Patric Liang

Treatment outcomes in diabetic patients with chronic limb-threatening ischemia

Objective: There are conflicting reports about outcomes after infrainguinal bypass for chronic limb‐threatening ischemia (CLTI) in patients with diabetes. We compared perioperative outcomes between patients with and patients without diabetes in the current era. Methods: The National Surgical Quality Improvement Program vascular module, 2011 to 2014, was used to identify patients undergoing infrainguinal revascularization for CLTI. Patients with and without diabetes were compared in terms of presentation, comorbidities, operative approach, and 30‐day outcomes. Major adverse limb events (MALEs) included 30‐day major reintervention or amputation, and major adverse cardiovascular events (MACEs) included 30‐day myocardial infarction, cardiac arrest, stroke, or death. Multivariable logistic regression was used to adjust for baseline differences. Results: We identified 8887 patients undergoing open (5744; 50% diabetic) or endovascular (3143; 62% diabetic) treatment for CLTI. Patients with diabetes were younger and more often nonwhite, nonsmokers, and obese. Patients with diabetes presented more often with tissue loss (71% vs 47%; P < .001) and were more likely to be treated with endovascular intervention (41% vs 29%; P < .001). The 30‐day mortality was similar before (open, 3.1% vs 2.8% [P = .53]; endovascular, 2.6% vs 2.1% [P = .37]) and after adjustment for baseline differences (open: odds ratio [OR], 1.1 [95% confidence interval (CI), 0.7‐1.5]; endovascular: OR, 1.2 [95% CI, 0.7‐2.0]). Patients with diabetes had longer lengths of stay (open, 8 vs 6 days [P < .001]; endovascular, 3 vs 2 days [P < .001]) and higher 30‐day readmission rates (open, 21% vs 18% [P < .01]; endovascular, 20% vs 15% [P < .01]); however, these differences were no longer significant after adjustment for baseline differences. Patients with diabetes had a higher rate of MACEs (7.0% vs 5.1%; P < .01) and lower rate of MALEs (8.1% vs 10%; P < .01) after bypass. After adjustment, patients with diabetes still had a lower rate of MALEs (OR, 0.7; 95% CI, 0.6‐0.9) but no longer had a higher rate of MACEs (OR, 1.2; 95% CI, 0.9‐1.6). Conclusions: CLTI patients with diabetes undergoing revascularization have similar 30‐day outcomes compared with those without diabetes, although they appear to be at lower risk for MALEs after bypass. Prolonged length of stay and readmission in patients with diabetes is not due to underlying diabetic disease but likely secondary to other baseline comorbidities, such as higher rates of tissue loss. Concern for worse perioperative outcomes in patients with diabetes after lower extremity bypass is unsubstantiated and should not discourage a physician from performing an open bypass.

RS06. Risk of Insulin-Dependent Diabetes Mellitus in Patients Undergoing Carotid Endarterectomy

the purpose of this study is to develop a score to predict the risk of stroke/ death after CAS. Methods:We analyzed the Vascular Quality Initiative dataset from 2009 to the present. Univariate andmultivariate methods were used to identify predictors associated with 30-day stroke/death. Logistic regression was performed and variable selection for the final model was made on backward stepwise selection to achieve model parsimony. This final model was validated by bootstrapping (1000 repetitions) and tested by calibration (Hosmer-Lemeshow) and discrimination (c-statistic). A risk score was made by converting regression coefficients for each predictor to integers from which probability (%) was calculated. Scores were grouped into five simplified categories. Results: We identified 11,479 patients who underwent CAS during the study period with a combined 30-day stroke/death rate of 3.8%. Patients who developed the outcome of 30-day stroke/death were older (median age, 75 years vs 72 years), more likely to be female (41.3% vs 35.8%), symptomatic (58% vs 40.1%), and diabetic (44.8% vs 37.4%), and less likely to be on statins (71.4% vs 81.8%) and antiplatelet agents (aspirin, 78.1% vs 86.8%; P2Y12-inhibitor, 61.8% vs 77.1%; all P < .05). The Table details the demographic variables, comorbidities, preoperative medication, and lesionspecific predictors that were analyzed. Independent predictors included in the final model were age, female gender, diabetes, coronary artery disease, chronic kidney disease, chronic obstructive pulmonary disease, symptomatic status, contralateral occlusion, restenotic lesion, preoperative statin use, and P2Y12-inhibitor use. The model had a c-statistic of 70.9%. The corresponding score for each predictor, risk of 30-day stroke/death and two examples are shown in the Fig. Conclusions: This study introduces an easy to use clinical tool for predicting stroke/death after CAS and will help surgeons and patients in weighing the risks versus the benefits of performing this procedure. In asymptomatic patients with high predicted stroke/death risk, medical management might be the safer option.

PC090. Risk Score for Groin Access Complication in Ultrasound-Guided Percutaneous Aortic Procedures

Unadjusted 30-day mortality was 16% in extent 2, 26% in extent 3, 19% in extent 4 disease (P < .03 for overall heterogeneity; Fig and Table); extent 3 was different from extent 2 and extent 4 (P < .009) but extent 2 versus extent 4 were not different from each other (P 1⁄4 .44). Vascular disease risk-burden was significant independent predictor of 30-day mortality, and for each 1-point increase in burden score, the odds of 30-day mortality increased by 1.5 time (P < .0001). After adjustment for other risk factors,

PC064. The Effect of Three-dimensional Image Fusion on Radiation Exposure, Contrast Dose, and Procedural Times During Carotid Artery Stenting

TheEffectofThree-dimensional ImageFusionon Radiation Exposure, Contrast Dose, and Procedural Times During Carotid Artery Stenting Nicholas J. Swerdlow, Douglas W. Jones, Alexander B. Pothof, Thomas F. X. O’Donnell, Patric Liang, Chun Li, Mark C. Wyers, Marc L. Schermerhorn. Beth Israel Deaconess Medical Center, Boston, Mass; Boston Medical Center, Boston, Mass; University Medical Center Utrecht, Utrecht, The Netherlands

VESS27. Statin Intensity One Year After Revascularization for Chronic Limb-Threatening Ischemia Is Associated With Higher Long-Term Survival

Objective: Endovascular aneurysm repair (EVAR) has reduced perioperative mortality for patients undergoing abdominal aortic aneurysm (AAA) repair despite the increase in elective aneurysm repair for the elderly. However, Medicare will not cover screening for beneficiaries older than 75 years, and AAA treatment in this population depends on incidental detection. Thus, we risk stratified elderly patients undergoing elective AAA repair to identify a subset of elderly patients who would potentially benefit from an expanded screening policy. Methods: We reviewed all patients undergoing elective EVAR in the Vascular Quality Initiative between 2003 and 2017. We used the beta coefficients from Cox regression models to construct a risk model for 5-year survival in patients >75 years old. Results: We identified 26,967 patients undergoing elective EVAR, 11,351 (42%) of whom were >75 years old. Perioperative mortality for the entire cohort was 0.9% (75 years, 0.6%; >75 years, 1.4%; P < .01). Although perioperative mortality varied directly with age, it was only 2.1% in the oldest group of patients (>85 years old). Factors included in our risk model for 5year survival in the elderly included age, aortic diameter, smoking status, white race, body mass index, renal function, diabetes, congestive heart failure, statin use, anemia (hemoglobin level <10 mg/dL), chronic obstructive pulmonary disease, prior aortic surgery, and beta blocker use. Total point values were 0 to 21 and classified patients into four risk categories. The lowest risk group (0-4 points) included 21% of the patients older than 75 years, whose 5-year survival was 89%, equivalent to that of patients younger than 75 years. Less than 1% of patients older than 75 years fell into the highest risk category (15+ points), who experienced 50% 5-year survival (Fig). Five-year survival in the four risk categories was statistically significantly different (P < .001), with a Harrell C statistic of 0.71. Conclusions: Elective EVAR in the elderly is associated with acceptable perioperative mortality. Our risk score can be used to define optimal patients for expanded screening based on expected postoperative 5-year survival to justify removing this Medicare coverage restriction.

Three-dimensional image fusion is associated with lower radiation exposure and shorter time to carotid cannulation during carotid artery stenting

Objective Three‐dimensional (3D) image fusion is associated with lower radiation exposure, contrast agent dose, and operative time during endovascular abdominal aortic aneurysm repair. Therefore, we evaluated the impact of this technology on carotid artery stenting (CAS). Methods We identified consecutive CAS procedures from 2009 to 2017 and compared those performed with and without 3D image fusion. For image fusion, we created a 3D reconstruction of the aortic arch anatomy based on preoperative computed tomography or magnetic resonance angiography that we merged with two‐dimensional fluoroscopy, allowing 3D image overlay. We compared radiation exposure, fluoroscopy time, contrast agent dose, time to common carotid artery (CCA) cannulation, time from CCA cannulation to completion angiography, and total procedure time in procedures with and without image fusion. We also assessed rates of 30‐day stroke/death, in‐hospital and 30‐day stroke, and acute kidney injury. We used multivariable linear regression to adjust for patient and procedural characteristics and used these models to compute the marginal effects of image fusion compared with no image fusion. Results There were 46 patients who underwent CAS with a 3D image fusion system and 70 patients without. Patients undergoing CAS with image fusion experienced 31% lower radiation exposure compared with the control group (207 ± 23 mGy vs 300 ± 26 mGy, respectively; P < .01), shorter fluoroscopy time (21 ± 6 minutes vs 24 ± 8 minutes; P = .02), shorter time to carotid cannulation (21 ± 9 minutes vs 31 ± 8 minutes; P < .001), and shorter total procedure time (47 ± 13 minutes vs 54 ± 18 minutes; P = .03). There was no difference in contrast material volume, time from CCA cannulation to completion angiography, or total in‐room time. After multivariable adjustment, 3D image fusion remained associated with lower radiation dose, shorter fluoroscopy time, and shorter time to carotid cannulation (all P < .05). The rate of 30‐day stroke/death was 2.7% (three strokes and no deaths at 30 days), and the rate of acute kidney injury was 1.8%. Conclusions CAS with 3D image fusion was associated with lower radiation exposure and shorter time to CCA cannulation. These results represent the potential technical advantage gained with image fusion and add to the growing body of evidence demonstrating its impact on radiation exposure and operative times during complex endovascular procedures.

PC016. Outcomes After Routine Ultrasound Usage in Percutaneous Endovascular Aortic Aneurysm Repair

CI, Confidence interval; PEVAR, percutaneous endovascular aortic aneurysm repair; US, ultrasound. P # .05 is significant. Percent calculated based on all EVARs performed by center as the denominator. Fig. Percent percutaneous endovascular aortic aneurysm (PEVAR), successful bilateral percutaneous access (bPEVAR), and ultrasound usage in the Vascular Quality Initiative between 2015 and 2017. *Percent calculated based on all EVARs performed by center as denominator. Journal of Vascular Surgery Abstracts e177 Volume 67, Number 6

Endovascular aneurysm repair in patients over 75 is associated with excellent 5-year survival, which suggests benefit from expanded screening into this cohort

Background Endovascular aneurysm repair (EVAR) has decreased the perioperative mortality for patients undergoing abdominal aortic aneurysm repair and has increased the rates of elective aneurysm repair in the elderly. However, Medicare will not cover abdominal aortic aneurysm screening for beneficiaries over 75 years of age. Consequently, abdominal aortic aneurysm treatment in this population depends on incidental detection. Targeted coverage for screening in this population, however, might be beneficial for a subgroup of patients. Methods To identify a subset of elderly patients who would potentially benefit from an expanded screening policy, we reviewed all patients greater than 75 years old undergoing elective EVAR in the Vascular Quality Initiative between 2003 and 2016. We used Cox regression with multivariable fractional polynomials to construct a risk model for 5‐year survival in elderly patients to identify a subpopulation who might benefit the most from screening and performed internal validation using the bootstrapping technique. Results We identified 10,676 patients greater than 75 years old undergoing elective EVAR. Although perioperative mortality varied with age, it was only 2.1% in the oldest group of patients (>85 years). Significant predictors included in our final risk model for 5‐year survival in the elderly included age, aortic diameter, hemoglobin, current smoking, white race, body mass index, renal function, congestive heart failure, statin use, chronic obstructive pulmonary disease, and ejection fraction. The risk model produced risk scores ranging from a possible −2 to 33. The mean and median risk score were 6.9 and 6.0, respectively, with a right skew. We categorized the risk scores into four groups: −2 to 4 points, 5‐8 points, 9‐13 points, and more than 13 points, with associated 5‐year survivals of 88%, 79%, 68%, and 49%, respectively. The model showed adequate discrimination and calibration, with a C‐statistic of 0.69 and a calibration score of 0.99 (predicted 5‐year survival of 0.78 compared with an observed 5‐year survival of 0.77) and a Brier score of 0.15. Internal validation demonstrated an optimism‐corrected C‐statistic of 0.69 and a calibration slope of 1.0. Conclusions Elective EVAR in elderly patients chosen to undergo repair is associated with acceptable perioperative mortality. Our risk score can be used to define optimal patients for expanded screening into all but the highest risk group based on expected postoperative 5‐year survival to justify removing this Medicare coverage restriction.