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de Mestral C, Abdel-Qadir HM, Austin PC, Chong AS, McAlister FA, Lindsay TF, Ross HJ, Oreopoulos G, Wijeysundera DN, Lee DS. Ambulatory Cardiology or General Internal Medicine Assessment Prior to Scheduled Major Vascular Surgery is Associated with Improved Outcomes. Ann Surg 2024:00000658-990000000-00871. [PMID: 38709199 DOI: 10.1097/sla.0000000000006321] [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] [Indexed: 05/07/2024]
Abstract
OBJECTIVE To characterize the association between ambulatory cardiology or general internal medicine (GIM) assessment prior to surgery and outcomes following scheduled major vascular surgery. BACKGROUND Cardiovascular risk assessment and management prior to high-risk surgery remains an evolving area of care. METHODS This is population-based retrospective cohort study of all adults who underwent scheduled major vascular surgery in Ontario, Canada, April 1, 2004-March 31, 2019. Patients who had an ambulatory cardiology and/or GIM assessment within 6 months prior to surgery were compared to those who did not. The primary outcome was 30-day mortality. Secondary outcomes included: composite of 30-day mortality, myocardial infarction or stroke; 30-day cardiovascular death; 1-year mortality; composite of 1-year mortality, myocardial infarction or stroke; and 1-year cardiovascular death. Cox proportional hazard regression using inverse probability of treatment weighting (IPTW) was used to mitigate confounding by indication. RESULTS Among 50,228 patients, 20,484 (40.8%) underwent an ambulatory assessment prior to surgery: 11,074 (54.1%) with cardiology, 8,071 (39.4%) with GIM and 1,339 (6.5%) with both. Compared to patients who did not, those who underwent an assessment had a higher Revised Cardiac Risk Index (N with Index over 2= 4,989[24.4%] vs. 4,587[15.4%], P<0.001) and more frequent pre-operative cardiac testing (N=7,772[37.9%] vs. 6,113[20.6%], P<0.001) but, lower 30-day mortality (N=551[2.7%] vs. 970[3.3%], P<0.001). After application of IPTW, cardiology or GIM assessment prior to surgery remained associated with a lower 30-day mortality (weighted Hazard Ratio [95%CI] = 0.73 [0.65-0.82]) and a lower rate of all secondary outcomes. CONCLUSIONS Major vascular surgery patients assessed by a cardiology or GIM physician prior to surgery have better outcomes than those who are not. Further research is needed to better understand potential mechanisms of benefit.
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Affiliation(s)
- Charles de Mestral
- ICES, Toronto, ON, Canada
- Department of Surgery, Temerty Faculty of Medicine, University of Toronto, ON, Canada
- Division of Vascular Surgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Husam M Abdel-Qadir
- ICES, Toronto, ON, Canada
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, ON, Canada
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, ON Canada
- Department of Medicine, Women's College Hospital, Toronto, ON, Canada
| | | | | | - Finlay A McAlister
- Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, AB, Canada
| | - Thomas F Lindsay
- Department of Surgery, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Heather J Ross
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, ON, Canada
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, ON Canada
| | - George Oreopoulos
- Department of Surgery, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Duminda N Wijeysundera
- ICES, Toronto, ON, Canada
- Department of Surgery, Temerty Faculty of Medicine, University of Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Douglas S Lee
- Department of Surgery, Temerty Faculty of Medicine, University of Toronto, ON, Canada
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, ON, Canada
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, ON Canada
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Feridooni T, Gordon L, Mahmood DN, Behdinan A, Eisenberg N, Crawford S, Lindsay TF, Roche-Nagle G. Age is not a sole predictor of outcomes in octogenarians undergoing complex endovascular aortic repair. J Vasc Surg 2024:S0741-5214(24)00952-2. [PMID: 38604321 DOI: 10.1016/j.jvs.2024.03.451] [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: 12/27/2023] [Revised: 03/22/2024] [Accepted: 03/31/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE To examine the perioperative, postoperative, and long-term outcomes of fenestrated/branched endovascular aneurysm repair (F/BEVAR) in octogenarians compared with nonoctogenarians. METHODS A multicenter, retrospective cohort study was conducted using the Vascular Quality Improvement database, which prospectively captures information on patients who undergo vascular surgery across 1021 academic and community hospitals in North America. All patients who underwent F/BEVAR endovascular aortic repair from 2012 to 2022 were included. Patients were stratified into two groups: those aged <80 years and those aged ≥80 years at the time of the procedure. The preoperative, intraoperative, and postoperative factors were compared between the two groups. The primary outcome was long-term all-cause mortality; secondary outcomes included aortic-specific mortality and aortic-specific reintervention. RESULTS A total of 6007 patients (aged <80 years, n = 4860; aged ≥80 years, n = 1147) who had undergone F/BEVAR procedures were included. No significant difference was found in technical success, postoperative length of stay, length of intensive care unit stay, postoperative bowel ischemia, and spinal cord ischemia. After adjustment for baseline covariates, octogenarians were more likely to suffer from a postoperative complication (odds ratio [OR]: 1.16; [95% confidence interval (CI): 0.98-1.37], P < .001) and be discharged to a rehabilitation center (OR: 1.60; [95% CI: 1.27-2.00], P < .001) or nursing home (OR: 2.23; [95% CI: 1.64-3.01], P < .001). Five-year survival was lower in octogenarians (83% vs 71%, hazard ratio [HR]: 1.70; [95% CI: 1.46-2.0], P < .0001). Multivariate Cox proportional hazard analysis demonstrated that age was associated with increased all-cause mortality (HR: 1.72, [95% CI: 1.39-2.12], P < .001) and aortic-specific mortality (HR: 1.92, [95% CI: 1.04-3.68], P = .038). Crawford extent II aortic disease was associated with an increase in all-cause mortality (HR 1.49; [95% CI: 1.01-2.19], P < .001), aortic-specific mortality (HR: 5.05; [95% CI: 1.35-18.9], P = .016), and aortic-specific reintervention (HR: 1.91; [95% CI: 1.24-2.93], P = .003). Functional dependence was associated with increased all-cause mortality (HR: 2.90; [95% CI: 1.87-4.51], P < .001) and aortic-specific mortality (HR: 4.93; [95% CI: 1.69-14.4], P = .004). CONCLUSIONS Our findings suggest that octogenarians do have a mildly increased mortality rate and rate of adverse events after F/BEVAR procedures. Despite this, when adjusted for other risk factors, on par with other medical comorbidities and therefore age should be strict exclusion criterion for F/BEVAR procedures, rather age should be considered in the global context of patient's aortic anatomy, health, and functional status.
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Affiliation(s)
- Tiam Feridooni
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Lauren Gordon
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Daniyal N Mahmood
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Asha Behdinan
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Naomi Eisenberg
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sean Crawford
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Graham Roche-Nagle
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Vervoort D, Tarola C, Chung JCY, Crawford SA, Lindsay TF, Fremes SE. Aortic Arch Innovation: Branching Out By Branching In? Can J Cardiol 2024:S0828-282X(24)00188-0. [PMID: 38430958 DOI: 10.1016/j.cjca.2024.02.023] [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: 02/20/2024] [Accepted: 02/26/2024] [Indexed: 03/05/2024] Open
Affiliation(s)
- Dominique Vervoort
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Tarola
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jennifer C Y Chung
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Sean A Crawford
- Division of Vascular Surgery, Peter Munk Cardiac Centre Toronto General Hospital, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre Toronto General Hospital, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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Mahmood DN, Rocha R, Ouzounian M, Teng Tan K, Forbes SM, Chung JCY, Lindsay TF. Thoracoabdominal Aortic Aneurysm Repair Using Fenestrated and Branched Endovascular Grafts for High-Risk Patients: Evolving yet Safe. J Endovasc Ther 2024:15266028241229005. [PMID: 38339966 DOI: 10.1177/15266028241229005] [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] [Indexed: 02/12/2024]
Abstract
PURPOSE The purpose was to investigate outcomes of high-risk patients undergoing thoracoabdominal aortic aneurysm (TAAA) repair using fenestrated or branched endovascular aneurysm repair (F/BEVAR) devices at a single center in Canada. MATERIALS AND METHODS A retrospective review of all patients undergoing endovascular TAAA repair with F/BEVAR from June 2007 to July 2020. Imaging and clinical endpoints of interest including death, reintervention, and target vessel patency were reported. RESULTS Ninety-five consecutive patients underwent endovascular TAAA repair using F/BEVAR stent grafts (63 males, median age 74 [interquartile range 70, 78] years). Repairs included 81 elective and 14 urgent/emergent cases (6 ruptures and 8 symptomatic). Graft deployment was 100% successful. Intraoperative target vessel revascularization was successful in 336/355 (94.6%) vessels with the celiac having the lowest success rate 72/82 (87.8%). In-hospital mortality was 9.5% (7.4% elective and 21.4% urgent/emergent, p=0.125) and permanent paraplegia was 4.2% (3.7% elective and 7.1% urgent/emergent, p=0.458). In-hospital complications included stroke in 5.3%, acute myocardial infarction in 8.4%, and bowel ischemia in 5.3%. No patients required permanent dialysis or tracheostomy during their hospital stay. However, 22 (23.2%) patients required additional unplanned procedures for various indications (branch occlusion, endoleaks, realignment) during their hospital stay. Patients were followed up for a mean of 3.6 ± 3.0 years. Clinical follow-up was 100%, with 80/86 (93%) having surveillance imaging. On follow-up imaging, 43 (50%) patients had at least 1 endoleak identified and 337/341 (98.8%) of the target vessels were found to be patent. At 5 years, cumulative probability of reintervention was 46.3% (95% confidence interval [CI], 36.1-56.4). Survival at 5 and 8 years was 50.1% (95% CI, 38.4-65.4) and 34.4% (95% CI, 22.5-52.8), respectively. Progression of aneurysmal disease leading to rupture on follow-up was confirmed in 1 patient at 10 years. CONCLUSION Endovascular TAAA repair provides a safe treatment option with a high technical success rate and low pulmonary and renal complications. Long-term survival is similar to previous literature; however, high rates of secondary reintervention reaffirm the need for ongoing patient follow-up and further technical improvements. CLINICAL IMPACT This study demonstrates that endovascular repair of TAAAs can be performed in a high-risk elderly population with acceptable rates of mortality, TALE and SCI, using evolving technology. The incidences of post-operative respiratory failure and renal dysfunction were lower in patients who underwent endovascular repair compared with open repair. Future technical and procedural refinements in addition to increasing surgical experience are expected to lead to further improvements in short- and long-term outcomes exceeding those of open repair.
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Affiliation(s)
- Daniyal N Mahmood
- Division of Vascular Surgery, Department of Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Rodolfo Rocha
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Kong Teng Tan
- Division of Interventional Radiology, Toronto General Hospital, Toronto, ON, Canada
| | - Samantha M Forbes
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jennifer C-Y Chung
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Department of Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
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Vervoort D, Hirode G, Lindsay TF, Tam DY, Kapila V, de Mestral C. One-time screening for abdominal aortic aneurysm in Ontario, Canada: a model-based cost-utility analysis. CMAJ 2024; 196:E112-E120. [PMID: 38316457 PMCID: PMC10843437 DOI: 10.1503/cmaj.230913] [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] [Accepted: 11/29/2023] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Screening programs for abdominal aortic aneurysm (AAA) are not available in Canada. We sought to determine the effectiveness and costutility of AAA screening in Ontario. METHODS We compared one-time ultrasonography-based AAA screening for people aged 65 years to no screening using a fully probabilistic Markov model with a lifetime horizon. We estimated life-years, quality-adjusted life-years (QALYs), AAA-related deaths, number needed to screen to prevent 1 AAA-related death and costs (in Canadian dollars) from the perspective of the Ontario Ministry of Health. We retrieved model inputs from literature, Statistics Canada, and the Ontario Case Costing Initiative. RESULTS Screening reduced AAA-related deaths by 84.9% among males and 81.0% among females. Compared with no screening, screening resulted in 0.04 (18.96 v. 18.92) additional life-years and 0.04 (14.95 v. 14.91) additional QALYs at an incremental cost of $80 per person among males. Among females, screening resulted in 0.02 (21.25 v. 21.23) additional life-years and 0.01 (16.20 v. 16.19) additional QALYs at an incremental cost of $11 per person. At a willingness-to-pay of $50 000 per year, screening was cost-effective in 84% (males) and 90% (females) of model iterations. Screening was increasingly cost-effective with higher AAA prevalence. INTERPRETATION Screening for AAA among people aged 65 years in Ontario was associated with fewer AAA-related deaths and favourable cost-effectiveness. To maximize QALY gains per dollar spent and AAA-related deaths prevented, AAA screening programs should be designed to ensure that populations with high prevalence of AAA participate.
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Affiliation(s)
- Dominique Vervoort
- Institute of Health Policy, Management and Evaluation (Vervoort, Tam, de Mestral), Division of Cardiac Surgery (Vervoort, Tam) and Institute of Medical Science (Hirode), University of Toronto; Toronto Centre for Liver Disease (Hirode), Toronto General Hospital, University Health Network; Division of Vascular Surgery, Department of Surgery (Lindsay), Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ont.; Division of Vascular Surgery (Kapila), William Osler Health System, Brampton, Ont.; Division of Vascular Surgery, Department of Surgery (de Mestral), St. Michael's Hospital, University of Toronto, Toronto, Ont
| | - Grishma Hirode
- Institute of Health Policy, Management and Evaluation (Vervoort, Tam, de Mestral), Division of Cardiac Surgery (Vervoort, Tam) and Institute of Medical Science (Hirode), University of Toronto; Toronto Centre for Liver Disease (Hirode), Toronto General Hospital, University Health Network; Division of Vascular Surgery, Department of Surgery (Lindsay), Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ont.; Division of Vascular Surgery (Kapila), William Osler Health System, Brampton, Ont.; Division of Vascular Surgery, Department of Surgery (de Mestral), St. Michael's Hospital, University of Toronto, Toronto, Ont
| | - Thomas F Lindsay
- Institute of Health Policy, Management and Evaluation (Vervoort, Tam, de Mestral), Division of Cardiac Surgery (Vervoort, Tam) and Institute of Medical Science (Hirode), University of Toronto; Toronto Centre for Liver Disease (Hirode), Toronto General Hospital, University Health Network; Division of Vascular Surgery, Department of Surgery (Lindsay), Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ont.; Division of Vascular Surgery (Kapila), William Osler Health System, Brampton, Ont.; Division of Vascular Surgery, Department of Surgery (de Mestral), St. Michael's Hospital, University of Toronto, Toronto, Ont
| | - Derrick Y Tam
- Institute of Health Policy, Management and Evaluation (Vervoort, Tam, de Mestral), Division of Cardiac Surgery (Vervoort, Tam) and Institute of Medical Science (Hirode), University of Toronto; Toronto Centre for Liver Disease (Hirode), Toronto General Hospital, University Health Network; Division of Vascular Surgery, Department of Surgery (Lindsay), Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ont.; Division of Vascular Surgery (Kapila), William Osler Health System, Brampton, Ont.; Division of Vascular Surgery, Department of Surgery (de Mestral), St. Michael's Hospital, University of Toronto, Toronto, Ont
| | - Varun Kapila
- Institute of Health Policy, Management and Evaluation (Vervoort, Tam, de Mestral), Division of Cardiac Surgery (Vervoort, Tam) and Institute of Medical Science (Hirode), University of Toronto; Toronto Centre for Liver Disease (Hirode), Toronto General Hospital, University Health Network; Division of Vascular Surgery, Department of Surgery (Lindsay), Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ont.; Division of Vascular Surgery (Kapila), William Osler Health System, Brampton, Ont.; Division of Vascular Surgery, Department of Surgery (de Mestral), St. Michael's Hospital, University of Toronto, Toronto, Ont
| | - Charles de Mestral
- Institute of Health Policy, Management and Evaluation (Vervoort, Tam, de Mestral), Division of Cardiac Surgery (Vervoort, Tam) and Institute of Medical Science (Hirode), University of Toronto; Toronto Centre for Liver Disease (Hirode), Toronto General Hospital, University Health Network; Division of Vascular Surgery, Department of Surgery (Lindsay), Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ont.; Division of Vascular Surgery (Kapila), William Osler Health System, Brampton, Ont.; Division of Vascular Surgery, Department of Surgery (de Mestral), St. Michael's Hospital, University of Toronto, Toronto, Ont.
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Chen JF, Ouzounian M, Peterson M, Tatangelo M, Dagenais F, Hage A, Lindsay TF, Chu MWA, Chung JCY. Outcomes of Total Aortic Arch Replacement in a Canadian Nationwide Registry. Can J Cardiol 2024:S0828-282X(24)00017-5. [PMID: 38218222 DOI: 10.1016/j.cjca.2024.01.007] [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: 05/06/2023] [Revised: 01/04/2024] [Accepted: 01/08/2024] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND Accurate benchmarking of outcomes after elective open total arch replacement is important for surgical decision making and for comparisons with emerging endovascular technologies. METHODS A multicentre registry of consecutive aortic arch procedures in 9 centres across Canada contained 250 elective total arch replacements from 2010 to 2021. A total of 728 patients undergoing elective hemiarch replacement over the same time period was used as a comparator group. Propensity score matching was used to construct 202 well matched pairs. RESULTS Patients undergoing total arch replacement were 63.2 ± 13.6 years old, and 34% were female. These patients were more likely to have connective tissue disorders compared with patients undergoing hemiarch replacement. When under hypothermic circulatory arrest, the total arch group uniformly used antegrade cerebral perfusion with median nadir temperature of 24°C (interquartile range [IQR] 21-25°C), and median duration 33 minutes (IQR 23-51 minutes). Before matching, in-hospital mortality and stroke rates were 5.2% and 10%, respectively, for the total arch group. After matching, the total arch group had in-hospital mortality similar to the hemiarch group (P = 0.58). Rates of stroke were also not statistically different (P = 0.11). The total arch group was more likely to experience delirium, prolonged intubation, increased intensive care unit length of stay, and transfusions. CONCLUSIONS Elective total arch replacement is performed with good in-hospital mortality rates that are similar to rates after elective hemiarch repairs. However, total arch replacement was associated with significantly higher rates of other morbidities, including delirium and prolonged intubation.
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Affiliation(s)
- Julia F Chen
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Vascular Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mark Peterson
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mark Tatangelo
- Department of Statistical Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Francois Dagenais
- Division of Cardiac Surgery, Department of Surgery, Laval University, Québec City, Québec, Canada
| | - Ali Hage
- Division of Cardiac Surgery, Department of Surgery, Western University, London, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Michael W A Chu
- Division of Cardiac Surgery, Department of Surgery, Western University, London, Ontario, Canada
| | - Jennifer C Y Chung
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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Rubin B, Lindsay TF, Roche-Nagle G, Forbes TL, Walker P. In memoriam: K. Wayne Johnston. J Vasc Surg 2024; 79:1-2. [PMID: 38129072 DOI: 10.1016/j.jvs.2023.11.030] [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] [Indexed: 12/23/2023]
Affiliation(s)
- Barry Rubin
- Division of Vascular Surgery, University Health Network & University of Toronto, Toronto, ON, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, University Health Network & University of Toronto, Toronto, ON, Canada
| | - Graham Roche-Nagle
- Division of Vascular Surgery, University Health Network & University of Toronto, Toronto, ON, Canada
| | - Thomas L Forbes
- Division of Vascular Surgery, University Health Network & University of Toronto, Toronto, ON, Canada.
| | - Paul Walker
- Division of Vascular Surgery, University Health Network & University of Toronto, Toronto, ON, Canada
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Li B, Ayoo K, Eisenberg N, Lindsay TF, Roche-Nagle G. Reply. J Vasc Surg 2024; 79:184-186. [PMID: 37741587 DOI: 10.1016/j.jvs.2023.09.023] [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: 06/10/2023] [Revised: 08/08/2023] [Accepted: 09/17/2023] [Indexed: 09/25/2023]
Affiliation(s)
- Ben Li
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kennedy Ayoo
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Naomi Eisenberg
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Graham Roche-Nagle
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
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McClure RS, Lindsay TF, Keir M, Bayne JP, Berry RF, Chu MWA, Chung JCY, Dagenais F, Ducas RA, Duncan A, Horne G, Klass D, Mongeon FP, Richer J, Rommens KL. The Aortic Team Model and Collaborative Decision Pathways for the Management of Complex Aortic Disease: Clinical Practice Update From the Canadian Cardiovascular Society/Canadian Society of Cardiac Surgeons/Canadian Society for Vascular Surgery/Canadian Association for Interventional Radiology. Can J Cardiol 2023; 39:1484-1498. [PMID: 37949520 DOI: 10.1016/j.cjca.2023.07.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 06/14/2023] [Revised: 07/30/2023] [Accepted: 07/31/2023] [Indexed: 11/12/2023] Open
Abstract
Disease of the aortic arch, descending thoracic, or thoracoabdominal aorta necessitates dedicated expertise across medical, endovascular, and surgical specialties. Cardiologists, cardiac surgeons, vascular surgeons, interventional radiologists, and others have expertise and skills that aid in the management of patients with complex aortic disease. No specialty is uniformly expert in all aspects of required care. Because of this dispersion of expertise across specialties, an aortic team model approach to decision-making and treatment is advocated. A nonhierarchical partnership across specialties within an interdisciplinary aortic clinic ensures that all treatment options are considered and promotes shared decision-making between the patient and all aortic experts. Furthermore, regionalization of care for aortic disease of increased complexity assures that the breadth of treatment options is available and that favourable volume-outcome ratios for high-risk procedures are maintained. An awareness of best practice care pathways for patient referrals for preventative management, acute care scenarios, chronic care scenarios, and pregnancy might facilitate a more organized management schema for aortic disease across Canada and improve lifelong surveillance initiatives.
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Affiliation(s)
- R Scott McClure
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada.
| | - Thomas F Lindsay
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Keir
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jason P Bayne
- Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Robert F Berry
- QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michael W A Chu
- London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Jennifer C-Y Chung
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Francois Dagenais
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec City, Quebec, Canada
| | - Robin A Ducas
- St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Audra Duncan
- London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Gabrielle Horne
- QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Darren Klass
- Vancouver Coastal Health, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Julie Richer
- University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Kenton L Rommens
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
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Li B, Beaton D, Eisenberg N, Lee DS, Wijeysundera DN, Lindsay TF, de Mestral C, Mamdani M, Roche-Nagle G, Al-Omran M. Using machine learning to predict outcomes following carotid endarterectomy. J Vasc Surg 2023; 78:973-987.e6. [PMID: 37211142 DOI: 10.1016/j.jvs.2023.05.024] [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] [Received: 02/17/2023] [Revised: 05/08/2023] [Accepted: 05/13/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVE Prediction of outcomes following carotid endarterectomy (CEA) remains challenging, with a lack of standardized tools to guide perioperative management. We used machine learning (ML) to develop automated algorithms that predict outcomes following CEA. METHODS The Vascular Quality Initiative (VQI) database was used to identify patients who underwent CEA between 2003 and 2022. We identified 71 potential predictor variables (features) from the index hospitalization (43 preoperative [demographic/clinical], 21 intraoperative [procedural], and 7 postoperative [in-hospital complications]). The primary outcome was stroke or death at 1 year following CEA. Our data were split into training (70%) and test (30%) sets. Using 10-fold cross-validation, we trained six ML models using preoperative features (Extreme Gradient Boosting [XGBoost], random forest, Naïve Bayes classifier, support vector machine, artificial neural network, and logistic regression). The primary model evaluation metric was area under the receiver operating characteristic curve (AUROC). After selecting the best performing algorithm, additional models were built using intra- and postoperative data. Model robustness was evaluated using calibration plots and Brier scores. Performance was assessed on subgroups based on age, sex, race, ethnicity, insurance status, symptom status, and urgency of surgery. RESULTS Overall, 166,369 patients underwent CEA during the study period. In total, 7749 patients (4.7%) had the primary outcome of stroke or death at 1 year. Patients with an outcome were older with more comorbidities, had poorer functional status, and demonstrated higher risk anatomic features. They were also more likely to undergo intraoperative surgical re-exploration and have in-hospital complications. Our best performing prediction model at the preoperative stage was XGBoost, achieving an AUROC of 0.90 (95% confidence interval [CI], 0.89-0.91). In comparison, logistic regression had an AUROC of 0.65 (95% CI, 0.63-0.67), and existing tools in the literature demonstrate AUROCs ranging from 0.58 to 0.74. Our XGBoost models maintained excellent performance at the intra- and postoperative stages, with AUROCs of 0.90 (95% CI, 0.89-0.91) and 0.94 (95% CI, 0.93-0.95), respectively. Calibration plots showed good agreement between predicted and observed event probabilities with Brier scores of 0.15 (preoperative), 0.14 (intraoperative), and 0.11 (postoperative). Of the top 10 predictors, eight were preoperative features, including comorbidities, functional status, and previous procedures. Model performance remained robust on all subgroup analyses. CONCLUSIONS We developed ML models that accurately predict outcomes following CEA. Our algorithms perform better than logistic regression and existing tools, and therefore, have potential for important utility in guiding perioperative risk mitigation strategies to prevent adverse outcomes.
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Affiliation(s)
- Ben Li
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Temerty Centre for Artificial Intelligence Research and Education in Medicine (T-CAIREM), University of Toronto, Toronto, ON, Canada
| | - Derek Beaton
- Data Science and Advanced Analytics Department, Unity Health Toronto, University of Toronto, Toronto, ON, Canada
| | - Naomi Eisenberg
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Douglas S Lee
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, University of Toronto, Toronto, ON, Canada
| | - Duminda N Wijeysundera
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, University of Toronto, Toronto, ON, Canada; Department of Anesthesia, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Thomas F Lindsay
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Charles de Mestral
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Muhammad Mamdani
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Temerty Centre for Artificial Intelligence Research and Education in Medicine (T-CAIREM), University of Toronto, Toronto, ON, Canada; Data Science and Advanced Analytics Department, Unity Health Toronto, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Graham Roche-Nagle
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Mohammed Al-Omran
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Temerty Centre for Artificial Intelligence Research and Education in Medicine (T-CAIREM), University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia.
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11
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Li B, Ayoo K, Eisenberg N, Lindsay TF, Roche-Nagle G. Reply. J Vasc Surg 2023; 78:839-840. [PMID: 37599035 DOI: 10.1016/j.jvs.2023.03.037] [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: 03/23/2023] [Accepted: 03/27/2023] [Indexed: 08/22/2023]
Affiliation(s)
- Ben Li
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kennedy Ayoo
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Naomi Eisenberg
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Graham Roche-Nagle
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
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12
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Li B, Ayoo K, Eisenberg N, Lindsay TF, Roche-Nagle G. The impact of race on outcomes following ruptured abdominal aortic aneurysm repair. J Vasc Surg 2023; 77:1413-1423. [PMID: 36702172 DOI: 10.1016/j.jvs.2023.01.181] [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: 09/20/2022] [Revised: 01/12/2023] [Accepted: 01/17/2023] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Racial differences in elective abdominal aortic aneurysm (AAA) repair outcomes have been previously reported; however, data on racial differences in ruptured AAA (rAAA) repair outcomes remain limited. This study assessed in-hospital and long-term mortality after rAAA repair in Black versus White patients. METHODS The Vascular Quality Initiative database was queried to identify all Black and White patients who underwent open or endovascular rAAA repair between 2003 and 2019. Baseline demographic and clinical characteristics were recorded, and independent t test and χ2 test were performed to assess differences between groups. In-hospital and 8-year mortality rates were the primary outcomes. Univariate and multivariate logistic regression and Cox proportional hazards analyses were conducted to analyze associations between race and outcomes. RESULTS Overall, 310 Black patients and 4679 White patients underwent rAAA repair. A greater proportion of Black patients underwent endovascular repair (73.2% vs 56.1%). Black patients had a lower mean age and were more likely to be female, with a greater proportion being Medicaid insured (9.7% vs 2.1%) or uninsured (4.8% vs 3.3%). Although Black patients were more likely to be current smokers and have hypertension, diabetes, and congestive heart failure, they were not more likely to receive risk reduction medications. The time from symptom onset to incision or access was higher for Black patients (median, 12.0 hours vs 7.0 hours). Similarly, the time from hospital admission to intervention was higher for Black patients (median, 2.8 hours vs 1.3 hours). In-hospital mortality was lower in Black patients (20.0% vs 28.6%; odds ratio [OR], 0.63; 95% confidence interval [CI], 0.47-0.83); however, this did not persist after adjusting for baseline characteristics (adjusted OR, 0.58; 95% CI, 0.30-1.07; P = .09). Furthermore, the 8-year survival was not different between groups (50.4% vs 46.6%; hazard ratio, 0.85; 95% CI, 0.57-1.26; P = .42), even when stratified by repair type. CONCLUSIONS This study identified racial differences in demographic, clinical, and procedural characteristics for patients undergoing rAAA repair. In particular, the door-to-intervention time for Black patients of 2.8 hours does not meet the Society for Vascular Surgery recommendation of 90 minutes. Despite these differences, the 8-year mortality is similar for Black and White patients. These differences should be investigated further, and there are opportunities to improve rAAA care for Black patients.
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Affiliation(s)
- Ben Li
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kennedy Ayoo
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Naomi Eisenberg
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Graham Roche-Nagle
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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13
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Mahmood DN, Forbes SM, Rocha R, Tan K, Ouzounian M, Chung JCY, Lindsay TF. Outcomes in octogenarians after thoracoabdominal and juxtarenal aortic aneurysm repair using fenestrated-branched devices justifies treatment. J Vasc Surg 2023; 77:694-703.e3. [PMID: 36441071 DOI: 10.1016/j.jvs.2022.10.028] [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: 07/07/2022] [Revised: 10/13/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To compare outcomes between octogenarians and nonoctogenarians undergoing thoracoabdominal aortic aneurysm repair and juxtarenal aortic aneurysm repair using branched and/or fenestrated endovascular devices (F/BEVAR) and compare octogenarian survival to population survival statistics from Ontario, Canada. METHODS Patients who underwent F/BEVAR at a single institution between 2007 and 2020 were retrospectively reviewed with a median follow-up of 3.3 years (interquartile range, 1.6-5.3). The median survival of an average 84-year-old Ontarian from Canada, adjusted for a male:female ratio of 4:1, was retrieved from publicly available Statistics Canada data. RESULTS In total, 68 octogenarians (25.8%) and 196 nonoctogenarians (74.2%) were included (mean age, 83.5 ± 3.0 vs 71.9 ± 5.8 years; P ≤ .001). The maximum aneurysm size was significantly larger in octogenarians (68.9 ± 11.4 mm vs 65.4 ± 10.0 mm; P = .017). No differences in the number of thoracoabdominal aortic aneurysm repairs (29.4% vs 38.3%; P = .19) or operative technical success (92.6% vs 85.7%; P = .136) were observed between the two cohorts. Postoperatively, no significant differences in overall in-hospital mortality (7.3% vs 5.1%; P = .49), elective in-hospital mortality (6.1% vs 4.4%; P = .49), stroke (1.5% vs 3.6%; P = .384), or spinal cord ischemia (2.9% vs 9.2%; P = .094) were seen between octogenarians and nonoctogenarians. There was no difference in survival at 4 years between the two cohorts (62.9% vs 71.1%; P = .22), however, survival at 6 years was significantly lower for octogenarians (44.5% vs 64.1%; hazard ratio, 1.96; P = .02). The cumulative rate of reintervention (44.1% vs 41.3%; P = .84) and freedom from branch instability (67.6% vs 73.5%; P = .33) at 6 years were not different between the two groups. When comparing octogenarians who survived to discharge from index hospitalization after F/BEVAR with 84-year-old Ontarians unmatched for comorbidities, a survival difference of 4.8% and 11.1% was noted at 4 and 6 years, respectively. CONCLUSIONS F/BEVAR in octogenarians is associated with no differences in technical success or postoperative adverse outcomes when compared with their younger counterparts. Octogenarians had increased mortality after 4 years and their survival at 4 years was comparable with that of an 84-year-old Ontarian. F/BEVAR was safe and effective in octogenarians deemed fit for intervention. Further research into preoperative patient selection and improving perioperative outcomes is needed.
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Affiliation(s)
- Daniyal N Mahmood
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Samantha M Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Rodolfo Rocha
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - KongTeng Tan
- Division of Interventional Radiology, Toronto General Hospital, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer C-Y Chung
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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14
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Forbes SM, Mahmood DN, Rocha R, Tan KT, Ouzounian M, Chung JCY, Lindsay TF. Females experience elevated early morbidity and mortality but similar mid-term survival compared to males after branched/fenestrated endovascular aortic aneurysm repair. J Vasc Surg 2022; 77:1349-1358.e5. [PMID: 36581014 DOI: 10.1016/j.jvs.2022.12.031] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/30/2022] [Accepted: 12/07/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The objective of this study was to identify sex-related differences in outcomes following branched and/or fenestrated endovascular aortic repair (B/FEVAR) for thoracoabdominal (TAAA) and juxtarenal (JRAA) aortic aneurysms. METHODS Chart review completed on 242 B/FEVAR patients (57 female; 23.5%) between 2007 and 2020 at a single center. Median follow-up time was 3.3 years (interquartile range [IQR], 1.6-5.3 years). RESULTS No statistically significant differences in age (females, 75.9 ± 5.4 years vs males, 74.7 ± 7.2 years; P = .162) or aneurysm size (64.9 ± 6.8 vs 65.8 ± 9.4 mm; P = .41) at presentation were observed between sexes. Females presented with fewer JRAAs (45.6% vs 73%; P < .001) and received more Crawford extent II (26.3% vs 10.8%; P =.004) TAAA coverage. Increased incidence of moderate/severe target vessel stenosis (29.8% vs 14%; P = .022) was observed in female patients. Intraoperatively, females had higher procedure times (530 [IQR, 425-625] vs 420 [IQR, 350-510] minutes; P < .001), fluoroscopy times (124.1 ± 49 vs 107.3 ± 43.5 minutes; P = .017), and contrast usage (200 [IQR, 150-270] vs 175 [IQR, 130-225] mL; P = .005). Unplanned intraoperative maneuvers (45.6% vs 28.1%; P = .043), graft delivery issues (24.6% vs 4.9%; P < .001), and additional intraoperative complications (61.4% vs 35.7%; P < .001) were also increased in females. Postoperatively, females had a longer intensive care unit (3 [IQR, 1-5] vs 1 [IQR, 1-3] days; P = .002) and hospital stay (8 [IQR, 5-13] vs 5 [IQR, 3-9] days; P < .001) and experienced increased rates of spinal cord ischemia (15.8% vs 3.8%; P = .001) and bowel ischemia (10.5% vs 2.7%; P = .013). In-hospital mortality (12.3% vs 2.7%; P = .004) was higher in female patients but mid-term (6-year) survival was 60.2% for all patients (95% confidence interval, 53.0%-68.5%) and was similar between sexes (hazard ratio, 0.95; P = .83), which were the primary endpoints. No sex differences in mid-term follow-up reintervention, endoleak, and rupture rates were observed. CONCLUSIONS Females experienced significantly higher B/FEVAR intraoperative times, complications, and in-hospital morbidity and mortality compared with males but similar mid-term outcomes. Anatomic and atherosclerotic differences may have contributed to the observed in-hospital differences.
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Affiliation(s)
- Samantha M Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Daniyal N Mahmood
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Rodolfo Rocha
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kongteng Tan Tan
- Division of Interventional Radiology, Toronto General Hospital, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer C-Y Chung
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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15
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Chen JF, Tan KT, Lindsay TF, Ouzounian M, Chung JCY. Surgery for complications after thoracic endovascular aortic repair with arch vessel debranching: Role of imaging in preoperative planning. J Card Surg 2022; 37:4144-4149. [PMID: 36259711 DOI: 10.1111/jocs.17051] [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: 09/06/2022] [Accepted: 09/16/2022] [Indexed: 01/06/2023]
Abstract
We describe here a series of patients who presented with failed hybrid arch and descending thoracic aortic aneurysm repairs, while highlighting the instrumental role that advanced medical imaging played in formulating an operative plan. Each case involved persistent 1A endoleaks and aneurysm sac growth after hybrid arch repairs tackled by arch debranching followed by thoracic endovascular aortic repair. Two open cases were described as well as one endovascular case. Imaging played a key role in elucidating the site of endoleak and in operative planning. These cases highlight the importance of multidisciplinary input between cardiac surgery, vascular surgery and radiology in management of complex aortic patients.
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Affiliation(s)
- Julia F Chen
- Department of Surgery, Division of Vascular Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kong Teng Tan
- Department of Medical Imaging, Division of Interventional Radiology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Department of Surgery, Division of Vascular Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Department of Surgery, Division of Cardiovascular Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer C-Y Chung
- Department of Surgery, Division of Cardiovascular Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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16
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Bhandari A, Mahmood DN, Rocha R, Forbes SM, Tan KT, Ouzounian M, Chung JCY, Lindsay TF. Evaluating Branch Characteristics of off-the-shelf t-Branch and Custom-made Stent Grafts in Endovascular Repair of Thoracoabdominal Aortic Aneurysms. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.07.037] [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: 10/14/2022]
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17
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Ascaso Arbona M, Witheford M, Chung JCY, Lindsay TF, Ouzounian M. Aortic Wall Injury After Thoracic Stent Grafts: Vigilance Is Required! Ann Thorac Surg 2022; 114:692-693. [PMID: 35395202 DOI: 10.1016/j.athoracsur.2022.03.050] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 03/26/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Maria Ascaso Arbona
- Division of Cardiovascular Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Miranda Witheford
- Division of Vascular Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer C Y Chung
- Division of Cardiovascular Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Toronto General Hospital, University of Toronto, 200 Elizabeth St, 4N-457, Toronto, ON, M5G2C4, Canada.
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Addas JAK, Mafeld S, Mahmood DN, Sidhu A, Ouzounian M, Lindsay TF, Tan KT. Minimally Invasive Segmental Artery Coil Embolization (MISACE) Prior to Endovascular Thoracoabdominal Aortic Aneurysm Repair. Cardiovasc Intervent Radiol 2022; 45:1462-1469. [PMID: 35927497 DOI: 10.1007/s00270-022-03230-y] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 07/15/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE Minimally Invasive Segmental Artery Coil Embolization (MISACE) is a novel approach to reduce paraplegia risk in Thoracoabdominal aortic aneurysm (TAAA) repair with limited data. We report our experience with MISACE as a method of spinal cord pre-conditioning to prevent spinal cord ischemia following endovascular repair of TAAA. MATERIAL AND METHODS A retrospective analysis of 17 patients who had an attempted MISACE prior to endovascular TAAA repair with mean follow-up of 350 days (2017-2020). Baseline patient and aneurysm characteristics along with procedural technique and outcomes were analyzed. RESULTS Mean age of 69 years and 76.5% were males. TAAA Crawford classification were II, n = 6 (35.3%), III, n = 4 (23.5%) and IV, n = 5 (29.4%). The mean aortic diameter was 70.6 ± 10.9 mm. Staged repair was performed on 9 patients. Technically successful embolization occurred in 14 patients (82.4%) and was unsuccessful in 3 patients. The median number of embolized arteries was 3 and 71% of the target arteries were between T9 and T12. Mean fluoroscopy time was 51.5 ± 22.5 min and mean contrast volume used was 132.8 ± 56.1 mL. Average number of catheters used was 4.6 and 3.5 wires. No complications related to the procedure. Mean interval between embolization to endovascular TAAA repair was 51.2 days (5-110 days). All patients received spinal drainage at the time of repair. Postoperatively, 2/14 of patients developed paraparesis in the MISACE successful group and 1/3 patients developed paraplegia in the unsuccessful group. CONCLUSIONS MISACE is a promising strategy to prevent SCI. This data demonstrates the technique is feasible and safe but anatomic challenges remain.
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Affiliation(s)
- Jamil A K Addas
- Department of Vascular and Interventional Radiology, University Health Network, Toronto, Canada.
| | - Sebastian Mafeld
- Department of Vascular and Interventional Radiology, University Health Network, Toronto, Canada
| | - Daniyal N Mahmood
- Division of Vascular Surgery, University Health Network, Toronto, Canada
| | - Arshdeep Sidhu
- Department of Vascular and Interventional Radiology, University Health Network, Toronto, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, University Health Network, Toronto, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, University Health Network, Toronto, Canada
| | - Kong Teng Tan
- Department of Vascular and Interventional Radiology, University Health Network, Toronto, Canada
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19
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Ascaso M, Ibrahim M, Chung JCY, Lindsay TF, Crawford S, Ouzounian M. Open descending thoracic aorta aneurysm repair with removal of multiple previous endovascular devices. Multimed Man Cardiothorac Surg 2022; 2022. [PMID: 35616992 DOI: 10.1510/mmcts.2022.024] [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] [Indexed: 06/15/2023]
Abstract
False lumen patency is a poor prognostic factor for favorable aortic remodeling in patients with chronic aortic dissection. Several endovascular techniques are available to obliterate the false lumen; however, they are not always successful. We present the case of a 55-year old male with a chronic type B dissection and a large descending thoracic aortic aneurysm with rapid growth, up to 90 mm, despite attempted control of the false lumen with several endovascular devices (thoracic aortic stent graft, Amplatzer device, glue and candy plug). Successful aneurysmal open repair was achieved by removing these devices during the procedure. This case demonstrates the technical challenges of explanting an aortic stent graft and multiple other devices during distal aortic repair.
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Affiliation(s)
| | - Marina Ibrahim
- Division of Cardiovascular Surgery, Department of Surgery, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Jennifer C Y Chung
- Division of Cardiovascular Surgery, University of Toronto, Toronto, Canada
| | - Thomas F Lindsay
- Division of Cardiovascular Surgery, Department of Surgery, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Sean Crawford
- Division of Cardiovascular Surgery, Department of Surgery, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, University of Toronto, Toronto, Canada
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20
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Li B, Eisenberg N, Witheford M, Lindsay TF, Forbes TL, Roche-Nagle G. Sex Differences in Outcomes Following Ruptured Abdominal Aortic Aneurysm Repair. JAMA Netw Open 2022; 5:e2211336. [PMID: 35536576 PMCID: PMC9092206 DOI: 10.1001/jamanetworkopen.2022.11336] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Sex differences in aortic surgery outcomes are commonly reported. However, data on ruptured abdominal aortic aneurysm (rAAA) repair outcomes in women vs men are limited. OBJECTIVE To assess differences in perioperative and long-term mortality following rAAA repair in women vs men. DESIGN, SETTING, AND PARTICIPANTS A multicenter, retrospective cohort study was conducted using the Vascular Quality Initiative database, which prospectively captures information on patients who undergo vascular surgery across 796 academic and community hospitals in North America. All patients who underwent endovascular or open rAAA repair between January 1, 2003, and December 31, 2019, were included. Outcomes were assessed up to January 1, 2020. EXPOSURES Patient sex. MAIN OUTCOMES AND MEASURES Demographic, clinical, and procedural characteristics were recorded, and differences between women vs men were assessed using independent t test and χ2 test. The primary outcomes were in-hospital and 8-year mortality. Associations between sex and outcomes were analyzed using univariable and multivariable logistic regression and Cox proportional hazards regression analysis. RESULTS A total of 1160 (21.9%) women and 4148 (78.1%) men underwent rAAA repair during the study period. There was a similar proportion of endovascular repairs in women and men (654 [56.4%] vs 2386 [57.5%]). Women were older (mean [SD] age, 75.8 [9.3] vs 71.7 [9.6] years), more likely to have chronic kidney disease (718 [61.9%] vs 2184 [52.7%]), and presented with ruptured aneurysms of smaller diameters (mean [SD] 68 [18.2] vs 78 [30.2] mm). In-hospital mortality was higher in women (34.4% vs 26.6%; odds ratio, 1.44; 95% CI, 1.25-1.66), which persisted after adjusting for demographic, clinical, and procedural characteristics (adjusted odds ratio, 1.36; 95% CI, 1.12-1.66; P = .002). Eight-year survival was lower in women (36.7% vs 49.5%; hazard ratio, 1.25; 95% CI, 1.04-1.50; P = .02), which persisted when stratified by endovascular and open repair. This survival difference existed in both the US and Canada. Variables associated with long-term mortality in women included older age and chronic kidney disease. CONCLUSIONS AND RELEVANCE Women who underwent rAAA repair had higher perioperative and 8-year mortality rates following both endovascular and open repair compared with men. Older age and higher rates of chronic kidney disease in women were associated with higher mortality rates. These findings suggest that future studies should assess the reasons for these disparities and whether opportunities exist to improve AAA care for women.
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Affiliation(s)
- Ben Li
- University Health Network, Peter Munk Cardiac Centre, Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Naomi Eisenberg
- University Health Network, Peter Munk Cardiac Centre, Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Miranda Witheford
- University Health Network, Peter Munk Cardiac Centre, Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F. Lindsay
- University Health Network, Peter Munk Cardiac Centre, Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Thomas L. Forbes
- University Health Network, Peter Munk Cardiac Centre, Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Graham Roche-Nagle
- University Health Network, Peter Munk Cardiac Centre, Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
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Chung JCY, Lindsay TF, Ouzounian M. Reply: Surveillance Following Acute Type A Aortic Dissection: The Need for Long-Term Clinical Oversight. J Am Coll Cardiol 2022; 79:e207. [PMID: 35272807 DOI: 10.1016/j.jacc.2022.01.007] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 01/05/2022] [Indexed: 10/18/2022]
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22
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Kennedy SA, Kennedy MK, Lindsay TF, Byrne J, Jaberi A, Gold WL, Tan K, Mafeld S. Percutaneous Drainage for Aortic Graft Infection Post-aneurysm Repair: A Viable Option? Vasc Endovascular Surg 2022; 56:369-375. [PMID: 35180037 PMCID: PMC9003758 DOI: 10.1177/15385744221075136] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Purpose Non-operative management of aortic graft infection is usually only considered in a palliative context. We describe the safety, efficacy, and clinical outcomes of percutaneous drainage of aortic graft infections (AGI) following either open or endovascular repair of aneurysmal disease. Methods Twelve consecutive patients (11 males, 1 female, mean age 72.7 ± 10.3 years, age range 52-88 years) between January 2010-July 2020 who underwent percutaneous drain insertion in either an infected aortic sac or periaortic abscess cavity following endovascular or open surgical graft repair were identified. Patient and procedural characteristics as well as clinical outcomes were determined. Results Of the 12 patients who underwent percutaneous drain insertion, five (41.7%) had undergone open abdominal aneurysm repair, one (8.3%) open thoracoabdominal aneurysmal repair, and six (50%) endovascular abdominal aneurysm repairs. Drain size ranged from 10-20 French. All were inserted under ultrasound (US), computed tomography (CT), and/or fluoroscopic guidance. Median duration of drain placement was 55.2 days (range 3-174). Five patients (41.7%) had the drain in place as a stabilizing bridge until or after definitive surgical explantation and aortic reconstruction. Seven patients (58.3%) were managed with drain placement and antibiotic therapy without surgical intervention. Six (50%) were alive at the most recent time of follow-up (median, 732 days, range 166-1650 days). Three patients (25%) died during follow-up with causes including erosion of aortic reconstruction into sigmoid colon, unrelated chronic obstructive pulmonary disease exacerbation, and severe clostridium difficile colitis and pseudomonal pneumonia (median 1244 days, range 992-1597 days). Three (25%) patients were lost to follow-up. No drain-related complications were noted. Conclusion Percutaneous drainage of AGI following endovascular or open aneurysm repair is a safe and viable management option either as a temporizing measure as a bridge to surgical graft explantation or as a non-surgical therapy for long term management.
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Affiliation(s)
- Sean A Kennedy
- Division of Vascular & Interventional Radiology, Joint Department of Medical Imaging, University Health Network and Mount Sinai Hospital, 7938University of Toronto, Toronto, ON, Canada
| | - M Katharine Kennedy
- Division of Vascular & Interventional Radiology, Joint Department of Medical Imaging, University Health Network and Mount Sinai Hospital, 7938University of Toronto, Toronto, ON, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Department of Surgery, 7989University of Toronto, Toronto, ON, Canada
| | - John Byrne
- Division of Vascular Surgery, Department of Surgery, 7989University of Toronto, Toronto, ON, Canada
| | - Arash Jaberi
- Division of Vascular & Interventional Radiology, Joint Department of Medical Imaging, University Health Network and Mount Sinai Hospital, 7938University of Toronto, Toronto, ON, Canada
| | - Wayne L Gold
- Division of Infectious Diseases, Department of Medicine, 33540University of Toronto, Toronto, ON, Canada
| | - KongTeng Tan
- Division of Vascular & Interventional Radiology, Joint Department of Medical Imaging, University Health Network and Mount Sinai Hospital, 7938University of Toronto, Toronto, ON, Canada
| | - Sebastian Mafeld
- Division of Vascular & Interventional Radiology, Joint Department of Medical Imaging, University Health Network and Mount Sinai Hospital, 7938University of Toronto, Toronto, ON, Canada
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23
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Ibrahim M, Lindsay TF, Chung JCY, Tan KT, Contreras J, Ouzounian M. Endovascular arch repair using the NEXUS arch endograft. Ann Cardiothorac Surg 2022; 11:62-64. [DOI: 10.21037/acs-2021-taes-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 08/25/2021] [Indexed: 11/06/2022]
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24
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An KR, de Mestral C, Tam DY, Qiu F, Ouzounian M, Lindsay TF, Wijeysundera HC, Chung JCY. Surveillance Imaging Following Acute Type A Aortic Dissection. J Am Coll Cardiol 2021; 78:1863-1871. [PMID: 34696957 DOI: 10.1016/j.jacc.2021.08.058] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Survivors of acute type A aortic dissection (ATAAD) repair remain at risk for long-term complications. Guidelines recommend postoperative imaging surveillance, but adherence is uncertain. OBJECTIVES The aim of this study was to define the real-world frequency of postoperative imaging and characterize long-term outcomes of ATAAD. METHODS Population-based administrative health databases for Ontario, Canada, were linked to identify patients who underwent ATAAD repair and survived at least 90 days. Guideline-directed imaging surveillance (GDIS) was defined as undergoing a computed tomographic or magnetic resonance imaging scan at 6 and 12 months postoperatively and then annually thereafter. Multivariable time-to-event analysis explored the associations between GDIS and all-cause mortality and reintervention. RESULTS A total of 888 patients who survived urgent ATAAD repair between April 1, 2005, and March 31, 2018, were included. Median follow-up after ATAAD repair was 5.2 years (interquartile range: 2.4-7.9 years). A total of 14% patients received GDIS throughout follow-up. At 6 years, 3.9% of patients had received GDIS. The mortality rate was 4% at 1 year, 14% at 5 years, and 29% at 10 years. Incidence of aortic reintervention was 3% at 1 year, 9% at 5 years, and 17% at 10 years; the majority of these were urgent (68%), and they carried a 9% 30-day mortality rate. Greater adherence to GDIS was associated with mortality (hazard ratio: 1.08; 95% confidence interval: 1.05-1.11) and reintervention (hazard ratio: 1.04; 95% confidence interval: 1.01-1.07). CONCLUSIONS Adherence to GDIS following ATAAD repair is poor, while long-term mortality and reinterventions remain substantial. Further research is needed to determine if guidelines should be modified.
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Affiliation(s)
- Kevin R An
- Division of Cardiac Surgery, Department of Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada. https://twitter.com/KevinAnMD
| | - Charles de Mestral
- Division of Vascular Surgery, Department of Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Derrick Y Tam
- Division of Cardiac Surgery, Department of Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Maral Ouzounian
- Division of Cardiac Surgery, Department of Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada. https://twitter.com/OuzounianMD
| | - Thomas F Lindsay
- Division of Vascular Surgery, Department of Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Harindra C Wijeysundera
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada. https://twitter.com/hwijeysundera
| | - Jennifer C-Y Chung
- Division of Cardiac Surgery, Department of Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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25
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Rocha RV, Lindsay TF, Nasir D, Lee DS, Austin PC, Chan J, Chung J, Forbes TL, Ouzounian M. Risk factors Associated with Long Term Mortality and Complications Following Thoracoabdominal Aortic Aneurysm Repair. J Vasc Surg 2021; 75:1135-1141.e3. [PMID: 34606954 DOI: 10.1016/j.jvs.2021.09.021] [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: 05/08/2021] [Accepted: 09/01/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the risk factors associated with late mortality or complications (Thoracoabdominal aortic Aneurysm Life-altering Events (TALE): composite of mortality, permanent paraplegia, permanent dialysis, and stroke) in patients undergoing endovascular or open thoracoabdominal aortic aneurysm (TAAA) repair. METHODS Population-based study of patients undergoing TAAA repair in Ontario, Canada, between 2006 - 2017. The association of baseline risk factors with mortality post repair and complications was examined with Cox hazards models with hospital-specific random effects. The survival of patients undergoing TAAA repair was compared to matched controls who were free from TAAA, matching on age, sex, area of residence, and average annual household income. Type of repair (endovascular vs open) was included in all models. RESULTS We identified 664 adults (mean age 69.3 ± 10.6, 71% men) undergoing TAAA repair. At 5 and 8-years, survival was 55.0% (95% confidence interval (CI) 49.8-60.1) and 44.6% (95% CI 40.4-49.6) for patients undergoing TAAA repair vs 85.6% (95% CI 83.9-87.1) and 76.3% (95% CI 73.8-78.8) for the control population, respectively ((HR 1.97, 95% CI 1.67-2.32, p<.01). In patients undergoing TAAA, freedom from TALE was 49.2% (95% CI 44.7-53.7) and 37.3% (95% CI 33.1- 42.4) at 5 and 8-years of follow-up, respectively. On multivariable analysis, risk factors associated with mortality during follow-up included older age (hazard ratio (HR) 1.21 (per 5-year increase), 95%CI 1.13-1.28), peripheral artery disease (HR 1.46, 95%CI 1.03-2.09), hypertension (HR 1.58, 95%CI 1.03-2.43), congestive heart failure (HR 1.78, 95%CI 1.34-2.36), and urgent procedures (HR 2.27, 95%CI 1.74-3.00). A lower rate of death was observed in those with previous coronary revascularization (HR 0.63, 95%CI 0.41-0.96) and repair at high-volume institutions (>60 TAAA repairs during the study period) (HR 0.71, 95%CI 0.55-0.91). Older age, chronic kidney disease, congestive heart failure, and urgent procedures were associated with higher rate of TALE. The type of repair (endovascular or open) was not associated with mortality or TALE. CONCLUSIONS TAAA repair is associated with reduced long-term survival compared to the general population regardless of mode of treatment. Urgent/emergent repair was the most profound risk factor late adverse events. Type of repair (endovascular or open) was not a predictor for long-term death or complications. Previous coronary revascularization and having the procedure performed at a high-volume institution were associated with improved late outcomes in patients undergoing TAAA repair.
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Affiliation(s)
- Rodolfo V Rocha
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Daniyal Nasir
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Douglas S Lee
- Cardiovascular Program, ICES, Toronto, Ontario, Canada; Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Justin Chan
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Chung
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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26
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Bhandari A, Mahmood DN, Rocha RV, Forbes S, Tan KT, Ouzounian M, Chung J, Lindsay TF. Outcomes of Off-the-Shelf t-Branch Stent-Grafts in Endovascular Repair of Thoracoabdominal Aortic Aneurysms. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.182] [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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27
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Ibrahim M, Chung JCY, Lindsay TF, Ouzounian M. Commentary: Aberrant vertebral arteries in aortic repair: Small but mighty! JTCVS Tech 2021; 7:57-58. [PMID: 34318206 PMCID: PMC8312118 DOI: 10.1016/j.xjtc.2021.03.032] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 03/28/2021] [Accepted: 03/31/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Marina Ibrahim
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer C.-Y. Chung
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F. Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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28
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Altoijry A, Lindsay TF, Johnston KW, Mamdani M, Al-Omran M. Vascular injury-related in-hospital mortality in Ontario between 1991 and 2009. J Int Med Res 2021; 49:300060520987728. [PMID: 33512260 PMCID: PMC7871087 DOI: 10.1177/0300060520987728] [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] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Trauma-related vascular injuries are major contributors to morbidity and mortality worldwide. We conducted a retrospective, population-based, cross-sectional study to examine temporal trends and factors associated with traumatic vascular injury-related in-hospital mortality in Ontario, Canada from 1991 to 2009. METHODS We obtained data on Ontario hospital admissions for traumatic vascular injury, including injury mechanism and body region; and patient age, sex, socioeconomic status, and residence from the Canadian Institute for Health Information Discharge Abstract Database and Registered Persons Database from fiscal years 1991 to 2009. We performed time series analysis of vascular injury-related in-hospital mortality rates and multivariable logistic regression analysis to identify significant mortality-associated factors. RESULTS The overall in-hospital mortality rate for trauma-related vascular injury was 5.5%. A slight but non-significant decline in mortality occurred over time. The likelihood of vascular injury-related in-hospital mortality was significantly higher for patients involved in transport-related accidents (odds ratio [OR[=2.21, 95% confidence interval [CI], 1.76-2.76), age ≥65 years (OR = 4.34, 95% CI, 2.25-8.38), or with thoracic (OR = 2.24, 95% CI, 1.56-3.20) or abdominal (OR = 2.45, 95% CI, 1.75-3.42) injuries. CONCLUSIONS In-hospital mortality from traumatic vascular injury in Ontario was low and stable from 1991 to 2009.
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Affiliation(s)
- Abdulmajeed Altoijry
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Thomas F Lindsay
- Division of Vascular Surgery, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - K Wayne Johnston
- Division of Vascular Surgery, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Muhammad Mamdani
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Mohammed Al-Omran
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada.,Division of Vascular Surgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
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29
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Ibrahim M, Chung JCY, Lindsay TF, Ouzounian M. Commentary: Cerebrospinal fluid drainage: One component of a successful distal aortic surgery program. JTCVS Tech 2021; 6:11-12. [PMID: 34318129 PMCID: PMC8300974 DOI: 10.1016/j.xjtc.2021.01.005] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 12/30/2020] [Accepted: 01/05/2021] [Indexed: 11/28/2022] Open
Affiliation(s)
- Marina Ibrahim
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer C-Y Chung
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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30
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Rocha RV, De Mestral C, Tam DY, Lee DS, Al-Omran M, Austin PC, Forbes TL, Ouzounian M, Lindsay TF. Health care costs of endovascular compared with open thoracoabdominal aortic aneurysm repair. J Vasc Surg 2020; 73:1934-1941.e1. [PMID: 33098943 DOI: 10.1016/j.jvs.2020.09.034] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 09/02/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To compare 1-year health care costs between endovascular and open thoracoabdominal aortic aneurysm (TAAA). METHODS Population-based administrative health databases were used to capture TAAA repairs performed in Ontario, Canada, between January 2006 and February 2017. All health care costs incurred by the Ministry of Health from a single-payer universal health care system were included. Costs of the aortic endografts and ancillary devices for the index procedure were estimated as C$44,000 per endovascular case vs C$1000 for open cases, based on previous reports. Costs (2017 Canadian dollars) were calculated in phases (1, 1-3, 3-6, and 6-12 months from surgery) with censoring for death. For each phase, propensity score matching of endovascular and open cases based on preoperative patient and hospital characteristics was used. The association between preoperative characteristics (including repair approach) and the first month postprocedure cost was characterized through multivariable analysis. RESULTS Overall 664 TAAA repairs were identified (open, n = 361 [54.5%] and endovascular, n = 303 [45.6%]). At 1 month, the median cost was higher for endovascular TAAA repair in the prematching cohort (C$64,892 vs C$36,647; P < .01). Similarly, in 241 well-balanced endovascular/open patient pairs after propensity score matching, the median health care costs were higher in endovascular TAAA cases during the first month (C$62,802 vs C$33,605; P < .01). The 1- to 3-month median cost was not statistically different between endovascular and open TAAA cases either before matching (C$2781 vs C$2618; P = .71) or after matching (C$2762 vs C$2092; P = .58). Likewise, in the 3- to 6-month and 6- to 12-month postprocedure intervals, there were no significant differences in the median health care costs between groups. On multivariable analysis, older age (5-year increments) (relative change [RC] in mean cost, 1.05; 95% confidence interval [CI], 1.04-1.06; P = .01), urgent procedures (RC, 1.29; 95% CI, 1.10-1.52; P < .01), and history of stroke (RC, 1.34; 95% CI, 1.00-1.78; P = .05) were associated with higher costs in the first postoperative month, whereas open relative to endovascular TAAA repair was associated with a decreased 1-month cost (RC, 0.65; 95% CI, 0.56-0.74; P < .01). CONCLUSIONS TAAA repair is expensive regardless of technique. Compared with open TAAA repair, endovascular repair was associated with a higher early cost, owing to the upfront cost of the endograft and aortic ancillary devices. There was no difference in cost from 1 to 12 months after repair. A decrease in the cost of endovascular devices might allow equivalent costs between endovascular and open TAAA repair.
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Affiliation(s)
- Rodolfo V Rocha
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Charles De Mestral
- Division of Vascular Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Cardiovascular Program, ICES, Toronto, Ontario, Canada
| | - Derrick Y Tam
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Douglas S Lee
- Cardiovascular Program, ICES, Toronto, Ontario, Canada; Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed Al-Omran
- Division of Vascular Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Thomas L Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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31
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Mahmood DN, Rocha R, Ouzounian M, Tan KT, Lindsay TF. Long-term Follow-Up Following Advanced Endovascular Thoracoabdominal Aortic Aneurysm Repair: A Single-Center Experience. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.04.330] [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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32
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Patel NR, Sidiqi A, Lindsay TF, Tan KT, Oreopoulos GD. Rare complication of esophageal necrosis and perforation after fenestrated endovascular aneurysm repair. J Vasc Surg Cases Innov Tech 2020; 6:181-184. [PMID: 32322771 PMCID: PMC7160524 DOI: 10.1016/j.jvscit.2020.02.004] [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] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 02/09/2020] [Indexed: 11/05/2022]
Abstract
Fenestrated endovascular aneurysm repair (FEVAR) is a minimally invasive technique used to treat complex abdominal aortic aneurysms. We present the case of a 69-year-old man with a juxtarenal abdominal aortic aneurysm treated with FEVAR. The patient experienced postoperative dysphagia and sepsis. Investigations revealed a perforated esophagus due to esophageal ischemia and necrosis, leading to complete esophagectomy and subsequent esophageal reconstruction. This case highlights esophageal necrosis and perforation as a potential complication of FEVAR and serves as a reminder to have a low threshold for investigating and emergently managing this condition, which otherwise has a high mortality rate.
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Affiliation(s)
- Neeral R Patel
- Interventional Radiology, Toronto General Hospital, Toronto, Ontario, Canada
| | - Abdul Sidiqi
- Interventional Radiology, Toronto General Hospital, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Vascular Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Kong Teng Tan
- Interventional Radiology, Toronto General Hospital, Toronto, Ontario, Canada
| | - George D Oreopoulos
- Interventional Radiology, Toronto General Hospital, Toronto, Ontario, Canada.,Vascular Surgery, Toronto General Hospital, Toronto, Ontario, Canada
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Eisenberg N, Roche-Nagle G, Lindsay TF, Oreopoulos G. Leveraging vascular quality initiative data to improve hospital length of stay for patients undergoing endovascular aneurysm repair. Can J Surg 2020; 63:E88-E93. [PMID: 32109014 DOI: 10.1503/cjs.003219] [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] [Indexed: 11/01/2022] Open
Abstract
Background The Society for Vascular Surgery Vascular Quality Initiative (SVS-SVQI) is a database that provides insight into standards of care and highlights opportunities for quality improvement by benchmarking institutional data against local, regional and national trends. Endovascular aneurysm repair (EVAR) is a frequently performed vascular operation. Postoperative length of stay in hospital (LOS) varies among institutions. We reviewed the morbidity and mortality of patients who underwent EVAR at our institution and the financial impact of increased LOS for these patients. In addition, we sought to identify modifiable factors associated with prolonged LOS. Methods We identified all patients who underwent elective EVAR between Jan. 1, 2011, and Dec. 31, 2014. Preoperative patient characteristics, intraoperative details, postoperative factors, long-term (1 yr) outcomes and cost data were reviewed. Univariate analysis was used to determine statistical differences between patients with LOS less than or equal to 2 days and greater than 2 days. Interventions were implemented to modify factors identified as having a negative impact on EVAR LOS. Results Identified factors that negatively affected EVAR LOS included social, neurologic, cardiovascular, urologic and renal issues. Following targeted interventions, LOS after EVAR decreased from an average of 3.8 to 3.0 days (p < 0.05). Logistic regression (n = 124) identified cardiovascular issues as the most significant predictor of LOS greater than 2 days (p = 0.001, odds ratio 14.24, 95% confidence interval 2.8–71.4). Reduction in LOS was associated with the additional benefit of 6.6% adjusted cost savings. Conclusion By leveraging SVS-VQI data, we were able to reduce EVAR LOS by identifying modifiable factors and instituting focused interventions. The reduction in LOS was associated with cost savings to the hospital.
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Affiliation(s)
- Naomi Eisenberg
- From the Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, Ont. (Eisenberg, Roche-Nagle, Lindsay, Oreopoulos); the Faculty of Medicine, University of Toronto, Toronto, Ont. (Roche-Nagle, Lindsay, Oreopoulos); and the Division of Vascular Interventional Radiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ont. (Roche-Nagle, Oreopoulos)
| | - Graham Roche-Nagle
- From the Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, Ont. (Eisenberg, Roche-Nagle, Lindsay, Oreopoulos); the Faculty of Medicine, University of Toronto, Toronto, Ont. (Roche-Nagle, Lindsay, Oreopoulos); and the Division of Vascular Interventional Radiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ont. (Roche-Nagle, Oreopoulos)
| | - Thomas F. Lindsay
- From the Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, Ont. (Eisenberg, Roche-Nagle, Lindsay, Oreopoulos); the Faculty of Medicine, University of Toronto, Toronto, Ont. (Roche-Nagle, Lindsay, Oreopoulos); and the Division of Vascular Interventional Radiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ont. (Roche-Nagle, Oreopoulos)
| | - George Oreopoulos
- From the Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, Ont. (Eisenberg, Roche-Nagle, Lindsay, Oreopoulos); the Faculty of Medicine, University of Toronto, Toronto, Ont. (Roche-Nagle, Lindsay, Oreopoulos); and the Division of Vascular Interventional Radiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ont. (Roche-Nagle, Oreopoulos)
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Rocha RV, Lindsay TF, Austin PC, Al-Omran M, Forbes TL, Lee DS, Ouzounian M. Outcomes after endovascular versus open thoracoabdominal aortic aneurysm repair: A population-based study. J Thorac Cardiovasc Surg 2019; 161:516-527.e6. [PMID: 31780062 DOI: 10.1016/j.jtcvs.2019.09.148] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 09/08/2019] [Accepted: 09/23/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE We sought to determine the early and late outcomes of endovascular versus open thoracoabdominal aortic aneurysm repair. METHODS We performed a multicenter population-based study across the province of Ontario, Canada, from 2006 to 2017. The primary end point was mortality. Secondary end points were time to first event of a composite of mortality, permanent spinal cord injury, permanent dialysis, and stroke, the individual end points of the composite, patient disposition at discharge, hospital length of stay, myocardial infarction, and secondary procedures at follow-up. RESULTS A total of 664 adults undergoing surgical repair of a thoracoabdominal aortic aneurysm (endovascular: n = 303 [45.5%] vs open: n = 361 [54.5%]) were identified using an algorithm of administrative codes validated against the operative records. Propensity score matching resulted in 241 patient pairs. Endovascular repairs increased during the study and currently comprise more than 50% of total repairs. In the matched sample, open repair was associated with a higher incidence of in-hospital death (17.4% vs 10.8%, P = .04), complications (26.1% vs 17.4%, P = .02), discharge to rehabilitation facilities (18.7% vs 10.0%, P = .02), and longer length of stay (12 [7-21] vs 6 [3-13] days, P < .01). Long-term mortality was not significantly different (hazard ratio, 1.09; 95% confidence interval, 0.78-1.50), nor were the other secondary end points, with the exception of secondary procedures, which were higher in the endovascular group (hazard ratio, 2.64; 95% confidence interval, 1.54-4.55). At 8 years, overall survival was 41.3% versus 44.6% after endovascular and open repair (P = .62). CONCLUSIONS Endovascular repair was associated with improved early outcomes but higher rates of secondary procedures after discharge. Long-term survival after thoracoabdominal aortic aneurysm repair is poor and independent of repair technique.
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Affiliation(s)
- Rodolfo V Rocha
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Peter C Austin
- Cardiovascular Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Mohammed Al-Omran
- Division of Vascular Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Douglas S Lee
- Cardiovascular Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Rocha RV, Lindsay TF, Friedrich JO, Shan S, Sinha S, Yanagawa B, Al-Omran M, Forbes TL, Ouzounian M. Systematic review of contemporary outcomes of endovascular and open thoracoabdominal aortic aneurysm repair. J Vasc Surg 2019; 71:1396-1412.e12. [PMID: 31690525 DOI: 10.1016/j.jvs.2019.06.216] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [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: 01/31/2019] [Accepted: 06/04/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The purpose of the study was to provide a systematic review of the literature reporting the contemporary early outcomes after endovascular and open repair of thoracoabdominal aortic aneurysms (TAAAs). METHODS MEDLINE and Embase were searched for studies from January 2006 to March 2018 that reported either endovascular (using branched or fenestrated endografts) or open repair of TAAA in at least 10 patients. Outcomes of interest included perioperative mortality, spinal cord injury (SCI), renal failure requiring dialysis, and stroke. Pooled proportions were determined using a random-effects model. RESULTS The analysis included 71 studies, of which 24 and 47 reported outcomes after endovascular and open TAAA repair, respectively. Endovascular cohort patients were older and had higher rates of coronary artery disease, chronic obstructive pulmonary disease, and diabetes. Endovascular repair was associated with higher rates of SCI (13.5%; 95% confidence interval [CI], 10.5%-16.7%) compared with open repair (7.4%; 95% CI, 6.2%-8.7%; P < .01) but similar rates of permanent paralysis (5.2% [95% CI, 3.8%-6.7%] vs 4.4% [95% CI, 3.3%-5.6%]; P = .39), lower rates of postoperative dialysis (6.4% [95% CI, 3.2%-9.5%] vs 12.0% [95% CI, 8.2%-16.3%]; P = .03) but similar rates of being discharged on permanent dialysis (3.7% [95% CI, 2.0%-5.9%] vs 3.8% [95% CI, 2.9%-5.3%]; P = .93), a trend to lower stroke (2.7% [95% CI, 1.9%-3.6%] vs 3.9% [95% CI, 3.0%-4.9%]; P = .06), and similar perioperative mortality (7.4% [95% CI, 5.9%-9.1%] vs 8.9% [95% CI, 7.2%-10.9%]; P = .21). CONCLUSIONS This systematic review summarizes the contemporary literature results of endovascular and open TAAA repair. Endovascular repair studies included patients with more comorbidities and were associated with higher rates of SCI but similar rates of permanent paraplegia, whereas open repair studies had higher rates of postoperative dialysis but similar rates of being discharged on permanent dialysis. Perioperative mortality rates were similar. Universally adopted reporting standards for patient characteristics, outcomes, and the conduct of contemporary comparative studies will allow better assessment and comparisons of the risks associated with the two surgical treatment options for TAAA.
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Affiliation(s)
- Rodolfo V Rocha
- Division of Cardiac Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jan O Friedrich
- Critical Care and Medicine Departments and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Shubham Shan
- Division of Cardiac Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sidhartha Sinha
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Bobby Yanagawa
- Division of Cardiac Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed Al-Omran
- Division of Vascular Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiac Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Crawford SA, Osman E, Doyle MG, Lindsay TF, Amon CH, Forbes TL. Impact of fenestrated stent graft misalignment on patient outcomes. J Vasc Surg 2019; 70:1056-1064. [DOI: 10.1016/j.jvs.2018.12.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 12/26/2018] [Indexed: 11/29/2022]
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Li B, Salata K, de Mestral C, Hussain MA, Aljabri BA, Lindsay TF, Verma S, Al-Omran M. Perceptions of Canadian Vascular Surgeons Toward Pharmacologic Risk Reduction in Patients with Peripheral Artery Disease: 2018 Update. Ann Vasc Surg 2019; 58:166-173.e4. [DOI: 10.1016/j.avsg.2018.11.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 11/30/2018] [Indexed: 12/24/2022]
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Rocha RV, Al-Omran M, Hussain MA, Lee DS, Forbes TL, Lindsay TF, Ouzounian M. Validation of endovascular and open thoracoabdominal aortic aneurysm repair in Ontario health administrative databases. CLIN INVEST MED 2019; 42:E19-25. [DOI: 10.25011/cim.v42i2.32812] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Indexed: 11/03/2022]
Abstract
Purpose: The positive predictive value (PPV) of endovascular and open thoracoabdominal aortic aneurysm (TAAA) repair coding was assessed in
Ontario health administrative databases.
Methods: Between 1 January 2006 and 31 March 2016, a random sample of 192 patients was identified using Canadian Classification of Health Intervention (CCI) procedure codes and Ontario Health Insurance Plan (OHIP) billing codes from administrative data. Blinded chart reviews were conducted at two cardiovascular centers to assess the level of agreement between the administrative records and the corresponding patients’ hospital charts. The PPV was calculated with 95% confidence intervals using hospital charts as the gold standard.
Results: The PPV for the single endovascular TAAA repair code, 1ID80GQNRN, was 0.90 (0.78, 0.97). A combination of all nine CCI open
TAAA repair codes was performed, with a PPV of 0.62 (0.47, 0.76). The combination of any one of the nine CCI codes AND the single OHIP code for open TAAA repair (R803) rendered a PPV of 0.98 (0.90, 1.00).
Conclusions: Endovascular TAAA repair may be identified using a single CCI code (1ID80GQNRN). Open TAAA repair may be identified using a combination of CCI and OHIP codes. Researchers may therefore use administrative data to conduct population-based studies of endovascular and open repair of TAAA.
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Rocha RV, Ouzounian M, de Mestral C, Forbes TL, Austin PC, Lee DS, Al-Omran M, Lindsay TF. PC020. Health Care Costs of Endovascular Compared With Open Thoracoabdominal Aortic Aneurysm Repair. J Vasc Surg 2019. [DOI: 10.1016/j.jvs.2019.04.303] [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: 11/25/2022]
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Mafeld S, Annamalai G, Lindsay TF, Zhong I, Tarulli E, Mironov O, Tan KT. Initial Experience With Viabahn VBX as the Bridging Stent Graft for Branched and Fenestrated Endovascular Aneurysm Repair. Vasc Endovascular Surg 2019; 53:395-400. [PMID: 31018828 DOI: 10.1177/1538574419840880] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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
PURPOSE To evaluate the feasibility and safety of a novel balloon-expandable, heparin-bonded endoprosthesis (Viabahn VBX, W. L. Gore and Associates) when used as a bridging stent graft (BSG) with fenestrated and branched endovascular aneurysm repair (FB-EVAR). FB-EVAR and BSGs increase repair complexity with the potential for endoleak formation, stenosis, thrombosis, and graft migration. The mechanical construction of the Viabahn VBX and its antithrombogenic properties may provide an advantage for FB-EVAR over existing BSGs. The efficacy, safety, and clinical outcomes were assessed. MATERIALS AND METHODS Research ethics board approved, prospective, single arm cohort, pilot study of patients undergoing FB-EVAR between February 2017 and January 2018. Fenestrated and branched endovascular aneurysm repair was performed per the standard institutional protocol by a team composed of vascular surgeons and interventional radiologists. Viabahn VBX endografts were used for all intended visceral branches as long as appropriately sized devices were available (Under Investigational Testing Authorization from Health Canada). Patient characteristics, procedural details, and technical and clinical outcomes were reviewed and summarized. RESULTS FB-EVAR was performed in 13 patients (9 male and 4 female) mean age of 74 (range: 61-83) with a total of 41 Viabahn VBXs stents implanted. Mean maximum aneurysm size was 6.7 cm (range: 5.5-9.0 cm) and included 5 juxtarenal abdominal aortic aneurysms and 8 thoracoabdominal; 3 type V, 3 type IV, and 2 type III (Crawford Classification). The Viabahn VBX was successfully deployed in 40 (98%) of 41 of cases. At median follow-up of 223 days (range: 2-462), there was a (40/40) 100% Viabahn VBX patency rate. Seven endoleaks were identified intra- or post procedurally in 6 (46%) of 13 cases, including 1 type IB, 3 type II, 2 type III, and 1 unclassified. Nine complications occurred in 6 patients. CONCLUSION The Viabahn VBX stent is a safe and effective BSG for FB-EVAR with no early stent thrombosis. Further evaluation is required to determine longer term stent efficacy.
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Affiliation(s)
- Sebastian Mafeld
- 1 Interventional Radiology, University of Toronto, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Ganesan Annamalai
- 1 Interventional Radiology, University of Toronto, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- 2 Division of Vascular Surgery, Department of Surgery, University of Toronto, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Iris Zhong
- 3 Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Emidio Tarulli
- 1 Interventional Radiology, University of Toronto, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Oleg Mironov
- 4 Department of Radiology, McMaster University, Hamilton, Ontario, Canada
| | - Kong-Teng Tan
- 1 Interventional Radiology, University of Toronto, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
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Rocha RV, Friedrich JO, Elbatarny M, Yanagawa B, Al-Omran M, Forbes TL, Lindsay TF, Ouzounian M. A systematic review and meta-analysis of early outcomes after endovascular versus open repair of thoracoabdominal aortic aneurysms. J Vasc Surg 2019; 68:1936-1945.e5. [PMID: 30470373 DOI: 10.1016/j.jvs.2018.08.147] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [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: 02/26/2018] [Accepted: 08/05/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The objective of this study was to compare the early results of endovascular vs open thoracoabdominal aortic aneurysm (TAAA) repair. METHODS MEDLINE and Embase were searched for studies from January 2006 to March 2018 that compared endovascular vs open repair of TAAA using branched or fenestrated endografts. Data were subjected to a meta-analysis using a random-effects model. The outcomes of interest included early mortality, spinal cord injury, renal failure requiring dialysis, stroke, and hospital length of stay. RESULTS Eight comparative studies met inclusion criteria. There were two retrospective propensity-matched studies, two unadjusted single-center retrospective studies, and four unadjusted national population-based studies. Mortality in the matched studies was equivalent in both groups. Pooled analysis of all unmatched observational studies revealed a survival benefit for endovascular over open repair (relative risk [RR], 0.63; 95% confidence interval [CI],0.45-0.87); P < .01, I2 = 47%). Endovascular repair was also associated with lower incidence of spinal cord injury (RR, 0.65; 95% CI, 0.42-1.01; P = .05; I2 = 28%). For unmatched studies, pooled RR of renal failure requiring dialysis significantly favored endovascular repair (RR, 0.44; 95% CI, 0.23-0.85; P = .01; I2 = 0%), although in the adjusted cohort, risk of dialysis was not different (RR, 1.00; 95% CI, 0.06-15.65; P = 1.00). Postoperative stroke rate was reported in three unadjusted studies and was not different between groups (RR, 0.81; 95% CI, 0.28-2.40; P = .71; I2 = 77%). Hospital length of stay was reported in four studies and was shorter in the endovascular group (mean difference, -4.4 days; 95% CI, -6.6 to -1.7; P < .01; I2 = 73%). CONCLUSIONS There are few reports comparing endovascular vs open repair of TAAAs. Short-term outcomes may be improved in patients undergoing endovascular treatment of TAAA on the basis of a limited number of studies with high risk of bias. These findings highlight the need for larger comparative studies with standardization of reporting.
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Affiliation(s)
- Rodolfo V Rocha
- Division of Cardiac Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Jan O Friedrich
- Department of Critical Care Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Malak Elbatarny
- Division of Cardiac Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Bobby Yanagawa
- Division of Cardiac Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed Al-Omran
- Division of Vascular Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiac Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada.
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Styra R, Lindsay TF. Reply. J Vasc Surg 2018; 68:1616-1617. [PMID: 30360853 DOI: 10.1016/j.jvs.2018.08.002] [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: 07/23/2018] [Accepted: 08/05/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Rima Styra
- Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Lindsay TF. Invited commentary. J Vasc Surg 2018; 68:73. [DOI: 10.1016/j.jvs.2017.11.059] [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] [Received: 11/19/2017] [Accepted: 11/21/2017] [Indexed: 10/28/2022]
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Styra RG, Larsen E, Baston D, Flockhart L, Elgie-Watson JE, Dimas MA, Lindsay TF. SS26. The Effect of Preoperative Cognitive Impairment and Type of Vascular Surgery Procedure on Postoperative Delirium With Associated Cost Implications. J Vasc Surg 2018. [DOI: 10.1016/j.jvs.2018.03.245] [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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Lindsay TF. Invited commentary. J Vasc Surg 2017; 66:1397. [DOI: 10.1016/j.jvs.2017.04.026] [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] [Received: 04/06/2017] [Accepted: 04/13/2017] [Indexed: 10/18/2022]
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Genis H, Crawford SA, Doyle MG, Lindsay TF, Amon CH, Forbes TL. Development of a Semiautomated Fenestrated Endovascular Aneurysm Repair Planning Technique. J Vasc Surg 2017. [DOI: 10.1016/j.jvs.2017.07.048] [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: 10/19/2022]
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Hussain MA, Al-Omran M, Lindsay TF. Risk-Reduction Program for Cardiovascular and Limb Events in Patients With Peripheral Arterial Disease-Reply. JAMA Surg 2016; 151:990-991. [PMID: 27487191 DOI: 10.1001/jamasurg.2016.2260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Mohamad A Hussain
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed Al-Omran
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada2Division of Vascular Surgery, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada3King Saud University-Li Ka Shing Collaborative Research Program and Department of Surgery, King Saud University, Riyadh, Saudi Arabia
| | - Thomas F Lindsay
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada4Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
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Abstract
Question: Is duplex scanning superior to clinical vein graft surveillance with respect to amputation rates, quality of life, and cost following femoropopliteal or femorocrural vein bypass graft? Population: Between 1998 and 2001, patients from 29 centers in the UK and Europe who had a patent vein graft 30 days following femoropopliteal or femorocrural vein bypass surgery for critical ischemia, claudication or symptomatic popliteal aneurysms were recruited for the study. Methods and results: There were 592 patients included in this multicenter randomized controlled trial. Patients with patent vein grafts at 30 days were randomized to receive or not receive duplex surveillance in addition to clinical examinations and ankle-brachial indices at 6 weeks (time of recruitment), and 3, 6, 9, 12 and 18 months. Stenoses within grafts were defined as slow peak systolic velocity (<45 cm/s), or a ratio of peak systolic velocity in an area of stenosis to any other area within 2 cm of >2. The primary endpoints were time to amputation and time to vascular mortality (MI, CHF, arrhythmia or CVA). Secondary outcomes included graft patency (whether primary or secondary, assisted or unassisted), cost, and quality of life as measured by SF-36 and EuroQol. The primary endpoints were analyzed according to an intention-to-treat analysis using Cox-regression and Kaplan-Meier life tables, while secondary outcomes were analyzed by the Mann-Whitney test and a t-test. Approximately 11% of patients died during the study, while 12% withdrew (45% of which were due to amputations). There were significantly more diagnostic interventions in the clinical follow-up group (31% vs 22%, P = 0.01). Between the clinical follow-up and duplex groups, there was no difference in amputation rate (7% vs 7%) or vascular death rate (3% vs 4%). A greater proportion of patients in the clinical follow-up group had a stenosis in the graft identified at the end of the study (19% vs 12%, p = 0.04). There were no differences in Kaplan-Meier estimates of primary, primary assisted and secondary patency rates between the two groups at 18 months. No differences in quality of life as measured by SF-36 or EuroQol were detected between the two groups. The cost per patient was greater in the duplex group (US$ 1537 vs US$ 2406, p = 0.002). Conclusion: The authors conclude that surveillance with duplex scanning following femoropopliteal or femorocrural bypass was more costly, but did not result in lower amputation rates.
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Affiliation(s)
- T F Lindsay
- Toronto General Hospital and the University of Toronto Department of Surgery, Ontario, Canada.
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Hussain MA, Al-Omran M, Mamdani M, Eisenberg N, Premji A, Saldanha L, Wang X, Verma S, Lindsay TF. Efficacy of a Guideline-Recommended Risk-Reduction Program to Improve Cardiovascular and Limb Outcomes in Patients With Peripheral Arterial Disease. JAMA Surg 2016; 151:742-50. [DOI: 10.1001/jamasurg.2016.0415] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Mohamad A. Hussain
- Division of Vascular Surgery, St Michael’s Hospital, Toronto, Ontario, Canada2Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed Al-Omran
- Division of Vascular Surgery, St Michael’s Hospital, Toronto, Ontario, Canada2Department of Surgery, University of Toronto, Toronto, Ontario, Canada3Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada4King Saud University–Li K
| | - Muhammad Mamdani
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada4King Saud University–Li Ka Shing Collaborative Research Program6Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada7Leslie
| | - Naomi Eisenberg
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Azra Premji
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lisa Saldanha
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Xuesong Wang
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Subodh Verma
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada3Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada4King Saud University–Li Ka Shing Collaborative Research Program12Division of Cardiac Surgery, St Michae
| | - Thomas F. Lindsay
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada10Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
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