Klaas H.J. Ultee

Percutaneous versus femoral cutdown access for endovascular aneurysm repair

OBJECTIVE Prior studies suggest that percutaneous access for endovascular abdominal aortic aneurysm repair (pEVAR) offers significant operative and postoperative benefits compared with femoral cutdown (cEVAR). National data on this topic, however, are limited. We compared patient selection and outcomes for elective pEVAR and cEVAR. METHODS We identified all patients undergoing either pEVAR (bilateral percutaneous access, whether successful or not) or cEVAR (at least one planned groin cutdown) for abdominal aortic aneurysms from January 2011 to December 2013 in the Targeted Vascular data set from the American College of Surgeons National Surgical Quality Improvement Program database. Emergent cases, ruptures, cases with an iliac conduit, and cases with a preoperative wound infection were excluded. Groups were compared by χ(2) test or t-test or the Mann-Whitney test where appropriate. RESULTS We identified 4112 patients undergoing elective EVAR, 3004 cEVAR patients (73%) and 1108 pEVAR patients (27%). Of all EVAR patients, 26% had bilateral percutaneous access; 1.0% had attempted percutaneous access converted to cutdown (4% of pEVARs); and the remainder had a planned cutdown, 63.9% bilateral and 9.1% unilateral. There were no significant differences in age, gender, aneurysm diameter, or prior open abdominal surgery. Patients undergoing cEVAR were less likely to have congestive heart failure (1.5% vs 2.4%; P = .04) but more likely to undergo any concomitant procedure during surgery (32% vs 26%; P < .01) than patients undergoing pEVAR. Postoperatively, pEVAR patients had shorter operative time (mean, 135 vs 152 minutes; P < .01), shorter length of stay (median, 1 day vs 2 days; P < .01), and fewer wound complications (2.1% vs 1.0%; P = .02). On multivariable analysis, the only predictor of percutaneous access failure was performance of any concomitant procedure (odds ratio, 2.0; 95% confidence interval, 1.0-4.0; P = .04). CONCLUSIONS Currently, one in four patients treated at Targeted Vascular National Surgical Quality Improvement Program centers are getting pEVAR, which is associated with a high success rate, shorter operation time, shorter length of stay, and fewer wound complications compared with cEVAR.

Combined Epidural-General Anesthesia vs General Anesthesia Alone for Elective Abdominal Aortic Aneurysm Repair

Importance Epidural analgesia (EA) is used as an adjunct procedure for postoperative pain control during elective abdominal aortic aneurysm (AAA) surgery. In addition to analgesia, modulatory effects of EA on spinal sympathetic outflow result in improved organ perfusion with reduced complications. Reductions in postoperative complications lead to shorter convalescence and possibly improved 30-day survival. However, the effect of EA on long-term survival when used as an adjunct to general anesthesia (GA) during elective AAA surgery is unknown. Objective To evaluate the association between combined EA-GA vs GA alone and long-term survival and postoperative complications in patients undergoing elective, open AAA repair. Design, Setting, and Participants A retrospective analysis of prospectively collected data was performed. Patients undergoing elective AAA repair between January 1, 2003, and December 31, 2011, were identified within the Vascular Society Group of New England (VSGNE) database. Kaplan-Meier curves were used to estimate survival. Cox proportional hazards regression models and multivariable logistic regression models assessed the independent association of EA-GA use with postoperative mortality and morbidity, respectively. Data analysis was conducted from March 15, 2015, to September 2, 2015. Interventions Combined EA-GA. Main Outcomes and Measures The primary outcome measure was all-cause mortality. Secondary end points included postoperative bowel ischemia, respiratory complications, myocardial infarction, dialysis requirement, wound complications, and need for surgical reintervention within 30 days of surgery. Results A total of 1540 patients underwent elective AAA repair during the study period. Of these, 410 patients (26.6%) were women and the median (interquartile range) age was 71 (64-76) years; 980 individuals (63.6%) received EA-GA. Patients in the 2 groups were comparable in terms of age, comorbidities, and suprarenal clamp location. At 5 years, the Kaplan-Meier-estimated overall survival rates were 74% (95% CI, 72%-76%) and 65% (95% CI, 62%-68%) in the EA-GA and GA-alone groups, respectively (P < .01). In adjusted analyses, EA-GA use was associated with significantly lower hazards of mortality compared with GA alone (hazard ratio, 0.73; 95% CI, 0.57-0.92; P = .01). Patients receiving EA-GA also had lower odds of 30-day surgical reintervention (odds ratio [OR], 0.65; 95% CI, 0.44-0.94; P = .02) as well as postoperative bowel ischemia (OR, 0.54; 95% CI, 0.31-0.94; P = .03), pulmonary complications (OR, 0.62; 95% CI, 0.41-0.95; P = .03), and dialysis requirements (OR, 0.44; 95% CI, 0.23-0.88; P = .02). No significant differences were noted for the odds of wound (OR, 0.88; 95% CI, 0.38-1.44; P = .51) and cardiac (OR, 1.08; 95% CI, 0.59-1.78; P = .82) complications. Conclusions and Relevance Combined EA-GA was associated with improved survival and significantly lower HRs and ORs for mortality and morbidity in patients undergoing elective AAA repair. The survival benefit may be attributable to reduced immediate postoperative adverse events. Based on these findings, EA-GA should be strongly considered in suitable patients.

Life expectancy and causes of death after repair of intact and ruptured abdominal aortic aneurysms

BACKGROUND Life expectancy and causes of death after abdominal aortic aneurysm (AAA) repair are not well characterized. Population aging and improved secondary prevention may have modified the prognosis of these patients. We designed a retrospective cohort study to determine the vital prognosis, causes of death, and differences in outcome after intact and ruptured AAA. METHODS All patients with AAA treated from 2003 to 2011 at a single university institution in The Netherlands were analyzed. Survival status was derived from civil registry data. Causes of death were obtained from death certificates. The primary end point was overall mortality. Secondary end points were cardiovascular, cancer-related, and AAA-related mortality. Predictors for perioperative and late survival were obtained by logistic regression and Cox regression models, respectively. RESULTS The study included 619 consecutive AAA patients (12% women; mean age, 72 years), of whom 152 (24.5%) had ruptured AAAs. Endovascular repair was performed in 390 (63%). Rupture (odds ratio [OR], 10.63; 95% confidence interval [CI], 4.80-23.5), open repair (OR, 3.59; 95% CI, 1.69-7.62), renal insufficiency (OR, 2.94; 95% CI, 1.51-3.46), and age (OR, 1.08 per year; 95% CI, 1.09-1.15) were predictors of 30-day mortality. Five-year survival expectancy was 65% for intact AAA and 41% for ruptured AAA (P < .001). Cardiovascular deaths unrelated to the AAA occurred in 35% and cancer-related deaths in 29% of deceased patients. Predictors for late mortality were history of prior malignant disease (hazard ratio, 2.83; 95% CI, 1.99-4.03) and age (hazard ratio, 1.08 per year; 95% CI, 1.05-1.10). After 30 days, only six deaths (1.1%) were AAA related. CONCLUSIONS Endovascular repair reduced perioperative mortality by threefold, but no survival benefit was observed at long term. After the perioperative period, survival of ruptured AAA and intact AAA patients was not different. Deaths were distributed in similar proportions between cardiovascular and cancer-related causes.

Risk factors for 30-day unplanned readmission following infrainguinal endovascular interventions

Objective: Unplanned hospital readmissions following surgical interventions are associated with adverse events and contribute to increasing health care costs. Despite numerous studies defining risk factors following lower extremity bypass surgery, evidence regarding readmission after endovascular interventions is limited. This study aimed to identify predictors of 30‐day unplanned readmission following infrainguinal endovascular interventions. Methods: We identified all patients undergoing an infrainguinal endovascular intervention in the targeted vascular module of the American College of Surgeons National Surgical Quality Improvement Program between 2012 and 2014. Perioperative outcomes were stratified by symptom status (chronic limb‐threatening ischemia [CLI] vs claudication). Patients who died during index admission and those who remained in the hospital after 30 days were excluded. Indications for unplanned readmission related to the index procedure were evaluated. Multivariable logistic regression was used to identify preoperative and in‐hospital (during index admission) risk factors of 30‐day unplanned readmission. Results: There were 4449 patients who underwent infrainguinal endovascular intervention, of whom 2802 (63%) had CLI (66% tissue loss) and 1647 (37%) had claudication. The unplanned readmission rates for CLI and claudication patients were 16% (n = 447) and 6.5% (n = 107), respectively. Mortality after index admission was higher for readmitted patients compared with those not readmitted (CLI, 3.4% vs 0.7% [P < .001]; claudication, 2.8% vs 0.1% [P < .01]). Approximately 50% of all unplanned readmissions were related to the index procedure. Among CLI patients, the most common indication for readmission related to the index procedure was wound or infection related (42%), whereas patients with claudication were mainly readmitted for recurrent symptoms of peripheral vascular disease (28%). In patients with CLI, predictors of unplanned readmission included diabetes (odds ratio, 1.3; 95% confidence interval, 1.01‐1.6), congestive heart failure (1.6; 1.1‐2.5), renal insufficiency (1.7; 1.3‐2.2), preoperative dialysis (1.4; 1.02‐1.9), tibial angioplasty/stenting (1.3; 1.04‐1.6), in‐hospital bleeding (1.9; 1.04‐3.5), in‐hospital unplanned return to the operating room (1.9; 1.1‐3.5), and discharge other than to home (1.5; 1.1‐2.0). Risk factors for those with claudication were dependent functional status (3.5; 1.4‐8.7), smoking (1.6; 1.02‐2.5), diabetes (1.5; 1.01‐2.3), preoperative dialysis (3.6; 1.6‐8.3), procedure time exceeding 120 minutes (1.8; 1.1‐2.7), in‐hospital bleeding (2.9; 1.2‐7.4), and in‐hospital unplanned return to the operating room (3.4; 1.2‐9.4). Conclusions: Unplanned readmission after endovascular treatment is relatively common, especially in patients with CLI, and is associated with substantially increased mortality. Awareness of these risk factors will help providers identify patients at high risk who may benefit from early surveillance, and prophylactic measures focused on decreasing postoperative complications may reduce the rate of readmission.

Perioperative outcome of endovascular repair for complex abdominal aortic aneurysms

Background: As endovascular aneurysm repair (EVAR) continues to advance, eligibility of patients with anatomically complex abdominal aortic aneurysms (AAAs) for EVAR is increasing. However, whether complex EVAR is associated with favorable outcome over conventional open repair and how outcomes compare with infrarenal EVAR remains unclear. This study examined perioperative outcomes of patients undergoing complex EVAR, focusing on differences with complex open repair and standard infrarenal EVAR. Methods: We identified all patients undergoing nonruptured complex EVAR, complex open repair, and infrarenal EVAR in the American College of Surgeons National Surgical Quality Improvement Program Targeted Vascular Module. Aneurysms were considered complex if the proximal extent was juxtarenal or suprarenal or when the Zenith Fenestrated endograft (Cook Medical, Bloomington, Ind) was used. Independent risks were established using multivariable logistic regression analysis. Results: Included were 4584 patients, with 411 (9.0%) undergoing complex EVAR, 395 (8.6%) undergoing complex open repair, and 3778 (82.4%) undergoing infrarenal EVAR. Perioperative mortality was 3.4% after complex EVAR, 6.6% after open repair (P = .038), and 1.5% after infrarenal EVAR (P = .005). Postoperative acute kidney injuries occurred in 2.3% of complex EVAR patients, in 9.5% of those undergoing complex open repair (P < .001), and in 0.9% of infrarenal EVAR patients (P = .007). Compared with complex EVAR, complex open repair was an independent predictor of 30‐day mortality (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.1‐4.4), renal function deterioration (OR, 4.8; 95% CI, 2.2‐10.5), and any complication (OR, 3.7; 95% CI, 2.5‐5.5). When complex vs infrarenal EVAR were compared, infrarenal EVAR was associated with favorable 30‐day mortality (OR, 0.5; 95% CI, 0.2‐0.9), and renal outcome (OR, 0.4; 95% CI, 0.2‐0.9). Conclusions: In this study assessing the perioperative outcomes of patients undergoing repair for anatomically complex AAAs, complex EVAR had fewer complications than complex open repair but carried a higher risk of adverse outcomes than infrarenal EVAR. Further research is warranted to determine whether the benefits of EVAR compared with open repair for complex AAA treatment are maintained during long‐term follow‐up.

Predictors of renal dysfunction after endovascular and open repair of abdominal aortic aneurysms

Objective: Renal complications after repair of abdominal aortic aneurysms (AAAs) have been associated with increased morbidity and mortality. However, limited data have assessed risk factors for renal complications in the endovascular era. This study aimed to identify predictors of renal complications after endovascular AAA repair (EVAR) and open repair. Methods: Patients who underwent EVAR or open repair of a nonruptured infrarenal AAA between 2011 and 2013 were identified in the National Surgical Quality Improvement Project Targeted Vascular module. Patients on hemodialysis preoperatively were excluded. Renal complications were defined as new postoperative dialysis or creatinine increase >2 mg/dL. Patient demographics, comorbidities, glomerular filtration rate (GFR), operative details, and outcomes were compared using univariate analysis between those with and without renal complications. Multivariable logistic regression was used to identify independent predictors of renal complications. Results: We identified 4503 patients who underwent elective repair of an infrarenal AAA (EVAR: 3869, open repair: 634). Renal complication occurred in 1% of patients after EVAR and in 5% of patients after open repair. There were no differences in comorbidities between patients with and without renal complications. A preoperative GFR <60 mL/min/1.73m2 occurred more frequently among patients with renal complications (EVAR: 81% vs 37%, P < .01; open: 60% vs 34%, P < .01). The 30‐day mortality was also significantly increased (EVAR: 55% vs 1%, P < .01; open: 30% vs 4%, P < .01). After adjustment, renal complications were strongly associated with 30‐day mortality (odds ratio [OR], 38.3; 95% confidence interval [CI], 20.4–71.9). Independent predictors of renal complications included GFR <60 mL/min/1.73m2 (OR, 4.6; 95% CI, 2.4–8.7), open repair (OR, 2.6; 95% CI, 1.3–5.3), transfusion (OR, 6.1; 95% CI, 3.0–12.6), and prolonged operative time (OR, 3.0; 95% CI, 1.6–5.6). Conclusions: Predictors of renal complications include elevated baseline GFR, open approach, transfusion, and prolonged operative time. Given the dramatic increase in mortality associated with renal complications, care should be taken to use renal protective strategies, achieve meticulous hemostasis to limit transfusions, and to use an endovascular approach when technically feasible.

Clinical presentation, management, follow-up, and outcomes of isolated celiac and superior mesenteric artery dissections

Objective: Isolated visceral artery dissections are rare entities with no current consensus guidelines for treatment and follow‐up. This study aims to evaluate the presentation, management, outcomes, and follow‐up practices for patients with isolated visceral artery dissections and to compare those with and without symptoms. Methods: In this retrospective analysis, we identified all patients with isolated celiac artery and/or isolated superior mesenteric artery dissections at a single institution between September 2006 and December 2014. Patients with concomitant aortic dissections were excluded. Cases were stratified by symptom status. Presentation, anatomic findings, treatment, outcomes, and follow‐up imaging were then compared between symptomatic and asymptomatic patients. Results: We identified 25 patients including 15 with symptoms and 10 without. There were no differences in patient comorbidities; however, symptomatic patients more frequently presented with thrombus (n = 10; 67% vs n = 1; 10%; P = .01) and inflammation (n = 8; 53% vs n = 1; 10%; P = .04), and trended toward increased stenosis (n = 12; 80% vs n = 4; 40%; P = .09) compared with asymptomatic patients. All asymptomatic patients were treated with observation alone with vessel diameter enlargement noted in 33% (n = 2) of patients on follow‐up imaging. Among symptomatic patients, standard treatment included a short course of anticoagulation (mean, 4.5 months) with lifelong antiplatelet therapy. Three patients underwent operative intervention for persistent or worsening symptoms, two during the index admission and one 10 months after presentation for chronic abdominal pain. Approximately 70% (n = 17) of patients in each group had follow‐up imaging (computed tomography angiography: n = 14; 56%; magnetic resonance angiography: n = 4; 16%; ultrasound: n = 13; 52%). Among patients treated nonoperatively, no patients complained of symptoms at follow‐up, and 50% of those with inflammation on initial imaging had resolution. Twenty‐five percent (n = 4) of patients had an increase in vessel size; however, all vessels remained less than 2 cm in maximal diameter. There were no ruptures or related deaths in either group. Conclusions: Among patients with visceral artery dissection, no ruptures occurred but diameter enlargement was documented. This disease progression suggests that routine surveillance may be appropriate; however, transitioning early to ultrasound imaging should be considered to decrease radiation, contrast, and associated costs.

Early extubation reduces respiratory complications and hospital length of stay following repair of abdominal aortic aneurysms

Background: Early extubation after cardiac surgery is associated with decreased hospital stay and resource savings with similar mortality and has led to the widespread use of early extubation protocols. In the Vascular Quality Initiative, there is significant regional variation in the frequency of extubation in the operating room (endovascular aneurysm repair [EVAR], 77%‐97%; open repair, 30%‐70%) after repair of intact abdominal aortic aneurysms (AAAs). However, the effects of extubation practices on patient outcomes after repair of AAAs are unclear. Methods: All patients undergoing repair of an intact AAA in the Vascular Study Group of New England from 2003 to 2015 were evaluated. Patients undergoing concomitant procedures or conversions were excluded. Timing of extubation was stratified for EVAR (operating room, <12 hours, >12 hours) and open repair (operating room, <12 hours, 12‐24 hours, >24 hours). Prolonged hospital stay was defined as >2 days after EVAR and >7 days after open repair. Univariate and multivariable analyses were completed, and independent predictors of extubation outside of the operating room were identified. Results: There were 5774 patients evaluated (EVAR, 4453; open repair, 1321). After both EVAR and open repair, respiratory complications, prolonged hospital stay, and discharge to a skilled nursing facility (SNF) increased with intubation time. After adjustment, the odds of complications increased with each 12‐hour delay in extubation: respiratory (EVAR: odds ratio [OR], 4.3 [95% confidence interval (CI), 3.0‐6.1]; open repair: OR, 1.8 [95% CI, 1.5‐2.2]), prolonged hospital stay (EVAR: OR, 2.7 [95% CI, 2.0‐3.8]; open repair: OR, 1.3 [95% CI, 1.1‐1.4]), and discharge to SNF (EVAR: OR, 2.0 [95% CI, 1.5‐2.8]; open repair: OR, 1.4 [95% CI, 1.1‐1.6]). Predictors of extubation outside of the operating room after EVAR included increasing age (OR, 1.5; 95% CI, 1.2‐1.8), congestive heart failure (OR, 1.9; 95% CI, 1.2‐3.0), chronic obstructive pulmonary disease (OR, 2.0; 95% CI, 1.4‐2.9), symptomatic aneurysm (OR, 3.8; 95% CI, 2.3‐5.7), and increasing diameter (OR, 1.01; 95% CI, 1.01‐1.01). After open repair, increasing age (OR, 1.4; 95% CI, 1.1‐1.6), congestive heart failure (OR, 1.8; 95% CI, 1.01‐3.3), dialysis (OR, 2.8; 95% CI, 1.7‐70), symptomatic aneurysm (OR, 2.8; 95% CI, 1.9‐4.3), and hospital practice patterns (OR, 1.01; 95% CI, 1.01‐1.01) were predictive of extubation outside of the operating room. Conclusions: The benefits of early extubation in cardiac patients are also seen after AAA repair. Suitable patients should be extubated in the operating room to decrease respiratory complications, length of stay, and discharge to an SNF. Early extubation protocols should be considered to reduce regional variation in extubation practices and to improve patient outcomes.

Patient selection and perioperative outcomes are similar between targeted and nontargeted hospitals (in the National Surgical Quality Improvement Program) for abdominal aortic aneurysm repair

Objective: The targeted vascular module in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) consists of self‐selected hospitals that choose to collect extra clinical details for better risk adjustment and improved procedure‐specific outcomes. The purpose of this study was to compare patient selection and outcomes between targeted and nontargeted hospitals in the NSQIP regarding the operative management of abdominal aortic aneurysm (AAA). Methods: We identified all patients who underwent endovascular aneurysm repair (EVAR) or open AAA repair from 2011 to 2013 and compared cases by whether the operation took place in a targeted or nontargeted hospital. EVAR and open repair as well as intact and ruptured aneurysms were evaluated separately. Only variables contained in both modules were used to evaluate rupture status and operation type. All thoracoabdominal aneurysms were excluded. Univariate analysis was performed for intact and ruptured EVAR and open repair grouped by complexity, defined as visceral involvement in open repair and a compilation of concomitant procedures for EVAR. Multivariable models were developed to identify effect of hospital type on mortality. Results: There were 17,651 AAA repairs identified. After exclusion of aneurysms involving the thoracic aorta (n = 352), there were 1600 open AAA repairs at targeted hospitals (21% ruptured) and 2725 at nontargeted hospitals (19% ruptured) and 4986 EVARs performed at targeted hospitals (6.7% ruptured) and 7988 at nontargeted hospitals (5.2% ruptured). There was no significant difference in 30‐day mortality rates between targeted and nontargeted hospitals for intact aneurysms (EVAR noncomplex, 1.8% vs 1.4% [P = .07]; open repair noncomplex, 4.2% vs 4.5% [P = .7]; EVAR complex, 5.0% vs 3.2% [P = .3]; open repair complex, 8.0% vs 6.0% [P = .2]). For ruptured aneurysms, again there was no difference in mortality between the targeted and nontargeted hospitals (EVAR noncomplex, 23% vs 25% [P = .4]; open repair noncomplex, 38% vs 34% [P = .2]; EVAR complex, 29% vs 33% [P = 1.0]; open repair complex, 27% vs 41% [P = .09]). Multivariable analysis further demonstrated that having an operation at a targeted vs nontargeted hospital had no impact on mortality for both intact and ruptured aneurysms (odds ratio, 1.1 [0.9‐1.4] and 1.0 [0.8‐1.3], respectively). Conclusions: This analysis highlights the similarities between targeted and nontargeted hospitals within the NSQIP for AAA operative management and suggests that data from the targeted NSQIP, in terms of AAA management, are generalizable to all NSQIP hospitals.

The impact of endovascular repair on specialties performing abdominal aortic aneurysm repair

BACKGROUND Abdominal aortic aneurysm (AAA) repair has been performed by various surgical specialties for many years. Endovascular aneurysm repair (EVAR) may be a disruptive technology, having an impact on which specialties care for patients with AAA. Therefore, we examined the proportion of AAA repairs performed by various specialties over time in the United States and evaluated the impact of the introduction of EVAR. METHODS The Nationwide Inpatient Sample (2001-2009) was queried for intact and ruptured AAA and for open repair and EVAR. Specific procedures were used to identify vascular surgeons (VSs), cardiac surgeons (CSs), and general surgeons (GSs) as well as interventional cardiologists and interventional radiologists for states that reported unique treating physician identifiers. Annual procedure volumes were subsequently calculated for each specialty. RESULTS We identified 108,587 EVARs and 85,080 open AAA repairs (3011 EVARs and 12,811 open repairs for ruptured AAA). VSs performed an increasing proportion of AAA repairs during the study period (52% in 2001 to 66% in 2009; P < .001). GSs and CSs performed fewer repairs during the same period (25% to 17% [P < .001] and 19% to 13% [P < .001], respectively). EVAR was increasingly used for intact (33% to 78% of annual cases; P < .001) as well as ruptured AAA repair (5% to 28%; P < .001). The proportion of intact open repairs performed by VSs increased from 52% to 65% (P < .001), whereas for EVAR, the proportion went from 60% to 67% (P < .001). The proportion performed by VSs increased for ruptured open repairs from 37% to 53% (P < .001) and for ruptured EVARs from 28% to 73% (P < .001). Compared with treatment by VSs, treatment by a CS (0.55 [0.53-0.56]) and GS (0.66 [0.64-0.68]) was associated with a decreased likelihood of undergoing endovascular rather than open AAA repair. CONCLUSIONS VSs are performing an increasing majority of AAA repairs, in large part driven by the increased utilization of EVAR for both intact and ruptured AAA repair. However, GSs and CSs still perform AAA repair. Further studies should examine the implications of these national trends on the outcome of AAA repair.