Kristina A. Giles

Infrapopliteal angioplasty for critical limb ischemia: relation of TransAtlantic InterSociety Consensus class to outcome in 176 limbs

OBJECTIVE Recent data suggest that percutaneous transluminal angioplasty (PTA) may be appropriate primary therapy for critical limb ischemia (CLI). However, little data are available regarding infrapopliteal angioplasty outcomes based on TransAtlantic InterSociety Consensus (TASC) classification. We report our experience with infrapopliteal angioplasty stratified by TASC lesion classification. METHODS From February 2004 to March 2007, 176 consecutive limbs (163 patients) underwent infrapopliteal angioplasty for CLI. Stents were placed for lesions refractory to PTA or flow-limiting dissections. Patients were stratified by TASC classification and suitability for bypass grafting. Primary outcome was freedom from restenosis, reintervention, or amputation. Primary patency, freedom from secondary restenosis, limb salvage, reintervention by repeat angioplasty or bypass, and survival were determined. RESULTS Median age was 73 years (range, 39-94 years). Technical success was 93%. Average follow-up was 10 months (range, 1-41 months). At 1 and 2 years, freedom from restenosis, reintervention, or amputation was 39% and 35%, conventional primary patency was 53% and 51%, and freedom from secondary restenosis and reintervention were 63% and 61%, respectively. Limb salvage was 84% at 1, 2, and 3 years. Within 2 years, 15% underwent bypass and 18% underwent repeat infrapopliteal PTA. Postoperative complications occurred in 9% and intraprocedural complications in 10%. The 30-day mortality was 5% (9 of 181). Overall survival was 81%, 65%, and 54% at 1, 2, and 3 years. TASC D classification predicted diminished technical success (75% D vs 100% A, B, and C; P < .001), primary restenosis, reintervention, or amputation (hazard ratio [HR], 3.4; 95% confidence interval [CI], 2.1-5.5, P < .001), primary patency (HR, 2.2; 95% CI, 1.3-3.9, P < .004), secondary restenosis (HR, 3.2; 95% CI, 1.6-6.4, P = .001), and limb salvage (HR, 2.6; 95% CI, 1.1-6.3, P < .05). Unsuitability for surgical bypass also predicted restenosis, reintervention, or amputation, secondary restenosis, need for repeated angioplasty, and inferior primary patency and limb salvage rates. CONCLUSION Infrapopliteal angioplasty is a reasonable primary treatment for CLI patients with TASC A, B, or C lesions. Restenosis, reintervention, or amputation was higher in patients who were unsuitable candidates for bypass; however, an attempt at PTA may be indicated as an alternative to primary amputation. Although restenosis, reintervention, or amputation is high after tibial angioplasty for CLI, excellent limb salvage rates may be obtained with careful follow-up and reinterventions when necessary, including bypass in 15%.

Mesenteric revascularization: management and outcomes in the United States, 1988-2006.

BACKGROUND Recent reports have suggested that angioplasty, with and without stenting (PTA/S), may have a lower perioperative mortality rate than open surgery for revascularization of acute (AMI) and chronic mesenteric ischemia (CMI). It is unclear if there has been nationwide adoption of this methodology or whether there is actually a mortality benefit. METHODS We identified all patients undergoing surgical (bypass, endarterectomy, or embolectomy) or PTA/S mesenteric revascularization from the Nationwide Inpatient Sample from 1988 to 2006. A diagnosis by International Classification of Diseases, 9th Revisioncoding of AMI or CMI was required for inclusion. We evaluated trends in management during this period and compared in-hospital death and complications between surgical bypass and PTA/S for the years 2000 to 2006. RESULTS From 1988 to 2006, there were 6342 PTA/S and 16,071 open surgical repairs overall. PTA/S increased steadily, surpassing all surgery for CMI in 2002. PTA/S for AMI has also increased and surpassed bypass in 2002 but has not surpassed all surgical procedures for AMI even in 2006. The mortality rate was lower after PTA/S than after bypass for CMI (3.7% vs 13%, P < .01) and AMI (16% vs 28%, P < .01). Bowel resection was more common after bypass than PTA/S for CMI (7% vs 3%, P < .01). This subgroup showed an increased in-hospital mortality rate for both repair types (54% and 25%, respectively). CONCLUSION PTA/S is being used with increasing frequency for revascularization of CMI and AMI. The lower in-hospital mortality rate for patients, as they are currently being selected, shows that PTA/S is appropriate therapy for selected patients with CMI. Longitudinal data are needed to determine the durability of this benefit. The greater proportion of patients undergoing bowel resection with bypass for AMI suggests a more advanced level of ischemia in this group, making comparison with PTA/S difficult. However, PTA/S may be useful in selected patients with AMI and appropriate anatomy. Further data with greater detail regarding symptomatology and anatomy will clarify appropriate patient selection.

Risk prediction for perioperative mortality of endovascular vs open repair of abdominal aortic aneurysms using the Medicare population

OBJECTIVES The impact of risk factors upon perioperative mortality might differ for patients undergoing open vs endovascular repair (EVAR) of abdominal aortic aneurysms (AAA). In order to investigate this, we developed a differential predictive model of perioperative mortality after AAA repair. METHODS A total of 45,660 propensity score matched Medicare beneficiaries undergoing elective open or endovascular AAA repair from 2001 to 2004 were studied. Using half the dataset we developed a multiple logistic regression model for a matched cohort of open and EVAR patients and used this to derive an easily evaluable risk prediction score. The remainder of the dataset formed a validation cohort used to confirm results. RESULTS The derivation cohort included 11,415 open and 11,415 endovascular repairs. Perioperative mortality was 5.3% and 1.8%, respectively. Independent predictors of mortality (relative risk [RR], 95% confidence interval [CI]) were open repair (3.2, 2.7-3.8); age (71-75 years 1.2, 0.9-1.6; 76-80 years 1.9, 1.4-2.5; >80 years 3.1, 2.4-4.2); female gender (1.5, 1.3-1.8); dialysis (2.6, 1.5-4.6); chronic renal insufficiency (2.0, 1.6-2.6); congestive heart failure (1.7, 1.5-2.1); and vascular disease (1.3, 1.2-1.6). There were no differential predictors of mortality across the two procedures. A simple scoring system was developed from a logistic regression model fit to both endovascular and open patients (area under the receiver operator curve [ROC] curve of 72.6) from which low, medium, and high risk groups were developed. The absolute predicted mortality ranged from 0.7% for an EVAR patient </=70 years of age with no comorbidities to 38% for an open patient >80 with all the comorbidities considered. Although relative risk was similar among age groups, the absolute difference was greater for older patients (with higher baseline risk). CONCLUSION Mortality after AAA repair is predicted by comorbidities, gender, and age, and these predictors have similar effects for both methods of AAA repair. This simple scoring system can predict repair mortality for both treatment options and thus may help guide clinical decisions.

Body Mass Index: Surgical Site Infections and Mortality after Lower Extremity Bypass from the National Surgical Quality Improvement Program 2005—2007

BACKGROUND Patients undergoing lower extremity bypass are at high risk for surgical site infections (SSI). We examined lower extremity bypasses by graft origin and body mass index (BMI) classification to analyze differences in postoperative mortality and SSI occurrence. METHODS The 2005-2007 National Surgical Quality Improvement Program (NSQIP), a multi-institutional risk-adjusted database, was queried to compare perioperative mortality (30-day), overall morbidity, and SSIs after lower extremity arterial bypass for peripheral arterial disease. Bypass was stratified by graft origin as aortoiliac, femoral, or popliteal. Patient demographics, comorbidities, operative, and postoperative occurrences were analyzed. RESULTS There were 7,595 bypasses performed (1,596 aortoiliac, 5,483 femoral, and 516 popliteal). Mortality was similar regardless of bypass origin (2.8%, 2.4%, and 2.7%; p = 0.57). SSIs occurred in 11% of overall cases (10%, 11%, and 11%; p = 0.47). Graft failure was significantly associated with postoperative SSI occurrence (odds ratio [OR] = 2.4, 95% confidence interval [CI] 1.9-3.1, p < 0.001), as was postoperative sepsis (OR = 6.5, 95% CI 5.1-8.3, p < 0.001). Independent predictors of mortality were age, aortoiliac bypass origin, underweight, normal weight, morbid obesity (compared to overweight and obese), end-stage renal disease, poor preoperative functional status, preoperative sepsis, chronic obstructive pulmonary disease, hypoalbuminemia, and cardiac disease. Independent predictors of SSI were obesity, diabetes, poor preoperative functional status, a history of smoking, and female gender. CONCLUSION SSIs occur frequently after lower extremity bypass regardless of bypass origin and are associated with early graft failure and sepsis. Obesity predicts postoperative SSI. Mortality risk was greatest in the underweight, followed by morbidly obese and normal-weight patients, while overweight and mild to moderate obesity were associated with the lowest mortality.

Changes in abdominal aortic aneurysm rupture and short-term mortality, 1995-2008: a retrospective observational study.

Objective:To examine the modern epidemiology of abdominal aortic aneurysm (AAA) rupture and short-term AAA-related mortality after the introduction of endovascular aneurysm repair (EVAR). Background:Previous epidemiologic studies have demonstrated stable rates of AAA repair, repair mortality, and AAA rupture. Recently, EVAR has been introduced as a less invasive treatment method, and its use has expanded to more than 75% of elective AAA repairs. Methods:We identified Medicare beneficiaries undergoing AAA repair and those hospitalized with a ruptured AAA during the period 1995 to 2008 and calculated standardized annual rates of AAA-related deaths due to either elective repair or rupture. Results:A total of 338,278 patients underwent intact AAA repair during the study period. There were 69,653 patients with AAA rupture, of whom 47,524 underwent repair. Intact repair rates increased substantially in those older than 80 years (57.7–92.3 per 100,000, P < 0.001) but decreased in those 65 to 74 years old (81.8–68.9, P < 0.001). A decline in ruptures with and without repair was seen in all age groups. By 2008, 77% of all intact repairs and 31% of all rupture repairs were performed with EVAR (P < 0.001). Operative mortality declined during the study period for both intact (4.9%–2.4%, P < 0.001) and ruptured (44.1%–36.3%, P < 0.001) AAA repair. Short-term AAA-related deaths decreased by more than half (26.1–12.1 per 100,000, P < 0.001), with the greatest decline occurring in those older than 80 years (53.7–27.3, P < 0.001). Conclusions:A recent decline in AAA rupture and short-term AAA-related mortality is demonstrated and likely related in part to the introduction and expansion of EVAR. This is due to decreased deaths from ruptures (with and without repair) and decreased mortality with intact repairs, particularly in patients older than 80 years.

Thirty-day mortality and late survival with reinterventions and readmissions after open and endovascular aortic aneurysm repair in Medicare beneficiaries.

OBJECTIVES Late survival is similar after open and endovascular abdominal aortic aneurysm (AAA) repair (EVAR), despite a perioperative benefit with EVAR. AAA-related reinterventions are more common after EVAR, whereas laparotomy-related reinterventions are more common after open repair. The effect of reinterventions on survival, however, is unknown. We therefore evaluated the rate of reinterventions and readmission after initial AAA repair, 30-day mortality, and the effect on long-term survival. METHODS We identified AAA-related and laparotomy-related reinterventions for propensity score-matched cohorts of 45,652 Medicare beneficiaries undergoing EVAR and open repair from 2001 to 2004. Follow-up was up to 6 years. Hospitalizations for ruptured AAA without repair and for bowel obstruction or ventral hernia without abdominal surgery were also recorded. Event rates were calculated per year and are presented through 6 years of follow-up as events per 100 person-years. Thirty-day mortality was calculated for each reintervention or readmission. RESULTS Through 6 years, overall reinterventions or readmissions were similar between repair methods but slightly more common after EVAR (7.6 vs 7.0/100 person-years; relative risk [RR], 1.1; P < .001). Overall 30-day mortality with any reintervention or readmission was 9.1%. EVAR patients had more ruptures (0.50 vs 0.09 [RR, 5.7; P < .001]), with a mortality of 28%, but these were uncommon. EVAR patients also had more AAA-related reinterventions through 6 years (3.7 vs 0.9 [RR, 4.0; P < .001]; mortality, 5.6%), most of which were minor endovascular reinterventions (2.4 vs 0.2 [RR, 11.4; P < .001]), with a 30-day mortality of 3.0%. However, minor open (0.8 vs 0.5 [RR, 1.4; P < .001]; mortality, 6.9%) and major reinterventions (0.4 vs 0.2 [RR, 2.4; P < .001]; mortality, 12.1%) were also more common after EVAR than open repair. Conversely, EVAR patients had fewer laparotomy-related reinterventions than open patients (1.4 vs 3.0 [RR, 0.5; P < .001]; mortality, 8.1%) and readmissions without surgery (2.0 vs 2.7 [RR, 0.7; P < .001]; mortality 10.9%). Overall, reinterventions or readmission accounted for 9.6% of all EVAR deaths and 7.6% of all open repair deaths in the follow-up period (P < .001). CONCLUSIONS Reintervention and readmission are slightly higher after EVAR. Survival is negatively affected by reintervention or readmission after EVAR and open surgery, which likely contributes to the erosion of the survival benefit of EVAR over time.

Population-based outcomes of open descending thoracic aortic aneurysm repair

OBJECTIVE To evaluate national outcomes after open repair of descending thoracic aortic aneurysm (DTA). METHODS The DTA repairs were identified from the NIS database from 1988-2003 by ICD9 codes for thoracic vascular resection and replacement (38.45) and a diagnosis of intact (441.1) or ruptured (441.2) thoracic aortic aneurysm; excluding thoraco-abdominal aneurysm, abdominal aortic aneurysm repair, cardioplegia, hypothermia, cardiac surgery, or aorta to carotid or subclavian bypass. Demographics and comorbidities were noted. Outcomes included in-hospital mortality, length of stay, and complications. Annual hospital surgical volume terciles (high, medium, and low) were quantified for the series and patients assigned accordingly. Outcomes were compared between intact and ruptured aneurysm characteristics as well as annual hospital volume. Predictors of peri-operative mortality were analyzed by multivariate logistic regression. RESULTS A total of 2549 DTA repairs were identified (1976 intact, 573 ruptured). Mortality was 18% overall; 10% for intact (age <65 6.2%, 65-74 11.3%, >/=75 17.6%, P < .001), 45% for ruptured (age <65 33.3%, 65-74 47.1%, >/=75 52.4%, P < .001). Mortality decreased over the 15-year time-period (P < .0001). Mortality after intact repair was lower at a high volume hospital (HVH) (8%) than a low volume hospital (LVH) (13%) or medium volume hospital (MVH) (12%). Hospital volume tercile did not predict rupture mortality. Complications after intact DTA repair were coded in 42%; including respiratory (13%), cardiac (11%), acute renal failure (8%), stroke (3%), and neurologic (non-stroke) (2%). Complications were coded in 49% after ruptured DTA repair including respiratory (13%), cardiac (13%), acute renal failure (20%), stroke (3%), and neuro (non-stroke) (2%). Predictors of mortality (for all DTA repairs) were (odd ratio [OR], 95% confidence interval [CI]): age 65-74 vs age <65 (1.8, 1.4-2.4), age >/=75 vs age <65 (2.7, 2.0-3.6), rupture (6.3, 5.1-7.9), and LVH or MVH vs HVH (1.3, 1.1-1.7). CONCLUSION Mortality after open repair of DTA is high and complications are common. Mortality is dependent upon age, rupture status, and hospital surgical volume. Results of endovascular DTA repair should be compared using similar population-based data.

Population-Based Outcomes Following Endovascular and Open Repair of Ruptured Abdominal Aortic Aneurysms

Purpose: To evaluate national outcomes after endovascular and open surgical repair of ruptured abdominal aortic aneurysms (rAAA). Methods: The Nationwide Inpatient Sample was interrogated to identify all repairs between 2000 and 2005 for rAAA based on ICD-9 codes. In the study period, 2323 patients (1794 men; median age 75 years, range 45–98) with rAAAs had endovascular repair, while 26,106 patients (20,311 men; median age 73 years, range 22–99) had an open procedure. Outcomes included in-hospital mortality, length of stay (LOS), complications, and hospitalization charge. A secondary analysis was performed to compare outcomes from low-, medium-, and high-volume institutions based on annual rAAA repair volume. Results: Patients in the endovascular group were significantly older (p<0.05). Mortality was 41% overall: 33% and 41% for endovascular versus open repair, respectively (p<0.001). Mortality after endovascular repair was lower than open surgery for patients ≥70 years (36% versus 47%, p<0.001), but not for those <70 years (24% versus 30%, p=0.15). LOS was shorter after endovascular repair (7 versus 9 days, p<0.001). Respiratory complications (8% versus 4%, p<0.05) and acute renal failure were more common following open repair (30% versus 23%, p<0.01). Costs were similar (endo

Open and endovascular repair of type B aortic dissection in the Nationwide Inpatient Sample.

73,590 versus open

Results for primary bypass versus primary angioplasty/stent for intermittent claudication due to superficial femoral artery occlusive disease

67,287, p=0.15). Mortality decreased as hospital surgical volume increased (low 44%, medium 39%, high 38%; p<0.001). Over time, endovascular repair utilization increased more rapidly at high-volume centers, and a lower mortality was seen with endovascular repair at high-volume compared to low-volume hospitals (22% versus 44%, p<0.001). Multivariate predictors of mortality were age, female gender, lower hospital surgical volume, open repair, and year of surgery. Conclusion: This population-based study found that mortality associated with rAAAs may be improved by the performance of endovascular repair, especially in older patients. Mortality after rAAA for both endovascular and open repairs was also lower at high-volume institutions.