Difference In Reintervention Rate Research Articles

Practice patterns in utilization of atherectomy and embolic protection devices in inpatient and outpatient treatment settings

ObjectiveThe frequency of atherectomy in lower extremity arterial disease has increased substantially over the past several years, specifically in the office-based laboratory (OBL) setting, yet the efficacy compared with other interventions and the consequences of distal embolization remain unknown. Embolic protection devices (EPDs) have been used at varying rates depending on physician and practice setting. Previous studies have described lesion characteristics to consider when weighing the benefits and drawbacks associated with device use. Our study focuses on the use of atherectomy and EPDs in femoropopliteal arterial disease to better characterize resource use trends and postoperative outcomes in the inpatient and OBL interventional settings. MethodsWe conducted a retrospective analysis on endovascular interventions performed for femoral-popliteal occlusive disease that were entered into the Vascular Quality Initiative data registry between 2017 and 2021. A one:one greedy match, adjusted analysis based on inpatient or OBL location of procedure was used to compare the groups. Hierarchical logistical regression with selective use of principal component analysis was used to further explore the differences in EPD use and immediate postoperative outcomes. A proportional hazard model was used to demonstrate differences in reintervention rates up to 2 years postoperatively between patients who underwent atherectomy in the inpatient vs OBL treatment setting. Results2849 matched pairs were inlcuded in the final analysis. In our cohort, there was 22% EPD use overall, 40% in the hospital setting and 4.4% in the OBL setting (P < .001). Among the patients with available follow-up information, OBL intervention setting increased probability of reintervention by 18% at 2 years postoperatively compared with the inpatient setting; however, there was no difference associated with EPD placement and rate of reintervention. ConclusionsUse of EPDs in the OBL setting compared with the hospital setting is dramatically decreased; however, no increased incidence of postoperative complications was seen compared to procedures performed in the hospital setting when controlling for patient and lesion characteristics. Patients with available follow-up data were more likely to undergo ipsilateral reintervention between 6 months and 2 years postoperatively if atherectomy was done in the OBL setting. Dedicated studies are encouraged to ensure patient safety, effective resource allocation, and long-term efficacy of OBL atherectomy as an ever-growing number of peripheral arterial procedures are transitioned to the OBL setting.

Effects of additional exercise therapy after a successful vascular intervention for people with symptomatic peripheral arterial disease.

Effects of additional exercise therapy after a successful vascular intervention for people with symptomatic peripheral arterial disease.

Evaluating the role of the Minimal Incision Retroperitoneal Necrosectomy (MIRN) in the management of infected pancreatic necrosis: Experience from a tertiary care center

BackgroundThe conventional open necrosectomy was associated with high mortality and morbidities like secondary organ failure, incisional hernia, enterocutaneous fistula, and external pancreatic fistula. In acute pancreatitis, collections are primarily confined to the retroperitoneal space. Hence, the retroperitoneal approach can be used to drain the collection and necrotic material. It benefits smaller incisions and better outcomes in terms of morbidity and mortality than the conventional open necrosectomy. This study primarily aims to describe the effects of minimal incision retroperitoneal necrosectomy versus conventional open necrosectomy for treating INP. Moreover, it provides evidence supporting the efficacy and safety of this method. MethodsA single-center retrospective study of the prospectively maintained database from April 2008 to December 2021. ResultsA total of 122 patients were included in the study. Seventy-eight patients had an open necrosectomy, 30 had a MIRN, and 14 had a VARD procedure. These three groups were comparable in demographic variables. Preoperative variables like APACHE II at presentation, Modified CTSI, percentage of necrosis, multi-organ failure, time to surgery, and need for preoperative ICU stay were comparable among the three groups. Postoperative mortality was low in the MIRN group{open 35.8 % vs. MIRN 20.5 % vs. VARD 35.7 %, p = 0.066}. The postoperative stay was also significantly low in the MIRN and VARD group {open 23.62 ± 16.61 vs. MIRN 11.77 ± 7.73, VARD 8.86 ± 2.98, p = 0.00}. No significant difference in re-intervention rate, postoperative bleeding, and enterocutaneous fistula. ConclusionMIRN is a simple and easy-to-adapt procedure for infected pancreatic necrosis in the appropriately selected patient group.

Sex differences in outcomes among adults undergoing abdominal aortic aneurysm repair

ObjectiveAlthough the differences in short-term outcomes between male and female patients in abdominal aortic aneurysm (AAA) repair have been well studied, it remains unclear if these sex disparities extend to other long-term adverse outcomes after AAA repair, such as reintervention and late rupture. MethodsWe performed a retrospective cohort study of 13,007 patients who underwent either endovascular (EVAR) or open AAA repair (OAR) between 2003 and 2015 using data from the Vascular Quality Initiative registries. Eligible patients were linked to fee-for-service Medicare claims to identify late outcomes of rupture and aneurysm-specific reintervention. ResultsThe mean age of our cohort was 76 ± 6.7 years, 22% were female, 94% were White, and 77% underwent EVAR. The 10-year rupture incidence was slightly higher for women at 4.8 per 1000 person-years, vs 3.9 for men, but this difference was not statistically significant after risk adjustment (hazard ratio [HR] = 1.13, 95% confidence interval [CI]: 0.74-1.73). Likewise, we found no sex difference in reintervention rates (5.1 vs 4.8 in women per 1000 person-years) even after risk adjustment (HR = 0.95, 95% CI: 0.83-1.09). Regression models suggest effect modification by repair type for reintervention, where women who underwent index EVAR had a higher risk of reintervention than men (HR = 1.08, 95% CI: 0.93-1.26), whereas women who underwent OAR were at a lower risk of reintervention than men (HR = 0.79, 95% CI: 0.58-1.08); however, neither effect reached statistical significance within each subgroup. In addition, we found that the risk of reintervention for women vs men varied by clinical presentation, where women were less likely to undergo reintervention after an elective or symptomatic AAA repair but were more likely to undergo reintervention after a repair for AAA rupture (HR = 1.70, 95% CI: 1.05-2.75). ConclusionsMale and female patients who underwent AAA repair had similar rates of reintervention and late aneurysm rupture in the 10 years after their procedure. However, our findings suggest that repair type and clinical presentation may affect the role of sex in clinical outcomes and warrant further exploration in these subgroups.

Epidemiology and outcomes of traumatic vascular injury repair by trauma surgeons and vascular surgeons in a collaborative model.

Management roles for peripheral vascular injuries (PVI) are a source of ongoing debate given the concern for the loss of vascular skills among general surgeons and trauma surgeons (TS). We sought to analyze outcomes of PVI managed by TSs or vascular surgeons (VSs). This is a retrospective study of a single, Level I trauma center. Trauma patients with PVI who underwent repair from 2010 to 2021 were included. Patients were separated into groups by the surgical specialty (TS or VS) undertaking the first intervention of the injured vessel. A total of 194 patients were included, with 101 (52%) PVI managed by TS and 93 (48%) by VS. The TS group had more penetrating injuries (84% vs. 63%, p < 0.01), were more often hypotensive (17% vs. 6%, p = 0.01), and had a higher median Injury Severity Score (10 vs. 9, p < 0.001). Time from arrival to operating room was lower in the TS group (77 vs. 257 minutes, p < 0.01), with no difference in rates of preoperative imaging. The TS group performed damage-control surgery (DCS) more frequently (21% vs. 1.1%, p < 0.01). There was no difference in reintervention rates between the two groups after excluding patients that required reintervention for definitive repair after DCS (13% vs. 9%, p = 0.34). Mortality was 8% in the TS group and 1% in the VS group ( p = 0.02) with no deaths related to the PVI repair in either group. There was no difference in PVI repair complication rates between the two groups (18% vs. 13%; p = 0.36). In our collaborative model at a high-volume trauma center, a wide variety of PVI are surgically managed by TS with VS. immediately available for consultation or for definitive repair of more complex vascular injuries. Trauma surgeons performed more DCS on higher acuity patients. No difference in vascular-related complications was detected between groups. Prognostic and Epidemiological; Level IV.

An Analysis of Sex-Based Outcomes Following Transcarotid Artery Revascularization.

Several studies suggest that females have higher perioperative adverse events and decreased benefit from carotid artery revascularization with transfemoral carotid artery stenting and carotid endarterectomy (CEA) compared to males. However, there are limited data of sex-based outcomes for transcarotid artery revascularization (TCAR). A retrospective review of prospectively maintained system-wide TCAR databases was performed between December 2015-January 2022. Patients who underwent TCAR were stratified based on sex. Relevant demographics, medical conditions, anatomical characteristics, intra- and postoperative courses, and adverse events were captured. 729 patients underwent TCAR, 486 (66.6%) male and 243 (33.3%) female. Males were more likely to be diagnosed with coronary artery disease (56.9% vs 47.7%, P<.01) and were active smokers (30.4% vs 21.4%, P < .01). Age, symptomatic status, BMI, hypertension, hyperlipidemia, diabetes mellitus, arrhythmia, chronic obstructive pulmonary disease, history of myocardial infarction, heart failure with reduced ejection fraction <30%, end-stage renal disease and Charlson Comorbidity Index were similar. In the perioperative period, there was no significant difference in reintervention rates (1.6% vs 1.2%, P = .75), cranial nerve palsy (.6% vs .4%, P > .99), ipsilateral stroke (1.9% vs 3.3%, P = .29), stent thrombosis (.4% vs .8%, P > .99), myocardial infarction (0% vs 0%, P > .99) and death (1.2% vs 1.2%, P > .99). In follow-up, no significant difference was found in reintervention, ipsilateral stroke, contralateral stroke, myocardial infarction, in-stent restenosis >50%, stent thrombosis, and death. Males and females did not have a statistically significant difference in outcomes when comparing ipsilateral stroke, in-stent thrombosis, conversion to CEA, and death after TCAR. However, our cohort comprised predominantly male patients and may conceal statistical significance as the females in our cohort did have a higher tendency toward developing complications. Future studies with a larger female cohort should be conducted to determine whether there is a true disparity of outcomes between the males and females undergoing TCAR.

“Large Diameter” Aortic Endografts are Associated With Aneurysm Sac Expansion

The purpose of this study was to evaluate the association between aortic endograft diameter and long-term outcomes following endovascular aneurysm repair (EVAR) performed in accordance with manufacturer instructions for use (IFU). A retrospective review of consecutive patients undergoing on-IFU EVAR (2000-2018) was performed to facilitate a comparative analysis of long-term patient outcomes based on device diameter. "Large diameter" devices were defined as >34mm. The primary outcome of interest was freedom from sac expansion throughout long-term follow-up. Analyses included standard bivariate analyses, Kaplan-Meier with log-rank comparison, and Cox proportional hazards multivariate analysis. A total of 1,099 underwent on-IFU EVAR from 2000-2018. Follow-up data were available for 980 patients. Of these, 75 patients (7.6%) were treated with >34-mm devices. There were no significant differences in demographics or comorbidities between the 2 groups, although preoperative abdominal aortic aneurysm size was greater in patients undergoing implantation of >34-mm devices (58±8.5mm vs. 56±17.4mm; P=0.05). Median follow-up was 10.3years. Patients with grafts >34mm had reduced freedom from sac expansion throughout follow-up (P=0.038). There were no significant differences in reintervention rates, open conversion, or rupture when stratified by graft diameter. A multivariate Cox regression identified patient age, preoperative abdominal aortic aneurysm size, need for reintervention, and use of >34-mm endografts as independent factors associated with expansion. The use of large diameter aortic endografts is associated with higher rates of sac expansion during long-term follow-up. Although there is undoubtedly a role for large diameter graft use in selected patients, it is important to recognize that these devices were typically approved post hoc without the same regulatory scrutiny of smaller endografts. These findings underscore the importance of ongoing surveillance for patients treated with >34-mm grafts, irrespective of compliance with manufacturer IFU.

Midterm Outcomes of Endovascular Versus Open Surgical Repair of Intact Descending Thoracic Aneurysms in Patients with Connective Tissue Disorders

Data on the efficacy of endovascular thoracic endovascular aneurysm repair (TEVAR) versus open surgical repair for chronic aortic pathology in patients with connective tissue disorders are limited. In particular, few studies have examined outcomes of TEVAR versus open repair for intact descending thoracic aortic aneurysms (DTAA) in this subset of patients beyond index hospitalization. Therefore, we investigate 5-year outcomes of TEVAR and open surgical repair of intact DTAAs in patients with known connective tissue disorders. Using the TriNetX Data Network, a global federated database of over 75 million patients, we conducted a retrospective cohort study of patients with connective tissue disorders and intact DTAAs, treated initially with either TEVAR or open surgery. Eligible patients were 1:1 propensity score-matched for several preoperative co-variates including demographics, surgical history, and comorbidities. We calculated and compared 5-year cumulative incidence and hazards of death, re-intervention, aortic dissection, renal failure, stroke, intracranial hemorrhage, paraplegia, and limb ischemia using the Kaplan-Meier method and Cox proportional hazards models. We identified 55 patients treated with TEVAR and 200 treated with open surgery. After matching, we compared 46 patients in each cohort. After matching, only incidence of re-intervention via endovascular approach was significantly higher among patients in the TEVAR cohort (27.1% vs. 4.8%, P=0.009). Rates and hazards of other outcomes were higher in the TEVAR group, however, differences were not statistically significant. Patients treated with TEVAR had numerically higher rates of adverse outcomes compared to open surgical patients, however only the difference in re-intervention rate was statistically significant. Given the evolving landscape of endovascular intervention, greater-powered studies are needed to determine the safety and efficacy of TEVAR for intact DTAAs in a select subset of connective tissue disorder patients.

Comparative effectiveness of sleeve gastrectomy vs Roux-en-Y gastric bypass in patients giving birth after bariatric surgery: reinterventions and obstetric outcomes.

Women of childbearing age comprise approximately 65% of all patients who undergo bariatric surgery in the USA. Despite this, data on maternal reintervention and obstetric outcomes after surgery are limited especially with regard to comparative effectiveness between sleeve gastrectomy and Roux-en-Y gastric bypass, the most common procedures today. Using IBM MarketScan claims data, we performed a retrospective cohort study of women ages 18-52 who gave birth after undergoing laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass with 2-year continuous follow-up. We balanced the cohort on observable characteristics using inverse probability weighting. We utilized multivariable logistic regression to examine the association between procedure selection and outcomes, including risk of reinterventions (revisions, enteral access, vascular access, reoperations, other) or adverse obstetric outcomes (pregnancy complications, severe maternal morbidity, and delivery complications). In all analyses, we controlled for age, U.S. state, and Elixhauser or Bateman comorbidities. From 2011 to 2016, 1,079 women gave birth within the first two years after undergoing bariatric surgery. Among these women, we found no significant difference in reintervention rates among those who had gastric bypass compared to sleeve gastrectomy (OR 1.41, 95% CI 0.91-2.21, P = 0.13). We then examined obstetric outcomes in the patients who gave birth after bariatric surgery. Compared to patients who underwent sleeve gastrectomy, those who had Roux-en-Y gastric bypass were not significantly more likely to experience any adverse obstetric outcomes. In this first national cohort of females giving birth following bariatric surgery, no significant difference was observed in persons who underwent Roux-en-Y gastric bypass versus sleeve gastrectomy with respect to either reinterventions or obstetric outcomes. This suggests possible equipoise between these two procedures with regards to safety within the first two years following a bariatric procedure among women who may become pregnant, but more research is needed to confirm these findings in larger samples.

Initial Treatment Choice Affects Cost-Effectiveness and Reintervention Rates for Dupuytren Contracture: A National Census Among Veterans Affairs Patients.

A multitude of treatments for Dupuytren contracture are available, including both invasive and minimally invasive options. This study compares the reintervention rates and costs associated with various treatment options for Dupuytren disease (DD) within the Veterans Affairs (VA) Health Administration. Using the Corporate Data Warehouse, a national census was performed including all patients treated for DD in years 2014 to 2020 within the VA health care system. Patients treated with collagenase clostridium histolyticum (CCH), percutaneous needle aponeurotomy (PNA), open fasciotomy, palmar fasciectomy, single finger fasciectomy, and multifinger fasciectomy were compared. The total cost of initial treatment was compared between modalities. The 5-year reintervention rates were compared using a Kaplan-Meier analysis. During the study period, 8530 patients were treated for DD (3501 fasciectomy, 3351 CCH, 880 PNA, 798 fasciotomy). The overall median treatment cost was found to be the least for PNA (P < .0001). The 5-year reintervention rates were significantly lower for single finger fasciectomy (6.5%), operative fasciotomy (8.2%), and palmar fasciectomy (9%) when compared with PNA (12.3%), multifinger fasciectomy (13.1%), and CCH (14.4%) (P < .001). However, reintervention rates were comparable between patients treated with PNA, multifinger fasciectomy, and CCH (P > .05). Within the VA population, PNA is the most affordable procedure per treatment episode and is associated with reintervention rates that are comparable to those of CCH. Multifinger fasciectomy, CCH, and PNA had comparable reintervention rates. The differences in reintervention rates may partially be explained by patients' willingness to consider additional treatment to correct any remaining or recurrent deformity.

Prevalence of hypercoagulable states in stented thrombotic iliac vein compression syndrome with comparison of re-intervention and anticoagulation regimens.

BACKGROUNDEndovascular therapy is playing an increasing role in the treatment of iliofemoral venous disease. Iliac stent patency is multifactorial, and current management is based on best clinical practices, varying by institution.AIMTo evaluate how thrombophilia influences management and outcomes of patients who undergo venous stenting for thrombotic iliac vein compression syndromes.METHODSA retrospective observational analysis was performed on 65 patients with thrombotic iliac vein compression syndrome that underwent common iliac vein (CIV) stenting between December 2013 and December 2019 at a large academic center. Search criteria included CIV stenting and iliac vein compression. Non-thrombotic lesions and iliocaval thrombosis and/or occlusions were excluded. A total of 65 patients were selected for final analysis. Demographic information, procedural data points, and post-procedural management and outcomes were collected. Statistical analyses included Fisher's exact and Chi-square tests to compare discrete variables and the Wilcoxon rank-sum test to compare continuous variables between thrombophilia positive and negative patients.RESULTS65 patients underwent successful balloon angioplasty and CIV stenting. Of these patients, 33 (50.8%) underwent thrombophilia testing, with 16 (48.5%) testing positive. Stent patency on ultrasound did not significantly differ between thrombophilia positive and negative patients at 1 mo (92.3% vs 81.3%, P = 0.6), 6 mo (83.3% vs 80%, P > 0.9), or 12 mo (77.8% vs 76.9%, P = 0.8). Immediately after stent placement, thrombophilia patients were more likely to be placed on dual therapy (aspirin and anticoagulation) or triple therapy (aspirin, clopidogrel, and anticoagulation) (50% vs 41.2%, P > 0.9), and remain on dual therapy at 6 mo (25% vs 12.5%, P = 0.5) and 12 mo (25% vs 6.7%, P = 0.6). There was no significant difference in re-intervention rates (25% vs 35.3%, P = 0.7) or number of re-interventions (average 2.3 vs 1.3 per patient, P = 0.4) between thrombophilia positive and negative patients.CONCLUSIONHalf of patients with stented thrombotic iliac vein compression syndrome and thrombophilia testing were positive. The presence of thrombophilia did not significantly impact stent patency or re-intervention rates.

Neonatal or infantile palliation for Tetralogy of Fallot with or without pulmonary atresia: Modified Blalock–Taussig shunt versus restrictive right ventricle to pulmonary artery connection. A 20-year experience

To compare mortality, morbidity and efficiency of modified Blalock–Taussig shunt (mBTS) versus restrictive right ventricle to pulmonary artery connection (RVPAc) in patients with Tetralogy of Fallot (TOF) and TOF with pulmonary atresia (TOF-PA). We performed a monocentric retrospective review of 198 patients (93 TOF and 105 TOF-PA) who had palliation between 1996 to 2016 in their first year of life. Patients with Major aorto-pulmonary collaterals were excluded. Median follow-up was 11.0 [95% CI: 5.8–16.2] years after palliation. Five patients were lost at the follow-up. Ninety-five patients underwent mBTS, and 103 had an RVPAc. Nakata index before palliation was 129 (80–170) mm 2 /m 2 in mBTS group and 100 (71–146) mm 2 /m 2 in RVPAc group ( P = 0.001). Weight at palliation was similar between mBTS and RVPAc patients ( P = 0.1). Age at the palliation was 12 days (7–24.7) in RVPAc group and 21 days (8–87.5) in mBTS group ( P = 0.0002). One hundred and seventy-five patients underwent repair and 5 are waiting for it. Among them 39 necessitated a repair with a pulmonary valve conduit (23 mBTS and 16 RVPAc P = 0.004). Two patients were unsuitable for repair. Eleven patients died before repair (5.7%). There was no difference in mortality rate regarding the type of palliation ( P = 0.92) or the anatomical group ( P = 0.76). Interstage reintervention before repair was n = 37 (20%). Thirty-three were surgical and four were percutaneous. No difference in reintervention rate between RVPAc or mBTS regarding the age, the weight at palliation or the anatomical group ( P = 0.56). The delay between the palliation and the complete repair was shorter in RVPAc [12.3 (6.3–37.9) months versus 6.5 (4.9–10.3) months for mBTS ( P < 0.01)]. RVPAc provide a better and a faster pulmonary artery growth in our population. It led us to limit the use of RVPAc conduit at the repair. We found no significant difference between mBTS and RVPAc for mortality and interstage reintervention.

Treatment of women with heavy menstrual bleeding: Results of a prospective cohort study alongside a randomised controlled trial

ObjectiveThe objective of this study was to compare the reintervention rate of women who opted for treatment with the levonorgestrel-releasing intrauterine system (LNG-IUS) to women who opted for endometrial ablation. Furthermore, the difference in reintervention rate between women in this observational cohort and women who were randomised was compared, with the hypothesis that women who actively decide on treatment have lower reintervention rates compared to women in a RCT. Study designAn observational cohort study alongside a multicentre randomised controlled trial (RCT) was conducted between April 2012 and January 2016, with a follow-up time of 24 months, in 26 hospitals and nearby general practices in the Netherlands. Women suffering from heavy menstrual bleeding, aged 34 years and older, without intracavitary pathology and without a future fertility desire, were eligible for this trial. Women who declined randomisation were asked to participate in the observational cohort. The outcome measure was reintervention rate at 24 months of follow-up. Results276 women were followed in the observational cohort of which 87 women preferred an initial treatment with LNG-IUS and 189 women preferred an initial treatment with endometrial ablation. At 24 months of follow-up women in the LNG-IUS-group were more likely to receive a reintervention compared to the women in the ablation group, 28/81 (35 %) versus 25/178 (14 %) (aRR 2.42, CI 1.47–3.98, p-value 0.001). No differences in reintervention rates were found between women in the observational cohort and women in the RCT. ConclusionsWomen who receive an LNG-IUS are more likely to undergo an additional intervention compared to women who receive endometrial ablation. Reintervention rates of women in the cohort and RCT population were comparable. The results of this study endorse the findings of the RCT and will contribute to shared decision making in women with heavy menstrual bleeding.

Reintervention After Infant Aortic Arch Repair Using a Tailored Autologous Pericardial Patch

Aortic arch reobstruction is a common complication after aortic repair, with rates of reintervention varying from 0% to 40%, depending on the disease and the institution. This study aimed to determine the reintervention rate in children undergoing aortic arch repair using a tailored autologous pericardial patch at our center (Monroe Carell, Jr Children's Hospital at Vanderbilt, Nashville, TN). This retrospective study examined all patients operated on by a single surgeon for aortic arch reconstruction through sternotomy, from 2011 to 2018, with 1 year of follow-up. Our data set was analyzed for normality by using the Shapiro-Wilk test, and nonparametric statistical methods were used. Kaplan-Meier survival analysis was performed, IBM SPSS software version 23 was used to perform all statistical analysis. A total of 171 patients met inclusion criteria. Twenty-three (13.5%) patients underwent aortic arch reinterventions during the study period, 17 (9.9%) catheter based and 3 (1.8%) surgical. Three patients (1.8%) had both. Freedom from reintervention at 1-year follow-up for the univentricular and biventricular patients was 82.1% and 89.4% (P= .174), respectively. To assess the growth of the aortic arch over time, cardiac catheterization measurements were used to index different parts of the aortic arch against the descending aorta. Ascending-to-descending aortic arch measurements revealed that the pre-Glenn median was 2.0 (interquartile range, 1.8 to 2.2), whereas the pre-Fontan median was 2.5 (interquartile range, 2.2 to 2.7) (P < .05). There was no significant difference in reintervention rates between biventricular and univentricular arches, and catheterization measurements showed significant growth of the arch over time. The use of a tailored autologous pericardial patch for aortic arch repair is comparable to other reported methods of arch repair.

Outcomes of Small Renal Artery Targets in Patients Treated by Fenestrated-Branched Endovascular Aortic Repair

The aim was to evaluate renal related outcomes in patients who had incorporation of a small (<4.0mm) renal artery (RA) during fenestrated-branched endovascular aortic repair (F-BEVAR). A total of 215 consecutive patients enrolled in a prospective F-BEVAR trial were reviewed. Computed tomography angiography centreline of flow reconstruction was used to measure mean RA diameter. Patients who had at least one <4.0mm main or accessory RA incorporated by fenestration or directional branch (study group) were compared with patients who had incorporation of two≥5.0mm RAs (control group). Endpoints were technical success of RA incorporation, RA rupture and kidney loss, primary and secondary RA patency, RA branch instability and re-interventions, and renal function deterioration. Twenty-four patients with 28<4.0mm RAs (16 accessory and 12 main RAs) were compared with 144 patients with 288≥5.0mm incorporated RAs. Study group patients were significantly younger than controls (72±8 vs. 75±8 years, p=.04) and more often females (46% vs. 21%, p=.018); there were no differences in cardiovascular risk factors and aneurysm extent. Technical success was 92% for <4.0mm and 99% for ≥5.0mm RA incorporation (p=.05). Inadvertent RA rupture occurred in three patients in the study group (13%) and in one (1%) in the control group (p=.009) resulting in kidney loss in two study group patients (8%) and one (1%) control group patient (p=.05). At one year, primary patency was 79±9% vs. 94±1% (p<.001) and secondary patency was 84±8% vs. 97±1% (p<.001) for study vs. control group; freedom from branch instability was 79±9% vs. 93±2% (p=.005), respectively. There were no differences in re-intervention rates and renal function deterioration between the groups. The mean follow up time was 21±14 months. Incorporation of <4.0mm RAs during F-BEVAR is associated with lower technical success, higher risk of arterial disruption and kidney loss, and lower patency rates at one year.

Residual incompetent tributaries after varicose vein surgery increased the need for reintervention after 8 years

ObjectiveThe aim of this study was to determine whether residual incompetent tributaries after varicose vein surgery affected the reintervention rate after longer follow-up. MethodsThe study is a retrospective review of data from a cohort of a previous randomized controlled study comparing surgery with and without preoperative duplex ultrasound, with follow-up after 2 months, 2 years, and 5 to 9 years clinically and with duplex ultrasound. The cohort was subdivided according to the duplex ultrasound findings 2 months after surgery: no venous incompetence, residual incompetent tributaries only, truncal incompetence, and combined truncal and tributary incompetence. Reintervention rates were compared between groups. ResultsThere were 280 patients (326 legs) who attended follow-up 2 months postoperatively and 164 patients (190 legs) after a median of 8 years (5-9 years). Another 53 patients (62 legs) were interviewed by telephone or had been reoperated on earlier during follow-up; thus, information was available for 217 patients (252 legs). Of the 252 legs, 56 (22%) were reoperated on during follow-up. In the subgroup with no venous incompetence at all 2 months postoperatively, 4 of 74 legs (5%) were reoperated on; and in the group with residual incompetent tributaries without truncal incompetence, 16 of 56 legs (29%) were reoperated on (P = .000). There was no significant difference in reintervention rate of the group with incompetent tributaries only compared with those with truncal incompetence without incompetent tributaries (12/42 legs [29%]; P = 1) or with combined incompetence of truncal vein and tributaries (22/64 legs [34%]; P = .495). The presence of perforating vein incompetence at 2 months postoperatively did not significantly alter the rate of reoperations (P = .159). In legs that had not been reoperated on, more incompetent veins could be seen progressively. In the group without any incompetent veins postoperatively, 37% still had normal findings at 8 years. ConclusionsResidual incompetent tributaries after treatment of varicose veins will increase the reintervention rate in the long term, as much as leaving a trunk vein untreated. Patients should be informed about the increased risk of reintervention if not all incompetent veins are targeted.

Functional outcomes of arteriovenous fistulas recruited with regional anesthesia

ObjectiveRegional anesthesia (RA)-induced vasodilation increases the proportion of patients with vein anatomy suitable for arteriovenous fistula (AVF) creation. The functional outcomes of AVFs created with veins initially small for size on preoperative duplex ultrasound mapping (≤2.4 mm) that are recruited under RA have not been clearly defined. We aimed to evaluate freedom from revision or thrombosis, time to first cannulation, and reintervention rates of AVFs created with veins recruited after induction of RA. MethodsA prospectively maintained quality improvement database from a single institution was queried for patients who had dialysis access created under RA. We compared AVFs created according to the original surgical plan (preoperative minimum vein diameter >2.5 mm) with AVFs recruited with RA (preoperative minimum vein diameter ≤2.4 mm). End points included freedom from revision or thrombosis, time to first cannulation, and reintervention rates. ResultsBetween May 2014 and April 2018, there were 208 dialysis access cases performed under RA. Excluding grafts, revisions, patients with previous ipsilateral AVFs, and those without preoperative ultrasound vein mapping, 135 patients were included in our analysis. Induction of RA with intraoperative duplex ultrasound allowed a change in surgical plan in 55 of 135 (42%) patients (recruited with RA), including 31 patients originally scheduled for an arteriovenous graft (mean preoperative distal upper arm cephalic vein diameter of 1.8 mm [standard deviation, 0.2 mm]) who were converted to an AVF (12 brachiobasilic, 11 brachiocephalic, and 8 radiocephalic). The remaining patients in the group of AVFs recruited with RA included 13 scheduled for brachiobasilic configurations who were converted to brachiocephalic or radiocephalic AVFs and 11 scheduled for brachiocephalic AVFs who were converted to radiocephalic AVFs. Comparing AVFs created according to the original surgical plan vs AVFs recruited with RA, there were no differences in reintervention rates (48% vs 49%; P = .90) or functional outcomes at 6 months (60% vs 65% used on hemodialysis [P = .58] and 7% vs 2% primary failure [P = .19]). ConclusionsIn this series, RA increased the proportion of patients who underwent AVF creation without compromising functional outcomes. Routine use of RA in access surgery could have significant implications in meeting national guidelines for autogenous access in the prevalent hemodialysis population.

A Comparison of Endovascular Stenting with Open Bypass for Iliac Occlusive Disease

Introduction - The endovascular approach to iliac occlusive disease is minimally invasive however it’s durability in severe disease (complete occlusion of the common and/or external iliac) is unclear. We compared our results for endovascular treatment of severe iliac occlusive disease to open bypass. Methods - All patients undergoing iliac inteventions from 2009 – 2015 were included. Procedures performed for acute ischaemia or those done to facilitate further endovascular intervention, such as EVAR, were excluded. Demographics co-morbities and operative details were recorded. Primary outcome was iliac patency. Results - 225 endovascular iliac procedures were performed on 288 legs. 47 individuals fitted the criterium for severe iliac disease. The open group for compariosn comprised seventeen patients (14 aortobifemoral bypasses and 3 aortibiiliac bypasses). The endovascular cohort were significantly older than the open cohort with a mean age of 66yrs vs 59yrs (p0.009). There were no statistical differences in gender, cardiac disease, smoking status, renal disease or indication for repair. Thirty-five (74.4%) endovascular interventions were technically successful on first attempt; 2 others following a second attempt. Five (13.5%) patients with a technically successful endovascular intervention required a second procedure for re-stenosis with median time to re-intervention of 295days (range 44-513). Primary assisted patency was 74% at 2yrs. Of the ten patients where technical success was not achieved via an endovascular approach; 5 had no further intervention, 3 underwent a fem-fem crossover graft and 2 had an axillary-bifemoral bypass. Three (17.6%) re-interventions were required in the open group; thrombectomy in two and one axillo-femoral bypass. Median time to re-intervention 2days (range 2-12). Primary-assisted patency at 2 yrs was 94% 30 day mortality in the open group was 5.8% (1/17) and 0% in (0/47) the endo group (p=0.26). Technical failure rate with an endovascular approach was significantly higher than open surgery – 10/47 vs 0/17 (p= 0.03). There was no statistical difference in re-intervention rates– 5/37 vs 3/17 (p= 0.28). Conclusion - An endovascular approach provides a viable first line appraoch to occlusive iliac disease with acceptable patency rates. Use of endovascular techniques allow for a low risk alternative to an open surgery albeit at the cost of a lower technical success rate.

Thirty-day outcomes from the Society for Vascular Surgery Vascular Quality Initiative thoracic endovascular aortic repair for type B dissection project

ObjectiveThe purpose of the Society for Vascular Surgery Vascular Quality Initiative thoracic endovascular aortic repair (TEVAR) for dissection project is to assess the effectiveness of TEVAR for type B dissection by evaluation in a prospective quality improvement registry. Here we describe the project cohort and 30-day outcomes of TEVAR for both acute dissection (AD) and chronic dissection (CD) patients and focus specifically on outcomes of uncomplicated AD patients based on timing of treatment. MethodsSummary statistics were performed comparing patients with AD (<30 days) and patients with CD. Both groups were further divided into those with complicated (ie, malperfusion or rupture) or uncomplicated presentation. Further subdivision of the uncomplicated AD patients into treatment at ≤48 hours, >48 hours to <7 days, ≥7 days to ≤14 days, and >14 days to <30 days was performed. Kaplan-Meier analysis was performed for 30-day survival and freedom from reintervention. ResultsData for 397 patients (204 AD patients and 193 CD patients) were collected from 40 institutions. Overall, AD patients were younger than CD patients (58.8 vs 62.2 years; P = .003). Technical success, including coverage of the primary entry tear, was 98.0% for AD patients and 99.0% for CD patients, with a trend toward a higher 30-day mortality in AD patients (AD, 9.3%; CD, 5.2%; P = .126). Any degree of procedure-related spinal cord ischemia occurred in 4.4% of AD patients vs 2.1% of CD patients (P = .261), with a deficit at discharge in 3.4% of AD patients vs 0.5% of CD patients (P = .068). Disabling stroke occurred in 2.5% of AD patients vs 1.6% of CD patients (P = .725); retrograde type A dissection occurred in 1.1% of AD patients vs 2.6% of CD patients (P = .412). There was a trend toward a lower freedom from reintervention in AD patients (90.7% vs 94.8%; P = .13). In uncomplicated AD patients, rapid aortic expansion was more common in the treatment groups of ≥7 days to ≤14 days and >14 days to <30 days compared with those treated within 7 days of dissection (P = .042). The uncomplicated AD cohorts based on timing of treatment were otherwise similar in demographics and presentation, with no significant differences in 30-day mortality or serious complications, such as spinal cord ischemia, stroke, or retrograde type A dissection. The 30-day reintervention rate for uncomplicated AD patients was 5.8%, with no apparent differences in reintervention rates according to timing of treatment of initial TEVAR. ConclusionsAs expected, AD patients demonstrated a trend toward a higher 30-day mortality and lower freedom from reintervention compared with CD patients. Mortality at 30 days after TEVAR for uncomplicated AD was 5.8%, and there were no clear patterns in mortality or reintervention based on timing of treatment. Further study and evaluation at longer follow-up are needed to determine the impact of timing of intervention in uncomplicated AD patients.

Multicentre Post-EVAR Surveillance Evaluation Study (EVAR-SCREEN)

Surveillance imaging is considered mandatory after endovascular aneurysm repair (EVAR), but many patients are lost to follow up and the impact of this is poorly understood. This study aimed to examine compliance with post-operative surveillance in the UK and the impact of mal-/non-compliance on endograft re-interventions and survival. EVAR-SCREEN centres reported EVAR for intact infrarenal abdominal aortic aneurysms (AAA) from 1 January 2007 to 31 December 2010, with follow up included up to 31 July 2014. Non-compliance was defined by the presence of a single 18 month period in which no surveillance imaging was performed. The outcomes were reported in compliant and non-compliant groups with survival analysis. EVAR was performed in 1414 patients in 10 UK centres. At the end of the study period there were 378 patients with five years of follow up available for analysis. Compliance with surveillance was 66% (61-68%). Compliance varied widely, from 9% to 88% between centres. Age (hazard ratio [HR] 1.03, 95% confidence interval [CI] 1.01-1.05; p=.02) and distance from hospital (HR 1.01, 95% CI 1.00-1.01; p<.001) were independent predictors of non-compliance. Non-compliant patients had lower all cause mortality in the first three years after EVAR, whereas compliant patients had lower all cause mortality 4-5 years after EVAR (p<.001). No significant difference in re-intervention rates was found between compliant and non-compliant patients. A substantial proportion of patients were non-compliant with surveillance after EVAR in the UK with considerable variation between centres. The survival benefit for EVAR after three years appeared to be related to compliance with surveillance which has implications for the future delivery of EVAR.