic surgery within fewer US centers, patients may face increased travel burden when accessing aortic surgery. Longer travel distances have been associated with inferior outcomes after major surgery; however, the impacts of distance on reinterventions and costs have not been described. This study aims to assess the association between patient travel distance and longer-term outcomes including costs and reinterventions after complex aortic surgery. METHODS A retrospective review was conducted of all patients in the Vascular Implant Surveillance and Interventional Outcomes Network database undergoing complex endovascular aortic repair including internal iliac or visceral vessel involvement, complex thoracic endovascular aortic repair including Zone 0-2 proximal extent or branched devices, and complex open abdominal aortic aneurysm repair including suprarenal or higher clamp sites. Travel distance was stratified by Rural-Urban Commuting Area population-density category. Multinomial logistic regression models, negative-binomial models, and zero-inflated Poisson models were used to assess the association between travel distance and index procedural and comprehensive first-year costs, long-term imaging, and long-term reinterventions, respectively. RESULTS Between 2011 and 2018, 8,782 patients underwent complex aortic surgery in the Vascular Implant Surveillance and Interventional Outcomes Network database, including 4,822 complex endovascular aortic repairs, 2,672 complex thoracic endovascular aortic repairs, and 1,288 complex open abdominal aortic aneurysm repairs. Median travel distance was 22.8 miles (interquartile range 8.6-54.8 miles, range 0-2,688.9 miles). Median age was 75 years for all distance quintiles. Patients traveling farther were more likely to be female (26.8% in quintile 5 [Q5] vs. 19.9% in Q1, P < 0.001) and to have had a prior aortic surgery (20.8% for Q5 vs. 5.9% for Q1, P < 0.001). Patients traveling farther had higher index procedural costs, with adjusted odds ratio (OR) 2.34 (95% confidence interval [CI] 1.86-2.94, P < 0.0001) of being in the highest cost tertile versus lowest for patients in Q5 vs. Q1. For patients with ≥ 1-year follow-up, those traveling farther had higher imaging costs, with adjusted Q5 OR 1.55 (95% CI 1.22-1.95, P = 0.0002), and comprehensive first-year costs, with adjusted Q5 OR 2.06 (95% CI 1.57-2.70, P < 0.0001). In contrast, patients traveling farther had similar numbers of reinterventions and imaging studies postoperatively. CONCLUSIONS Patients traveling farther for complex aortic surgery have higher procedural costs, postoperative imaging costs, and comprehensive first-year costs. These patients should be targeted for increased care coordination for improved outcomes and healthcare system burden.
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Affiliation(s)
- Zach M Feldman
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA.
| | - Xinyan Zheng
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Jialin Mao
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Brandon J Sumpio
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Jahan Mohebali
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - David C Chang
- Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, MA
| | - Philip P Goodney
- Division of Vascular and Endovascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Sunita D Srivastava
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Mark F Conrad
- Steward Center for Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston, MA
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Feldman ZM, Sumpio BJ, Kim Y, Kwolek CJ, LaMuraglia GM, Conrad MF, Srivastava SD. Inferior mesenteric artery revascularization can supplement salvage of mesenteric ischemia. J Vasc Surg Cases Innov Tech 2023; 9:101041. [PMID: 37363142 PMCID: PMC10285280 DOI: 10.1016/j.jvscit.2022.08.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/24/2022] [Indexed: 06/28/2023] Open
Abstract
The inferior mesenteric artery (IMA) has often been overlooked in favor of the celiac or superior mesenteric artery in arterial mesenteric ischemia, owing to the typically robust visceral collateral networks. In the present report, we have described a case series of patients in whom "salvage" revascularization of the IMA was performed after attempted celiac or superior mesenteric artery revascularization had been unsuccessful. The restored IMA inflow had resolved the symptoms for three patients. However, sole IMA revascularization was insufficient to reverse the course for two other patients with severe acute-on-chronic mesenteric ischemia. The IMA should be considered for salvage revascularization in the appropriate clinical scenario.
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Affiliation(s)
- Zach M. Feldman
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Brandon J. Sumpio
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Young Kim
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | | | - Glenn M. LaMuraglia
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Mark F. Conrad
- Steward Center for Vascular and Endovascular Surgery, St. Elizabeth’s Medical Center, Boston, MA
| | - Sunita D. Srivastava
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
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Png CYM, Kim Y, Jessula S, DeCarlo CS, Waller HD, Feldman ZM, Sumpio BJ, Lee S, Dua A, Srivastava SD, Conrad MF. Reassuring Intraoperative Parameters Do Not Obviate the Need for Infrainguinal Bypass Completion Angiograms. Ann Surg 2023; 277:e1164-e1168. [PMID: 34966067 DOI: 10.1097/sla.0000000000005363] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine if routine completion angiography for lower extremity bypasses using vein conduit results in lower rates of postoperative bypass occlusion. SUMMARY OF BACKGROUND DATA With the increasing availability of on-table angiography and significant advancements in endovascular techniques, some operators routinely perform completion angiograms. The effect of this surgical paradigm has yet to be rigorously compared to the more widespread selective use of completion imaging in the modern era. METHODS This retrospective cohort study included infrainguinal arterial bypass procedures utilizing vein conduit completed at a single hospital system from 2001 to 2018 and compared postoperative outcomes between bypasses that underwent routine completion angiography versus selective completion angiography. Notably, any bypasses that underwent completion angiography due to intraoperative concerns were excluded from this analysis. RESULTS 666 bypasses that were performed in 589 patients met inclusion criteria. 126 (16.9%) bypasses were classified into the routine completion angiogram group compared to 540 (81.0%) into the selective completion angiogram group. Patients who underwent routine completion angiograms had a rate of intraoperative reintervention of 22.2%. The routine angiogram group had lower rates of reintervention (3.9% vs 10.0%, P = 0.03) and graft occlusion (2.3% vs 9.2%, P = 0.01) at 1-month postoperatively. CONCLUSION Lower extremity bypasses using vein conduit that undergo routine completion angiography are associated with lower rates of graft occlusion at 30-days postoperatively. Completion angiography should thus be routinely performed in infrainguinal bypasses that utilize venous conduit.
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Affiliation(s)
- C Y Maximilian Png
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston MA
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Feldman ZM, Zheng X, Mao J, Sumpio BJ, Mohebali J, Chang DC, Goodney PP, Conrad MF, Srivastava SD. Longer patient travel distance is associated with increased non-index readmission after complex aortic surgery. J Vasc Surg 2023; 77:1607-1617.e7. [PMID: 36804783 DOI: 10.1016/j.jvs.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 02/07/2023] [Accepted: 02/09/2023] [Indexed: 02/17/2023]
Abstract
OBJECTIVE Recently evolving practice patterns in complex aortic surgery have led to regionalization of care within fewer centers in the United States, and thus patients may have to travel farther for complex aortic care. Travel distance has been associated with inferior outcomes after non-vascular surgery, particularly non-index readmission. This study aims to assess the impact of patient travel distance on perioperative outcomes and readmissions after complex aortic surgery. METHODS A retrospective review was conducted of all patients in the Vascular Quality Initiative and Vascular Implant Surveillance and Interventional Outcomes Network databases undergoing complex endovascular aortic repair (EVAR) including internal iliac or visceral vessel involvement, complex thoracic endovascular aortic repair (TEVAR) including zone 0 to 2 proximal extent or branched devices, and complex open abdominal aortic aneurysm (AAA) repair including suprarenal or higher clamp sites. Travel distance was stratified by rural/urban commuting area (RUCA) population-density category. Wilcoxon and χ2 tests were used to assess relationships between travel distance quintiles and baseline characteristics, mortality, and readmission. Travel distance and other factors were included in multivariable Cox models for survival and Fine-Gray competing risk models for freedom from readmission. RESULTS Between 2011 and 2018, 8782 patients underwent complex aortic surgery in the Vascular Quality Initiative and Vascular Implant Surveillance and Interventional Outcomes Network databases, including 4822 complex EVARs, 2672 complex TEVARs, and 1288 complex open AAA repairs. Median travel distance was 22.8 miles (interquartile range [IQR], 8.6-54.8 miles). Median age was 75 years for all distance quintiles, but patients traveling longer distances were more likely female (26.8% in quintile 5 [Q5] vs 19.9% in Q1; P < .001), white (93.8% of Q5 vs 83.8% of Q1; P < .001), to have larger-diameter AAAs (median 59 mm for Q5 vs 55 mm for Q1; P < .001), and to have had prior aortic surgery (20.8% for Q5 vs 5.9% for Q1; P < .001). Overall 30-day readmission was more common at farther distances (18.1% for Q5 vs 14.8% for Q1; P = .003), with higher non-index readmission (11.2% for Q5 vs 2.7% for Q1; P < .001) and conversely lower index readmission (6.9% for Q5 vs 12.0% for Q1; P < .001). Multivariable-adjusted Fine-Gray models confirmed greater hazard of non-index readmission with farther distance, with a Q5 hazard ratio of 3.02 (95% confidence interval, 2.12-4.30; P < .001). Multivariable-adjusted Cox models demonstrated no association between travel distance and long-term survival but found that non-index readmission was associated with increased long-term mortality (hazard ratio, 1.46; 95% confidence interval, 1.20-1.78; P = .0001). CONCLUSIONS Patients traveling farther for complex aortic surgery demonstrate higher non-index readmission, which, in turn, is associated with increased long-term mortality risk. Aortic centers of excellence should consider targeting these patients for more comprehensive follow-up and care coordination to improve outcomes.
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Affiliation(s)
- Zach M Feldman
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA.
| | - Xinyan Zheng
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY
| | - Jialin Mao
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY
| | - Brandon J Sumpio
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Jahan Mohebali
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - David C Chang
- Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, MA
| | - Philip P Goodney
- Division of Vascular and Endovascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Mark F Conrad
- Steward Center for Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston, MA
| | - Sunita D Srivastava
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
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Chou EL, Pettinger M, Haring B, Allison MA, Mell MW, Hlatky MA, Wactawski-Wende J, Wild RA, Shadyab AH, Wallace RB, Snetselaar LG, Madsen TE, Eagleton MJ, Conrad MF, Liu S. Association of Premature Menopause With Risk of Abdominal Aortic Aneurysm in the Women's Health Initiative. Ann Surg 2022; 276:e1008-e1016. [PMID: 33156064 DOI: 10.1097/sla.0000000000004581] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine if premature menopause and early menarche are associated with increased risk of AAA, and to explore potential effect modification by smoking history. SUMMARY OF BACKGROUND DATA Despite worse outcomes for women with AAA, no studies have prospectively examined sex-specific risk factors, such as premature menopause and early menarche, with risk of AAA in a large, ethnically diverse cohort of women. METHODS This was a post-hoc analysis of Women's Health Initiative participants who were beneficiaries of Medicare Parts A&B fee-for-service. AAA cases and interventions were identified from claims data. Follow-up period included Medicare coverage until death, end of follow-up or end of coverage inclusive of 2017. RESULTS Of 101,119 participants included in the analysis, the mean age was 63 years and median follow-up was 11.3 years. Just under 10,000 (9.4%) women experienced premature menopause and 22,240 (22%) experienced early men-arche. Women with premature menopause were more likely to be overweight, Black, have >20 pack years of smoking, history of cardiovascular disease, hypertension, and early menarche. During 1,091,840 person-years of follow-up, 1125 women were diagnosed with AAA, 134 had premature menopause (11.9%), 93 underwent surgical intervention and 45 (48%) required intervention for ruptured AAA. Premature menopause was associated with increased risk of AAA [hazard ratio 1.37 (1.14, 1.66)], but the association was no longer significant after multivariable adjustment for demographics and cardiovascular disease risk factors. Amongst women with ≥20 pack year smoking history (n = 19,286), 2148 (11.1%) had premature menopause, which was associated with greater risk of AAA in all models [hazard ratio 1.63 (1.24, 2.23)]. Early menarche was not associated with increased risk of AAA. CONCLUSIONS This study finds that premature menopause may be an important risk factor for AAA in women with significant smoking history. There was no significant association between premature menopause and risk of AAA amongst women who have never smoked. These results suggest an opportunity to develop strategies for better screening, risk reduction and stratification, and outcome improvement in the comprehensive vascular care of women.
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Affiliation(s)
- Elizabeth L Chou
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Mary Pettinger
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Bernhard Haring
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Matthew A Allison
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California
| | - Matthew W Mell
- Division of Vascular Surgery, University of California Davis Medical Center, Sacramento, California
| | - Mark A Hlatky
- Department of Health Research and Policy, Campus Drive, Stanford University School of Medicine, Stanford, California
| | - Jean Wactawski-Wende
- Department of Epidemiology and Environmental Health, University at Buffalo, Buffalo, New York
| | - Robert A Wild
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Aladdin H Shadyab
- Department of Family Medicine and Public Health, University of California San Diego School of Medicine, La Jolla, California
| | - Robert B Wallace
- Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, Iowa
| | - Linda G Snetselaar
- Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, Iowa
| | - Tracy E Madsen
- Department of Emergency Medicine, Division of Sex and Gender, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Simin Liu
- Departments of Epidemiology, Surgery, and Medicine, Brown University, Providence, Rhode Island
- Department of Internal Medicine, University of Würzburg, Würzburg, Germany
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11
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Nooromid M, De Martino R, Squizzato F, Benedetto F, De Caridi G, Chou EL, Conrad MF, Pantoja J, Abularrage C, Sorber R, Garcia-Ortega DY, Luna-Ortiz K, Eichler C, Zarkowsky D, Chia M, Kalluri A, Cohnert T, Szeberin Z, Grotemeyer D, Shalhub S, Fagg D, Jackson MJ, Charlton-Ouw K, Gombert A, Jacobs M, Boyd A, Motaganahalli R, Uceda D, Woo K, Eskandari MK. Surgical resection and graft replacement for primary inferior vena cava leiomyosarcoma: A multicenter experience. Eur J Vasc Endovasc Surg 2022. [DOI: 10.1016/j.ejvs.2022.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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12
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Janko MR, Hubbard G, Back M, Shah SK, Pomozi E, Szeberin Z, DeMartino R, Wang LJ, Crofts S, Belkin M, Davila VJ, Lemmon GW, Wang SK, Czerny M, Kreibich M, Humphries MD, Shutze W, Joh JH, Cho S, Behrendt CA, Setacci C, Hacker RI, Sobreira ML, Yoshida WB, D'Oria M, Lepidi S, Chiesa R, Kahlberg A, Go MR, Rizzo AN, Black JH, Magee GA, Elsayed R, Baril DT, Beck AW, McFarland GE, Gavali H, Wanhainen A, Kashyap VS, Stoecker JB, Wang GJ, Zhou W, Fujimura N, Obara H, Wishy AM, Bose S, Smeds M, Liang P, Schermerhorn M, Conrad MF, Hsu JH, Patel R, Lee JT, Liapis CD, Moulakakis KG, Farber MA, Motta F, Ricco JB, Bath J, Coselli JS, Aziz F, Coleman DM, Davis FM, Fatima J, Irshad A, Shalhub S, Kakkos S, Zhang Q, Lawrence PF, Woo K, Chung J. In-situ Bypass Is Associated with Superior Infection-free Survival Compared to Extra-Anatomic Bypass for the Management of Secondary Aortic Graft Infections Without Enteric Involvement. J Vasc Surg 2022; 76:546-555.e3. [PMID: 35470015 DOI: 10.1016/j.jvs.2022.03.869] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 03/27/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The optimal revascularization modality following complete resection of aortic graft infection (AGI) without enteric involvement remains unclear. The purpose of this investigation is to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients undergoing complete excision of AGI. METHODS A retrospective, multi-institutional study of AGI from 2002-2014 was performed using a standardized database. Baseline demographics, comorbidities, and perioperative variables were recorded. The primary outcome was infection-free survival. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariable analyses were performed. RESULTS 241 patients at 34 institutions from 7 countries presented with AGI during the study period (median age 68 years; 75% male). The initial aortic procedures that resulted in AGI were 172 surgical grafts (71%) and 66 endografts (27%) and 3 unknown (2%). 172 (71%) of the patients underwent complete excision of infected aortic graft material followed by in situ (in-line) bypass (ISB), including antibiotic-treated prosthetic graft (35%), autogenous femoral vein (NAIS) (24%), and cryopreserved allograft (41%). 69 patients (29%) underwent extra-anatomic bypass (EAB). Overall median Kaplan-Meier (KM) estimated survival was 5.8 years. Perioperative mortality was 16%. When stratified by ISB versus EAB, there was a significant difference in KM estimated infection-free survival (2910 days, IQR 391, 3771 versus 180 days, IQR 27, 3750 days; p<0.001). There were otherwise no significant differences in presentation, comorbidities, nor perioperative variables. Multivariable Cox regression showed lower infection-free survival among patients with EAB (HR 2.4, 95% CI 1.6-3.6; p<0.001), polymicrobial infection (HR 2.2, 95% CI 1.4-3.5; p=0.001), MRSA infection (HR 1.7, 95% CI 1.1-2.7; p=0.02), as well as the protective effect of omental/muscle flap coverage (HR 0.59, 95% CI 0.37-0.92; p=0.02). CONCLUSIONS After complete resection of AGI, perioperative mortality is 16% and median overall survival is 5.8 years. EAB is associated with nearly a two-and-half fold higher re-infection/mortality compared to ISB. Omental and/or muscle flap coverage of the repair appear protective.
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Affiliation(s)
- Matthew R Janko
- Division of Vascular Surgery and Endovascular Therapy, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Grant Hubbard
- Division of Vascular Surgery and Endovascular Therapy, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Martin Back
- Division of Vascular Surgery, Department of Surgery, University of Florida, Gainesville, FL
| | - Samir K Shah
- Division of Vascular Surgery, Department of Surgery, University of Florida, Gainesville, FL
| | - Eniko Pomozi
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Zoltan Szeberin
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Randall DeMartino
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Linda J Wang
- Department of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Sarah Crofts
- Department of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Michael Belkin
- Department of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Victor J Davila
- Division of Vascular Surgery, Department of General Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Gary W Lemmon
- Division of Vascular Surgery, Department of Surgery, Indiana University, Indianapolis, IN
| | - Shihuan K Wang
- Division of Vascular Surgery, Department of Surgery, Indiana University, Indianapolis, IN
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg Bad Krozingen, Freiburg, Germany
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, University Heart Center Freiburg Bad Krozingen, Freiburg, Germany
| | - Misty D Humphries
- Division of Vascular Surgery, Department of Surgery, UC Davis Health, Sacramento, CA
| | - William Shutze
- Texas Vascular Associates, The Heart Hospital Plano, Plano, TX
| | - Jin Hyun Joh
- Division of Vascular Surgery, Department of Surgery, Kyung Hee University Hospital at Gangdong, Seoul, South Korea
| | - Sungsin Cho
- GermanVasc Research Group, Department of Vascular Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian-Alexander Behrendt
- GermanVasc Research Group, Department of Vascular Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carlo Setacci
- Department of Vascular and Endovascular Surgery, University of Siena, Sienna, Italy
| | - Robert I Hacker
- Division of Vascular Surgery, Surgical Arts of St. Louis, Bridgeton, MO
| | - Marcone Lima Sobreira
- Department of Surgery and Orthopedics, Botucatu School of Medicine, Paulista State University, São Paulo, Brazil
| | - Winston Bonetti Yoshida
- Department of Surgery and Orthopedics, Botucatu School of Medicine, Paulista State University, São Paulo, Brazil
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, Trieste, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, Trieste, Italy
| | - Roberto Chiesa
- Department of Vascular Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Kahlberg
- Department of Vascular Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - Michael R Go
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH
| | - Anthony N Rizzo
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Southern California, Los Angeles, CA
| | - Ramsey Elsayed
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Southern California, Los Angeles, CA
| | - Donald T Baril
- Division of Vascular Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Graeme E McFarland
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Hamid Gavali
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Wanhainen
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Vikram S Kashyap
- Division of Vascular Surgery and Endovascular Therapy, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Jordan B Stoecker
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Wei Zhou
- Division of Vascular Surgery, Department of Surgery, University of Arizona, Tucson, AZ
| | - Naoki Fujimura
- Department of Surgery, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Andrew M Wishy
- Division of Vascular and Endovascular Surgery, Brooke Army Medical Center, San Antonio, TX
| | - Saideep Bose
- Division of Vascular Surgery, Department of Surgery, Saint Louis University, St Louis, MO
| | - Matthew Smeds
- Division of Vascular Surgery, Department of Surgery, Saint Louis University, St Louis, MO
| | - Patric Liang
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Marc Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mark F Conrad
- Division of Vascular Surgery, St Elizabeth's Hospital, Brighton, MA
| | - Jeffrey H Hsu
- Division of Vascular Surgery, Kaiser Permanente, Fontana, CA
| | - Rhusheet Patel
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Jason T Lee
- Division of Vascular Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Christos D Liapis
- Department of Vascular Surgery, Attikon University Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos G Moulakakis
- Department of Vascular Surgery, Attikon University Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Mark A Farber
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Fernando Motta
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers Medical School, Poitiers, France
| | - Jonathan Bath
- Cardiovascular Surgical Clinics, University of Missouri, Columbia, MO
| | - Joseph S Coselli
- Division of Vascular Surgery, Penn State Health Heart and Vascular Institute, Hershey, PA
| | - Faisal Aziz
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Dawn M Coleman
- MedStar Heart and Vascular Institute, Georgetown University, Washington, DC
| | - Frank M Davis
- MedStar Heart and Vascular Institute, Georgetown University, Washington, DC
| | - Javairiah Fatima
- Cardiovascular Center at Tufts Medical Center, Tufts University School of Medicine, Boston, MA
| | - Ali Irshad
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA
| | - Sherene Shalhub
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA
| | - Stavros Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Qianzi Zhang
- Division of Vascular and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Peter F Lawrence
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Karen Woo
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Jayer Chung
- Division of Vascular and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
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Izquierdo-Garcia D, Diyabalanage H, Ramsay IA, Rotile NJ, Mauskapf A, Choi JK, Witzel T, Humblet V, Jaffer FA, Brownell AL, Tawakol A, Catana C, Conrad MF, Caravan P, Ay I. Imaging High-Risk Atherothrombosis Using a Novel Fibrin-Binding Positron Emission Tomography Probe. Stroke 2022; 53:595-604. [PMID: 34965737 PMCID: PMC8792326 DOI: 10.1161/strokeaha.121.035638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE High-risk atherosclerosis is an underlying cause of cardiovascular events, yet identifying the specific patient population at immediate risk is still challenging. Here, we used a rabbit model of atherosclerotic plaque rupture and human carotid endarterectomy specimens to describe the potential of molecular fibrin imaging as a tool to identify thrombotic plaques. METHODS Atherosclerotic plaques in rabbits were induced using a high-cholesterol diet and aortic balloon injury (N=13). Pharmacological triggering was used in a group of rabbits (n=9) to induce plaque disruption. Animals were grouped into thrombotic and nonthrombotic plaque groups based on gross pathology (gold standard). All animals were injected with a novel fibrin-specific probe 68Ga-CM246 followed by positron emission tomography (PET)/magnetic resonance imaging 90 minutes later. 68Ga-CM246 was quantified on the PET images using tissue-to-background (back muscle) ratios and standardized uptake value. RESULTS Both tissue-to-background (back muscle) ratios and standardized uptake value were significantly higher in the thrombotic versus nonthrombotic group (P<0.05). Ex vivo PET and autoradiography of the abdominal aorta correlated positively with in vivo PET measurements. Plaque disruption identified by 68Ga-CM246 PET agreed with gross pathology assessment (85%). In ex vivo surgical specimens obtained from patients undergoing elective carotid endarterectomy (N=12), 68Ga-CM246 showed significantly higher binding to carotid plaques compared to a D-cysteine nonbinding control probe. CONCLUSIONS We demonstrated that molecular fibrin PET imaging using 68Ga-CM246 could be a useful tool to diagnose experimental and clinical atherothrombosis. Based on our initial results using human carotid plaque specimens, in vivo molecular imaging studies are warranted to test 68Ga-CM246 PET as a tool to stratify risk in atherosclerotic patients.
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Affiliation(s)
- David Izquierdo-Garcia
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA,Harvard-MIT Department of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA
| | | | - Ian A. Ramsay
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA,Collagen Medical, LLC, Belmont, MA,The Institute for Innovation in Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA
| | - Nicholas J. Rotile
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA,The Institute for Innovation in Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA
| | - Adam Mauskapf
- Cardiovascular Research Center, Division of Cardiology, Department of Medicine Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Ji-Kyung Choi
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - Thomas Witzel
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | | | - Farouc A. Jaffer
- Cardiovascular Research Center, Division of Cardiology, Department of Medicine Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Anna-Liisa Brownell
- Gordon Center for Medical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - Ahmed Tawakol
- Nuclear Cardiology, Division of Cardiology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Ciprian Catana
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA,The Institute for Innovation in Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA
| | - Mark F. Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Peter Caravan
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA,The Institute for Innovation in Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA
| | - Ilknur Ay
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
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14
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Hart KL, Boitano LT, Tanious A, Conrad MF, Eagleton MJ, Lillemoe KD, Perlis RH, Srivastava SD. Trends in Female Authorship in High Impact Surgical Journals Between 2008 and 2018. Ann Surg 2022; 275:e115-e123. [PMID: 32590539 DOI: 10.1097/sla.0000000000004057] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study evaluates the distribution of authorship by sex over the last 10 years among the top 25 surgical journals. SUMMARY OF BACKGROUND DATA Despite an increase in women entering surgical residency, there remains a sex disparity in surgical leadership. Scholarly activity is the foundation for academic promotion. However, few studies have evaluated productivity by sex in surgical literature. METHODS Original research in the 25 highest-impact general surgery/subspecialty journals were included (1/2008-5/2018). Journals with <70% identified author sex were excluded. Articles were categorized by sex of first, last, and overall authorship. We examined changes in proportions of female first, last, and overall authorship over time, and analyzed the correlation between these measurements and journal impact factor. RESULTS There were 71,867 articles from 19 journals included. Sex was successfully predicted for 87.3% of authors (79.1%-92.5%). There were significant increases in the overall percentage of female authors (β = 0.55, P < 0.001), female first authors (β = 0.97, P < 0.001), and female last authors (β = 0.53, P < 0.001) over the study period. Notably, all cardiothoracic subspecialty journals did not significantly increase the proportion of female last authors over the study period. There were no correlations between journal impact factor and percentage of overall female authors (rs = 0.39, P = 0.09), female first authors (rs = 0.29, P = 0.22), or female last author (rs = 0.35, P = 0.13). CONCLUSIONS This study identifies continued but slow improvement in female authorship of high-impact surgical journals during the contemporary era. However, the improvement was more apparent in the first compared to senior author positions.
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Affiliation(s)
- Kamber L Hart
- Center for Quantitative Health and Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Adam Tanious
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Roy H Perlis
- Center for Quantitative Health and Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Sunita D Srivastava
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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15
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Chou EL, Lino Cardenas CL, Chaffin M, Arduini AD, Juric D, Stone JR, LaMuraglia GM, Eagleton MJ, Conrad MF, Isselbacher EM, Ellinor PT, Lindsay ME. Vascular smooth muscle cell phenotype switching in carotid atherosclerosis. JVS Vasc Sci 2022; 3:41-47. [PMID: 35128489 PMCID: PMC8802874 DOI: 10.1016/j.jvssci.2021.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 11/02/2021] [Indexed: 11/28/2022] Open
Abstract
Carotid plaque instability contributes to large vessel ischemic stroke. Although vascular smooth muscle cells (VSMCs) affect atherosclerotic growth and instability, no treatments aimed at improving VSMC function are available. Large genetic studies investigating atherosclerosis and carotid disease in relation to the risk of stroke have implicated polymorphisms at the HDAC9 locus. The HDAC9 protein has been shown to affect the VSMC phenotype; however, how this might affect carotid disease is unknown. We conducted a pilot investigation using single nuclei RNA sequencing of human carotid tissue to identify cells expressing HDAC9 and specifically investigate the role of the HDAC9 in carotid atherosclerosis. We found that carotid VSMCs express HDAC9 and genes typically associated with immune characteristics. Using cellular assays, we have demonstrated that recruitment of macrophages can be modulated by HDAC9 expression. HDAC9 expression might affect carotid plaque stability and progression through its effects on the VSMC phenotype and recruitment of immune cells.
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Affiliation(s)
- Elizabeth L. Chou
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Mass
- Correspondence: Elizabeth L. Chou, MD, Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, 55 Fruit St, WACC 440, Boston, MA 02114
| | - Christian L. Lino Cardenas
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Mass
- Division of Cardiology, Massachusetts General Hospital, Boston, Mass
| | - Mark Chaffin
- Cardiovascular Disease Initiative, The Eli and Edythe L. Broad Institute of MIT and Harvard, Cambridge, Mass
- Precision Cardiology Laboratory, The Eli and Edythe L. Broad Institute of MIT and Harvard and Bayer US LLC, Cambridge, Mass
| | - Alessandro D. Arduini
- Cardiovascular Disease Initiative, The Eli and Edythe L. Broad Institute of MIT and Harvard, Cambridge, Mass
- Precision Cardiology Laboratory, The Eli and Edythe L. Broad Institute of MIT and Harvard and Bayer US LLC, Cambridge, Mass
| | - Dejan Juric
- Cancer Center, Massachusetts General Hospital, Boston, Mass
- Harvard Medical School, Boston, Mass
| | - James R. Stone
- Department of Pathology, Massachusetts General Hospital, Boston, Mass
- Harvard Medical School, Boston, Mass
| | - Glenn M. LaMuraglia
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
- Thoracic Aortic Center, Massachusetts General Hospital, Boston, Mass
- Harvard Medical School, Boston, Mass
| | - Matthew J. Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
- Thoracic Aortic Center, Massachusetts General Hospital, Boston, Mass
- Harvard Medical School, Boston, Mass
| | - Mark F. Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
- Thoracic Aortic Center, Massachusetts General Hospital, Boston, Mass
- Harvard Medical School, Boston, Mass
| | - Eric M. Isselbacher
- Division of Cardiology, Massachusetts General Hospital, Boston, Mass
- Thoracic Aortic Center, Massachusetts General Hospital, Boston, Mass
| | - Patrick T. Ellinor
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Mass
- Cardiovascular Disease Initiative, The Eli and Edythe L. Broad Institute of MIT and Harvard, Cambridge, Mass
- Precision Cardiology Laboratory, The Eli and Edythe L. Broad Institute of MIT and Harvard and Bayer US LLC, Cambridge, Mass
| | - Mark E. Lindsay
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Mass
- Division of Cardiology, Massachusetts General Hospital, Boston, Mass
- Thoracic Aortic Center, Massachusetts General Hospital, Boston, Mass
- Cardiovascular Disease Initiative, The Eli and Edythe L. Broad Institute of MIT and Harvard, Cambridge, Mass
- Precision Cardiology Laboratory, The Eli and Edythe L. Broad Institute of MIT and Harvard and Bayer US LLC, Cambridge, Mass
- Harvard Medical School, Boston, Mass
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DeCarlo C, Gifford R, Boitano LT, Mohebali J, Clouse WD, Conrad MF. The Effect of Retrograde External Iliac Artery Runoff on Aortofemoral Bypass Limb Patency. Ann Vasc Surg 2021; 80:78-86. [PMID: 34780956 DOI: 10.1016/j.avsg.2021.09.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Superficial femoral artery (SFA) and profunda patency has been shown to affect aortofemoral bypass (AFB) limb patency. However, the effect of retrograde flow through the external iliac artery (EIA) is unknown and is the subject of this analysis. METHODS Institutional AFB data from 2000-2017 were gathered, excluding those where SFA/EIA patency could not be determined. The cohort was divided into limbs with and without EIA occlusion; primary outcome was limb-based primary patency. Kaplan-Meier estimated patency; cox proportional-hazards model evaluated EIA patency while controlling for other factors. RESULTS Over the study period, there were AFB 557 limbs in 281 patients. Of the 435 AFB limbs in 220 patients that met inclusion criteria and were included in the analysis, 162 had EIA occlusion and 273 had a patent EIA. Mean age was 69.6±9.0. EIA occlusions were more common in male patients (59.9% vs 44.6%; p=0.001), patients with CAD (43.8% vs 34.1%; p=0.042), COPD (34.6% vs 20.5%; p=0.001), and CHF (14.8% vs 5.9%; p=0.002). Limbs with EIA occlusions more often underwent end-to-side proximal anastomosis (40.7% vs 24.2%; p<0.001) and simultaneous infrainguinal bypass (7.4% vs 0.7%; p<0.001). Median clinical follow-up was 4.4 years (IQR: 1.6-8.4). Five-year primary patency was 83.1% (95% CI: 74.5%-90.0%) for EIA occlusion limbs and 85.9% (95% CI: 80.2%-90.0%) with patent EIA limbs (p=0.96). While controlling for other factors, EIA stenosis or occlusion did not affect primary patency. For patients with a proximal occlusion (occluded aorta, occluded common iliac, or end-to-end proximal anastomosis) and occluded SFA (N=73), EIA occlusion had a HR of 1.92 for loss of patency, but this was not statistically significant. CONCLUSION EIA patency did not influence primary patency in the overall cohort Further investigation on the topic in specific patient subgroups is warranted to determine the effect of EIA patency.
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Affiliation(s)
- Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114.
| | - Ryan Gifford
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114
| | - Jahan Mohebali
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville VA, 22903
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114
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O'Donnell TF, McElroy IE, Mohebali J, Boitano LT, Lamuraglia GM, Kwolek CJ, Conrad MF. Late Type 1A Endoleaks: Associated Factors, Prognosis and Management Strategies. Ann Vasc Surg 2021; 80:273-282. [PMID: 34752856 DOI: 10.1016/j.avsg.2021.08.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 08/13/2021] [Accepted: 08/19/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Unlike periprocedural Type 1A endoleaks, late appearing proximal endoleaks have been poorly described. METHODS We studied all elective EVAR from 2010 -2018 in a single institution. Late endoleaks were defined as those appearing after 1 year. We used Cox regression to study factors associated with late Type 1A endoleaks and survival. RESULTS Of 477 EVAR during the study period, 411 (86%) had follow-up imaging, revealing 24 Type 1A endoleaks; 4 early and 20 late. Freedom from Type 1A endoleaks was 99%, 92-81% at 1, 5 and 8 years with a median time to occurrence of 2.5 years (.01-8.2 years). On completion angiogram, only 10% of patients with a late Type 1A had a proximal endoleak, and 60% had no endoleak. Only 21% of late Type 1As were diagnosed on routine 1-year CT angiogram, but 79% had stable or expanding sacs. Two thirds (65%) of the patients eventually diagnosed with late Type 1A endoleaks had previously been treated for other endoleaks, mostly Type 2 (10/13). Age (HR 1.07/year [1.02-1.12], P = 0.01), neck diameter >28mm (HR 3.5 [1.2-10.3], P = 0.02), neck length <20mm (HR 3.0 [1.1-8.6], P = 0.04), and neck angle>60 degrees (HR 3.4 [1.5-7.9], P = 0.004) were associated with higher rates of Type 1A endoleak, but not female sex, endograft, or the use of suprarenal fixation. 2 patients had proximal degeneration and 5 experienced graft migration. There were 2 ruptures (10%), and 13 patients underwent repair with 5 open conversions. Median survival after late Type 1A repair was 6.6 years (0-8.4 years). CONCLUSION Late appearing Type 1A endoleaks have a high rate of rupture and present significant diagnostic and management challenges. Careful surveillance is needed in patients with hostile neck anatomy and those who undergo intervention for other endoleaks. Adverse neck anatomy may be better suited for open repair or fenestrated/branched devices rather than conventional EVAR.
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Affiliation(s)
- Thomas Fx O'Donnell
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Imani E McElroy
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Jahan Mohebali
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Glenn M Lamuraglia
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Christopher J Kwolek
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
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DeCarlo C, Conrad MF. Reply. J Vasc Surg 2021; 74:1430-1431. [PMID: 34598759 DOI: 10.1016/j.jvs.2021.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 06/13/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
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DeCarlo C, Mohebali J, Dua A, Conrad MF, Mohapatra A. Preoperative Anemia Is Associated With Postoperative Renal Failure After Elective Open Aortic Repair. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.07.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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DeCarlo C, Mohebali J, Dua A, Conrad MF, Mohapatra A. Morbidity and mortality associated with open repair of visceral aneurysms. J Vasc Surg 2021; 75:632-640.e2. [PMID: 34560216 DOI: 10.1016/j.jvs.2021.08.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 08/18/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The Society for Vascular Surgery (SVS) recently published clinical practice guidelines on the management of visceral aneurysms. However, studies investigating the perioperative outcomes of open repair of visceral aneurysms have been limited to single-center experiences with variable results that span multiple decades. In the present study, we sought to detail the morbidity and mortality associated with open repair of visceral aneurysms using a national database in the contemporary era. METHODS National Surgical Quality Improvement Program data from 2013 to 2019 were queried for patients who had undergone open repair of visceral aneurysms, which had been classified as mesenteric, renal, or splenic using Current Procedural Terminology and International Classification of Diseases codes. The primary endpoint was the composite of major complications (cardiovascular, pulmonary, progressive renal failure, deep wound infection, return to operating room, sepsis) and 30-day mortality. Logistic regression was used to identify the predictors of the primary endpoint for nonruptured aneurysm cases. RESULTS Of the 304 aneurysms, 263 were nonruptured (137 mesenteric, 66 renal, 60 splenic) and 41 were ruptured (24 mesenteric, 1 renal, 16 splenic) and had undergone open repair. For those with nonruptured aneurysms, their mean age was 59.4 ± 14.7 years and 48.3% were women. For those with nonruptured aneurysms, the 30-day mortality was 1.9% and the major complication rate was 12.9%. A return to the operating room (5.3%) and prolonged ventilator support (3.8%) were especially common. As expected, rupture was associated with significantly greater mortality (22.0%; P < .001) and major complications (34.1%; P = .001). The use of postoperative transfusion was common in the elective group but was significantly greater in the ruptured group (24.3% vs 80.5%; P < .001). The predictors of the primary outcome for nonruptured aneurysms included male sex (odds ratio [OR], 2.93; 95% confidence interval [CI], 1.28-6.7; P = .011), anticoagulation (not discontinued before surgery) or bleeding disorder (OR, 4.52; 95% CI, 1.37-14.7; P = .012), and albumin <3.0 g/dL (OR, 4.66; 95% CI, 1.17-18.6; P = .029). Neither age nor aneurysm location were significant risk factors. CONCLUSIONS Open repair of visceral aneurysms was associated with acceptable morbidity and mortality, although these risks are significantly greater once ruptured. Male sex, bleeding risk, and low albumin were all risk factors for adverse events and should be considered for operative planning and postoperative care.
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Affiliation(s)
- Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
| | - Jahan Mohebali
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Abhisekh Mohapatra
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
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Tanious A, Boitano LT, Latz C, Kim Y, Decarlo C, Dua A, Eagleton MJ, Conrad MF. Fate of Type II Endoleaks During Ruptured EVAR. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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22
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Tanious A, Boitano LT, Decarlo C, Kim Y, Shames ML, Conrad MF, Eagleton MJ, Schwartz SI. Case Logging Habits of Integrated Vascular Surgery Residents. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Nooromid M, De Martino R, Squizzato F, Benedetto F, De Caridi G, Chou EL, Conrad MF, Pantoja J, Abularrage C, Sorber R, Garcia-Ortega DY, Luna-Ortiz K, Eichler C, Zarkowsky D, Chia M, Kalluri A, Cohnert T, Szeberin Z, Grotemeyer D, Shalhub S, Fagg D, Jackson MJ, Charlton-Ouw K, Gombert A, Jacobs M, Boyd A, Motaganahalli R, Uceda D, Woo K, Eskandari MK. Surgical resection and graft replacement for primary inferior vena cava leiomyosarcoma: a multicenter experience. J Vasc Surg Venous Lymphat Disord 2021; 10:617-625. [PMID: 34271247 DOI: 10.1016/j.jvsv.2021.06.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 06/30/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Primary leiomyosarcoma of the inferior vena cava (IVC) is best managed with surgical resection when technically feasible. However, consensus is lacking regarding the best choice of conduit and reconstruction technique. The aim of the present multicenter study was to perform a comprehensive assessment through the VLFDC (Vascular Low Frequency Disease Consortium) to determine the most effective method for caval reconstruction after resection of primary leiomyosarcoma of the IVC. METHODS A multicenter, standardized database review of patients who had undergone surgical resection and reconstruction of the IVC for primary leiomyosarcoma from 2007 to 2017 was performed. The demographics, periprocedural details, and postoperative outcomes were analyzed. RESULTS A total of 92 patients (60 women and 32 men), with a mean age of 60.1 years (range, 30-88 years) were treated. Metastatic disease was present in 22%. The tumor location was below the renal veins in 49 (53%), between the renal and hepatic veins in 52 (57%), and above the hepatic veins in 13 patients (14%). The conduits used for reconstruction included ringed polytetrafluoroethylene (PTFE; n = 80), nonringed PTFE (n = 1), Dacron (n = 1), autogenous vein (n = 1), bovine pericardium (n = 4), and cryopreserved tissue (n = 5). Complete R0 resection was accomplished in 73 patients (79%). In-hospital mortality was 2%, with a median length of stay of 8 days. The primary patency of PTFE reconstructed IVCs was 97% and 92% at 1 and 5 years, respectively, compared with 73% at 1 and 5 years for the non-PTFE reconstructed IVCs. The overall 1-, 3-, and 5-year survival for the entire cohort were 94%, 86%, and 65%, respectively CONCLUSIONS: The findings from our multi-institutional study have demonstrated that complete en bloc resection of IVC leiomyosarcoma with vascular surgical reconstruction in selected patients results in low perioperative mortality and is associated with excellent long-term patency. A ringed PTFE graft was the most commonly used conduit for caval reconstruction, yielding excellent long-term primary patency.
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Affiliation(s)
- Michael Nooromid
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill; Division of Vascular and Endovascular Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pa
| | - Randall De Martino
- Department of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Francesco Squizzato
- Department of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Filippo Benedetto
- Division of Vascular and Endovascular Surgery, University of Messina, Messina, Italy
| | - Giovanni De Caridi
- Division of Vascular and Endovascular Surgery, University of Messina, Messina, Italy
| | - Elizabeth L Chou
- Division of Vascular Surgery and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Mark F Conrad
- Division of Vascular Surgery and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Joe Pantoja
- Division of Vascular Surgery, Department of Surgery, David Geffen School of Medicine, Los Angeles, Calif
| | - Christopher Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Md
| | - Rebecca Sorber
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Md
| | - Dorian Yarih Garcia-Ortega
- Department of Skin and Soft Tissue Tumors and Head and Neck, Instituto Nacional de Cancerologia, Mexico City, Mexico
| | - Kuauhyama Luna-Ortiz
- Department of Skin and Soft Tissue Tumors and Head and Neck, Instituto Nacional de Cancerologia, Mexico City, Mexico
| | - Charles Eichler
- Division of Vascular Surgery and Endovascular Therapy, University of California, San Francisco, San Francisco, Calif
| | - Devin Zarkowsky
- Division of Vascular Surgery and Endovascular Therapy, University of California, San Francisco, San Francisco, Calif
| | - Matthew Chia
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Aravind Kalluri
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Tina Cohnert
- Department of Vascular Surgery, Graz Medical University, Graz, Austria
| | - Zoltan Szeberin
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Dirk Grotemeyer
- Department of Vascular Surgery, Hopitaux Robert Schuman, Hopital Kirchberg, Luxembourg City, Luxembourg
| | - Sherene Shalhub
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, Wash
| | - Damen Fagg
- Department of Vascular Surgery, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Mark J Jackson
- Department of Vascular Surgery, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Kristofer Charlton-Ouw
- Department of Clinical Sciences, University of Houston College of Medicine and Gulf Coast Vascular, HCA Houston Healthcare, Gulf Coast Division, Houston, Tex
| | - Alexander Gombert
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Michael Jacobs
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - April Boyd
- Division of Vascular Surgery, Department of Surgery, Health Sciences Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Raghu Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Domingo Uceda
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Karen Woo
- Division of Vascular Surgery, Department of Surgery, David Geffen School of Medicine, Los Angeles, Calif
| | - Mark K Eskandari
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill.
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Mohebali J, Latz CA, Cambria RP, Patel VI, Ergul EA, Lancaster RT, Conrad MF, Clouse WD. The Long-term Fate of Renal and Visceral Vessel Reconstruction After Open Thoracoabdominal Aortic Aneurysm Repair. J Vasc Surg 2021; 74:1825-1832. [PMID: 34171425 DOI: 10.1016/j.jvs.2021.05.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 05/17/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES In the ever-advancing era of endovascular thoracoabdominal aneurysm (TAAA) repair, understanding long-term patency of renovisceral reconstructions after open TAAA repair provides important benchmarks. METHODS Institutional open TAAA repair patient data were queried. Patients dying during index admission or with incomplete operative detail were excluded. Visceral and renal reconstructions were categorized as bypass, incorporation into a proximal or distal beveled aortic anastomosis, inclusion button, Carrel patch, or hybrid stent along with endarterectomy/stent adjuncts. Axial imaging or angiography determined long-term patency. Vessel event was defined as new occlusion or reintervention after repair. Overall time-to-event analysis was performed as well as separate analyses for each vessel (Celiac, SMA, right renal, left renal) by reconstruction type utilizing Kaplan-Meier methods. Log-rank testing was employed to compare reconstructive strategies. RESULTS Over 28-years, 604 repairs [Type I 106(18%), Type II 73(12%), Type III 195(32%), Type IV 230(38%)] were identified. Follow-up (median 500 days) was available in 410/570(72%) Celiac, 406/573(71%) SMA, 379/532(71.2%) right renal, and 370/515(72%) left renal reconstructions. There were five celiac, one SMA, eight right renal, and ten left renal events. No type of reconstruction or adjunct was significantly associated with event. Overall 5-year patency of all renal/visceral reconstructions was 94% (95%CI [90%-96%]). Estimated 5-year patency of the Celiac, SMA, left renal, and right renal were similar, and were 99%, 100%, 97%, and 96%, respectively (p = .09). CONCLUSIONS Visceral and renal long-term patency after open TAAA repair is excellent regardless of reconstructive technique. No differences are appreciated even when target vessel disease is addressed at the time of reconstruction. These findings continue to substantiate the effective long-term durability of open TAAA repair and are particularly germane to the ongoing evolution of endovascular strategies.
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Affiliation(s)
- Jahan Mohebali
- Massachusetts General Hospital Division of Vascular and Endovascular Surgery, Harvard Medical School, Boston, MA
| | - Christopher A Latz
- Massachusetts General Hospital Division of Vascular and Endovascular Surgery, Harvard Medical School, Boston, MA
| | - Richard P Cambria
- Divison of Vascular Surgery, Steward Medical Group, St. Elizabeth's Medical Center, Brighton, MA
| | - Virendra I Patel
- Divison of Vascular Surgery and Endovascular Interventions, Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York, NY
| | - Emel A Ergul
- Massachusetts General Hospital Division of Vascular and Endovascular Surgery, Harvard Medical School, Boston, MA
| | - R Todd Lancaster
- Massachusetts General Hospital Division of Vascular and Endovascular Surgery, Harvard Medical School, Boston, MA
| | - Mark F Conrad
- Massachusetts General Hospital Division of Vascular and Endovascular Surgery, Harvard Medical School, Boston, MA
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
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O'Donnell TFX, McElroy IE, Boitano LT, Mohebali J, Lamuraglia GM, Kwolek CJ, Conrad MF. Comparison of treatment options for aortic necks outside standard endovascular aneurysm repair instructions for use. J Vasc Surg 2021; 74:1548-1557. [PMID: 34019983 DOI: 10.1016/j.jvs.2021.04.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 04/16/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE/BACKGROUND Endovascular aneurysm repair (EVAR) is associated with worse outcomes in patients whose anatomy does not meet the device instructions for use (IFU). However, whether open surgical repair (OSR) and commercially available fenestrated EVAR (Zenith Fenestrated [ZFEN]) represent better options for these patients is unknown. METHODS We identified all patients without prior aortic surgery undergoing elective repair of abdominal aortic aneurysms with neck length ≥4 mm at a single institution with EVAR, OSR, and ZFEN. We applied device-specific aneurysm neck-related IFU to EVAR patients, and a generic EVAR IFU to ZFEN and OSR patients. Long-term outcomes were studied using propensity scores with inverse probability weighting. We compared outcomes in patients undergoing EVAR by adherence to IFU and outcomes by repair types in the subset of patients not meeting IFU. RESULTS Of 652 patients (474 EVAR, 34 ZFEN, 143 OSR), 211 had measurements outside of standard EVAR IFU (109 EVAR [23%], 27 ZFEN [80%], and 74 OSR [52%]). Perioperative mortality was 0.5% overall. For EVAR, treatment outside the IFU was associated with significantly higher adjusted rates of long-term type IA endoleak (22% at 5 years compared to 2% within IFU, hazard ratio [HR]: 5.8 [3.1-10.9], P < .001), and lower survival (5- and 10-year survival: 56% and 34% vs 81% and 53%, HR: 2.3 [1.2-4.3], P = .01). There was no difference in reinterventions or open conversion. In patients not meeting IFU, ZFEN was associated with higher adjusted rates of reinterventions (EVAR as referent: HR: 2.6 [1.5-4.4, P < .001), whereas OSR and EVAR patients experienced similar reintervention rates (HR: 0.7 [0.4-1.1], P = .13). Patients outside the IFU experienced lower mortality with OSR compared with either EVAR (HR: 0.4 [0.2-0.9], P = .005) or ZFEN (HR: 0.3 [0.1-0.7], P = .002). When restricted to patients outside the IFU deemed fit for open repair, OSR patients remained associated with lower adjusted mortality compared with ZFEN (HR: 0.2 [0.1-0.5], P < .001), but statistical significance was lost in the comparison to EVAR (HR: 0.6 [0.3-1.1], P = .1). CONCLUSIONS Treatment outside device-specific IFU is associated with adverse long-term outcomes. Open surgical repair is associated with higher long-term survival in patients who fall outside of the EVAR IFU and should be favored over EVAR or ZFEN in suitable patients. A three-vessel-based fenestrated strategy may not be a durable solution for difficult aortic necks, but more data are needed to evaluate the performance of newer, four-vessel devices.
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Affiliation(s)
- Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Imani E McElroy
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Jahan Mohebali
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Glenn M Lamuraglia
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Christopher J Kwolek
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
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DeCarlo C, Tanious A, Boitano LT, Mohebali J, Stone DH, Clouse WD, Conrad MF. Addition of common carotid intervention increases the risk of stroke and death after carotid artery stenting for asymptomatic patients. J Vasc Surg 2021; 74:1919-1928. [PMID: 34019994 DOI: 10.1016/j.jvs.2021.04.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 04/16/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND A recent review of Vascular Study Group of New England data suggested that simultaneous endovascular treatment of tandem carotid lesions (TCAL: common carotid artery + internal carotid artery) is associated with a fourfold increase in perioperative neurologic events and death. However, given the small cohort, the effect of symptomatic status could not be evaluated. This study sought to determine the risk of simultaneous TCAL stenting in cohorts stratified by symptom status. METHODS Vascular Quality Initiative data (2005-2020) were queried for carotid stenting procedures (CAS). Emergent and bilateral procedures, patients with prior ipsilateral CAS, internal carotid artery lesions with stenosis <50%, and hybrid transcarotid procedures were excluded. The cohort was stratified by symptomatic status. The primary outcome was the composite of perioperative stroke and death. Predictors of stroke/death were determined with multivariable logistic regression for symptomatic and asymptomatic patients with TCAL forced into the models. RESULTS There were 18,886 carotid arteries stented (18,441 patients): 18,077 (96%) with isolated carotid artery lesions and 809 (4%) with TCAL. Mean age was 70.0 ± 9.7. Symptomatic lesions were present in 58.9% of cases (isolated carotid artery lesions: 59.1% vs TCAL: 52.5%; P < .001). More TCAL arteries had a prior carotid endarterectomy (38.3% vs 23.8%; P < .001). TCAL had a higher perioperative stroke/death (3.4% vs 1.8%; P = .026) for asymptomatic lesions, but not symptomatic lesions (4.5% vs 3.7%; P = .41). TCAL were independently associated with stroke/death in asymptomatic patients (odds ratio, 1.85; 95% confidence interval, 1.03-3.33; P = .039) but not symptomatic patients (odds ratio, 1.22; 95% confidence interval, 0.76-1.97; P = .42). CONCLUSIONS The addition of endovascular treatment of common carotid artery lesions with CAS is associated with almost double the risk of perioperative stroke/death in asymptomatic patients and should be avoided if possible. Treatment of TCAL is not associated with an increased risk of stroke/death for symptomatic lesions.
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Affiliation(s)
- Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
| | - Adam Tanious
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Jahan Mohebali
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - David H Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, Va
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
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DeCarlo C, Tanious A, Boitano LT, Mohebali J, Stone DH, Clouse WD, Conrad MF. Hybrid and Total Endovascular Approaches to Tandem Carotid Artery Lesions Have Similar Short- and Long-Term Outcomes. Ann Vasc Surg 2021; 76:20-27. [PMID: 33831532 DOI: 10.1016/j.avsg.2021.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/22/2021] [Accepted: 02/23/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Addition of ipsilateral proximal endovascular intervention (PEI, common carotid/innominate) increases the risk of perioperative stroke/death for both carotid endarterectomy (CEA) and carotid stenting (CAS). However, these approaches have not been directly compared and is the subject of this study. METHODS VQI (2005-2020) was queried for CEA and CAS with PEI, excluding emergent, bilateral, and repeat procedures, patients with prior ipsilateral CAS, ICA lesions with stenosis<50%, and transcarotid ICA stents. Primary outcome were the composite of perioperative stroke/death and long-term stroke/reintervention/death. Operative approach was evaluated with logistic regression, adjusted propensity scores, symptomatic status, and stenosis>70%. Long-term outcomes were compared with Kaplan-Meier Analysis. RESULTS There were 1,433 patients (795 endovascular;638 hybrid); mean age 69.8±9.4 years. Patients undergoing hybrid procedures were more likely to be female (49.4% vs. 37.5%; P < 0.001), less likely to have diabetes (29.5% vs. 38.2%; P P< 0.001), less likely to have a prior ipsilateral CEA (3.8% vs. 32.2%; P< 0.001), less likely to be symptomatic (34.6% vs. 52.8%; P < 0.001), and less likely to have >70% stenosis (77.3% vs. 95.6%%; P < 0.001). Perioperative stroke/death was 3.6% for hybrid and 3.9% for endovascular approaches (P = 0.77). In the multivariable model, hybrid operative approach (compared to the total endovascular approach) was not significantly associated with stroke/death (OR 1.29; 95%CI: 0.55-3.07; P = 0.56). For the 981 patients with long-term follow-up (556 endovascular; 425 hybrid), 1-year freedom from stroke/reintervention/death was 94.0% (95%CI: 90.9%-96.0%) for hybrid approach vs. 92.3% (95%CI: 89.5%-94.4%) for endovascular approach (P = 0.27). CONCLUSION Although simultaneous repair of tandem carotid lesions portends worse outcomes when compared to CEA or CAS alone, there was no difference in short or long-term stroke and death rates with a hybrid or totally endovascular approach. Therefore, it is reasonable to use either approach in the select patients who require simultaneous repair of both lesions.
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Affiliation(s)
- Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Adam Tanious
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jahan Mohebali
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David H Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, New Hampshire
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville Virginia
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Chou EL, Wang LJ, McLellan RM, Feldman ZM, Latz CA, LaMuraglia GM, Clouse WD, Eagleton MJ, Conrad MF. Evolution in the Presentation, Treatment, and Outcomes of Patients with Acute Mesenteric Ischemia. Ann Vasc Surg 2021; 74:53-62. [PMID: 33823263 DOI: 10.1016/j.avsg.2021.01.116] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 01/19/2021] [Accepted: 01/28/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVES 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 of AMI over the past two decades. METHODS AMI patients presenting at a single institution were reviewed (1993-2016). Venous thrombosis patients were excluded. Primary outcome was 30-day mortality. Patients were stratified by etiology and diagnosis date (before 2004 versus 2004 and later). Ordered logistic regression was performed for longitudinal temporal analysis. RESULTS 303 patients were identified. AMI mechanisms included: embolic (49%), thrombotic (29%), and non-occlusive (NOMI) (22%). The majority were women (55%), 50% had atrial fibrillation, and 23% were on anticoagulation (AC) therapy. Mean age was 72±13 years. 345 procedures were performed in 242 patients: 321 open and 24 hybrid/endovascular. Among the 189 embolic/thrombotic patients who were managed operatively, 45% (n=85) underwent mesenteric revascularization while 39 (21%) had findings of non-survivable bowel necrosis (NSBN). Among the 104 patients who did not undergo revascularization, 64 (62%) died within 30-days compared to 36 out of 85 (42%) patients who were revascularized (P=0.01). 30-day mortality was 61% and stable over time (P=0.91); when stratified by AMI etiology, the thrombotic cohort had worse survival than embolic and NOMI patients (P=0.04). Since 2000, there was a significant decrease in the percentage of embolic AMI events (P=0.04). The percentage of patients who underwent operative management decreased also over time (P=0.01, 81% → 61%), which was correlated with an increasing number of patients being made comfort measures only (CMO) prior to surgical intervention (50% → 70%, P=0.02). The majority of patients (55%) were ultimately made CMO during their hospitalization. Predictors of 30-day mortality included a preoperative white blood cell count (WBC) ≥ 25 K/ µL. (OR 3.0, P=0.002) and lactate ≥ 2.3 mmol/L (OR 2.8, P=0.045). NSBN predictors included WBC ≥ 24 K/ µL. (OR 3.4 P=0.03) and lactate ≥ 3.8 mmol/L (OR 3.6, P=0.04). CONCLUSIONS Despite advances in critical care over the past 25 years, AMI continues to be associated with poor prognosis. The survival benefit observed in patients who undergo revascularization supports an aggressive approach towards early vascular intervention, although this requires further study. The importance of early diagnosis, prognostication and advanced directives is highlighted given the high morbidity, mortality and use of comfort measures associated with AMI.
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Affiliation(s)
- Elizabeth L Chou
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA.
| | - Linda J Wang
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Rachel M McLellan
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Zach M Feldman
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Christopher A Latz
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Glenn M LaMuraglia
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
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Feldman ZM, Wang LJ, Chou EL, Latz CA, Sumpio BJ, Eagleton MJ, Conrad MF. Venous mesenteric ischemia carries high procedural burden and elevated mortality in patients with severe presentation. J Vasc Surg Venous Lymphat Disord 2021; 9:1479-1487. [PMID: 33741519 DOI: 10.1016/j.jvsv.2021.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/04/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Venous mesenteric ischemia (VMI) presents with variable severity resulting in a spectrum of outcomes. This study sought to characterize the natural history of VMI and identify drivers of intervention and adverse outcomes. METHODS All patients who presented to our institution with acute and subacute VMI between 1993 and 2016 were identified. Images were reviewed to determine thrombosis location and charts were reviewed to identify clinical factors and outcomes. Univariate analysis was performed for demographics, comorbidities, and presenting characteristics, with primary outcomes of intervention, readmission, and 30-day mortality. A survival analysis was performed with log-rank difference testing for demographics, comorbidities, and presenting characteristics. RESULTS We identified 103 patients with acute and subacute VMI. The locations of the thrombosis included the superior mesenteric vein (SMV) (31.1%); SMV and portal vein (35.9%); SMV, portal, and splenic veins (15.5%); and other combinations of portomesenteric veins (17.4%), without correlation between the location and outcomes. Most patients were male (60.6%), 22.3% were actively smoking, and the median Charlson comorbidity score was 4 (interquartile range, 2-7). The mean patient age was 61.3 years. More than one-half had a known hypercoagulability (52.4%), 22.3% had prior bowel resection, and 8.7% had prior mesenteric venous intervention, including transjugular intrahepatic portosystemic shunt procedures. Thirty-five patients underwent 83 procedures during their hospitalization, and 23 patients underwent surgical intervention specifically. Prior mesenteric venous procedure, abdominal tenderness, and lactatemia of more than 1.5 mmol/L were associated with an increased need for surgical intervention (P < .05). Patients with leukocytosis of greater than 10K/μL had increased surgical intervention (P = .10), although without statistical significance. However, symptoms for less than 2 weeks (P < .05) were associated with decreased surgical intervention. The 30-day mortality was low in this cohort (6.8%), but was increased in patients requiring intervention (11.4%). For those undergoing procedures, a shorter time to intervention was associated with an improved 30-day mortality (8.7% for procedures on hospital days 0-1 vs 16.7% for hospital day 2 or later; P = .01). Abdominal tenderness and lactatemia were associated with increased 30-day mortality (6.8% vs 3.6% [P < .01] and 16.0% vs 3.8% [P = .03], respectively). A Kaplan-Meier survival analysis revealed a median survival of 7.1 years, with a 1-year survival rate of 74.9%, a 3-year survival rate of 67.1%, and a 5-year survival rate of 57.9%. Negative predictors of survival included a higher Charlson comorbidity index (hazard ratio, 3.7; P < .01) and malignancy (hazard ratio, 3.1; P < .01). CONCLUSIONS The 30-day mortality of VMT is low, but more than one-third of patients required an intervention beyond anticoagulation. Comorbidity, a prior mesenteric vessel or intestinal operation, and presentation with tenderness or relevant laboratory abnormalities portend worse outcomes. Early intervention is associated with improved outcomes.
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Affiliation(s)
- Zach M Feldman
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
| | | | - Elizabeth L Chou
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Christopher A Latz
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Brandon J Sumpio
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
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DeCarlo C, Gifford R, Boitano LT, Mohebali J, Clouse WD, Conrad MF. The Effect of Retrograde External Iliac Artery Runoff on Aortofemoral Bypass Limb Patency. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2020.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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DeCarlo C, Tanious A, Boitano LT, Mohebali J, Stone DH, Clouse WD, Conrad MF. Simultaneous treatment of common carotid lesions increases the risk of stroke and death after carotid artery stenting. J Vasc Surg 2021; 74:592-598.e1. [PMID: 33545307 DOI: 10.1016/j.jvs.2020.12.089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/21/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Tandem carotid artery lesions that involve simultaneous internal carotid artery (ICA) and common carotid artery (CCA) stenoses present a complex clinical problem. Some studies have shown that the addition of a retrograde proximal intervention to treat a CCA lesion during a carotid endarterectomy (CEA) increases the risk of stroke and death. However, the stroke and death risks associated with a totally endovascular approach to tandem lesions is unknown and is the subject of this study. METHODS Vascular Study Group of New England data for the years 2005 to 2020 were queried for carotid artery stenting (CAS) procedures. Emergent and bilateral procedures, procedures for indications other than atherosclerosis, patients with prior ipsilateral CAS, ICA lesions with stenosis of less than 50%, and transcarotid procedures were excluded. The cohort was divided into tandem and isolated lesion groups. The primary outcome was the composite of stroke and death. Predictors of stroke or death were determined with multivariable logistic regression. RESULTS There were 2016 carotid arteries stented in 1950 patients-1881 (96%) with isolated lesions and 135 (4%) with tandem lesions. The mean patient age was 69.6 ± 9.0 years. Tandem lesions were more likely to be present in women (50.4% vs 33.0%; P < .001) and in patients with a prior carotid endarterectomy (45.9% vs 35.4%; P = .014). Other covariates were similar between the groups. Symptomatic lesions accounted for 42.3% of cases (isolated, 42.2% vs tandem, 43.0%; P = .86). Arteries in the tandem group more often required multiple stents to treat the ICA lesion (9.6% vs 5.2%; P = .027). ICA neuroprotection had similar outcomes in both groups (tandem: success 94.1%, failure 3.7%; isolated: success 96.3%, failure 1.8%; P = .29). The tandem group experienced a higher 30-day mortality (2.2% vs 0.6%; P = .039), more perioperative neurologic events (stroke or transient ischemic attack) (8.1% vs 2.0%; P < .001), and a higher incidence of stroke or death (5.9% vs 1.9%; P = .002). Predictors of the primary outcome in the multivariable model included treatment of tandem lesions (odds ratio [OR], 3.10; 95% confidence interval [CI], 1.39-6.89; P = .006), symptomatic lesions (OR, 2.24; 95% CI, 1.21-4.17; P = .010), chronic obstructive pulmonary disease (OR, 2.14; 95% CI, 1.17-3.92; P = .014), general anesthesia (OR, 3.34; 95% CI, 1.35-8.26; P = .009), and advancing age (OR, 1.05 per year; 95% CI, 1.01-1.09; P = .006). CONCLUSIONS The addition of endovascular treatment of tandem CCA lesions with CAS is associated with a three-fold increase in perioperative stroke and death and should be avoided if possible.
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Affiliation(s)
- Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
| | - Adam Tanious
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Jahan Mohebali
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - David H Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville VA
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
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Wang LJ, Nixon TP, Crofts SC, Latz CA, Goudreau BJ, Conrad MF, Eagleton MJ, Clouse WD. Comparison of 30 Day Stroke and Death in Hybrid Intervention and Open Surgical Reconstruction for the Treatment of Tandem Carotid Bifurcation and Supra-aortic Trunk Disease. Eur J Vasc Endovasc Surg 2021; 61:83-88. [DOI: 10.1016/j.ejvs.2020.08.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 08/18/2020] [Accepted: 08/27/2020] [Indexed: 11/29/2022]
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Upchurch GR, Escobar GA, Azizzadeh A, Beck AW, Conrad MF, Matsumura JS, Murad MH, Perry RJ, Singh MJ, Veeraswamy RK, Wang GJ. Society for Vascular Surgery clinical practice guidelines of thoracic endovascular aortic repair for descending thoracic aortic aneurysms. J Vasc Surg 2021; 73:55S-83S. [DOI: 10.1016/j.jvs.2020.05.076] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 12/17/2022]
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Goudreau BJ, Wang LJ, Latz CA, Conrad MF, Williams CA, Tracci MC, Kern JA, Clouse WD. Adding Supra-Aortic Trunk Surgical Reconstruction to Carotid Endarterectomy: Implications on Risk of Stroke and Death. J Am Coll Surg 2020; 232:629-635. [PMID: 33316428 DOI: 10.1016/j.jamcollsurg.2020.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 11/30/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Additive risks of combining supra-aortic trunk surgical reconstruction (SAT) with carotid endarterectomy (CEA) for associated carotid bifurcation and great vessel disease management are not well defined. This study sought to define risk of combining SAT with CEA. STUDY DESIGN Isolated CEA (ICEA) and CEA+SAT (from 2005 to 2015) were identified from NSQIP, excluding nonocclusive indications. CEA+SAT were compared with ICEA as well as a propensity-matched ICEA cohort. Primary outcomes included 30-day stroke, death, and composite (SD). Outcomes were then weighted by symptomatic status. Univariate and logistic regression analyses were performed. RESULTS Patients included 79,477 ICEA and 270 CEA+SAT. SAT reconstructions included 19 (7%) aorto-carotid bypasses, 21 (8%) carotid-subclavian transpositions, 85 (31%) carotid-carotid bypasses, and 145 (54%) carotid-subclavian bypasses. There was no difference in 30-day mortality (vs CEA+SAT 1.5% vs ICEA 0.7% p = 0.12). CEA+SAT had higher rates of stroke (3.7% vs 1.6%, p = 0.005) and stroke and death (SD) (4.8% vs 2.1%, p = 0.001). Predictors of SD included CEA+SAT (odds ratio [OR] 5.2, 95% CI 1.03-26.3, p = 0.046) and symptomatic status (OR 1.9, 95% CI 1.1-3.2, p = 0.02). After propensity matching, CEA+SAT continued to have higher rates of stroke (3.4% vs 0.4%, p = 0.01) and SD (4.5% vs 1.5%, p = 0.04), with similar mortality (1.5% vs 1.1%, p = 0.70). No differences were noted in primary endpoints in asymptomatic patients. In symptomatic patients, CEA+SAT carried significantly higher stroke (5.6% vs 2.1%, p = 0.04) and SD risk (7.0% vs 2.8%, p = 0.03). CONCLUSIONS CEA+SAT confers increased risk of stroke and SD over ICEA. Symptomatic status and concomitant procedure contribute to this risk. Management should be considered within the context of lesion characteristics, patient longevity, and individual operative risk profile.
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Affiliation(s)
- Bernadette J Goudreau
- Divisions of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | | | | | | | - Carlin A Williams
- Divisions of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Margaret C Tracci
- Divisions of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - John A Kern
- Divisions of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - W Darrin Clouse
- Divisions of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA.
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DeCarlo C, Boitano LT, Schwartz SI, Lancaster RT, Conrad MF, Eagleton MJ, Brewster DC, Clouse WD. Laparotomy- and groin-associated complications are common after aortofemoral bypass and contribute to reintervention. J Vasc Surg 2020; 72:1976-1986. [DOI: 10.1016/j.jvs.2019.09.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 09/19/2019] [Indexed: 10/24/2022]
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DeCarlo C, Manxhari C, Boitano LT, Mohebali J, Schwartz SI, Eagleton MJ, Conrad MF. Transabdominal approach associated with increased long-term laparotomy complications after open abdominal aortic aneurysm repair. J Vasc Surg 2020; 73:1603-1610. [PMID: 33080323 DOI: 10.1016/j.jvs.2020.08.154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/31/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Although the transabdominal approach (TAA) and lateral approach (LA) to open abdominal aortic aneurysm repair (OAR) are both acceptable and widely used, a paucity of data evaluating subsequent postoperative laparotomy-associated complications (LCs) is available. The aim of the present study was to establish the incidence of LCs after OAR and determine which approach was associated with an increase in long-term LCs. METHODS An institutional database for OAR (2010-2019) was queried, excluding urgent and emergent cases. The primary endpoint was long-term LCs, defined as any complication related to entry into the abdomen. The LA included retroperitoneal and thoracoabdominal approaches and the TAA included all patients with midline incisions. A Kaplan-Meier analysis was used to estimate the freedom from LCs, and the Fine-Gray method was used to determine the predictors of LCs, with death as a competing risk. RESULTS A total of 241 patients (mean age, 70.0 ± 9.1 years; 71.7% men) had undergone OAR, 91 via a TAA and 150 via a LA. The patients in the TAA group were significantly younger (age, 66.7 ± 8.9 vs 72.1 ± 8.7 years; P < .001), more likely to be male (83.5% vs 64.7%; P = .002), and more likely to have a history of small bowel obstruction (SBO; 3.3% vs 0%; P = .025). Patients in the LA group were more likely to have required a supraceliac clamp (20.7% vs 1.1%; P < .001). No difference was found in the incidence of perioperative complications or long-term mortality. The most common LCs were hernia (TAA, 26.4%; LA, 11.3%; P = .003), SBO (TAA, 8.8%, LA, 1.3%; P = .005), and other (TAA, 13.2%; LA, 2.0%; P = .001), which included evisceration, bowel ischemia, splenic injuries requiring reintervention, enterocutaneous fistula, internal hernia, and retrograde ejaculation. Operative LCs were more common in the TAA group (17.6% vs 2.7%; P < .001). The unadjusted 1-, 3-, and 5-year freedom from LCs was 77.7% (95% confidence interval [CI], 66.0%-85.8%), 60.5% (95% CI, 46.5%-71.9%), and 54.0% (95% CI, 38.8%-67.0%) for TAA and 94.8% (95% CI, 88.8%-97.7%), 82.2% (95% CI, 72.2%-88.9%), and 79.1% (95% CI, 68.4%-86.5%) for LA, respectively (log-rank P < .001). The predictors for LCs were a history of SBO (P = .001), increasing body mass index (P = .005), and the use of the TAA (P < .001). CONCLUSIONS Use of the TAA was an independent predictor of long-term LCs after OAR, along with an increasing body mass index and a history of SBO. In patients with amenable anatomy, the LA is favorable for preventing long-term LCs, especially in high-risk patients.
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Affiliation(s)
- Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
| | - Christina Manxhari
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Jahan Mohebali
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Samuel I Schwartz
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
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DeCarlo C, Boitano LT, Molina RL, Weinberg I, Conrad MF, Eagleton MJ, Dua A. Pregnancy and Preeclampsia Are Associated With Acute Adverse Peripheral Arterial Events. Arterioscler Thromb Vasc Biol 2020; 41:526-533. [PMID: 33054392 DOI: 10.1161/atvbaha.120.315174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Acute peripheral arterial events, such as aortic dissection, carotid artery dissection, vertebral artery dissection, and ruptured renoviseral aneurysms, have been reported during pregnancy in case series, but there is a paucity of population-based data. This study sought to establish pregnancy and preeclampsia as risk factors for acute peripheral arterial events. Approach and Results: All women who gave birth between 1998 and 2020 within a multicenter health care system were identified. Births that occurred in women <18 or >50 years of age were excluded. Primary outcome was any acute peripheral arterial event that was symptomatic or required intervention. Cox regression model was used to evaluate the association between vascular events and pregnancy as a time-varying covariate. The pregnancy exposure period was from the estimated date of conception to 3 months postpartum. There were 277 697 pregnancies (81.3% deliveries, 17.0% abortions, and 1.7% ectopics) among 176 635 women with 1.68 million patient-years of total follow-up (median, 7.9 years; interquartile range, 2.4-16.2). Preeclampsia complicated 5.3% of pregnancies; 67 790 of 225 763 (30.0%) deliveries were delivered by cesarean. Ninety-six acute arterial events occurred during follow-up, of which 24 occurred during pregnancy, including the postpartum period. Pregnancy (hazard ratio, 1.85 [95% CI, 1.01-3.38]; P=0.046) and preeclampsia (hazard ratio, 10.9 [95% CI, 5.24-22.7]; P<0.001) were significant independent predictors of acute arterial events. CONCLUSIONS While taking into account limitations from estimating conception and outcome dates, pregnancy, especially when complicated by preeclampsia, is associated with an increased risk of acute peripheral arterial events.
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Affiliation(s)
- Charles DeCarlo
- Division of Vascular Surgery, Department of Surgery (C.D., L.T.B., M.F.C., M.J.E., A.D.), Massachusetts General Hospital, Boston
| | - Laura T Boitano
- Division of Vascular Surgery, Department of Surgery (C.D., L.T.B., M.F.C., M.J.E., A.D.), Massachusetts General Hospital, Boston
| | - Rose L Molina
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (R.L.M.).,Division of Women's Health, Brigham and Women's Hospital, Boston, MA (R.L.M.)
| | - Ido Weinberg
- Fireman Vascular Center (I.W.), Massachusetts General Hospital, Boston.,Department of Medicine, Division of Vascular Medicine (I.W.), Massachusetts General Hospital, Boston
| | - Mark F Conrad
- Division of Vascular Surgery, Department of Surgery (C.D., L.T.B., M.F.C., M.J.E., A.D.), Massachusetts General Hospital, Boston
| | - Matthew J Eagleton
- Division of Vascular Surgery, Department of Surgery (C.D., L.T.B., M.F.C., M.J.E., A.D.), Massachusetts General Hospital, Boston
| | - Anahita Dua
- Division of Vascular Surgery, Department of Surgery (C.D., L.T.B., M.F.C., M.J.E., A.D.), Massachusetts General Hospital, Boston
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Ramirez JL, Zarkowsky DS, Boitano LT, Conrad MF, Arya S, Gasper WJ, Conte MS, Iannuzzi JC. A novel preoperative risk score for nonhome discharge after elective thoracic endovascular aortic repair. J Vasc Surg 2020; 73:1549-1556. [PMID: 33065243 DOI: 10.1016/j.jvs.2020.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 10/01/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Nonhome discharge (NHD) to a rehabilitation or skilled nursing facility after vascular surgery is poorly described despite its large impact on patients. Understanding postsurgical NHD risk is essential to providing adequate preoperative counseling and shared decision making, particularly for elective surgeries. We aimed to identify independent predictors of NHD after elective thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysms (TAA) and to create a clinically useful preoperative risk score. METHODS Elective TEVAR cases for descending TAA were queried from the Society for Vascular Surgery Vascular Quality Initiative from 2014 to 2018. A risk score was created by splitting the dataset into two-thirds for model development and one-third for validation. A parsimonious stepwise hierarchical multivariable logistic regression controlling for hospital level variation was performed in the development dataset, and the beta-coefficients were used to assign points for a risk score. This score was then cross-validated and model performance assessed. RESULTS Overall, 1469 patients were included and 213 (14.5%) required NHD. At baseline, patients who required NHD were more likely to be ≥80 years old (35.2% vs 19.4%), female (58.7% vs 40.6%), functionally dependent (42.3% vs 24.0%), and anemic (46.5% vs 27.8%), and to have chronic obstructive pulmonary disease (41.3% vs 33.4%), congestive heart failure (18.8% vs 11.1%), and American Society of Anesthesiologists class ≥4 (51.6% vs 39.8%; all P < .05). Multivariable analysis in the development group identified independent predictors of NHD that were used to create an 18-point risk score. Patients were stratified into three groups based upon their risk score: low risk (0-7 points; n = 563) with an NHD rate of 4.3%, moderate risk (8-11 points; n = 701) with an NHD rate of 17.0%, and high risk (≥12 points; n = 205) with an NHD rate of 34.2%. The risk score had good predictive ability with a c-statistic of 0.75 for model development and a c-statistic of 0.72 in the validation dataset. CONCLUSIONS This novel risk score can predict NHD after TEVAR for TAA using characteristics that can be identified preoperatively. The use of this score may allow for improved risk assessment, preoperative counseling, and shared decision making.
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Affiliation(s)
- Joel L Ramirez
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif
| | - Devin S Zarkowsky
- Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Aurora, Colo
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University, Palo Alto, Calif
| | - Warren J Gasper
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif
| | - James C Iannuzzi
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif.
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DeCarlo C, Latz CA, Boitano LT, Pendleton AA, Mohebali J, Conrad MF, Eagleton MJ, Schwartz SI. Percutaneous brachial access associated with increased incidence of complications compared with open exposure for peripheral vascular interventions in a contemporary series. J Vasc Surg 2020; 73:1723-1730. [PMID: 33031886 DOI: 10.1016/j.jvs.2020.08.143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/18/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Although percutaneous brachial access has been used more often for peripheral vascular interventions (PVIs), previous studies have suggested that open brachial artery exposure for access is associated with fewer complications than percutaneous access. The present study sought to determine the incidence of complications for each access method and identify the predictors of access site complications after brachial access. METHODS The Vascular Quality Initiative national database was queried for all patients who had undergone PVI with brachial artery access from 2016 to 2019. Procedures with simultaneous thrombolysis or open procedures were excluded. The primary outcome was any perioperative brachial artery access complications. Multivariable logistic regression was used to identify any associated predictors. RESULTS A total of 1400 procedures had been performed for 1242 patients; 189 procedures (13.5%) had used an open exposure. The mean patient age was 67.3 ± 9.5 years, and 55.7% of the procedures were on men. No significant demographic differences were found between the open and percutaneous groups. Open exposure procedures were more likely to have used sheaths >5F (79.4% vs 59.0%; P < .001) and treated more arteries (2.0 ± 1.8 vs 1.7 ± 0.9; P < .001) but less likely to have used multiple access sites (8.5% vs 20.1%; P < .001). Access complications occurred in 7.5% of the percutaneous procedures and 1.6% of the open exposures (P = .003). Percutaneous access was independently associated with the occurrence of brachial access complications (odds ratio [OR], 5.92; 95% confidence interval [CI], 1.76-19.9; P = .004). Other associated factors included female sex (OR, 2.23; 95% CI, 1.44-3.44; P < .001), congestive heart failure (OR, 2.02; 95% CI, 1.26-3.24; P = .003), and increasing sheath size (OR, 1.36 per each 1F increase in size; 95% CI, 1.07-1.72; P = .011); diabetes was protective (OR, 0.53; 95% CI, 0.33-0.83; P = .006). CONCLUSIONS Open exposure might be advantageous compared with percutaneous access for preventing complications after brachial access. However, the difference in complications was driven by hematomas that were managed nonoperatively. Operative complications were more common in the percutaneous group, although this did not reach statistical significance. Percutaneous access should be used cautiously in women, patients with a history of congestive heart failure, those without diabetes, and interventions in which larger sheaths are required.
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Affiliation(s)
- Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
| | - Christopher A Latz
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Anna A Pendleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Jahan Mohebali
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Samuel I Schwartz
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
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Latz CA, Boitano LT, Tanious A, Wang LJ, Schwartz SI, Pendleton AA, DeCarlo C, Dua A, Conrad MF. Endovascular Versus Open Repair for Ruptured Complex Abdominal Aortic Aneurysms: A Propensity Weighted Analysis. Ann Vasc Surg 2020; 68:34-43. [DOI: 10.1016/j.avsg.2020.04.073] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 04/21/2020] [Accepted: 04/27/2020] [Indexed: 12/31/2022]
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O'Donnell TF, Boitano LT, Mohebali J, LaMuraglia GM, Kwolek CJ, Conrad MF. Off-Label Use of Endovascular Aneurysm Repair Devices Is Associated With Adverse Outcomes and Should Be Avoided. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.06.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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O'Donnell TF, Mohebali J, Boitano LT, LaMuraglia GM, Kwolek CJ, Conrad MF. Natural History of Late Type IA Endoleaks. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Latz CA, Boitano LT, DeCarlo C, Feldman Z, Png M, Mohebali J, Dua A, Conrad MF. Short- and Long-term Outcomes After Concurrent Splenectomy for Thoracoabdominal Aortic Aneurysm Repair. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.06.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Chou EL, Pettinger M, Haring B, Mell MW, Hlatky MA, Wactawski-Wende J, Allison MA, Wild RA, Shadyab AH, Wallace RB, Snetselaar LG, Eagleton MJ, Conrad MF, Liu S. Lipoprotein(a) levels and risk of abdominal aortic aneurysm in the Women's Health Initiative. J Vasc Surg 2020; 73:1245-1252.e3. [PMID: 32882349 DOI: 10.1016/j.jvs.2020.07.106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/26/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Few studies have prospectively examined the associations of lipoprotein(a) [Lp(a)] levels with the risk of abdominal aortic aneurysm (AAA), especially in women. Accounting for commonly recognized risk factors, we investigated the baseline Lp(a) levels and the risk of AAA among postmenopausal women participating in the ongoing national Women's Health Initiative. METHODS Women's Health Initiative participants with baseline Lp(a) levels available who were beneficiaries of Medicare parts A and B fee-for-service at study enrollment or who had aged into Medicare at any point were included. Participants with missing covariate data or known AAA at baseline were excluded. Thoracic aneurysms were excluded owing to the different pathophysiology. The AAA cases and interventions were identified using the International Classification of Diseases, 9th and 10th revision, codes and Current Procedural Terminology codes from claims data. Hazard ratios were computed using Cox proportional hazard models according to the quintiles of Lp(a). RESULTS The mean age of the 6615 participants included in the analysis was 65.3 years. Of the 6615 participants, 66.6% were non-Hispanic white, 18.9% were black, 7% were Hispanic and 4.7% were Asian/Pacific Islander. Compared with the participants in the lowest Lp(a) quintile, those in higher quintiles were more likely to be overweight, black, and former or current smokers, to have hypertension, hyperlipidemia, and a history of cardiovascular disease, and to use menopausal hormone therapy and statins. During 65,476 person-years of follow-up, with a median of 10.4 years, 415 women had been diagnosed with an AAA and 36 had required intervention. More than one half had required intervention for a ruptured AAA. We failed to find a statistically significant association between Lp(a) levels and incident AAA. Additional sensitivity analyses stratified by race, with exclusion of statin users and alternative categorizations of Lp(a) using log-transformed levels, tertiles, and a cutoff of >50 mg/dL, were conducted, which did not reveal any significant associations. CONCLUSIONS We found no statistically significant association between Lp(a) levels and the risk of AAA in a large and well-phenotyped sample of postmenopausal women. Women with high Lp(a) levels were more likely to be overweight, black, and former or current smokers, and to have hypertension, hyperlipidemia, and a history of cardiovascular disease, or to use hormone therapy and statins compared with those with lower Lp(a) levels. These findings differ from previous prospective, case-control, and meta-analysis studies that had supported a significant relationship between higher Lp(a) levels and an increased risk of AAA. Differences in the association could have resulted from study limitations or sex differences.
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Affiliation(s)
- Elizabeth L Chou
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
| | - Mary Pettinger
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Wash
| | - Bernhard Haring
- Department of Internal Medicine, University of Würzburg, Würzburg, Germany
| | - Matthew W Mell
- Division of Vascular Surgery, University of California, Davis, Medical Center, Sacramento, Calif
| | - Mark A Hlatky
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, Calif
| | - Jean Wactawski-Wende
- Department of Epidemiology and Environmental Health, State University of New York at Buffalo, Buffalo, NY
| | - Matthew A Allison
- Department of Family Medicine and Public Health, University of California, San Diego, School of Medicine, La Jolla, Calif
| | - Robert A Wild
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Aladdin H Shadyab
- Department of Family Medicine and Public Health, University of California, San Diego, School of Medicine, La Jolla, Calif
| | - Robert B Wallace
- Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, Iowa
| | - Linda G Snetselaar
- Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, Iowa
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Simin Liu
- Department of Epidemiology and Medicine, Brown University, Providence, RI
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Tanious A, Boitano L, Canha L, Chou EL, Wang LJ, Latz C, Eagleton MJ, Conrad MF. Thoracic aortic remodeling with endografting after a decade of thoracic endovascular aortic repair experience. J Vasc Surg 2020; 73:844-849. [PMID: 32707385 DOI: 10.1016/j.jvs.2020.06.120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 06/22/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Thoracic endovascular aortic repair (TEVAR) results have been studied in short-term time frames. This study aimed to evaluate midterm and long-term outcomes of TEVAR, emphasizing postoperative aortic remodeling and need for reintervention. METHODS This is an institutional retrospective review of TEVAR for isolated descending thoracic aortic aneurysms. Data were collected from 2004 to 2018. Primary outcomes studied included aneurysm sac remodeling, freedom from reintervention, and all-cause mortality. Other outcomes studied include endoleak rates, neurologic complication rates, and any overall postoperative complication rates. RESULTS During the study period, 219 patients underwent TEVAR for descending thoracic aortic aneurysms. The median effect of TEVAR on sac diameter was a 0.7-cm decrease in size (interquartile range, -1.4 to 0.0 cm). During the study period, 80% (n = 147) of patients experienced aneurysm sac regression or stability. Perioperative neurologic complications occurred in 16% (n = 34) of patients. Significant predictors of sac growth were endoleak (odds ratio [OR], 65; P < .001), preoperative carotid-subclavian bypass (OR, 8; P = .003), and graft oversizing <20% (OR, 15; P = .046). Every 1-mm increase in aortic diameter at the proximal TEVAR landing zone led to an increased odds of endoleak (OR, 2; P = .049). Access complications (OR, 8) and subclavian artery coverage (OR, 6) significantly increased the odds of reintervention, whereas every percentage of graft oversizing protected against reintervention (OR, 0.005). Life-table analysis revealed an overall survival of 78% (71%-83%) at median follow-up. At 3 years, survival was 88% (80%-93%) for those with aneurysm sac stability or regression, whereas it was 70% (49%-84%) for those with aneurysm sac growth (P = .0402). Cox proportional hazards model showed that the only protective factor for mortality was percentage oversizing, with every 1% of oversizing having a hazard ratio (HR) of <.001 (P = .032). This was counterbalanced by the fact that patients with graft oversizing >30% had an increased odds of mortality with HR >10 (P = .049). Other significant factors that increased the odds of mortality included endoleak (HR, 3.6; P = .033), diabetes (HR, 4.1; P = .048), age (every 1-year increase in age; HR, 1.2; P = .002), year of surgery (every year subsequent to 2004; HR, 1.3; P = .012), and peripheral artery disease (HR, 5.2; P = .041). CONCLUSIONS The majority of patients (80%) experience sac stability or regression after TEVAR, which offers a clear survival advantage. Endoleaks are predictive of sac growth, conferring increased mortality. Rigorous surveillance is necessary to prevent future aortic events through reintervention.
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Affiliation(s)
- Adam Tanious
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
| | - Laura Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Lauren Canha
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Elizabeth L Chou
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Linda J Wang
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Christopher Latz
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
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Latz CA, DeCarlo C, Boitano L, Png CYM, Patell R, Conrad MF, Eagleton M, Dua A. Blood type and outcomes in patients with COVID-19. Ann Hematol 2020; 99:2113-2118. [PMID: 32656591 PMCID: PMC7354354 DOI: 10.1007/s00277-020-04169-1] [Citation(s) in RCA: 189] [Impact Index Per Article: 47.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 07/06/2020] [Indexed: 01/28/2023]
Abstract
This study aimed to determine if there is an association between ABO blood type and severity of COVID-19 defined by intubation or death as well as ascertain if there is variability in testing positive for COVID-19 between blood types. In a multi-institutional study, all adult patients who tested positive for COVID-19 across five hospitals were identified and included from March 6th to April 16th, 2020. Hospitalization, intubation, and death were evaluated for association with blood type. Univariate analysis was conducted using standard techniques and logistic regression was used to determine the independent effect of blood type on intubation and/or death and positive testing. During the study period, there were 7648 patients who received COVID-19 testing throughout the institutions. Of these, 1289 tested positive with a known blood type. A total of 484 (37.5%) were admitted to hospital, 123 (9.5%) were admitted to the ICU, 108 (8.4%) were intubated, 3 (0.2%) required ECMO, and 89 (6.9%) died. Of the 1289 patients who tested positive, 440 (34.2%) were blood type A, 201 (15.6%) were blood type B, 61 (4.7%) were blood type AB, and 587 (45.5%) were blood type O. On univariate analysis, there was no association between blood type and any of the peak inflammatory markers (peak WBC, p = 0.25; peak LDH, p = 0.40; peak ESR, p = 0.16; peak CRP, p = 0.14) nor between blood type and any of the clinical outcomes of severity (admission p = 0.20, ICU admission p = 0.94, intubation p = 0.93, proning while intubated p = 0.58, ECMO p = 0.09, and death p = 0.49). After multivariable analysis, blood type was not independently associated with risk of intubation or death (referent blood type A; blood type B: AOR: 0.72, 95% CI: 0.42–1.26, blood type AB: AOR: 0.78, CI: 0.33–1.87, blood type O: AOR: 0.77, CI: 0.51–1.16), rhesus factor positive (Rh+): AOR: 1.03, CI: 0.93–1.86. Blood type A had no correlation with positive testing (AOR: 1.00, CI: 0.88–1.13), blood type B was associated with higher odds of testing positive for disease (AOR: 1.28, CI: 1.08–1.52), AB was also associated with higher odds of testing positive (AOR: 1.37, CI: 1.02–1.83), and O was associated with a lower risk of testing positive (AOR: 0.84, CI: 0.75–0.95). Rh+ status was associated with higher odds of testing positive (AOR: 1.23, CI: 1.003–1.50). Blood type was not associated with risk of intubation or death in patients with COVID-19. Patients with blood types B and AB who received a test were more likely to test positive and blood type O was less likely to test positive. Rh+ patients were more likely to test positive.
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Affiliation(s)
- Christopher A Latz
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital (MGH), 15 Parkman Street, Boston, MA, 02214-3117, USA.
| | - Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital (MGH), 15 Parkman Street, Boston, MA, 02214-3117, USA
| | - Laura Boitano
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital (MGH), 15 Parkman Street, Boston, MA, 02214-3117, USA
| | - C Y Maximilian Png
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital (MGH), 15 Parkman Street, Boston, MA, 02214-3117, USA
| | - Rushad Patell
- Division of Hematology, Department of Medicine, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, USA
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital (MGH), 15 Parkman Street, Boston, MA, 02214-3117, USA
| | - Matthew Eagleton
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital (MGH), 15 Parkman Street, Boston, MA, 02214-3117, USA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital (MGH), 15 Parkman Street, Boston, MA, 02214-3117, USA
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Eskandari M, Nooromid M, DeMartino RR, Conrad MF, Abularrage C, Grotemeyer D, De Caridi G, Woo K. Leiomyosarcoma of the Inferior Vena Cava: A Multicenter Experience. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.04.130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Latz CA, DeCarlo C, Boitano LT, Wang LJ, Feldman ZM, Pendleton AA, Conrad MF, Schwartz S. Twenty-eight-Year Experience With Ruptured and Symptomatic Type I-III Thoracoabdominal Aortic Aneurysms at a Large Tertiary Referral Center. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.04.073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Wang LJ, Crofts SC, Nixon TP, Goudreau BJ, Chang DC, Conrad MF, Eagleton MJ, Clouse WD. Impact of Adding Carotid Endarterectomy to Supra-aortic Trunk Surgical Reconstruction. Ann Vasc Surg 2020; 69:27-33. [PMID: 32599112 DOI: 10.1016/j.avsg.2020.06.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/20/2020] [Accepted: 06/20/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Up to 20% of patients requiring open supra-aortic trunk (SAT) reconstruction have significant carotid artery stenosis. The addition of carotid endarterectomy (CEA) to SAT has been described. Yet, additive risks are not well defined and controversy remains as to whether concomitant CEA increases stroke risk. This study assessed the perioperative effects of adding CEA to SAT. METHODS Using the National Surgical Quality Improvement Program (NSQIP), patients who underwent SAT from 2005 to 2015 were evaluated. SAT + CEA were identified. An isolated SAT (ISAT) cohort was created by removing patients who underwent concurrent secondary procedures. Nonocclusive indications were excluded. SAT + CEA were compared with ISAT as well as a propensity-matched ISAT cohort. Primary outcomes were 30-day stroke, death, and composite stroke/death/myocardial infarction (SDM). Univariate and logistic regression analyses were performed. RESULTS After review, 1,515 patients were identified: 1,245 ISAT (82%) and 270 SAT + CEA (18%). Most were women (56%), 86% were Caucasian, and 24% were symptomatic. Average age was 65 ± 12 years and SAT + CEA were older (69 vs. 64 years, P < 0.001). CEA + SAT were more likely to be men (53% vs. 42%, P < 0.001), have hypertension (86% vs. 75%, P < 0.001) and diabetes (26% vs. 20%, P = 0.04). SAT procedures included the following: carotid-subclavian bypass (68%), carotid-carotid bypass (16%), aorta-great vessel bypass (9%), and carotid-subclavian transposition (7%). ISAT were more likely to undergo carotid-subclavian bypass than SAT + CEA (71% vs. 54%, P < 0.001). Overall stroke was 2.3%, death 1.4%, and SDM 4.6%. There were no differences in 30-day stroke (ISAT 2.0% vs. SAT + CEA 3.7%, P = 0.09) or mortality (1.4% vs. 1.5%, P = 0.88). SAT + CEA had higher rates of SDM (7% vs. 4%, P = 0.03). On logistic regression, urgency was a predictor of SDM (operating room [OR] 3.6, 95% confidence interval [CI] 1.5-8.4, P = 0.003); addition of CEA was not predictive of stroke (OR 1.4, 95% CI 0.5-4.2, P = 0.52) or SDM (OR 1.5, 95% CI 0.6-3.6, P = 0.40). After propensity matching, there were no longer differences in demographics or primary end points between the 2 cohorts. CONCLUSIONS Addition of CEA does not confer increased perioperative stroke or SDM risk over ISAT. Perioperative outcomes appear to be more affected by disseminated disease risk factors than the addition of CEA. In patients undergoing SAT, it is reasonable to consider performing combined CEA in populations with tandem carotid bifurcation disease and appropriate operative risk profile.
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Affiliation(s)
- Linda J Wang
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Sarah C Crofts
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Thomas P Nixon
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Bernadette J Goudreau
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - David C Chang
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA.
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Boitano LT, DeCarlo C, Schwartz MR, Tanious A, LaMuraglia GM, Conrad MF, Eagleton MJ, Schwartz SI. Surgeon specialty significantly affects outcome of asymptomatic patients after carotid endarterectomy. J Vasc Surg 2020; 71:1242-1252. [DOI: 10.1016/j.jvs.2019.04.489] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 04/21/2019] [Indexed: 10/25/2022]
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