Clinton D. Protack

Metabolic syndrome: A predictor of adverse outcomes after carotid revascularization.

BACKGROUNDnMetabolic syndrome (MetS) is rapidly increasing in prevalence and is associated with carotid plaque development and is a risk factor for stroke. The aim of this study is to describe the outcomes for patients with MetS after carotid revascularization (carotid endarterectomy [CEA] and carotid stenting [CAS]).nnnMETHODSnA database of patients undergoing carotid revascularization for primary atherosclerotic lesions was queried from 1996 to 2006. MetS was defined as the presence of >or=3 of the following criteria: blood pressure >or=130 mm Hg/>or=90 mm Hg; Triglycerides >or=150 mg/dL; high-density lipoproteins (HDL) <or=50 mg/dL for women and <or=40 mg/dL for men; fasting blood glucose >or=110 mg/dL; or Body Mass Index (BMI) >or=30 kg/m(2). Multivariate and Kaplan-Meier analyses were performed to outcomes. The average follow-up period was 4.5 years. A major adverse event (MAE) was defined as the occurrence of stroke, myocardial infarction (MI), or death.nnnRESULTSnA total of 921 patients (mean age: 71 +/- 10 years; 64% male) underwent 750 CEAs and 171 CAS. Thirty-one percent were identified as having MetS, 48% were asymptomatic, 87% had hypertension, 27% had hyperlipidemia, 32% were considered diabetic, and 14% had chronic renal insufficiency. The morbidity and mortality rates for all patients were 16.9% and 1.1%, respectively. The 30-day combined stroke/death rate was 3.6%. The 30-day MAE rates were: 6.7% vs 3.3% for MetS vs No-MetS (P = .02). The 90-day MAE rates were 8.7% vs 4.9% for MetS vs No-MetS (P = .03). MetS patients were more likely to experience a complication than No-MetS patients (23% vs 14%, P = .001). By Kaplan-Meier analysis, there was no difference between MetS and No-MetS patients with respect to patency, restenosis, re-intervention, or survival, but a difference existed for freedom from stroke, MI, and MAE. The difference between stroke rates was maintained between MetS and No-MetS, when subgrouped by those with and without symptoms. For patients with diabetes mellitus (DM), those with MetS had a 68% and 410% higher risk of developing an MAE and MI, respectively. However, for patients without diabetes, MetS was not significantly associated with MAE, stroke, or MI. No factors were found to be significantly associated with risk of stroke in all cases (in all patients, patients with diabetes, and patients without diabetes).nnnCONCLUSIONnMetS is prevalent among patients undergoing carotid revascularization. MetS patients are at a greater risk for perioperative morbidity as well as stroke, MI, and MAE during follow-up when compared to patients without MetS. Long-term stroke prevention is poor in the presence of MetS. MetS should be considered a significant risk factor for patients undergoing carotid revascularization.

Impact of Chronic Kidney Disease on Outcomes of Superficial Femoral Artery Endoluminal Interventions

While aggressive endoluminal therapy for superficial femoral artery (SFA) occlusive disease is commonplace, the implications of chronic kidney disease (CKD) on long-term outcomes in this population are unclear. We examined the consequences of endovascular treatment of the SFA in patients with and without varying stages of CKD. A database of patients undergoing endovascular treatment of the SFA between 1986 and 2007 was queried, and two groups were defined: estimated glomerular filtration rate (eGFR) <or=60 and >60 mL/min/1.73 cm(2). Intention-to-treat analysis was performed. Results were standardized to TransAtlantic Inter-Society Consensus (TASC-II) and Society for Vascular Surgery criteria. Kaplan-Meier analyses were performed to assess time-dependent outcomes. Factor analyses were performed using a Cox proportional hazard model for time-dependent variables. Data are presented as mean +/- standard deviation where appropriate. There were 525 limbs in 535 patients (68% male, average age 66 +/- 14 years) that underwent endovascular treatment for claudication or chronic critical limb ischemia (51%). Patients with eGFR <or=60 were older and had significantly more coronary artery disease, congestive heart failure, diabetes mellitus, and hyperlipidemia. TASC-II lesion distribution was equivalent (37% for TASC-II C and D), but tibial runoff was significantly worse in the eGFR <or=60 group. In addition, there were more inflow and outflow interventions in the eGFR <or=60 group. In patients with claudication, there was no difference in patency or limb salvage between those with eGFR <or=60 and >60. In patients with critical limb ischemia, there was no difference in patency between those with eGFR <or=60 and >60. Limb salvage was worse in patients with eGFR <or=60 compared to eGFR >60. With respect to limb salvage, six factors were significantly associated with a reduction in rates: presence of tissue loss at presentation (relative risk [RR] = 6.45, p = 0.003), 0 or 1 vessel tibial runoff (RR = 2.56, p < 0.01), progression of distal disease noted in follow-up (RR = 4.62, p < 0.01), embolization at the initial intervention (RR = 2.70, p < 0.05), diabetes mellitus (RR = 3.71, p < 0.01), and a history of congestive heart disease (RR = 2.42, p < 0.01). Notable factors that were not significantly associated included lesion calcification (p = 0.64), TASC C or D lesion categorization (p = 0.99), acute occlusion at initial intervention (p = 0.40), and adjuvant stenting (p = 0.67). CKD does not impact the patency of SFA interventions. Limb salvage in patients with critical ischemia is significantly worse when the eGFR is <or=60 mL/min/1.73 cm(2).

Hybrid Debranching-Endovascular Repair of Visceral Patch Aneurysm After Thoracoabdominal Aneurysm Repair

A visceral patch aneurysm is a significant complication after extensive thoracoabdominal aneurysm repair, and open procedures to correct these lesions are associated with a high perioperative mortality. We report the case of a 6-cm visceral patch aneurysm occurring in a patient with a completely replaced descending and abdominal aorta that was successfully corrected by staged debranching and endovascular repair with a dedicated thoracic endograft. Hybrid procedures are a successful option to treat complex repairs in the reoperative setting. They have the potential to lower perioperative risk and enhance patient care.