John J. Ricotta

A systematic review and meta-analysis of randomized trials of carotid endarterectomy vs stenting.

OBJECTIVEnThe purpose of this systematic review and meta-analysis was to synthesize the available evidence derived from randomized controlled trials (RCTs) regarding the relative efficacy and safety of endarterectomy vs stenting in patients with carotid artery disease.nnnMETHODSnWe searched MEDLINE, EMBASE, Current Contents, and Cochrane CENTRAL through July 2010 to update previous systematic reviews. Two reviewers determined trial eligibility and extracted descriptive, methodologic, and outcome data (death, nonfatal stroke, and nonfatal myocardial infarction). Random-effects meta-analysis was used to pool relative risks and the I(2) statistic was used to assess heterogeneity.nnnRESULTSnThirteen RCTs proved eligible enrolling 7484 patients, of which 80% had symptomatic disease. Methodological quality was moderate to high, with better quality among RCTs published after 2008. Compared with carotid endarterectomy, stenting was associated with increased risk of any stroke (relative risk [RR], 1.45; 95% confidence interval [CI], 1.06-1.99; I(2) = 40%), decreased risk of periprocedural myocardial infarction (MI; RR, 0.43; 95% CI, 0.26- 0.71; I(2) = 0%), and nonsignificant increase in mortality (RR, 1.40; 95% CI, 0.85-2.33; I(2) = 5%). When analysis was restricted to the two most recent trials with the better methodology and more contemporary technique, we found stenting to be associated with a significant increase in the risk of any stroke (RR, 1.82; 95% CI, 1.35-2.45) and mortality (RR, 2.53; 95% CI, 1.27-5.08) and a nonsignificant reduction of the risk of MI (RR, 0.39; 95% CI, 0.12-1.23). For every 1000 patients opting for stenting rather than endarterectomy, 19 more patients would have strokes and 10 fewer would have MIs. Outcome data in asymptomatic patients were sparse and imprecise; hence, these conclusions apply primarily to symptomatic patients.nnnCONCLUSIONnCompared with endarterectomy, carotid artery stenting (CAS) significantly increases the risk of any stroke and decreases the risk of MI.

Trends in Treatment of Ruptured Abdominal Aortic Aneurysm: Impact of Endovascular Repair and Implications for Future Care

OBJECTIVEnOur aim was to determine national trends in treatment of ruptured abdominal aortic aneurysm (RAAA), with specific emphasis on open surgical repair (OSR) and endovascular aneurysm repair (EVAR) and its impact on mortality and complications.nnnMETHODSnData from the Nationwide Inpatient Sample (NIS) from 2005 to 2009 were queried to identify patients older than 59 years with RAAA. Three groups were studied: nonoperative (NO), EVAR, and OSR. Chi-square analysis was used to determine the relationship between treatment type and patient demographics, clinical characteristics, and hospital type. The impact of EVAR compared with OSR on mortality and overall complications was examined using logistic regression analysis.nnnRESULTSnWe identified 21,206 patients with RAAA from 2005 to 2009, of which 16,558 (78.1%) underwent operative repair and 21.8% received no operative treatment. In the operative group, 12,761 (77.1%) underwent OSR and 3,796 (22.9%) underwent EVAR. Endovascular aneurysm repair was more common in teaching hospitals (29.1% vs 15.2%, p < .0001) and in urban versus rural settings. Nonoperative approach was twice as common in rural versus urban hospitals. Reduced mortality was seen in patients transferred from another institutions (31.2% vs 39.4%, p = 0.014). Logistic regression analysis demonstrated a benefit of EVAR on both complication rate (OR = 0.492; CI, 0.380-0.636) and mortality (OR=0.535; CI, 0.395-0.724).nnnCONCLUSIONSnEndovascular aneurysm repair use is increasing for RAAA and is more common in urban teaching hospitals while NO therapy is more common in rural hospitals. Endovascular aneurysm repair is associated with reduced mortality and complications across all age groups. Efforts to reduce mortality from RAAA should concentrate on reducing NO and OSR in patients who are suitable for EVAR.

Comparison of surgical operative experience of trainees and practicing vascular surgeons: A report from the Vascular Surgery Board of the American Board of Surgery

INTRODUCTIONnThe Vascular Surgery Board (VSB) of the American Board of Surgery sought to answer the following questions: what is the scope of contemporary vascular surgery practice? Do current vascular surgery residents obtain training that is appropriate for their future career expectations and for successful Board certification? How effectively do practicing vascular surgeons incorporate emerging technologies and procedures into practice?nnnMETHODSnWe analyzed the operative logs submitted to the VSB by recent vascular surgery residents applying for the Vascular Surgery Qualifying Examination (QE; 2006-2009) or by practicing vascular surgeons applying for the Vascular Surgery Recertification Examination (RE; 1995-2009). The relationship between reported operative experience and performance of the QE and RE was examined.nnnRESULTSnThere has been a threefold increase in the mean number of primary cases reported by both RE and QE applicants over the past 15 years and the increase in case volume has been driven largely by an increase in the number of endovascular procedures. Endovascular procedures have been broadly incorporated into the practice of most vascular surgeons applying for recertification. The number of major open surgical cases reported by recent QE applicants has remained unchanged over the period of observation. For QE applicants, the number of endovascular aneurysm repairs (EVARs) has reached a plateau at approximately 50 cases, whereas the mean number of open infrarenal aneurysm repairs has decreased for both QE and RE applicants, reflecting national trends favoring EVAR. There was a significant association between case volume and performance on the QE but not on the RE.nnnCONCLUSIONnOver the past 15 years, there has been a significant increase in the total number of operative cases reported to the VSB by both QE and RE applicants. Contrary to popular belief, the volume of major open vascular surgery reported by recent vascular surgery residents has remained relatively stable since 1994. Over the same time period, endovascular procedures have been rapidly incorporated into clinical practice by the majority of vascular surgeons applying for recertification by the VSB. Current vascular surgery residents receive a rich operative experience in both open and endovascular procedures that is reflective of contemporary practice.

Endovascular management of acute aortic dissections

INTRODUCTIONnAcute aortic dissection (AAD) is one of the most common aortic emergencies that vascular specialists are asked to manage. Traditional surgical interventions for cases complicated by malperfusion have resulted in significant morbidity and mortality. With increasing availability of thoracic endografts, endovascular interventions for complicated AAD have become more acceptable. We reviewed our experience with endovascular treatment of AAD since January 2005.nnnMETHODSnMedical records of patients admitted for AAD from January 1, 2005, to December 31, 2008, were entered into our vascular registry and analyzed for risk factors, extent of dissection, type of management, fate of the false lumen, complications, and survival. There were 249 admissions for aortic dissections during the study period. Our study group included 28 patients with complicated AAD who underwent endovascular intervention.nnnRESULTSnDuring the study interval, 28 patients (16 male) underwent 44 procedures. The average age was 54 years. Risk factors differed from the typical atherosclerotic patient and were dominated by an 89.3% incidence of hypertension. Five patients (17.9%) presented with a history of recent cocaine use. The average length of stay was 25.1 days (range, 1-196 days). Stanford type B dissections were present in all but one patient. Twenty-six thoracic endografts were placed in 25 patients. Eight patients required multiple procedures in addition to a thoracic endograft. Morbidity occurred in 17 (60.7%) patients, with renal insufficiency occurring in 11 patients (39.3%) and one requiring permanent dialysis. Four neurologic events occurred: three strokes (10.7%) and one patient (3.6%) with temporary paraplegia. Three patients (10.7%) died in the periprocedural period, with ruptured dissection in one and pericardial tamponade in another. Eight of 10 computed tomography scans (80%) available for review in follow-up showed complete thrombosis of the thoracic false lumen.nnnCONCLUSIONSnComplicated AAD remains a challenging problem, with significant morbidity and mortality rates. However, our early experience with endovascular management offers a favorable reduction in mortality from historic controls.

The influence of contralateral occlusion on results of carotid interventions from the Society for Vascular Surgery Vascular Registry

OBJECTIVEnData on the influence of contralateral carotid occlusion (CCO) on carotid endarterectomy (CEA) are conflicting and are absent for carotid artery stenting (CAS). This study evaluated the influence of CCO on CEA and CAS.nnnMETHODSnWe evaluated patients with and without CCO in the Society for Vascular Surgery Vascular Registry. Primary outcome was a composite of periprocedural death, stroke, or myocardial infarction (MI) (major adverse cardiovascular events [MACE]) and its individual components. Further analysis was done to identify the influence, if any, of symptom status on outcomes.nnnRESULTSnThere were 1128 CAS and 666 CEA patients with CCO. CAS patients were more often symptomatic with a greater incidence of coronary artery disease, congestive heart failure, diabetes, chronic obstructive pulmonary disease, and New York Heart Association class >III. Absolute risk of periprocedural MACE (2.7% for CAS vs. 4.2% for CEA), death (1.1% for CAS vs. 0.7% for CEA), stroke (2.1% for CAS vs. 3.1% for CEA), and MI (0.3% for CAS vs. 0.6% for CEA) was statistically equivalent for both. This equivalence was maintained when patients with CCO were segregated according to symptom status and after adjusting for periprocedural risk. There were 16,646 patients without contralateral occlusion (5698 CAS; 10,948 CEA). Patients without contralateral occlusion with CEA have better outcomes in periprocedural MACE (1.8% for patients without contralateral occlusion vs 4.2% for patients with CCO), and stroke (1.1% for patients without contralateral occlusion vs. 3.1% for patients with CCO) (P < .0001 for both). In CAS patients, CCO did not significantly affect periprocedural MACE (3.2% for patients without contralateral occlusion vs. 2.7% for patients with CCO), death (0.8% for patients without contralateral occlusion vs. 1.0% for patients with CCO), stroke (2.3% for patients without contralateral occlusion vs. 2.1% for patients with CCO), or MI (0.6% for patients without contralateral occlusion vs. 0.3% for patients with CCO). In CEA patients, CCO increased MACE, primarily by increasing stroke rates in asymptomatic (0.7% vs. 2.0%; P = .0095) and symptomatic (1.7% vs. 4.9%; P = .0012) patients.nnnCONCLUSIONSnAlthough CEA is preferred in patients without contralateral occlusion, regardless of symptom status, based on lower rates of periprocedural MACE, death, and stroke, the benefit of CEA is lost in patients with CCO because of increased stroke rates in CCO patients after CEA but not after CAS regardless of symptom status. The results of CAS and CEA in patients with CCO are equivalent and within acceptable American Heart Association guidelines.

Elective endovascular aneurysm repair in the elderly: trends and outcomes from the Nationwide Inpatient Sample.

OBJECTIVESnThis study attempted to identify trends in the use of endovascular aneurysm repair (EVAR) and outcomes in elective abdominal aortic aneurysm (AAA) repair over a 5-year period in a nationwide dataset, with specific attention to patients older than 80 years.nnnMETHODSnThe Nationwide Inpatient Sample database was queried for elective AAA repair during 2005 to 2009. Number of EVAR cases, ratio of EVAR/open aneurysm repair (OAR), major clinical outcomes, and discharge status were analyzed by decade. Interval data were compared with analysis of variance (ANOVA) and proportions via chi-squared tests.nnnRESULTSnA total of 174,714 AAA repairs (124,869 EVARs) were identified. The ratio of EVAR/OAR increased with increasing age. Between 2005 and 2009, the total number of AAA repairs increased by 21% (7,179 vs. 8,554) and EVARs increased by 50% (5,057 vs. 7,650; P < 0.05) in patients older than 80 years. In 2009, 85% of AAA repairs in patients older than 80 years were EVARs. Patients older than 80 years constituted 25% of the total EVAR cohort. Although the in-hospital mortality rate remained acceptable in all age groups, EVAR-associated mortality, length of stay, and discharge to a skilled nursing facility increased with each successive decade of life (P < 0.05). Rates of postoperative myocardial infarction and acute renal failure also increased with increasing age (P < 0.05). EVAR results are presented by decade.nnnCONCLUSIONSnEVAR is being performed with increasing frequency in patients older than 80 years, with one-quarter of EVAR performed in patients aged 80 years and older in the current sample. Although mortality rates remain acceptable in this elderly population, EVAR and OAR are associated with an age-dependent increase in death, complications, and discharge to extended care facilities. These factors, in addition to long-term risk of aneurysm rupture, should be considered when evaluating the appropriateness of elective aneurysm repair in the elderly.

Graft-free surgical retroperitoneal vascular access as bail-out technique for failed percutaneous approach to transcatheter aortic valve replacement.

BACKGROUNDnSurgical retroperitoneal access to the iliac artery may provide an alternative route for transcatheter aortic valve replacement (TAVR) in patients with aortic stenosis and prohibitively small common femoral arteries.nnnMETHODSnConsecutive patients undergoing TAVR via the femoral approach were divided into two groups; standard percutaneous access (n=103) and surgical retroperitoneal access (n=15) for patients in whom dilators could not be advanced without resistance. For retroperitoneal access, proximal groin vessels were exposed surgically and direct puncture was performed. The sheath was tunneled from the level of the initial inguinal puncture site in order to achieve coaxial entry of the sheath into the vessel.nnnRESULTSnBaseline characteristics were similar in both groups. Procedural characteristics were insignificantly different between groups; although, procedure time was longer (34 min), while fluoroscopy time and contrast utilization were lower in the retroperitoneal access group. There was no outcome difference between groups.nnnCONCLUSIONSnSurgical retroperitoneal access is a reasonable alternative for transcatheter aortic valve replacement in high-risk patients with aortic stenosis who have poor percutaneous access options due to peripheral vascular disease.

Contemporary results of carotid endarterectomy in “normal-risk” patients from the Society for Vascular Surgery Vascular Registry

OBJECTIVEnAcceptable complication rates after carotid endarterectomy (CEA) are drawn from decades-old data. The recent Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) demonstrated improved stroke and mortality outcomes after CEA compared with carotid artery stenting, with 30-day periprocedural CEA stroke rates of 3.2% and 1.4% for symptomatic (SX) and asymptomatic (ASX) patients, respectively. It is unclear whether these target rates can be attained in normal-risk (NR) patients experienced outside of the trial. This study was done to determine the contemporary results of CEA from a broader selection of NR patients.nnnMETHODSnThe Society for Vascular Surgery (SVS) Vascular Registry was examined to determine in-hospital and 30-day event rates for NR, SX, and ASX patients undergoing CEA. NR was defined as patients without anatomic or physiologic risk factors as defined by SVS Carotid Practice Guidelines. Raw data and risk-adjusted rates of death, stroke, and myocardial infarction (MI) were compared between the ASX and SX cohorts.nnnRESULTSnThere were 3977 patients (1456 SX, 2521 ASX) available for comparison. The SX group consisted of more men (61.7% vs 57.0%; P = .0045) but reflected a lower proportion of white patients (91.3% vs 94.4%; P = .0002), with lower prevalence of coronary artery disease (P < .0001), prior MI (P < .0001), peripheral vascular disease (P = .0017), and hypertension (P = .029), although New York Heart Association grade >3 congestive heart failure was equally present in both groups (P = .30). Baseline stenosis >80% on duplex imaging was less prevalent among SX patients (54.2% vs 67.8%; P < .0001). Perioperative stroke rates were higher for SX patients in the hospital (2.8% vs 0.8%; P < .0001) and at 30 days (3.4% vs 1.0%; P < .0001), which contributed to the higher composite death, stroke, and MI rates in the hospital (3.6% vs 1.8; P = .0003) and at 30 days (4.5% vs 2.2%; P < .0001) observed in SX patients. After risk adjustment, the rate of stroke/death was greater among SX patients in the hospital (odds ratio, 2.05; 95% confidence interval, 1.18-3.58) although not at 30 days (odds ratio, 1.36; 95% confidence interval, 0.85-2.17). No in-hospital or 30-day differences were observed for death or MI by symptom status.nnnCONCLUSIONSnThe SVS Vascular Registry results for CEA in NR patients are similar by symptom status to those reported for CREST and may serve as a benchmark for comparing results of alternative therapies for treatment of carotid stenosis in NR patients outside of monitored clinical trials. The contemporary perioperative risk of stroke after CEA in NR patients continues to be higher for SX than for ASX patients.

Pylephlebitis and acute mesenteric ischemia in a young man with inherited thrombophilia and suspected foodborne illness

We report on a young man who developed complicated pylephlebitis after foodborne illness. Despite antibiotics and resection of the focus of infectious colitis, he developed extensive small bowel infarction. He was treated with anticoagulation, local thrombolytic infusion, and resection of irreversibly ischemic small bowel. Thrombophilia workup demonstrated heterozygosity for factor V Leiden and the prothrombin G20210A mutation. The complications of pylephlebitis can be minimized by using systemic anticoagulation, thrombectomy, and/or local thrombolytic infusion along with antibiotics and surgical management of the infection. Evaluation for thrombophilic states should be considered, particularly if a patient does not respond to initial therapy.

Patient based Abdominal Aortic Aneurysm rupture risk prediction combining clinical visualizing modalities with fluid structure interaction numerical simulations

Fluid structure interaction (FSI) simulations of patient-specific fusiform non-ruptured and contained ruptured Abdominal Aortic Aneurysm (AAA) geometries were conducted. The goals were: (1) to test the ability of our FSI methodology to predict the location of rupture, by correlating the high wall stress regions with the rupture location, (2) estimate the state of the pathological condition by calculating the ruptured potential index (RPI) of the AAA and (3) predict the disease progression by comparing healthy and pathological aortas.