Association Between Conduit Type and Outcomes After Open Repair of Popliteal Artery Aneurysms

INTRODUCTION

Prior studies have demonstrated acceptable midterm outcomes with prosthetic conduits for above-knee bypass for occlusive disease in patients with inadequate segment great saphenous vein (GSV). In this study we aimed to investigate whether this holds true for open repair of popliteal artery aneurysms (PAA).

METHODS

We queried the Vascular Quality Initiative data for patients who underwent open PAA repair (OPAR). We divided the cohort into three groups based on the conduit used: GSV, other autologous veins, or prosthetic graft. Study outcomes included primary patency, freedom from major amputation, amputation-free survival, and overall survival at 1 y. Kaplan-Meier survival estimates, log-rank tests and multivariable Cox regression were used to compare outcomes between study groups.

RESULTS

A total of 4016 patients underwent bypass for PAA from January 2010 to October 2021. The three cohorts were significantly different in many demographic and clinical characteristics. The adjusted odds of postoperative amputation among symptomatic patients were 3-fold higher for prosthetic conduits compared to the GSV (odds ratio, 3.20; 95% CI, 1.72-5.92; P < 0.001). For the 1-y outcomes, the adjusted risk of major amputation was almost 3-fold higher for patients with symptomatic disease undergoing bypass with prosthetic conduits (hazard ratio [HR], 2.97; 95% CI, 1.35-6.52; P = 0.007). When compared with GSV, prosthetic conduits were associated with 96% increased risk of death when used for repair in symptomatic patients (adjusted hazard ratio (aHR), 1.96; 95% CI, 1.29-2.97; P = 0.002) but no significant association with mortality in asymptomatic patients (aHR, 0.83; 95% CI, 0.37-1.87; P = 0.652). When compared with GSV, prosthetic conduits were associated with a 2-fold increased risk of 1-y major amputation or death when used for repair in symptomatic patients (aHR, 2.03; 95% CI, 1.40-2.94; P < 0.001) but no significant association with mortality in asymptomatic patients (aHR, 0.91; 95% CI, 0.42-1.98; P = 0.816). Comparing bypass with other veins to the GSV among patients with symptomatic disease, there was no statistically significant difference in major amputation risk (HR; 2.44; 95% CI, 0.55-10.82; P = 0.242) and no difference in the adjusted risk of all-cause mortality (aHR, 0.77; 95% CI, 0.26-2.44; P = 0.653). There were no differences in the adjusted risk of loss of primary patency comparing other veins to GSV (HR, 1.53; 95% CI, 0.85-2.76; P = 0.154) and prosthetic conduits to GSV (HR, 0.85; 95% CI, 0.57-1.26; P = 0.422).

CONCLUSIONS

This large study shows that among patients undergoing OPAR, 1-y primary patency does not differ between conduit types. However, prosthetic conduits are associated with significantly higher risk of amputation and death compared to GSV among symptomatic patients. Though non-GSV autologous veins are less often used for OPAR, they have comparably acceptable outcomes as GSV.

Impact of Flow Reversal Duration on Neurological Outcomes of Transcarotid Artery Revascularization (TCAR)

BACKGROUNDS

Flow reversal is a key component of transcarotid artery revascularization (TCAR). However, the impact of flow reversal duration on neurological outcomes and the duration of flow reversal which optimizes TCAR's outcomes is not known. We evaluated the association of flow reversal time with the intraoperative and postoperative neurological outcomes of TCAR.

METHODS

We studied all patients undergoing TCAR from September 2016 to October 2021. The exposure of interest was the duration of flow reversal. Multivariable logistic and fractional polynomial models were used to study the impact of flow reversal duration on in-hospital stroke, intraoperative neurological change/intolerance and stroke/death following TCAR and to identify the flow reversal time above which significant perioperative neurological events occur.

RESULTS

The study included 19,462 patients with mean age of 73.4 years who were mostly Caucasian (91%) and male (63%). The mean flow reversal time was 10.7 minutes, and the overall stroke rate was 1.4%. The odds of intraoperative neurological change increased by 3.6% per minute increase in flow reversal time (odds ratio (OR), 1.04; 95%, 1.01-1.06; P < 0.002). Flow reversal duration >10 minutes was associated with 78% increased odds of neurological changes compared to flow reversal duration <10 minutes. There was no significant association between flow reversal duration and stroke, and stroke/death in the first 5 minutes after initiation of flow reversal. The odds of stroke increased by 2.7% per minute increase in flow reversal time >5 minutes (OR, 1.03; 95%, 1.01-1.04; P < 0.001), with flow reversal duration >10 minutes associated with 38% increased odds of stroke compared to flow reversal duration ≤10 minutes (OR, 1.37, 95% confidence interval (CI), 1.09-1.73, P = 0.006). The odds of stroke/death increased by 2.5% per minute increase in flow reversal time >5 minutes (OR, 1.03; 95%, 1.01-1.04; P < 0.001). Flow reversal duration >10 minutes was associated with 25% increased odds of stroke/death compared to flow reversal duration <10 minutes (OR, 1.25, 95% CI, 1.01-1.53, P = 0.038). Symptomatic status did not modify outcomes.

CONCLUSIONS

Our findings suggest that outcomes following TCAR are optimal if the duration of flow reversal is minimized. A clinical cutoff time of 10 minutes is suggested by this study and recommended as a guide. Further studies targeted at the flow reversal component of TCAR are needed to solidify the evidence regarding the clinical effects of temporarily induced retrograde cerebral blood flow during TCAR.

Association of Renin-Angiotensin-Aldosterone System Inhibitor Usage Patterns with Mid-Term Amputation Free Survival After Lower Extremity Bypass for Peripheral Arterial Disease

OBJECTIVE

Different renin-angiotensin-aldosterone system inhibitor (RAASI) usage patterns exist among patients undergoing lower extremity bypass (LEB) for peripheral arterial disease (PAD). We studied the association of RAASI usage patterns with LEB outcomes to determine which pattern is associated improved survival after LEB.

METHODS

We evaluated PAD patients who underwent LEB between January 2014 and December 2018 in the Vascular Quality Initiative (VQI) Medicare matched database. Study cohorts included no RAASI use, preoperative RAASI use only, postoperative RAASI use only, and continuous RAASI use both pre-and postoperatively. Logistic and Cox regression was used to adjust for potential confounders. Primary outcome was 2-year amputation free survival (AFS).

RESULTS

Of 19,012 patients included, 1574 (8.3%) were on RAASIs preoperatively only, 1051 (5.5%) postoperatively only, and 8484 (45.2%) continuously. Compared to no RAASI use, isolated preoperative RAASI use was associated with 2.8-fold increased odds of 30-day mortality (aOR, 2.75; 95%CI, 2.15-3.51; P<0.001) whereas continuous RAASI use had 56% lower odds of 30-day mortality (aOR, 0.44; 95%CI, 0.34-0.58; P<0.001). Two-year AFS was 63.2% for no RAASI use and 60.4%, 66.2% and 73.4% for preoperative, postoperative, and continuous RAASI use respectively (P<0.001). While no RAASI use and postoperative RAASI use had comparable adjusted risks of 2-year major amputation or death (aHR, 0.94; 95%CI, 0.83-1.06; P=0.312), this risk was 14% higher for preoperative RAASI use (aHR, 1.14; 95%CI, 1.04-1.26; P=0.006) and 23% lower for continuous RAASI use (aHR, 0.77; 95%CI, 0.72-0.82; P<0.001).

CONCLUSIONS

Isolated preoperative RAASI use was associated with worse 30-day mortality and 2-year AFS while continuous RAASI use was associated with improved 30-day mortality and 2-year AFS. Optimum survival benefit may be derived from continuous RAAS inhibition in the pre- and postoperative periods.

Contemporary outcomes of concomitant suprainguinal bypass with infrainguinal revascularization procedures in patients with chronic limb-threatening ischemia

OBJECTIVE

Combined suprainguinal and infrainguinal revascularization is sometimes necessary in the treatment of patients with chronic limb-threatening ischemia (CLTI). However, data on outcomes of concomitant revascularization procedures are lacking. We studied the outcomes of patients with CLTI who underwent suprainguinal bypass (SIB) alone, SIB with concomitant infrainguinal bypass (IIB), and SIB with concomitant infrainguinal peripheral endovascular intervention (IIPVI).

METHODS

We reviewed all patients in the Vascular Quality Initiative with CLTI who underwent SIB from January 2010 to June 2020. Logistic regression, Kaplan-Meier survival estimates, log-rank tests, and Cox regression were used to analyze outcomes. Outcomes were 30-day mortality, perioperative myocardial infarction, perioperative major amputation, 1-year amputation-free survival, and 5-year survival.

RESULTS

Of 8037 patients included, 81.3% (n = 6537) underwent SIB alone, 9.7% (n = 783) underwent SIB+IIB, and 8.9% (n = 717) underwent SIB+IIPVI. The indication for surgery was rest pain in 5040 (62.5%) and tissue loss in 3031 (37.6%). There were no significant differences in 30-day mortality and perioperative myocardial infarction rates. However, there was 2.8-fold increased odds of perioperative major amputation in both SIB+IIPVI (odds ratio [OR], 2.76; 95% confidence interval [CI], 1.30-5.88; P = .008) and SIB+IIB (OR, 2.79; 95% CI, 1.38-5.54; P = .004) among patients with rest pain as compared with SIB alone. Comparing SIB+IIPVI with SIB alone, there were no significant differences in 1-year freedom from amputation and amputation-free survival. SIB+IIPVI was associated with a 27% increased risk of 5-year mortality (hazard ratio [HR], 1.27; 95% CI, 1.03-1.55; P = .035). Compared with SIB alone, SIB+IIB was associated with 97% increased risk of 1-year major amputation among patients with rest pain (HR, 1.97; 95% CI, 1.06-3.69; P = .033), but a 47% decreased risk of 1-year major amputation or death for patients with tissue loss (HR, 0.53; 95% CI, 0.37-0.78; P = .001). SIB+IIPVI, compared with SIB+IIB, was associated with a two-fold increased risk of 1-year major amputation or death (HR, 2.04; 95% CI, 1.04-2.23), P = .003) and a 52% increased risk of 5-year mortality (HR,1.52; 95% CI, 1.04-2.24; P = .032) among patients with tissue loss.

CONCLUSIONS

This study shows that SIB with concomitant infrainguinal revascularization in patients with rest pain is associated with an increased risk of amputation, whereas SIB+IIB in patients with tissue loss is associated with decreased risk of amputation or death. SIB+IIB outperformed SIB+IIPVI in patients with tissue loss. SIB with infrainguinal revascularization should be limited in patients with rest pain in line with current guidelines, but SIB+IIB may be preferred in patients with tissue loss.

Prediction of thirty-day mortality risk after thoracic endovascular aortic repair for intact descending thoracic aortic aneurysms: Derivation of risk calculator in the Vascular Quality Initiative

OBJECTIVE

Thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysm (DTAA) is associated with high perioperative survival, although mortality is a possible outcome. However, no risk score has been developed to predict mortality after TEVAR for intact DTAA to aid in risk discussion and preoperative patient selection. Our objective was to use a multi-institutional database to develop a 30-day mortality risk calculator for TEVAR after DTAA repair.

METHODS

The Vascular Quality Initiative database was queried for patients treated with TEVAR for intact DTAA between August 2014 and August 2020. Univariable and multivariable analyses aided in developing a 30-day mortality risk score. Internal validation was done with K-fold cross-validation and calibration curve analysis.

RESULTS

Of 2141 patients included in the analysis, 90 (4.2%) died within 30 days after the procedure. Clinically relevant variables identified to be independently associated with 30-day mortality and therefore used to derive the predictive model included age 75 years or greater (odds ratio [OR], 2.27; 95% confidence interval [CI], 1.50-3.44; P < .001), coronary artery disease (OR, 1.60; 95% CI, 1.03-2.47; P = .036), American Society of Anesthesiologists class IV/V (OR, 2.39; 95% CI, 1.39-4.10; P = .002), urgent vs elective procedure (OR, 3.47; 95% CI, 1.90-6.33; P < .001), emergent vs elective procedure (OR, 5.27; 95% CI, 2.36-11.75; P < .001), prior carotid revascularization (OR, 3.24; 95% CI, 1.64-6.39; P = .001), and proximal landing zone <3 (OR, 2.51; 95% CI, 1.65-3.81; P < .001). The model showed an area under the receiver operating characteristic curve of 0.75. Internal validation demonstrated a bias-corrected area under the receiver operating characteristic curve of 0.73 (95% CI, 0.66-0.79) and a calibration slope of 1.00 with a corresponding intercept of 0.00.

CONCLUSIONS

This study provides a novel clinically relevant risk prediction model to estimate 30-day mortality risk after TEVAR for DTAA. The TEVAR Mortality Risk Calculator provides useful prognostic information to guide patient selection and facilitate preoperative discussions and shared decision making. An easily accessible online version of the TEVAR Mortality Risk Score is available to facilitate ease of use.

Derivation of a Coronary Age Calculator Using Traditional Risk Factors and Coronary Artery Calcium: The Multi-Ethnic Study of Atherosclerosis

Background

The optimal method for communicating coronary heart disease (CHD) risk to individual patients is not yet clear. Recent research supports the concept of "coronary age" for more effective risk communication. We defined an individual's coronary age as the age at which an average healthy individual would have an equivalent estimated CHD risk as that calculated for the index individual, building on our previously validated MESA (Multi‐Ethnic Study of Atherosclerosis) 10‐year CHD Risk Score equations with and without coronary artery calcium (CAC).

Methods and Results

We derived a coronary age by (1) calculating the MESA 10‐year CHD risk; (2) mathematically setting this equal to an equation describing risk of an average healthy MESA participant, as a function of age; and (3) solving for age. The risk discrimination of the resultant coronary age was compared with that of chronological age, the MESA CHD Risk Score, and CAC alone. Approximately 95% of coronary age values ranged from 30 years less to 30 years higher than chronological age. Although the mean chronological age of individuals experiencing CHD events compared with those free of events was 67.4 versus 61.8 years, the difference in coronary age including CAC was larger (80.6 versus 62.8 years). Coronary age with CAC had identical predictive ability to that of MESA CHD Risk Score and outperformed chronological age and CAC alone.

Conclusions

The newly derived coronary age is a convenient transformation of MESA CHD Risk, retaining very good risk discrimination. This easy‐to‐communicate tool will be available for patients and clinicians, potentially facilitating risk communication in routine care.

The association of estimated glomerular filtration rate with outcomes following infrainguinal bypass for peripheral arterial disease

OBJECTIVE

Chronic kidney disease (CKD) is a recognized predictor of long-term survival, frequently coexisting with peripheral arterial disease (PAD). Estimated glomerular filtration rate (eGFR) is a more accurate marker of renal function than creatinine. This study sought to determine the graded impact of CKD, defined by eGFR, on infrainguinal lower extremity bypass (LEB) outcomes.

METHODS

This retrospective study examined 44,332 patients from the Vascular Quality Initiative database who underwent LEB between January 2003 and November 2019. The GFR was estimated using the Modification of Diet in Renal Disease equation. Multivariable logistic regression was used to study perioperative mortality and Kaplan-Meier survival estimation and multivariable Cox regression were used to evaluate 5-year mortality, 1-year major amputation, and major amputation/death.

RESULTS

The 30-day mortality odds was increased for CKD 3 (odds ratio [OR], 1.58; 95% confidence interval [CI], 1.32-1.91; P < .001) and CKD 5 (OR, 3.08; 95% CI, 2.45-3.87; P < .001) relative to CKD 1 to 2. Comparing CKD stages 3, 4, and 5 with CKD 1 and 2, there was a stepwise increase in the adjusted hazard of 5-year mortality (hazard ratio [HR], 1.18; 95% CI, 1.09-1.27; P < .001), (HR, 1.73; 95% CI; 1.47-2.03; P < .001) and (HR, 2.58; 95% CI, 2.33-3.84; P < .001), respectively. Although the risk of 1-year death or major amputation did not differ for CKD 3 compared with CKD 1, this was 50% higher for CKD 4 (HR, 1.50; 95% CI, 1.26-1.78; P < .001) and doubled for CKD 5 (HR, 2.07; 95% CI, 1.87-2.29; P < .001) compared with CKD 1 and 2. The adjusted HR for major amputation in 1 year was 0.81 (95% CI, 0.71-0.92; P = .002), 1.14 (95% CI, 0.84-1.54; P = .396) and 1.56 (95% CI,1.31-1.84; P < .001) for CKD 3, 4, and 5, respectively, compared with CKD 1 and 2.

CONCLUSIONS

The estimated GFR is a useful predictor of postoperative mortality, overall survival, and/or amputation after LEB in patients with PAD. It should be considered in the preoperative risk-benefit analysis process to guide patient selection in the population with concomitant PAD and CKD being considered for LEB.

Thromboembolism risk of COVID-19 is high and associated with a higher risk of mortality: A systematic review and meta-analysis

BACKGROUND

Studies have suggested that there is increased risk of thromboembolism (TE) associated with coronavirus disease 2019 (COVID-19). However, overall arterial and venous TE rates of COVID-19 and effect of TE on COVID-19 mortality is unknown.

METHODS

We did a systematic review and meta-analysis of studies evaluating TE in COVID-19. We searched PubMed, Cochrane, and Embase for studies published up to June 12, 2020. Random effects models were used to produce summary TE rates and odds ratios (OR) of mortality in COVID-19 patients with TE compared to those without TE. Heterogeneity was quantified with I 2 .

FINDINGS

Of 425 studies identified, 42 studies enrolling 8271 patients were included in the meta-analysis. Overall venous TE rate was 21% (95% CI:17-26%): ICU, 31% (95% CI: 23-39%). Overall deep vein thrombosis rate was 20% (95% CI: 13-28%): ICU, 28% (95% CI: 16-41%); postmortem, 35% (95% CI:15-57%). Overall pulmonary embolism rate was 13% (95% CI: 11-16%): ICU, 19% (95% CI:14-25%); postmortem, 22% (95% CI:16-28%). Overall arterial TE rate was 2% (95% CI: 1-4%): ICU, 5% (95%CI: 3-7%). Pooled mortality rate among patients with TE was 23% (95%CI:14-32%) and 13% (95% CI:6-22%) among patients without TE. The pooled odds of mortality were 74% higher among patients who developed TE compared to those who did not (OR, 1.74; 95%CI, 1.01-2.98; P = 0.04).

INTERPRETATION

TE rates of COVID-19 are high and associated with higher risk of death. Robust evidence from ongoing clinical trials is needed to determine the impact of thromboprophylaxis on TE and mortality risk of COVID-19.

FUNDING

None.

Intravenous ketorolac is associated with reduced mortality and morbidity after open abdominal aortic aneurysm repair

OBJECTIVES

The role of non-steroidal anti-inflammatory drugs in aortic aneurysm disease has been debated. Animal studies demonstrated that intrathecal ketorolac reduces the inflammatory response associated with aortic clamping. However, no human-subject study evaluated this association. Therefore, we sought to explore the effects of ketorolac use in open abdominal aortic aneurysm repair.

METHODS

The Premier Healthcare Database (June 2009-March 2015) was inquired to capture patients who underwent open abdominal aortic aneurysm repair for non-ruptured abdominal aortic aneurysm, identified via International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Intravenous ketorolac was coded as any or none. Outcomes were in-hospital mortality, cardiac, respiratory, renal, neurological, and hemorrhagic complications. Multivariable logistic regression coarsened exact matching followed by conditional fixed-effect regression modeling were performed.

RESULTS

A total of 6394 patients were identified (ketorolac: 806; 12.6%). Patients who received ketorolac were younger and less likely to have hypertension (76.1% vs. 79.3%), diabetes mellitus (12.5% vs. 17.4%), or chronic kidney disease (8.3% vs. 21.4%; all p values ≤ .033). There was no significant difference in medication use including oral non-steroidal anti-inflammatory drugs and malignant or musculoskeletal diseases. Mortality, respiratory, and renal complications were less prevalent with ketorolac (2.5% vs. 4.9%, 25.2% vs. 34.6%, 10.0% vs. 21.1%; p ≤ .002). Ketorolac was associated with lower adjusted odds for those events: 0.58 (0.36-0.93), 0.53 (0.42-0.68), and 0.72 (0.60-0.86), respectively (all p values ≤ .025). There was no association with neurological, cardiac, or hemorrhagic complications. The findings were replicated by coarsened exact matching analysis.

CONCLUSION

This study demonstrated 40% mortality reduction with intravenous ketorolac following open abdominal aortic aneurysm repair. The survival benefit could be due to its anti-inflammatory and opioid-sparing properties. This is evident by its protective effect against respiratory outcomes. The lack of association with the classical non-steroidal anti-inflammatory drugs-related cardiac and hemorrhagic complication could be attributable to the short-term use of ketorolac compared with non-steroidal anti-inflammatory drugs chronic use.

Racial and Gender Disparity in Aortoiliac Disease Open Revascularization Procedures

BACKGROUND

The impact of race and gender on surgical outcomes has been studied in infrainguinal revascularization for peripheral arterial disease. The aim of this study is to explore how race and gender affect the outcomes of suprainguinal bypass (SIB) for aortoiliac occlusive disease.

MATERIALS AND METHODS

Patients who underwent SIB were identified from the procedure-targeted National Surgical Quality Improvement Program data set (2011-2016). Patients were stratified into four groups: nonblack males, black males (BM), nonblack females, and black females (BF). Primary outcomes were 30-d major adverse cardiac events, a composite of myocardial infarction, stroke, or death; postoperative bleeding requiring transfusion or intervention; major amputation and prolonged length of stay (>10 d). Predictors of outcomes were determined by multivariable logistic regression analysis.

RESULTS

About 5044 patients were identified. BM were younger, more likely to be smokers, less likely to be on antiplatelet drug or statin, and to receive elective SIB (all P ≤ 0.01). BFs were more likely to be diabetic and functionally dependent (all P ≤ 0.02). Major adverse cardiac events were not significantly different among all groups. BM had a threefold higher risk of amputation (adjusted odds ratio [OR] [95% confidence interval (95% CI)], 3.10 [1.50-6.43]; P < 0.002). Female gender was associated with bleeding in both races, that association was more drastic in BF (OR [95% CI], 2.43 [1.63-3.60]; P < 0.0001), whereas nonblack females (OR [95% CI], 1.46 [1.19-1.80]; P < 0.0001). BF had higher odds of prolonged length of stay (OR [95% CI]: 1.62 [1.08-2.42]; P < 0.019).

CONCLUSIONS

In this large retrospective study, we demonstrated the racial and gender disparity in SIB outcomes. BM had more than threefold increase in amputation risk as compared with nonblack males. Severe bleeding risk was more than doubled in BF. Race and gender consideration is warranted in risk assessment when patients are selected for aortoiliac disease revascularization, which in turn necessitate preoperative risk modification and optimization in addition to enhancing their access to primary preventive care measures.