R. Todd Lancaster

Does the Surgical Apgar Score Measure Intraoperative Performance

Objective:To evaluate whether Surgical Apgar Scores measure the relationship between intraoperative care and surgical outcomes. Summary Background Data:With preoperative risk-adjustment now well-developed, the role of intraoperative performance in surgical outcomes may be considered. We previously derived and validated a 10-point Surgical Apgar Score—based on intraoperative blood loss, heart rate, and blood pressure—that effectively predicts major postoperative complications within 30 days of general and vascular surgery. This study evaluates whether the predictive value of this score comes solely from patients’ preoperative risk or also measures care in the operating room. Methods:Among a systematic sample of 4119 general and vascular surgery patients at a major academic hospital, we constructed a detailed risk-prediction model including 27 patient-comorbidity and procedure-complexity variables, and computed patients’ propensity to suffer a major postoperative complication. We evaluated the prognostic value of patients’ Surgical Apgar Scores before and after adjustment for this preoperative risk. Results:After risk-adjustment, the Surgical Apgar Score remained strongly correlated with postoperative outcomes (P < 0.0001). Odds of major complications among average-scoring patients (scores 7–8) were equivalent to preoperative predictions (likelihood ratio (LR) 1.05, 95% CI 0.78–1.41), significantly decreased for those who achieved the best scores of 9–10 (LR 0.52, 95% CI 0.35–0.78), and were significantly poorer for those with low scores—LRs 1.60 (1.12–2.28) for scores 5–6, and 2.80 (1.50–5.21) for scores 0–4. Conclusions:Even after accounting for fixed preoperative risk—due to patients’ acute condition, comorbidities and/or operative complexity—the Surgical Apgar Score appears to detect differences in intraoperative management that reduce odds of major complications by half or increase them by nearly 3-fold.

Late Aortic Remodeling Persists in the Stented Segment After Endovascular Repair of Acute Complicated Type B Aortic Dissection

OBJECTIVE Thoracic endovascular aortic repair (TEVAR) for acute complicated type B aortic dissection (AD) promotes early positive aortic remodeling. However, little is known about the long-term effect of TEVAR on the dissected aorta, which is the goal of this study. METHODS Between August 2005 and August 2009, 31 patients with complicated type B AD were treated with TEVAR and had >1-year follow-up imaging. Computed tomography angiograms obtained at 1 month, 1 year, and long term (average, 42 months) were compared with baseline scans. The largest diameters of the stented thoracic aorta, stented true lumen, and stented false lumen were recorded at each time point, as were the values in the unstented distal thoracic aorta and the abdominal aorta. Changes over time were evaluated by a mixed effect analysis of variance model of repeated measures. RESULTS The average age of the cohort was 56 years, and 74% were male. Indications for TEVAR were as follows: 61% malperfusion, 32% refractory hypertension, 45% impending rupture, and 32% persistent pain; 58% had more than one indication. All patients were treated in the acute phase within 7 days of the initial presentation. The average length of aorta covered was 19 cm. Observation of the stented segment over time showed that the maximum diameter of the stented thoracic aorta was stable (P = NS), the diameter of the stented true lumen increased (P < .001), and the diameter of the stented false lumen decreased (P < .001); 84% had complete false lumen obliteration across the stented aortic segment. Observation of the uncovered thoracic aorta over time showed that the maximum diameter increased (P = .014), as did the visceral segment of the aorta (P < .001). The average growth of the visceral segment was 31% in patients with a patent false lumen vs 3% in those with a thrombosed false lumen (P = .004). One patient had aneurysmal degeneration of the false lumen and required an additional endograft at 18 months. CONCLUSIONS TEVAR of acute AD promotes long-term remodeling across the stented segment, with false lumen obliteration in 84% of patients. However, false lumen obliteration beyond the stented segment appears necessary to prevent late aneurysmal degeneration of the distal aorta.

Predictors of late aortic intervention in patients with medically treated type B aortic dissection

Background Patients with medically managed type B aortic dissection (TBAD) have a high incidence of aorta‐related complications over time. Whereas early thoracic endovascular aortic repair (TEVAR) to seal the entry tear can promote aortic remodeling and prevent late aneurysm formation, there are sparse data as to which patients will benefit from such therapy. The goal of this study was to identify clinical and anatomic factors that are associated with the need for subsequent aortic intervention in patients who present with uncomplicated TBAD. These factors could guide the selection of patients who will benefit from TEVAR in the subacute phase. Methods Patients who presented with acute uncomplicated TBAD and were initially managed medically from January 2000 to December 2013 were included in the study. Timing of intervention was stratified into early (within 180 days of initial presentation) and late (181 days and later) cohorts. All patients had follow‐up axial imaging studies. These imaging studies were reviewed for anatomic criteria in a retrospective fashion. Predictors of aortic intervention were determined using Cox regression analyses. Results There were 254 patients (65% men) with medically managed acute TBAD. The average age at presentation was 66.3 years, and 82.5% had a history of hypertension. Mean follow‐up was 6.8 years (range, 0.1‐13.6 years). There were a total of 97 (38%) patients who required an aortic intervention during follow‐up; 30 (12%) patients required an early intervention, and 67 (26%) were treated during late follow‐up (100% for aneurysmal degeneration). Predictors of late aortic intervention included entry tear >10 mm (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.5‐3.8; P = .03), total aortic diameter >40 mm at time of presentation (OR, 2.2; 95% CI, 1.8‐4.3; P = .02), false lumen diameter >20 mm (OR, 1.8; 95% CI, 1.3‐4.7; P = .03), and increase in total aortic diameter >5 mm between serial imaging studies (OR, 2.3; 95% CI, 1.3‐3.5; P = .02). Complete thrombosis of the false lumen was protective against late operative intervention (OR, 0.22; 95% CI, 0.11‐0.48; P < .01). Conclusions Nearly 40% of patients who present with an uncomplicated TBAD will ultimately require an aortic intervention. All of the late interventions were performed for aneurysmal degeneration. A variety of readily available anatomic features can predict the need for eventual operative intervention in TBAD; accordingly, these parameters can guide the desirability of early TEVAR.

Use of extracorporeal bypass is associated with improved outcomes in open thoracic and thoracoabdominal aortic aneurysm repair

Objective: There is no consensus on the use or benefit of extracorporeal circulation (EC) during aneurysm repair of the descending thoracic aorta (DTA) or thoracoabdominal aorta (TAA). We evaluated the role of EC during DTA or TAA aneurysm repair using U.S. Medicare data. Methods: Medicare (2004‐2007) patients undergoing open repair of nonruptured DTA or TAA aneurysm were identified by International Classification of Diseases, Ninth Revision code. Specific exclusions included ascending aortic or arch repairs, concomitant cardiac procedures, and procedures employing deep hypothermic circulatory arrest. The impact of EC (code 3961) on early and late outcomes was analyzed using univariate analysis and multivariable regression. Survival was assessed using Kaplan‐Meier analysis and Cox proportional hazards regression models. Results: There were 4230 patients who had repair of intact DTA or TAA aneurysms, 2433 (57%) of which employed EC. Differences in baseline clinical features of EC and non‐EC patients showed that patients undergoing aortic reconstruction with EC were older (73 ± 1 years vs 72 ± 1 years; P = .002), were more likely to be female (53% vs 47%; P < .001), and had more hypertension (56% vs 53%; P = .02); they had less chronic obstructive pulmonary disease (28% vs 34%; P < .0001), peripheral vascular disease (5.7% vs 11.3%; P < .001), and chronic kidney disease (7.7% vs 5.5%; P = .003). The 30‐day mortality (9.7% for EC vs 12.2%; P = .02) and any major complication (49% for EC vs 58%; P < .001) were significantly reduced with EC use. EC use was associated with a shorter length of stay (13.5 ± 13 days vs 17.2 ± 18 days; P < .01) and lower total hospital charges (

Characterization of perioperative contralateral stroke after carotid endarterectomy

151,000 ± 140,000 vs

Does speed matter? The impact of operative time on outcome in laparoscopic surgery

180,000 ± 190,000; P < .01) compared with non‐EC patients. EC patients were more likely to be discharged home instead of to an extended care facility (67% vs 56%; P < .01). Multivariable regression modeling to adjust for baseline clinical differences showed EC to independently reduce the risk of operative mortality (odds ratio [OR], 0.80; 95% confidence interval [CI], 0.65‐0.97; P = .02), any complication (OR, 0.67; 95% CI, 0.59‐0.76; P < .01), pulmonary complications (OR, 0.68; 95% CI, 0.59‐0.79; P < .01), and acute renal failure (OR, 0.52; 95% CI, 0.44‐0.61; P < .01). Long‐term survival was higher (log‐rank, P < .01) in EC patients at 1 year (81% ± 0.8% vs 73% ± 1%) and 5 years (67% ± 1% vs 52% ± 1%). Risk‐adjusted Cox proportional hazards regression also showed that EC was independently associated with improved long‐term survival (hazard ratio, 0.69; 95% CI, 0.63‐0.74; P < .01). Conclusions: Although important clinical variables such as DTA or TAA aneurysm extent and spinal cord ischemic complications cannot be assessed with the Medicare database, EC use during open DTA and TAA aneurysm repair is associated with improved late survival and a significant reduction in operative mortality, morbidity, and procedural costs. These data indicate that EC should be a more widely applied adjunct in open DTA or TAA aneurysm repair.

The natural history of splanchnic artery aneurysms and outcomes after operative intervention

Objective Contralateral stroke is an infrequent cause of perioperative stroke after carotid endarterectomy (CEA). Whereas the risks of ipsilateral stroke complicating CEA have been discriminated, factors that lead to contralateral stroke are poorly defined. The purpose of this study was to identify the risk of perioperative (30‐day) contralateral stroke after CEA as well as predisposing preoperative and operative factors. Its specific effect on long‐term survival was interrogated. Methods The Vascular Study Group of New England (VSGNE) was queried from April 1, 2003, to February 29, 2016, for all CEAs. Duplicated patients and those without complete data were excluded. Patients sustaining contralateral stroke after CEA in the 30‐day postoperative period were identified. Demographic, preoperative, and operative factors were analyzed to identify discriminators between those with and those without contralateral stroke. Logistic regression modeling was performed to identify factors independently associated with contralateral stroke. The effect of contralateral stroke on 5‐year survival was compared with patients with ipsilateral stroke and no stroke using the Kaplan‐Meier method. Log‐rank testing compared survival curves. Results There were 10,837 CEAs performed during the study. Average age was 70.4 ± 9.3 years; 6605 (61%) patients were male, and 40% (n = 4324) were performed for symptoms. Most were current or former smokers (n = 8619 [80%]). Coronary artery disease and congestive heart failure were identified in 31% and 8.6%, respectively. Overall, there were 190 strokes within 30 days of CEA (1.8%); 131 were ipsilateral (1.3%), and 59 (0.5%) patients were identified as having contralateral perioperative stroke. Thirteen patients sustained bilateral stroke (0.1%). Significant univariate associations included urgency (P = .0001), ipsilateral stenosis severity (P = .004), length of operation (P = .0001), CEA with coronary artery bypass graft (P = .0001), CEA with other arterial surgery (P = .01), and CEA with proximal endovascular procedure (P = .03). Contralateral occlusion (P = .06) and degree of contralateral carotid stenosis (P = .14) did not correlate. After logistic regression analysis of significant univariate anatomic and operative factors, length of procedure (odds ratio [OR], 1.08/15 minutes; 95% confidence interval [CI], 1.01‐1.15; P = .02), urgency of operation (OR, 2.5; 95% CI, 1.3‐4.6; P = .006), and concomitant proximal endovascular intervention (OR, 8.7; 95% CI, 4.5‐31.2; P = .001) remained predictors of contralateral stroke after CEA. Occurrence of both ipsilateral (P < .001) and contralateral (P = .023) stroke significantly reduced 5‐year survival compared with those without stroke. There was no difference in the negative survival effect based on laterality of stroke (P = .24). Conclusions Contralateral stroke after CEA is rare, affecting 0.5% of patients. Traditional risk reduction medical therapy does not affect occurrence. Degree of contralateral stenosis, including contralateral occlusion, does not predict perioperative contralateral stroke. Urgency of operation, length of operation, and performance of concomitant, ipsilateral endovascular intervention predict contralateral stroke risk with CEA. Contralateral stroke affects long‐term survival similar to ipsilateral stroke after CEA.