Higher Risk Of Reintervention Research Articles

P1331OPTIMAL PLANNING OF VASCULAR ACCESS IS CALLED FOR IN WOMEN. AVF ARE MORE INTERVENED AND ABANDONED DESPITE LESS CO-MORBIDITY

Abstract Background and Aims Central venous catheter (CVC) increase the risk of infection, central stenosis, hospitalizations, morbidity, mortality and later arterio-venous (AV) access failure. Vascular access planning begins in the predialysis stage of Chronic Kidney Disease (CKD). An optimal timely referral to vascular surgeon is possible since 80 % of patients are known to kidney units before initiating hemodialysis (HD). Despite this, some 71 % (75% women and 68 % men respectively) of incident patients had a CVC as vascular access when starting HD in Sweden during 2017. Some reports have shown increased risk of AVF failure in women which has been contradicted by others. The aim of this study was to determine factors of importance for achieving a functioning fistula for women and men. Method Data from the national Swedish Renal Registry (SRR), that covers the disease progression from CKD phase to renal replacement therapy, was used as well as mandatory national registries. Data was extracted from 2011 to 2017 for, sex, age, primary renal diagnosis, number of CVC, patient phase, co-morbidity, socio-economic factors as well as interventions and complications. A Royston-Palmer model was used for hazard ratio (HR). Cumulative incidence plots were used for fistula patency. P value < .005 was considered significant Results The study included 5040 patients at baseline (33% women). The mean age, the time in dialysis before fistula placement and numbers of CVC did not differ between the sexes. Prevalence of polycystic kidney disease was the only primary diagnosis that differed between the sexes (10.7% among women versus 6.5% among men respectively p<.01). Cancer, hypertension and ischemic heart disease, was more prevalent among men (24.0 vs 19.1 p<.001, 80,9% vs 75.7, p<.001 and 25.3 vs 18.0 p<001). Education level were similar between the sexes whereas more men were married and born in Sweden as compared women (49.3 vs 41.6 p<.001 and 78.9 vs 73.0 p<.001). Age, diabetes and peripheral arterial disease increased the risk for reinterventions by 6% and 28% and 36% (HR 1.06 [1.03,1.15], 1.28[1.18,1.40], and 1.36[1.19,1.56] respectively. The risk for reintervention and abandonment was higher for women (HR 1.19 [95% CI: 1,09,1,56, and 1.42[1,26,1.60)]. Figure 1. shows cumulative incidence for primary patency in lower arm fistula for men and women. Incidence of secondary patency abandonment is higher for women with lower and upper arm AVF while no differences between men and women were observed for AV grafts. Conclusion When receiving the first fistulas, men present a higher co-morbidity as compared to women while age and time of dialysis with a CVC is similar between the sexes. Only 42% will receive an AVF in CKD phase with detriment for men. The consequence of placement in CKD phase could matter and needs to be further analysed. AVF confers a higher risk for reintervention and abandonment, particularly among women which may explain the higher use of CVC. This higher risk must be taken into account when planning for vascular access and follow up.

Early and Midterm Outcomes of Open and Endovascular Revascularization of Chronic Mesenteric Ischemia

BackgroundRevascularization strategies for chronic mesenteric ischemia (CMI) include open (OR) and endovascular (ER) modalities. The primary objective of this study was to analyze the safety and effectiveness of OR and ER and the impact of clinical and morphological variables on early and midterm outcomes in a consecutive series of CMI patients in a tertiary referral center.Patients and methodsFrom 2004 to 2017, all CMI patients treated with OR and ER were retrospectively identified. Patient records, preoperative imaging, as well as peri- and postoperative outcomes were analyzed. Univariable and multivariable analysis was performed to identify clinical or morphological variables affecting reintervention rates within 2 years.ResultsIn total, 63 patients (33% male; mean age 71, range 60–76 years) were treated by ER (41 patients) or OR (22 patients) for CMI. Mean follow-up was 26 (10–71) months. 30-day mortality was 0.0% after ER and 4.5% after OR (p = 0.069); 30-day morbidity was 9.8% vs. 31.8%, respectively (p = 0.030). Length of stay was significantly longer after OR (14 vs. 4 days; p < 0.001). Freedom from reintervention rate after 2 years was 82% after OR and 73% after ER (p = 0.14). Overall survival did not differ after 2 years (OR 85% vs. ER 86%; p = 0.35). Multivariable analysis revealed that smoking was associated with higher risk of reintervention (hazard ratio, HR: 4.14; 95% confidence interval, CI 1.11–15.53; p = 0.03). Additionally, a nonsignificant trend of lower reintervention rates after OR was detected (HR 0.23 95% CI 0.05–1.08; p = 0.06).ConclusionDue to a lower invasiveness, despite the higher reintervention rate, an “endovascular first” strategy is justified and recommended.

Infrarenal Abdominal Aortic Aneurysm Endovascular Treatment: Long-term Results From a Single-Center Experience in an Unselected Patient Population

The aim of the present study was to evaluate early-, mid-, and long-term outcomes in an unselected population of patients treated for abdominal aortic aneurysms (AAAs) by endovascular aneurysm repair (EVAR) with different commercially available off-the-shelf devices. A retrospective study was conducted on a prospectively compiled computerized database on patients presenting an infrarenal AAA treated between January 2008 and December 2015 in a high-volume Italian tertiary referral Center. Demographic, clinical, and specific morphological features were considered as potentially influencing the outcomes and the type of the implanted device. Outcome measures were procedure-related reintervention, AAA-related, and all-cause mortality rates at 30-day, 12-month, and long-term follow-up. Reinterventions considered for the analysis were AAA rupture, graft infection, type I or III endoleaks, type II endoleaks with sac enlargement > 5mm, graft stenosis or occlusions, procedures related to renal or visceral ischemia, and reintervention for access vessel injury. Of 498 EVAR procedures performed for elective infrarenal AAA treatment during the entire study period, 479 patients were enrolled, the mean age was 73.5±7.34years (range 51-91), and 416 (86.84%) were men. The mean maximum AAA diameter was 52.02±8.04mm (range 39-90.2), a maximum AAA diameter ≥59mm was recorded in 107 patients (22.33%), and an aortic neck length was <10mm in 137 (28.60%). Technical success was achieved in all patients. At a mean follow-up of 52.97±26.16months (range 1-120), overall reintervention and death rates were 8.14% and 20.04%, respectively, without AAA-related deaths. At univariate analysis, hypertension was the only demographical variable found to be associated with higher risk of reintervention, P=0.04 (OR: 2.34; CI 95%: 1.00-5.42). Furthermore, male sex (P=0.02; OR: 2.62; CI 95%: 1.09-6.27) and chronic renal insufficiency (P=0.003; OR: 2.08; CI 95%: 1.27-3.42) were associated with higher mortality rates. AAA diameter ≥59mm was statistically associated with a higher rate of both reintervention and mortality: P<0.001 (OR: 9.05; CI 95%: 4.52-18.11) and <0.001 (4.00; 2.46-6.49), respectively. Our experience seems to suggest that EVAR could be safely and effectively performed in an unselected patients' population, with encouraging results up to a ten-year follow-up.

Long-term Device Outcomes of Mesh Implants in Pelvic Organ Prolapse Repairs.

To evaluate the longer-term safety and reintervention outcomes of mesh implants in pelvic organ prolapse (POP) repairs. We conducted a population-based cohort study of women undergoing POP repairs in inpatient and outpatient surgical settings between 2008 and 2016 in New York State. Multivariable logistic regression was used based on patient and procedural characteristics and hospital volume between mesh and nonmesh groups to obtain propensity scores for each individual. Long-term safety events and reinterventions were assessed using time-to-event analysis. We identified 54,194 women undergoing POP repairs (12,989 with mesh, and 41,205 without mesh). Mean age was 59.8 (±13.1) years, and median follow-up was 4.7 years (interquartile range, 2.4-6.8 years). In the propensity score-matched 12,284 pairs of women, POP repair with mesh was associated with a higher risk of reintervention when compared with POP repair without transvaginal mesh (hazard ratio 1.40, 95% CI 1.27-1.54, P<.001). The estimated risk of undergoing a reintervention at 5 years was 8.8% (95% CI 8.2-9.3%) in the mesh group and 6.3% (5.9-6.8%) in the nonmesh group. Among patients who had reinterventions, 18.5% of those operated with mesh had a reintervention related to mesh-related complications. Even though transvaginal mesh has been removed from the market, the risk of mesh complications did not diminish over time and these women warrant close follow-up. Continued surveillance of mesh in POP repairs is essential to ensure safety for the women who have already been implanted.

Atrioventricular Valve Function Predicts Reintervention in Complete Atrioventricular Septal Defect.

Objective:Technical performance score (TPS) has been associated with both early and late outcomes across a wide range of congenital cardiac procedures. A previous study has shown that the presence of residual lesions before discharge, as measured by TPS, is accurately able to identify patients who required postdischarge reinterventions after complete atrioventricular septal defect (CAVSD) repair. The aim of this study is to determine which subcomponents of TPS best predict postdischarge reinterventions after CAVSD repair.Methods:This was a single-center retrospective review of patients with CAVSD after repair between January 2000 and March 2016. We assigned TPS (class 1, no residua; class 2, minor residua; class 3, major residua or reintervention before discharge for residua) based on subcomponent scores from discharge echocardiograms. Outcome of interest was postdischarge reintervention.Results:Among 344 patients, median age was 3.2 months (interquartile range [IQR], 2.4-4.2). There were 34 (10%) postdischarge reinterventions. Median follow-up was 2.6 years (IQR, 0.09-7.9). Trisomy 21 and concomitant procedure were associated with postdischarge reinterventions. After adjusting for these factors, among the subcomponents, left atrioventricular valve stenosis and regurgitation, right atrioventricular valve regurgitation, residual ventricular septal defect, and abnormal conduction at discharge were significantly associated with postdischarge reinterventions.Conclusions:We demonstrated the ability of TPS to predict postdischarge reinterventions in patients who underwent CAVSD repair. Residual left and right atrioventricular valve regurgitation and abnormal conduction at discharge were among the subcomponents strongly associated with postdischarge reinterventions. Thus, TPS may aid clinicians in identifying children at higher risk for reintervention.

Long-Term Outcomes of Open Surgery and Stent Graft Treatment in Patients Undergoing Repeat Thoracic Aortic Aneurysm Repair from Previous Anastomosis Site.

Objective: The purpose of this study was to compare the long-term outcomes of open surgery and thoracic endovascular aortic repair (TEVAR) in patients undergoing repeat thoracic aortic repair from previous anastomosis site.Methods: From January 2009 to December 2017, 68 patients needed repeat aortic surgery from previous anastomosis site. Twenty-three patients had dissected distal aorta and 45 patients had non-dissected distal aorta. Early and long-term outcomes of open surgery and TEVAR were compared in both groups.Results: There were no significant differences in patient background between the two treatments in both groups. Open surgery was associated with longer intensive care unit stay, but there was no significant difference in in-hospital mortality in both groups. In patients with dissected distal aorta, there was no significant difference in long-term mortality (p=0.73). However, TEVAR was associated with higher risk of reintervention (p=0.038). In non-dissected distal aorta patients, acute kidney injury (p=0.002) and prolonged ventilation (p=0.032) were more often observed in open surgery. However, there were no significant differences in long-term mortality (p=0.23) and freedom from reintervention (p=0.13).Conclusions: Long-term outcomes were similar between open surgery and TEVAR in both groups. However, TEVAR in patients with dissected distal aorta was associated with higher risk, for reintervention.

Midterm prognosis of type B aortic dissection with and without dissecting aneurysm of descending thoracic aorta after endovascular repair

Few studies support guidelines for the use of thoracic endovascular aortic repair (TEVAR) to address type B aortic dissection (TBAD) coexisting with descending thoracic aortic dissection and aneurysm (dTADA). This cohort study investigated midterm outcomes of TBAD with dTADA (dTADA group, n = 31) and without dTADA (non-dTADA group, n = 98) after TEVAR. Compared with the non-dTADA group, the dTADA group exhibited higher incidences of type Ia endoleak (29.0% vs. 3.1%, P < 0.001) and reintervention (16.1% vs. 5.1%, P = 0.045). The completely thrombosed rate of the thoracic false lumen was significantly lower in the dTADA group than in the non-dTADA group (45.2% vs. 80.6%, P < 0.001). Although the two groups exhibited similar mortality rates, TBAD coexisting with no regressive dTADA after TEVAR was an independent predictor of mortality (HR: 15.52, 95% CI: 1.614–149.233, P = 0.018). Moreover, the change percentages of false lumen retraction and true lumen re-expansion in the dTADA group were significantly inferior to those of the non-dTADA group at levels of 4th, 6th, 8th and 10th thoracic vertebra throughout follow-up. In conclusion, in the presence of preexisting dTADA, the failure of the dTADA to regress after TEVAR is associated with lower survival and a higher risk of reintervention.

Early Duplex Surveillance Following Deep Venous Stenting for the Treatment of Post- Thrombotic Syndrome can Predict Patients at Greatest Risk for Re-intervention

Background: Endovascular treatment of post-thrombotic syndrome using nitinol venous stents is associated with symptomatic improvement, but ∼40% require re-intervention. We examined whether ultrasound surveillance was sensitive for re-intervention, and whether it was possible to predict patients at greatest risk of re-intervention. Methods: Stent patency was assessed between 2012–2017 using duplex ultrasonography 24hrs, 2wks, 6wks, 3mths, 6mths, 1yr and yearly post-intervention. Maximum in-stent stenosis was calculated, with re-interventions performed when stent diameter reduction was >50%. Patient demographics were collected to determine which factors were associated with re- intervention. Results: Cumulative patency was 167/194 (86%). However, 79 (41%) patients required re-intervention to maintain patency, of which 40/79 (51%) occurred within 3wks of their procedure. Stenting across the inguinal ligament was associated with a higher risk of early re-intervention (HR 1.817; p=0.048, 95% CI [1.005–3.285]). Re-interventions immediately followed surveillance in 70/79 (87%) cases, and this was driven by scan results rather than symptom change. At 6wks, maximum in-stent stenosis <30% was a strong predictor of being low risk for re- intervention at 6mths (HR 0.038; p=0.003, 95% CI [0.004-0.322]). Conversely, maximum in- stent stenosis between 30-50% at 6wks was associated with a higher risk of re-intervention at 6mths (HR 29.90; p=0.002, 95% CI [3.519–253.989]). Conclusions: Ultrasound surveillance should occur at frequent intervals up to 3wks post deep venous stenting. Surveillance at 6wks could be used to differentiate between patients that require further surveillance before 6mths. These may include patients with maximum in-stent stenosis between 30-50% at 6wks and patients with stents crossing the inguinal ligament.

Five-year clinical outcomes of uterine artery embolization for symptomatic leiomyomas: An analysis of risk factors for reintervention

ObjectivesThe objective of this study is to investigate the five-year reintervention rate of uterine artery embolization (UAE) for symptomatic leiomyomas and to identify potential predictive factors of reintervention. MethodsFrom March 2011 to February 2012, 92 consecutive women (mean age 41.9 years, range 28–55 years) underwent bilateral UAE. Contrast-enhanced magnetic resonance imaging (MRI) was performed at three-month follow-up. After annual follow-up, a survey on clinical outcome and reintervention incidences was performed at five-year follow-up. Potential predictive factors of reintervention were evaluated. ResultsOf the 67 patients, menorrhagia and/or bulk-related symptoms were resolved after UAE in all but one patient (98.5%). At median follow-up of 60 months (range, 5–60 months), reintervention rate was 10.4%, with seven reintervention cases (five myomectomy and two hysterectomy cases). Complete (100%) or near complete (90–99%) infarction rate of the dominant leiomyoma was 96.4% (54 of 56). Independent factors of reintervention on multivariate logistics regression analysis included near complete or partial (<90%) infarction of the dominant leiomyoma (odds ratio [OR] 22.238; 95% confidence interval [CI] 2.405–205.620; p = 0.006), as well as the presence of non-dominant viable leiomyomas (OR 12.134; 95% CI 1.213–121.409; p = 0.034). ConclusionUAE provides excellent and sustained symptom improvement of symptomatic leiomyomas with a low reintervention rate at five-year follow-up. In addition to near complete or partial infarction of the dominant leiomyoma on follow-up MRI, the presence of viable non-dominant leiomyomas indicates a higher risk of reintervention.

410. Nitinol venous stent outcomes in peripartum women following treatment for acute ilio-femoral deep vein thrombosis

Introduction Deep vein thrombosis (DVT) is the leading cause of morbidity and mortality within pregnant and post-partum women. Contemporary management of acute ilio-femoral DVT includes catheter-directed thrombolysis and stenting of an obstructive lesion. Objective This study examines venous stent related outcomes of peripartum women (pregnant or within 6wks post-partum) with acute ilio-femoral DVT. Methods Peripartum women (2012–2017) treated for acute ilio-femoral DVT were included for analysis. Primary patency was defined as a patent stent with Results Of 190 patients treated for acute ilio-femoral DVT, 81 (43%) were women. Cumulative patency was 88% (median follow-up 2.3 yrs; range 30–328 wks). From this group, 9 women were peripartum (11%). Onset of DVT was post-partum for all (mean 4 wks after birth; range 3–6 wks). Two women were treated with catheter-directed thrombolysis alone, and 7 women were also stented. Median age at the time of stent placement was 29yrs (range 22–41 yrs). Primary, primary-assisted, and secondary patency rates were 14%, 43%, and 43%, respectively. Re-intervention was required in 6/7 (86%) peripartum women, with mean time to re-intervention of 9 wks (range 1–33 wks). Venous stenting in peripartum women was associated with a higher risk of re-intervention (HR 6.58; p = 0.0001, 95% CI [2.46, 17.60]), and was a strong predictor of cumulative patency loss (HR 10.71; p = 0.002, 95% CI [2.37, 48.51]). Discussion Peripartum women are significantly more likely to require re-intervention and experience patency loss compared with their non-peripartum counterpart. Thresholds for intervention may need to be higher and periprocedural anticoagulation strategies require more investigation if treatment is to be offered in the peripartum period.

Secondary Interventions after Vein Stent Placements: Why Do Venous Stents Fail?

This study was undertaken to better characterize the secondary interventions after venous stenting for chronic, proximal venous outflow obstruction. A retrospective study of 486 patients (mean age, 59.7 years; range, 19-91 years; SD 13.5 years; 56% female; 91% had edema; CEAP class III 66.7%; CEAP class VI 11.1%; bilateral iliac stents placement 58%; 30-day follow-up 89.4%; mean follow-up duration >320 days) who underwent 545 consecutive venous stenting for chronic proximal venous outflow obstruction between January 2013 and October 2016 at single institution. Wilcoxon Mann-Whitney tests used in categorical variables (comorbidities). Simple logistic regressions for interval variables (total stent length). Multiple logistic regressions used to analyze 6-month, 1-year, and 3-year reintervention rates. Reintervention rates were 5.7% (n = 31), 10.8% (n = 59), and 16.5% (n = 90) at 6 months, 1 year, and 3 years, respectively. The most common findings during reinterventions were new or previously missed lesions in the native vessel (n = 56, 10.3%) and in-stent stenosis (n = 24, 4.4%). Other findings included contralateral iliac venous outflow obstruction owing to unilateral inferior vena cava iliac stents 3.5% (n = 19), stent malposition 2.4% (n = 13), and acute stent thrombosis 1.5% (n = 8). Univariate analysis revealed postthrombotic state (28.2% vs 12.7%; P < .001), hypertension (20.8% vs 12.9%; P = .017), diabetes (26.1% vs 14.5%; P = .003), higher CEAP classes (OR, 1.28; P = .017) were associated with a higher risk of reintervention. Patients who had larger stent diameters (18-20 mm vs 16 mm; OR, 0.94; P < .001) and a higher number of stents placed during initial intervention (OR, 0.63; P = .001) were at a lower risk of reintervention. Multivariate analysis showed that patients who are postthrombotic (OR, 2.35; P = .001), diabetic (OR, 1.85; P = .033), and with smaller stent diameters (OR, 1.06; P = .003) were at a higher risk of reintervention. Assessment for 3 years after vein stenting for chronic proximal venous outflow obstruction demonstrates an acceptable incidence of reinterventions. Stenosis in a native vein, either new or missed from initial stent procedure, was the most common finding. Impairment of contralateral venous outflow infrequently complicated unilateral inferior vena cava/common iliac stents placed for May-Thurner syndrome. Acute stent thrombosis was an infrequent finding. Many reinterventions seemed preventable with modifications in the initial procedure.

Outcomes of antegrade and retrograde open mesenteric bypass for acute mesenteric ischemia

BackgroundAcute mesenteric ischemia (AMI) is a challenging clinical problem associated with significant morbidity and mortality. Few contemporary reports focus specifically on patients undergoing open mesenteric bypass (OMB) or delineate outcome differences based on bypass configuration. This is notable, because there is a subset of patients who are poor candidates for endovascular intervention including those with flush mesenteric vessel occlusion, long segment occlusive disease, and a thrombosed mesenteric stent and/or bypass. This analysis reviewed our experience with OMB in the treatment of AMI and compared outcomes between patients undergoing either antegrade or retrograde bypass. MethodsA single-center, retrospective review was performed to identify all patients who underwent OMB for AMI from 2002 to 2016. A preoperative history of mesenteric revascularization, demographics, comorbidities, operative details, and outcomes were abstracted. The primary end point was in-hospital mortality. Secondary end points included complications, reintervention, and overall survival. Kaplan-Meier estimation and Cox proportional hazards regression were used to analyze all end points. ResultsEighty-two patients (female 54%; age 63 ± 12 years) underwent aortomesenteric bypass (aortoceliac/superior mesenteric, n = 44; aortomesenteric, n = 38) for AMI. A history of prior stent/bypass was present in 20% (n = 16). A majority (76%; n = 62) underwent antegrade bypass and the remainder received retrograde infrarenal aortoiliac inflow. Patients receiving antegrade OMB were more likely to be male (53% vs 25%; P = .02), have coronary artery disease (48% vs 25%; P = .06), chronic obstructive pulmonary disease (52% vs 25%; P = .03), and peripheral arterial disease (60% vs 35%; P = .05). Concurrent bowel resection was evenly distributed (antegrade, 45%; retrograde, 45%; P = .9) and 37% (n = 30) underwent subsequent resection during second look operations. The median duration of stay was 16 days (interquartile range, 9-35 days) and 78% (n = 64) experienced at least one major complication with no difference in rates between antegrade/retrograde configurations. In-hospital mortality was 37% (n = 30; multiple organ dysfunction, 22; bowel infarction, 4; hemorrhage/anemia, 2; arrhythmia, 1; stroke, 1; 30-day mortality, 26%). The median follow-up was 8 months (interquartile range, 1-26 months). The 1- and 3-year primary patency rates were both 82% ± 6% (95% confidence interval, 71%-95%), with 10 patients requiring reintervention. Estimated survival at 1 and 5 years was 57% ± 6% and 50% ± 6%, respectively. Bypass configuration was not associated with complication rates (P > .10), in-hospital mortality (log-rank, P = .3), or overall survival (log-rank, P = .9). However, a higher risk of reintervention was observed in patients undergoing retrograde bypass (hazard ratio, 3.0; 95% confidence interval, 0.9-11.0; P = .08). ConclusionsOMB for AMI results in significant morbidity and mortality, irrespective of bypass configuration. Antegrade OMB is associated with comparable outcomes as retrograde OMB. The bypass configuration choice should be predicated on patient presentation, anatomy, physiology, and surgeon preference; however, an antegrade configuration may provide a lower risk of reintervention.

Outcomes of Antegrade and Retrograde Open Mesenteric Bypass for Acute Mesenteric Ischemia

Acute mesenteric ischemia (AMI) is a challenging clinical problem associated with significant morbidity and mortality. Despite increasing adoption of endovascular strategies to manage AMI, few contemporary reports focus on patients undergoing open mesenteric bypass (OMB). This is notable because there is a subset of patients who are poor candidates for peripheral intervention, including those with flush aortic visceral vessel occlusion, long-segment occlusive disease, and thrombosed mesenteric stents or bypass. Historical reports identify a retrograde OMB configuration as the safest choice because of the perception that an antegrade approach has higher risk. The purpose of this analysis was to review our experience with OMB and to compare outcomes of antegrade and retrograde OMB in the treatment of AMI. A single-center, retrospective chart review was performed to identify all patients who underwent OMB for AMI from 2002 to 2016. Preoperative history of mesenteric revascularization, demographics, comorbidities, operative details, and outcomes were abstracted. The primary end point was in-hospital mortality. Secondary end points included complications, reintervention, and overall survival. Kaplan-Meier methodology was used to characterize reintervention and survival. Eighty-two patients (female, 54%; age, 63 ± 12 years) underwent aortomesenteric bypass (aortoceliac/superior mesenteric, n = 44; aortomesenteric, n = 38) for AMI. History of prior stent or bypass was present in 20% (n = 16). A majority (76%; n = 62) underwent antegrade bypass; the remainder received retrograde infrarenal aortoiliac inflow. Patients receiving antegrade OMB were significantly more likely to be male (53% vs 25%; P = .03) and to have coronary artery disease (48% vs 25%; P = .05), chronic obstructive pulmonary disease (52% vs 25%; P = .03), and peripheral arterial disease (60% vs 35%; P = .05). Additional details regarding comorbidities, procedure-related variables, and outcomes are highlighted in the Table. For all subjects, concurrent bowel resection occurred in 45% (n = 37; antegrade vs retrograde, P = .9), whereas 37% (n = 30) underwent subsequent resection during second-look operations. In-hospital mortality was 34% (n = 28; 30-day mortality, 26%; multiple organ dysfunction, 20; bowel infarction, 4; hemorrhage/anemia, 2; arrhythmia; 1, stroke, 1), median length of stay was 16 (interquartile range, 9-35) days, and 76% (n = 64) experienced at least one major complication with no difference between antegrade and retrograde configurations. At mean follow-up of 18 ± 29 (median, 4; interquartile range, 1-26) months, 10 (12%) subjects experienced aortomesenteric bypass reintervention (bypass thrombosis + redo bypass, 4; percutaneous transluminal angioplasty, 3; mycotic pseudoaneurysm + redo mesenteric bypass, 2; femoral vein conduit anastomotic aneurysm, 1; primary patency: 82% ± 6% at 1 year, 82% ± 6% at 3 years [95% confidence interval, 0.7-0.9]). Overall survival at 1 year and 5 years was 57% ± 5% and 50% ± 6%, respectively (Fig). Bypass configuration was not associated with significant differences in complications or survival; however, retrograde bypass had higher risk of reintervention (hazard ratio, 3.7; 95% confidence interval, 1-14; P = .05). OMB for AMI results in significant morbidity and mortality, irrespective of bypass configuration. Antegrade OMB is associated with outcomes comparable to those of retrograde OMB. The bypass configuration choice should be predicated on the patient's presentation, the anatomy, and the surgeon's preference; however, an antegrade configuration may provide lower risk of reintervention.TablePatient demographics, comorbidities, procedure-specific details, and outcomes of open mesenteric bypass (OMB) for acute mesenteric ischemia (AMI)VariableAll patients (N = 82)Antegrade (n = 62)Retrograde (n = 20)P valueAge, years63 ± 1264 ± 1060 ± 17.6Gender, male46% (38)53% (33)25% (5).03Comorbidities Hypertension889080.24 Smoking815865.06 Peripheral artery disease546035.05 Dyslipidemia465230.09 Coronary artery disease434825.05 COPD455225.03 CRI (eGFR <60)323425.5 Diabetes2223201 CHF161810.5 Cerebrovascular disease161325.3 Arrhythmia7851Admission mode Emergency department272630 Transfer656950 Direct admit85200.1Procedure details Bowel resection (index)4545450.9 Blood loss500 (200-750)500 (250-800)400 (100-500).3 Packed red cells0.5 (0-3)1 (0-3)0 (0).004 Intravenous fluids3000 (3000-4500)3500 (3000-4500)2500 (1800-3100).02Conduit Dacron495625 Autogenous vein352955 Bovine161520.04Vessels bypassed SMA + celiac546840 SMA alone463292<.0001Outcomes LOS, days16 (9-35)22 (9-39)13 (9-17).09 Any complication7877801 30-Day death262335.3 In-hospital death343435.3Disposition Home343435 Rehabilitation unit262430 Death383935 Hospital transfer230.9Reintervention12825.07CHF, Congestive heart failure; COPD, chronic obstructive pulmonary disease; CRI, chronic renal insufficiency; eGFR, estimated glomerular filtration rate; LOS, length of stay; SMA, superior mesenteric artery.Categorical variables are presented as %. Continuous variables are presented as mean ± standard deviation or median (interquartile range). Open table in a new tab

Recent Strategies for the Management of Renal Angiomyolipoma: A Review of Diagnostic and Therapeutic Approaches

Recent prophylactic treatment options and diagnostic tools show a suboptimal improvement in patients with renal angiomyolipoma (AML). This study was an attempt to review management strategies applied before invasive options. An extensive research on medical databases such as PubMed and Scopus was performed from 1999 to 2016 using the following keywords: ‘kidney’, ‘renal’, and ‘angiomyolipoma’. All related studies on patients treating with conservative or minimally-invasive procedures were included. However, reports on surgical treatments were excluded. Treatment strategies have been selected based on outcomes resulting from computed tomography (CT) and magnetic resonance (MR) imaging. Fat content and tumor size are the most common used indications for AMLs. Unenhanced CT and chemical shift imaging provide good evidence in case of fat-poor AMLs. Chemical analysis and percutaneous biopsy are recommended in case of a diagnostic challenge. A tumor size of 6 cm or larger in diameter might necessitate invasive treatment, while AMLs patients with tumors around 4cmmay require prophylactic treatment. Of all treatment options, embolization indicated a high risk of reintervention. Moreover, everolimus and sirolimus as 2 inhibitors of mammalian target of rapamycin (mTOR) have been evaluated in clinical trials and demonstrated promising outcomes. In conclusion, advances in imaging techniques along with mTOR inhibitors and embolic materials potentiate functional outcomes in AMLs. © 2017, Nephro-Urology Monthly.

Long-Term Outcomes After Surgical Pulmonary Arterioplasty and Risk Factors for Reintervention

Although surgical patch arterioplasty is the conventional therapy for branch pulmonary artery (PA) stenosis, limited data exist on long-term outcomes. We examined the incidence of and risk factors for reintervention after surgical arterioplasty for branch PA stenosis in biventricular congenital heart disease. This retrospective cohort study included patients with 2-ventricle physiology who underwent patch arterioplasty for PA stenosis at a single high-volume congenital heart center during a 10-year period. Freedom from surgical or percutaneous reintervention for recurrent PA stenosis was evaluated. Univariate and multivariable Cox regression analyses were performed to determine risk factors for reintervention. Among 135 patients, the median age at patch arterioplasty was 0.9 years. Survival to hospital discharge (or 30 days postoperatively) was 96%. During a median follow-up period of 4.0 years, reintervention for PA stenosis occurred in 38 of 115 patients (33%) at a median time to reintervention of 1.4 years. The overall 10-year reintervention rate was 54%. In univariate analysis, age less than 30 days at initial arterioplasty, congenital PA stenosis (vs acquired), and bilateral PA stenosis (vs unilateral) were significantly associated with reintervention. In multivariable analysis, neonatal age (adjusted hazard ratio, 3.6; p= 0.002) and bilateral PA stenosis (adjusted hazard ratio, 2.8; p= 0.005) remained independently associated with reintervention. Long-term reintervention for recurrent PA stenosis after patch arterioplasty is common. Patients with bilateral PA stenosis or age younger than 30 days at the time of the index pulmonary arterioplasty are at higher risk for reintervention. These patients may benefit from frequent monitoring or novel approaches to repair.

Depression in Older Adults Undergoing Interventions for Peripheral Arterial Disease

The objective of this study was to investigate the association between depression and mortality in older adults undergoing endovascular or open interventions for peripheral arterial disease (PAD). This was a preplanned analysis of the FRaily Assessment In Lower Extremity arterial Disease (FRAILED) prospective cohort study including two centers in Montreal, Canada, designed to examine frailty in patients with PAD. Consecutive patients undergoing endovascular or open interventions for PAD (Rutherford class 3 or higher) were enrolled. Depression was assessed before the intervention using the 15-item Geriatric Depression Scale Short Form, with a score of >5 being consistent with depression. The primary outcome was all-cause mortality at 6 months. The secondary outcomes were readmission or need for reintervention. Among 149 older adults with a mean age of 70.3 ± 11.1 years, 54.7% received endovascular interventions and 45.3% received open interventions. The prevalence of screened depression was 28.4% (n = 42), whereas this had been documented in only 3.3% (n = 5) of patients in the clinical chart. The incidence of all-cause mortality was 10.0% (n = 15) in the depressed group and 1.3% (n = 2) in the nondepressed group. Univariate analysis demonstrated that depressive symptoms were associated with low appetite, weight loss, and anemia. After adjusting for relevant covariates, worsening depression scores were found to be independently predictive of 6-month mortality (odds ratio [OR], 1.48; 95% confidence interval [CI], 1.08-2.29) but not of vascular reintervention (OR, 1.11; 95% CI, 0.99-1.26) or readmission (OR, 1.16; 95% CI, 0.96-1.39). Depression is underdiagnosed in older adults undergoing endovascular or open interventions for PAD. Worsening depression scores using the Geriatric Depression Scale Short Form were found to be predictive of all-cause mortality 6 months after the intervention. The effect of depression on mortality did not appear to be mediated by a higher risk of reintervention or readmission.

PC166 A Matched Case-Control Study on Open and Endovascular Treatment of Popliteal Artery Aneurysms

This study compared early and late results of open and endovascular management of popliteal artery aneurysm (PAA) in a retrospective single-center matched case-control study. From January 1981 to December 2015, 309 consecutive interventions for PAA were performed in our institution. Data concerning these interventions were prospectively inserted in a dedicated database. A retrospective analysis of such database was performed, and 59 interventions carried out with endovascular repair (ER) were found, while the remaining 250 intervention were open repair (OR). ER was preferred in older asymptomatic patients, while OR was offered more frequently to patients with a thrombosed PAA and a poor run-off status. A one-to-one coarsened exact matching on the basis of all the baseline demographic, clinical and anatomical covariates significantly different between the two treatment options was performed, and two equivalent groups of 56 ERs and ORs were generated. The two groups were compared in terms of perioperative (<30 days) results with χ2 test and of follow-up outcomes with Kaplan-Meier curves and log-rank test. There were no differences between the two groups in perioperative deaths, thromboses, and amputations. The 30-day amputation and death rate was 2% in ER group and 5% in OR group (P = .3). Follow-up was available for 108 patients (96.5% of the study group) with a mean duration of 53 months, significantly different in the two groups (71 months in OR group and 36 months in ER group; P < .001). Estimated 4-year survival rates were 89% (standard error [SE], 0.055) in OR patients and 94% (SE, 0.08) in ER patients (P = .4; log-rank, 0.7). At the same time interval, primary patency rates were 72% (SE, 0.06) in ER group and 75% (SE, 0.07) in OR group (P = .9; log-rank, 0.01). Twenty-two PAA-related reinterventions were performed during follow-up, 11 in each group. Estimated 4-year freedom from reintervention was 85% (SE, 0.06) in OR patients and 66% (SE, 0.08) in ER patients (P = .1; log-rank, 2.1). Secondary patency rates at 48 years were 75% (SE, 0.08) in ER group and 83% (SE, 0.055) in OR group (P = .9; log-rank, 0.02), while the corresponding figures in terms of limb preservation was 94% in both groups (P = .4, log-rank, 0.9), respectively. OR and ER of PAAs provided in this retrospective single-center experience similar perioperative and follow-up results in equivalent groups of patients. There is a trend toward a higher risk of reintervention in ER patients, requiring further analysis and a longer follow-up time.

Percutaneous coronary intervention with second-generation drug-eluting stent versus bare-metal stent: Systematic review and cost-benefit analysis.

BackgroundDrug-eluting stents (DESs) were considered as ground-breaking technology promising to eradicate restenosis and the necessity to perform multiple revascularization procedures subsequent to percutaneous coronary intervention. Soon after DESs were released on the market, however, there were reports of a potential increase in mortality and of early or late thrombosis. In addition, DESs are far more expensive than bare-metal stents (BMSs), which has led to their limited use in many countries. The technology has improved over the last few years with the second generation of DESs (DES-2). Moreover, costs have come down and an improved safety profile with decreased thrombosis has been reported.ObjectivePerform a cost–benefit analysis of DES-2s versus BMSs in the context of a publicly funded university hospital in Quebec, Canada.MethodsA systematic review of meta-analyses was conducted between 2012 and 2016 to extract data on clinical effectiveness. The clinical outcome of interest for the cost–benefit analysis was target-vessel revascularization (TVR). Cost units are those used in the Quebec health-care system. The cost–benefit analysis was based on a 2-year perspective. Deterministic and stochastic models (discrete-event simulation) were used, and various risk factors of reintervention were considered.ResultsDES-2s are much more effective than BMSs with respect to TVR rate ratio (i.e., 0.29 to 0.62 in more recent meta-analyses). DES-2s seem to cause fewer deaths and in-stent thrombosis than BMSs, but results are rarely significant, with the exception of the cobalt–chromium everolimus DES. The rate ratio of myocardial infraction is systematically in favor of DES-2s and very often significant. Despite the higher cost of DES-2s, fewer reinterventions can lead to huge savings (i.e., -$479 to -$769 per patient). Moreover, the higher a patient’s risk of reintervention, the higher the savings associated with the use of DES-2s.ConclusionDespite the higher purchase cost of DES-2s compared to BMSs, generalizing their use, in particular for patients at high risk of reintervention, should enable significant savings.

Are drug-coated balloons cost effective for femoropopliteal occlusive disease? A comparison of bare metal stents and uncoated balloons.

To perform a cost-effectiveness analysis to help hospital decision-makers with regard to the use of drug-coated balloons compared with bare metal stents and uncoated balloons for femoropopliteal occlusive disease. Clinical outcomes were extracted from the results of meta-analyses already published, and cost units are those used in the Quebec healthcare network. The literature review was limited to the last four years to obtain the most recent data. The cost-effectiveness analysis was based on a 2-year perspective, and risk factors of reintervention were considered. The cost-effectiveness analysis indicated that drug-coated balloons were generally more efficient than bare metal stents, particularly for patients with higher risk of reintervention (up to CAD$1686 per patient TASC II C or D). Compared with uncoated balloons, results indicated that drug-coated balloons were more efficient if the reintervention rate associated with uncoated balloons is very high and for patients with higher risk of reintervention (up to CAD$3301 per patient). The higher a patient's risk of reintervention, the higher the savings associated with the use of a drug-coated balloon will be. For patients at lower risk, the uncoated balloon strategy is still recommended as a first choice for endovascular intervention.

Thoracoscopy in the management of pediatric empyemas

IntroductionThoracoscopy is increasingly being used in the treatment of empyema. This study assesses feasibility, efficacy and safety in children. Material and methodsClinical files of patients who underwent primary thoracoscopy for empyema between 2006 and 2014 were reviewed. Demographic, clinical and surgical data were analyzed and a comparison between the period before (period1) and after (period2) the learning curve was performed. ResultsNinety-one patients (53 males, 58%) were submitted to thoracoscopy at a median age of 4 years. There were 19 conversions to thoracotomy with a steady decrease of conversion rate until 2009 (period1) and no conversions thereafter (period2). There was no difference in any of the analyzed parameters between patients submitted to thoracoscopy alone and those requiring conversion in period1. Six cases (6.6%) needed redo-operation (five in period2) and thoracotomy was the elected approach in four. Necrotizing pneumonia was present in 60% of the reoperated cases; in other words, in period2 3 out of 9 cases with necrotizing pneumonia required reintervention (p=0.07). Thoracotomy was avoided in sixty-eight (75%) patients (62% in period1 versus 92% in period2, p=0.001). Discussion and conclusionsThoracoscopic approach for empyema is feasible and safe avoiding a significant number of thoracotomies after a short learning curve. An increase of reintervention rate should be expected, but throracoscopy alone is effective in the great majority of the cases. Necrotizing pneumonia may be associated with a higher risk of reintervention, as it is a contra-indication to thoracoscopy and probably surgery.