Hanaa Dakour Aridi

Efficacy and Safety of Digital Single-Operator Cholangioscopy for Difficult Biliary Stones

BACKGROUND & AIMS: It is not clear whether digital single‐operator cholangioscopy (D‐SOC) with electrohydraulic and laser lithotripsy is effective in removal of difficult biliary stones. We investigated the safety and efficacy of D‐SOC with electrohydraulic and laser lithotripsy in an international, multicenter study of patients with difficult biliary stones. METHODS: We performed a retrospective analysis of 407 patients (60.4% female; mean age, 64.2 years) who underwent D‐SOC for difficult biliary stones at 22 tertiary centers in the United States, United Kingdom, or Korea from February 2015 through December 2016; 306 patients underwent electrohydraulic lithotripsy and 101 (24.8%) underwent laser lithotripsy. Univariate and multivariable analyses were performed to identify factors associated with technical failure and the need for more than 1 D‐SOC electrohydraulic or laser lithotripsy session to clear the bile duct. RESULTS: The mean procedure time was longer in the electrohydraulic lithotripsy group (73.9 minutes) than in the laser lithotripsy group (49.9 minutes; P < .001). Ducts were completely cleared (technical success) in 97.3% of patients (96.7% of patients with electrohydraulic lithotripsy vs 99% patients with laser lithotripsy; P = .31). Ducts were cleared in a single session in 77.4% of patients (74.5% by electrohydraulic lithotripsy and 86.1% by laser lithotripsy; P = .20). Electrohydraulic or laser lithotripsy failed in 11 patients (2.7%); 8 patients were treated by surgery. Adverse events occurred in 3.7% patients and the stone was incompletely removed from 6.6% of patients. On multivariable analysis, difficult anatomy or cannulation (duodenal diverticula or altered anatomy) correlated with technical failure (odds ratio, 5.18; 95% confidence interval, 1.26–21.2; P = .02). Procedure time increased odds of more than 1 session of D‐SOC electrohydraulic or laser lithotripsy (odds ratio, 1.02; 95% confidence interval, 1.01–1.03; P < .001). CONCLUSIONS: In a multicenter, international, retrospective analysis, we found D‐SOC with electrohydraulic or laser lithotripsy to be effective and safe in more than 95% of patients with difficult biliary stones. Fewer than 5% of patients require additional treatment with surgery and/or extracorporeal shockwave lithotripsy to clear the duct.

Statins reduce mortality and failure to rescue after carotid artery stenting

Objective: The benefit of statins has been well established in reducing morbidities and mortality after carotid endarterectomy. However, the potential advantage of statin use in patients undergoing carotid artery stenting (CAS) remains largely unknown. The purpose of this study was to evaluate the effect of statins on postoperative outcomes after CAS. Methods: The Premier Healthcare Database was retrospectively analyzed to identify all patients who underwent CAS from 2009 to 2015. Univariate (χ2 test, t‐test) and multivariate models (logistic regression) were used to evaluate the effect of statins on postoperative outcomes. Results: A total of 17,800 patients underwent CAS during the study period; 12,416 (70%) patients were taking statins. The statin group had more symptomatic patients (41% vs 31%; P < .001) and had significantly higher comorbidities including hypertension, diabetes, coronary artery disease, dyslipidemia, history of congestive heart failure, history of stroke, history of myocardial infarction (MI), and peripheral artery disease (all P < .05). Postoperative mortality was 1.0% vs 1.8% in the statin and nonstatin groups, respectively (P < .001). Statin use had no effect on odds of postoperative stroke (odds ratio [OR], 1.09; 95% confidence interval [CI], 0.88‐1.34; P = .44) and higher odds of MI (OR, 2.08; 95% CI, 1.26‐3.45; P = .004). After adjustment for potential confounders, statins were associated with 64% reduction in the odds of death (OR, 0.36; 95% CI, 0.27‐0.47; P < .001) and 18% reduction in stroke/death (OR, 0.82; 95% CI, 0.68‐0.99; P = .03). In patients who had a stroke or MI, statin users had significantly lower failure to rescue (lower mortality) compared with nonstatin users (11.4% vs 30.8%; P < .001). Conclusions: Statin use is associated with significant reduction in mortality and failure to rescue in patients who develop major complications (stroke/MI) after CAS. Therefore, statin use should be strongly encouraged in all patients undergoing CAS.

Anesthetic type and hospital outcomes after carotid endarterectomy from the Vascular Quality Initiative database

Objective: Studies on the safety of carotid endarterectomy (CEA) under different anesthetic techniques are sometimes contradictory. The aim of this study was to compare real‐world outcomes of CEA under general anesthesia (GA) vs regional or local anesthesia (RA/LA). Methods: A retrospective analysis of the Vascular Quality Initiative database (2003‐2017) was performed. Primary outcomes included perioperative stroke, death, and myocardial infarction (MI) occurring during the hospital stay. Univariate and multivariate analyses were used. To minimize selection bias and to evaluate comparable groups, patients were matched on baseline variables using coarsened exact matching. Results: Of 75,319 CEA cases, 6684 (8.9%) were performed under RA/LA. These patients were more likely to be older (median age, 72 vs 71 years) and male (62.5% vs 60.2%), with higher American Society of Anesthesiologists class (class 3‐5, 94.2% vs 93.0%) than those undergoing CEA‐GA (all P < .001). CEA‐GA had higher crude rates of in‐hospital cardiac outcomes including MI mainly diagnosed clinically or on electrocardiography (0.5% vs 0.2%; P = .01), dysrhythmia (1.6% vs 1.2%; P < .001), acute congestive heart failure (CHF; 0.5% vs 0.2%; P < .001), and hemodynamic instability (27.0% vs 20.0%; P < .001) compared with CEA‐RA/LA. No difference in perioperative stroke or death was seen between the two groups. On multivariate analysis, CEA‐GA was associated with twice the odds of in‐hospital MI (adjusted odds ratio [aOR], 1.95; 95% confidence interval [CI], 1.06‐3.59; P = .03), 4 times the odds of acute CHF (aOR, 3.92; 95% CI, 1.84‐8.34; P < .001), and 1.5 times the odds of hemodynamic instability (aOR, 1.54; 95% CI, 1.44‐1.66; P < .001). Patients undergoing CEA‐GA had 1.8 times the odds of staying in the hospital for >1 day (aOR, 1.80; 95% CI, 1.67‐1.93; P < .001). Coarsened exact matching confirmed our results. Risk factors associated with increased cardiac complications (MI and CHF) under GA included female gender, increased age, Medicaid insurance, history of smoking, medical comorbidities (such as hypertension, diabetes, coronary artery disease, and CHF), prior ipsilateral carotid intervention, and urgent/emergent procedures. Conclusions: Patients undergoing CEA under GA have higher odds of postoperative MI, acute CHF, and hemodynamic instability compared with those undergoing CEA under RA/LA. They are also more likely to stay in the hospital for >1 day. However, the overall risk of cardiac adverse events after CEA was low, which made the differences clinically irrelevant. The choice of anesthesia approach to CEA should be driven by the teams experience and the patients risk factors and preference.

Management of tibioperoneal trunk aneurysm in a patient with Behçet disease

Only a few cases of infrapopliteal aneurysms are reported in the literature. These are commonly associated with trauma, infection, and iatrogenic injuries and mostly present as pseudoaneurysms. We report the case of a 44-year-old man with Behçet disease and an 8-cm tibioperoneal trunk aneurysm and discuss the management options of these aneurysms.

IP249. Anemia as an Independent Predictor of Adverse Outcomes After Carotid Revascularization

at 7% (n 1⁄4 17). Overall, there has been a significant trend toward increased vascular operative consultations during the study period (Fig). Conclusions: Vascular surgeons are essential team members at a level I trauma center. Vascular consultation in this setting is often unplanned and requires immediate intervention. When consulted, the vascular surgery service is effective in quickly gaining control of the situation to provide exposure, hemorrhage control, and revascularization if warranted. The frequency of vascular consultation is increasing, and it is paramount that hospitals provide adequate staffing to meet rising demand. Declining experience of trauma surgeons with vascular trauma may have an influence on this increase in demand.

PC006. Fenestrated and Chimney Endovascular versus Open Repair of Juxtarenal, Pararenal and Suprarenal Abdominal Aortic Aneurysms: A 5-Year National Study (2012-2016)

Objectives: A significant and sustained paradigm shift in abdominal aortic aneurysm treatment toward endovascular technology has come at a cost of open surgical procedures despite similar long-term survival. We sought to determine morbidity and mortality rate in patients undergoing open surgical repair (OSR) for abdominal aortic aneurysms at a single high-volume open regional center. Methods: All patients who underwent OSR for asymptomatic and nonruptured symptomatic abdominal aortic aneurysms were identified retrospectively from May 1, 2007, to March 31, 2017, using International Classification of Diseases, 10th edition, diagnosis codes at a single center in Gatineau, Quebec, Canada. The primary outcome was a descriptive analysis of all-cause mortality. Secondary outcomes of interest were predictors of adverse perioperative events after OSR using multivariable linear and logistic regression. Results: The cohort consisted of 316 consecutive patients with a mean age of 70.18 6 7.61 years, with 75% (n 1⁄4 237) being male. The perioperative risk of cardiovascular adverse events using the revised cardiac risk index was relatively low with a mean of 1.63 6 0.69 points. The median operative time was 95 minutes. The incidence of death at 30 days was 0.003% (n 1⁄4 1), death at 12 months was 0.02% (n 1⁄4 6), and all-cause death was 23.7% (n 1⁄4 75) over a median follow-up of 4.9 years (Fig). For the entire OSR cohort, the 1and 5-year calculated probability of survival was 97.7% and 82.0%, respectively. Operative time of 95 minutes or less was associated with decreased need for transfusions in the perioperative period (odds ratio, 0.29; 95% confidence interval, 0.17-0.48), decreased postoperative complications (odds ratio, 0.30; 95% confidence interval, 0.19-0.48), and decreased duration of stay (ß -2.7; 95% CI, -4.64 to -0.84) when adjusted for clinically relevant covariates. Conclusions: OSR of AAAs remains a safe and effective treatment option for patients who are appropriate candidates with a probability of survival at 5 years of 82%. OSR of AAAs can be done in less than 95 minutes and is associated with a reduction in transfusion requirements, reduction in postoperative complications, and reduced duration of stay.

IP045. Racial Disparities in Endovascular Repair of Thoracic Aortic Aneurysm and Dissection

Objective: Malignant aortic tumors are exceedingly rare. For that reason, no case series have been published so far in the literature, and a comprehensive review of clinical and therapeutic aspects is lacking. The aim of this study was to analyze all known cases of malignant aortic tumors and to identify predictors of patients’ survival. Methods: All patients with a diagnosis of aortic tumor treated in a single center together with all case reports and reviews available in the literature (through a specific PubMed search with keywords such as malignant and aorta or aortic tumor or sarcoma or angiosarcoma) were analyzed. Tumor primary location, clinical presentation, histologic features, and treatment choice were all examined. Survival at 1 year, 2 years, and 5 years and the possible preoperative and operative predictors of outcome were evaluated by Kaplan-Meier analysis with log-rank test. Results: In addition to the 5 cases treated in our center, 218 other cases of malignant aortic tumor have been reported in the literature from 1873 to 2017. Overall, the mean age of the patients was 60.1 6 11.9 years, and the male to female ratio was 1.59:1. The mean overall survival from diagnosis was 13.6 6 7.7 months; 1-, 3-, and 5-year survival rates were 35.2% 6 3.7%, 10.9% 6 2.6%, and 6.1% 6 2.2%, respectively (Fig). Chronic hypertension (P 1⁄4 .03), fever (P 1⁄4 .03), back pain (P 1⁄4 .01), asthenia (P 1⁄4 .04), and signs of peripheral embolization (P 1⁄4 .007) were significant predictors of patients’ poor outcome. Histologic subtypes had different impacts on

A prospective randomized study of bovine carotid artery biologic graft and expanded polytetrafluoroethylene for permanent hemodialysis access

Objective: Arteriovenous grafts (AVGs) remain reliable substitutes for permanent hemodialysis access in scenarios that preclude the placement of native arteriovenous fistulas (AVFs). The majority of AVGs are constructed of expanded polytetrafluoroethylene (ePTFE), which is relatively inexpensive and readily available, but synthetic AVGs have poor patency rates. On the other hand, biologic grafts confer an advantage by virtue of their inherent similarity to the native human vasculature. However, evidence to support the current preference of synthetic conduits over biologic grafts in clinical practice is scarce. The aim of this protocol is to propose a contemporary re‐evaluation and comparison between ePTFE and bovine carotid artery (BCA) grafts. Methods: This prospective randomized controlled trial is being conducted at an academic hospital center. A total of 100 patients at least 18 years of age and undergoing AVG placement will be recruited and prospectively randomized into two parallel groups with a 1:1 allocation ratio. Patients eligible to receive AVF and those with a known allergic reaction or history of intolerance to any ePTFE or BCA component will not be included in the study. Moreover, patients with a recent active infection at the site of previous AVG placement and patients with a bleeding disorder, an active malignant disease, or a life expectancy <1 year or who refuse blood transfusion and pregnant women will be excluded. Patients will receive either BCA (experimental) or standard ePTFE grafts (control) in compliance with the National Kidney Foundation Kidney Disease Outcomes Quality Initiative guidelines for AVG creation. Primary end points include primary, primary assisted, secondary, and functional patency at 1 year and 2 years after graft placement. Secondary outcomes include complications (pseudoaneurysms, infections, and steal syndrome) and reintervention rates during the first and second postoperative years. Outcomes will be assessed and documented every 6 months. Results: Once the study is completed, analysis of the data will be performed using univariate methods, and Kaplan‐Meier and multivariate Cox proportional regression analyses will be employed to evaluate and to compare outcomes between BCA and ePTFE over time. Conclusions: The creation of a functional and durable dialysis vascular access is crucial in the treatment of patients with end‐stage renal disease and is a challenging quest for vascular surgeons. The proposed study compares the outcomes of synthetic and biologic AVG options in patients who are poor candidates for a native AVF. This will help derive contemporary evidence and improve the care of vascular access patients.

PC192. The Interplay of Age, Intravenous, and Oral Beta-Blocker Use in Patients With Type B Thoracic Aortic Dissection

Fig 2. Estimated adjusted probability of death stratified by repair type and oral 88 types. Adjusted for age, gender, history of HTN, CCI, dissection level (thoracoabdominal vs thoracic), nonelective versus elective repair, teaching versus nonteaching institution, and aspirin and statin intake. Besma Nejim, Caitlin W. Hicks, Hanaa Dakour Aridi, Satinderjit Locham, Brian Nolan, Mahmoud B. Malas. Johns Hopkins University School of Medicine, Baltimore, Md; Johns Hopkins Hospital, Baltimore, Md; Maine Medical Center, Portland, Me

PC072. The Impact of Stent Geometry on Outcomes of Carotid Artery Stenting

Conclusions: Patients undergoing CAS are at higher risk for postoperative embolization. The risk for postoperative embolization is related to the length of the lesion and calcification. Identifying the preoperative risk factors may help to guide patient selection and, thereby, reduce embolization-related neurocognitive impairment. Understanding these risky lesions may also help to guide the selection of technique when selecting CAS or CEA for a patient and decrease morbidity. Patients undergoing stenting for atherosclerotic disease, therefore, may be at greater risk for embolization and neurocognitive impairment than those undergoing CAS for radiation-induced stenosis or other indications.