Major Vascular Procedures Research Articles

Management of bleeding in vascular surgery

Management of acute coagulopathy and blood loss during major vascular procedures poses a significant haemostatic challenge to anaesthetists. The acute coagulopathy is multifactorial in origin with tissue injury and hypotension as the precipitating factors, followed by dilution, hypothermia, acidemia, hyperfibrinolysis and systemic inflammatory response, all acting as a self-perpetuating spiral of events. The problem is confounded by the high prevalence of antithrombotic agent use in these patients and intraoperative heparin administration. Trials specifically examining bleeding management in vascular surgery are lacking, and much of the literature and guidelines are derived from studies on patients with trauma. In general, it is recommended to adopt permissive hypotension with a restrictive fluid strategy, using a combination of crystalloid and colloid solutions up to one litre during the initial resuscitation, after which blood products should be administered. A restrictive transfusion trigger for red cells remains the mainstay of treatment except for the high-risk patients, where the trigger should be individualized. Transfusion of blood components should be initiated by clinical evidence of coagulopathy such as diffuse microvascular bleeding, and then guided by either laboratory or point-of-care coagulation testing. Prophylactic antifibrinolytic use is recommended for all surgery where excessive bleeding is anticipated. Fibrinogen and prothrombin complex concentrates administration are recommended during massive transfusion, whereas rFVIIa should be reserved until all means have failed. While debates over the ideal resuscitative strategy continue, the approach to vascular haemostasis should be scientific, rational, and structured. As far as possible, therapy should be monitored and goal directed.

Racial/Ethnic Disparities in Perioperative Outcomes of Major Procedures: Results From the National Surgical Quality Improvement Program.

To determine the association between race/ethnicity and perioperative outcomes in individuals undergoing major oncologic and nononcologic surgical procedures in the United States. Prior work has shown that there are significant racial/ethnic disparities in perioperative outcomes after several types of major cardiac, general, vascular, orthopedic, and cancer surgical procedures. However, recent evidence suggests attenuation of these racial/ethnic differences, particularly at academic institutions. We utilized the American College of Surgeons National Surgical Quality Improvement Program database to identify 142,344 patients undergoing one of the 16 major cancer and noncancer surgical procedures between 2005 and 2011. Eighty-five percent of the cohort was white, with black and Hispanic individuals comprising 8% and 4%, respectively. In multivariable analyses, black patients had greater odds of experiencing prolonged length of stay after 10 of the 16 procedures studied (all P < 0.05), though there was no disparity in odds of 30-day mortality after any surgery. Hispanics were more likely to experience prolonged length of stay after 5 surgical procedures (all P < 0.04), and were at greater odds of dying within 30 days after colectomy, heart valve repair/replacement, or abdominal aortic aneurysm repair (all P < 0.03). Fewer disparities were observed for Hispanics, than for black patients, and also for cancer, than for noncancer surgical procedures. Important racial/ethnic disparities in perioperative outcomes were observed among patients undergoing major cancer and noncancer surgical procedures at American College of Surgeons National Surgical Quality Improvement Program institutions. There were fewer disparities among individuals undergoing cancer surgery, though black patients, in particular, were more likely to experience prolonged length of stay.

Effect of Delirium and Other Major Complications on Outcomes After Elective Surgery in Older Adults.

Major postoperative complications and delirium contribute independently to adverse outcomes and high resource use in patients who undergo major surgery; however, their interrelationship is not well examined. To evaluate the association of major postoperative complications and delirium, alone and combined, with adverse outcomes after surgery. Prospective cohort study in 2 large academic medical centers of 566 patients who were 70 years or older without recognized dementia or a history of delirium and underwent elective major orthopedic, vascular, or abdominal surgical procedures with a minimum 3-day hospitalization between June 18, 2010, and August 8, 2013. Data analysis took place from December 13, 2013, through May 1, 2015. Major postoperative complications, defined as life-altering or life-threatening events (Accordion Severity grade 2 or higher), were identified by expert-panel adjudication. Delirium was measured daily with the Confusion Assessment Method and a validated medical record review method. The following 4 subgroups were analyzed: (1) no complications or delirium; (2) complications only; (3) delirium only; and (4) complications and delirium. Adverse outcomes included a length of stay (LOS) of more than 5 days, institutional discharge, and rehospitalization within 30 days of discharge. In the 566 participants, the mean (SD) age was 76.7 (5.2) years, 236 (41.7%) were male, and 523 (92.4%) were white. Forty-seven patients (8.3%) developed major complications and 135 (23.9%) developed delirium. Compared with no complications or delirium as the reference group, major complications only contributed to prolonged LOS only (relative risk [RR], 2.8; 95% CI, 1.9-4.0); by contrast, delirium only significantly increased all adverse outcomes, including prolonged LOS (RR, 1.9; 95% CI, 1.4-2.7), institutional discharge (RR, 1.5; 95% CI, 1.3-1.7), and 30-day readmission (RR, 2.3; 95% CI, 1.4-3.7). The subgroup with complications and delirium had the highest rates of all adverse outcomes, including prolonged LOS (RR, 3.4; 95% CI, 2.3-4.8), institutional discharge (RR, 1.8; 95% CI, 1.4-2.5), and 30-day readmission (RR, 3.0; 95% CI, 1.3-6.8). Delirium exerted the highest attributable risk at the population level (5.8%; 95% CI, 4.7-6.8) compared with all other adverse events (prolonged LOS, institutional discharge, or readmission). Major postoperative complications and delirium are separately associated with adverse events and demonstrate a combined effect. Delirium occurs more frequently and has a greater effect at the population level than other major complications.

Pre-operative Risk Stratification Update for Cardiac and Major Vascular Surgery

Pre-operative risk stratification of patients for cardiac and major vascular procedures remains an evolving process. There are several models that generate risk scores and estimate post-operative morbidity and mortality outcomes. In addition to predicting outcomes, risk stratification can guide the need for further perioperative investigations and also assist in providing individualized therapy. An ideal model for risk stratification is one with not only good validity but is also reproducible. The risk stratification system needs to be applicable across diverse patient populations and hospital practice. In this article, we review various pre-operative risk stratification models and access their usefulness for cardiac and major vascular surgery.

Occurrence of “never events” after major open vascular surgery procedures

"Never events" refers to harmful hospital-acquired conditions that the Centers for Medicare and Medicaid Services identified in 2008 as largely preventable and that would no longer be reimbursed. Our goal was to identify the incidence, predictive factors, temporal trend, and associated consequences of never events after major open vascular surgery procedures. The Nationwide Inpatient Sample (NIS) (2003-2011) was queried to identify never events applicable to vascular surgery patients, including air embolism, catheter-based urinary tract infections (UTIs), stage 3 and 4 pressure ulcers, falls/trauma, blood incompatibility, vascular catheter infections, complications of poor glucose control, retained foreign objects, and wrong-site surgery. We specifically evaluated open abdominal aortic aneurysm repair, carotid endarterectomy, and lower extremity bypass/femoral endarterectomy. Multivariable logistic regression was used to predict never events based on preoperative variables. Multivariable logistic and gamma regression models were used to study mortality, hospital length of stay (LOS), and charges. Never events were identified in 774 of 267,734 patients. The distribution of never events were falls/trauma (59%), pressure ulcers (19%), catheter-based UTI (9%), vascular catheter infection (6%), complications of poor glucose control (5%), and retained objects (4%). Rates of falls and catheter-based UTIs have increased since 2008. Multivariable predictors of any never event included lower extremity bypass, abdominal aortic aneurysm, weight loss, nonelective admission, paralysis, repair, congestive heart failure, altered mental status, renal failure, weekend admission, diabetes, female gender, and age. Race, insurance, hospital type, income level, geography, July to September admission, and other comorbidities were not predictive. After risk factor adjustment, never events were associated with increased perioperative mortality (odds ratio, 2.7; 95% confidence interval [CI], 1.5-34.8; P< .001), LOS (means ratio, 1.9; 95% CI, 1.7-2.0; P<.001), and total charges (means ratio, 1.7; 95% CI, 1.6-1.8; P< .001). Never events after major vascular surgery are associated with a number of perioperative factors and are predictive of increased charges, LOS, and mortality. Falls and catheter-based UTIs have increased in frequency since the Centers for Medicare and Medicaid Services announced that it would no longer reimburse for these complications. This study establishes baseline never event rates in the vascular surgery patient population and identifies high-risk patients to target for quality improvement.

Impact of “Do Not Resuscitate” Status on the Outcome of Major Vascular Surgical Procedures

Patients with Do Not Resuscitate (DNR) orders may still be offered surgery that aims to prolong or improve quality of life. The widely accepted approach of "required reconsideration" mandates that patients and surgeons discuss perioperative risks and expected outcomes in the context of the patient's values and preferences. However, surgical outcomes in this patient population have not been well-defined. The objectives of this study are to assess outcomes in DNR patients undergoing major vascular procedures, and develop an evidence basis for informed, shared decision-making. Patients undergoing common major vascular procedures were identified in the 2007-2010 National Surgical Quality Improvement Project databases. DNR patients were defined as those with an active DNR order within 30days before surgery. Demographics, comorbidities, procedural details, and complications were compared with those without DNR orders. To isolate the impact of DNR status, multivariate regression and 1:1 propensity score matching were used to compare outcomes between DNR patients and a non-DNR cohort of comparably high-risk patients. Of 110,279 patients undergoing major vascular surgery, 1,565 (1.4%) had active DNR orders 30days preceding surgery. DNR patients were more likely to be functionally dependent (69% vs. 15%; P<0.0001), over 80years of age (53% vs. 20%; P<0.001), and suffer from a variety of cardiac, pulmonary, and systemic comorbidities. The most common procedures in DNR patients were major amputation (38.4%), lower extremity bypass (20%), and peripheral thromboembolectomy (11.7%). Unadjusted 30-day mortality was significantly higher among DNR patients (21% vs. 3.4%; P<0.001). After 1:1 propensity score matching, with the 2 cohorts differing only with respect to DNR status, perioperative mortality remained significantly higher among DNR patients (21% vs. 13%; P<0.01). There was a trend toward reduced cardiopulmonary resuscitation in patients with recent DNR (1.7% vs. 2.6%; P=0.07). DNR patients are at high risk for major complications and mortality after vascular surgery procedures. Compared with a matched cohort of "high-risk" non-DNR patients, those with DNR orders suffered equivalent rates of postoperative morbidity, but markedly increased mortality. This suggests that DNR status, independent of comorbidities and perioperative complications, may increase the risk of "failure to rescue." These findings have implications not only for risk adjustment, but also provide an evidence basis for shared decision-making in challenging circumstances.

PC140. Routine Postoperative Troponin Testing Following Major Vascular Surgical Procedures Carries Short-Term and Long-Term Prognostic Significance

This study determined the utility of routine postoperative troponin T (PO TnT) measurements in patients undergoing major vascular surgical reconstructions (VSRs). Data from consecutive patients undergoing VSRs and routine PO TnT measurement from 2010 to 2012 were retrospectively analyzed. An elevated Tn was >0.01 ng/mL within the current admission, further characterized as low (0.02-0.2 ng/mL) and high (>0.2 ng/mL). Patients without complete Tn panels or research authorization were excluded. Cox proportional hazards model was used to evaluate the effect of preoperative risk factors, type of procedure and PO TnT levels on early-term and long-term mortality. Of 1814 patients undergoing VSRs over the 3-year period, 1632 (1136 males, 496 females; mean age 70 years) met inclusion criteria. There were 1088 open, 529 endovascular, and 15 hybrid procedures. TnT levels were >0.01 ng/mL in 394 patients (24%). Of these, 56 were attributed to non-ST segment elevation myocardial infarction, 6 ST segment elevation myocardial infarction, 46 demand ischemia, 22 miscellaneous cardiac abnormalities, 96 renal insufficiency, and 168 had asymptomatic troponin leaks. Medical management was optimized in all patients. Coronary catheterizations were performed in 13 patients and intervention in seven. Thirty-day mortality was significantly higher in Tn+ vs Tn– patients (2.9% vs 0.7%, P < .001). On multivariate analysis, elevated Tn (hazard ratio [HR], 2.7; P < .001), Society for Vascular Surgery/American Association for Vascular Surgery Score (HR, 1.08 per 1 point; P < .01) and age (HR, 1.20 per 10 years; P < .05) were associated with mortality. Cumulative probability of death in Tn+ patients remained significantly higher at 1 (13% vs 3%), 2 (17% vs 4%), and 4 years (31% vs 10%; P < .001) and was directly proportional to the maximum Tn level (P < .001, Fig). Comparison of the 168 patients with asymptomatic Tn leaks to Tn– patients yielded similar results, with significantly higher mortality at 30 days (2.5% vs 0.7%), 1 (7% vs 3%), 2 (12% vs 4%), and 4 years (25% vs 10%; P < .001). Elevated TnT levels, including mild asymptomatic elevations, following major VSRs are independently associated with higher early-term and long-term mortality. Routine Tn testing is worthwhile and serves to risk-stratify patients for future medical and surgical care.

Trend, Risk Factors, and Costs of Clostridium difficile Infections in Vascular Surgery

Starting in December 2013, the Hospital Inpatient Quality Reporting Program included Clostridium difficile infection (CDI) rates as a new publically reported quality measure. Our goal was to review the trend, hospital variability in CDI rates, and associated risk factors and costs in vascular surgery. The rates of CDI after major vascular procedures including aortic abdominal aneurysm (AAA) repair, carotid endarterectomy or stenting, lower extremity revascularization (LER), and LE amputation were identified using Nationwide Inpatient Sample database for 2000-2011. Risk factors associated with CDI were analyzed with hierarchical multivariate logistic regression. Extra costs, length of stay (LOS), and mortality were assessed for propensity-matched hospitalizations with and without CDI. During the study period, the rates of CDI after vascular procedures had increased by 74% from 0.6 in 2000 to 1.05% in 2011, whereas the case fatality rate was stable at 9-11%. In 2011, the highest rates were after ruptured aortic abdominal aneurysm (rAAA) repair (3.3%), followed by lower extremity amputations (2.3%) and elective open AAA (1.3%). The rates of CDI increased after all vascular procedures during the 12 years. The highest increase was after endovascular LER (151.8%) and open rAAA repair (135.7%). In 2011, patients who had experienced CDI had median LOS of 15 days (interquartile range, 9-25 days) compared with 8.3 days for matched patients without CDI, in-hospital mortality 9.1% (compared with 5.0%), and $13,471 extra cost per hospitalization. The estimated cost associated with CDI in vascular surgery in the United States was ∼$98 million in 2011. Hospital rates of CDI varied from 0 to 50% with 3.5% of hospitals having infection rates ≥5%. Factors associated with CDI included multiple chronic conditions, female gender, surgery type, emergent and weekend hospitalizations, hospital transfers, and urban locations. Despite potential reduction of infection rates as evidenced by the experience of hospitals with effective interventions, CDI is increasing among vascular surgery patients. It is associated with prolonged LOS, increased mortality, and higher costs.

The Vascular Surgery Workforce: A Survey of Consultant Vascular Surgeons in the UK, 2014

The purpose of this study was to describe the demographics, training, and practice characteristics of consultant vascular surgeons across the UK to provide an assessment of current, and inform future prediction of workforce needs. A questionnaire was developed using a modified Delphi process to generate questionnaire items. The questionnaire was emailed to all consultant vascular surgeons (n=450) in the UK who were members of the Vascular Society of Great Britain & Ireland. 352 consultant vascular surgeons from 95 hospital trusts across the UK completed the survey (78%response rate). The mean age was 50.6 years old, the majority (62%) were mid-career, but 24% were above the age of 55. Currently, 92% are men and only 8% women. 93% work full-time, with 60% working >50 hours, and 21% working >60 hours per week. The average team was 5 to 6 (range 2-10) vascular surgeons, with 23% working in a large team of ≥8. 17% still work in small teams of ≤3. Over 90% of consultant vascular surgeons perform the major index vascular surgery procedures (aneurysm repair, carotid endarterectomy, infra-inguinal bypass, amputation). While 84% perform standard endovascular abdominal aortic aneurysm repair (EVAR), <50% perform more complex endovascular aortic therapy. The majority of vascular surgeons "like their job" (85%) and are "satisfied" (69%) with their job. 34% of consultant vascular surgeons indicated they were "extremely likely" to retire within the next 10 years. This study provides the first detailed analysis of the new specialty of vascular surgery as practiced in the UK. There is a need to plan for a significant expansion in the consultant vascular surgeon workforce in the UK over the next 10 years to maintain the status quo.

Evidence-based carotid artery–based interventions for stroke risk reduction

Approximately 800,000 individuals still experience a stroke in the United States each year. Despite a relative rate reduction of 37% over the last decade, in 2009, stroke still caused 1 of every 19 deaths (ranks only behind heart disease, cancer, and chronic lower respiratory disease). It remains the leading cause of serious long-term disability, with a staggering economic toll (estimated $38.6 billion in 2009). Driven by trends such as the aging population and rise in the metabolic syndrome, projections show that by 2030 an additional 4 million people will have had a stroke, a 22% increase in prevalence from 2013. Evidence supports a multitude of risk factors for stroke: age, high blood pressure, diabetes mellitus, cardiac dysrhythmias, hyperlipidemia, smoking, physical inactivity, genetics, chronic kidney disease, sleep apnea, prior stroke, and extracranial carotid artery occlusive disease. Great attention over the past few decades to modifiable risk factors such as hypertension likely underlies trends in stroke rate reductions. It is important to recognize that in the totality of modifiable risk factors for stroke, an asymptomatic high-grade carotid stenosis holds a relative risk of approximately 2.0. This is about the same or less than other factors such as cigarette smoking, hypertension, diabetes, high-density lipoprotein (HDL) o35 mg/dL, nonvalvular atrial fibrillation, sickle cell disease, oral contraceptive use, periodontal disease, and physical inactivity. Thus, to overly focus on a carotid stenosis without addressing other medical issues ignores important opportunities for stroke risk reduction. The diversity of risk factors for cerebrovascular accidents reflects the variety of underlying pathophysiologies for death of brain tissue. Approximately 15% of strokes are hemorrhagic, and the remainder are primarily ischemic. Surgeons were drawn into the field by mechanistic links between extracranial carotid artery atherosclerotic disease and thromboembolism from these lesions to the brain, leading to ischemia and infarction (Fig 1). Links between the extracranial carotid and stroke were first made by the Nobel laureate Egas Moniz in the 1920s. Several pioneers (C. Miller Fisher, Michael DeBakey, Felix Eastcott, Sir George Pickering, and Charles Rob) then moved this pathophysiological knowledge forward toward surgical therapy in the 1950s, and the carotid endarterectomy (CEA) operation evolved into the most commonly performed major vascular procedure in the world in subsequent decades. Extracranial carotid artery stenosis underlies approximately 1 in 4 strokes. Approximately 100,000 open CEA

Abdominal Aortic Resection and Y-Graft Placement to Achieve Complete Cytoreduction in Stage IIIc Ovarian Carcinoma

Major vascular resection with reconstruction in patients with gynecologic malignancy is rarely performed and infrequently reported. A 40-year-old woman undergoing surgery for stage IIIc ovarian papillary serous adenocarcinoma was left with a 7-cm aortic metastasis not separable from the infrarenal abdominal aorta. An aortic resection with prosthetic graft placement was performed to achieve complete tumor resection. She remains disease-free in excess of 10 years with no evidence of graft complication. Major vascular reconstructive procedures for the management of malignancy need not be precluded in properly selected circumstances.

Risk score for unplanned vascular readmissions

Vascular surgery patients have high readmission rates, and identification of high-risk groups that may be amenable to targeted interventions is an important strategy for readmission prevention. This study aimed to determine predictors of unplanned readmission and develop a risk score for predicting readmissions after vascular surgery. The National Surgical Quality Improvement Program database for 2011 was queried for major vascular surgical procedures. The primary end point was unplanned 30-day readmissions. The data were randomly split into two-thirds for development and one-third for validation. Multivariable logistic regression was used to create and validate a point score system to predict unplanned readmissions. Overall, 24,929 patients were included, with 2507 readmissions (10.1%). A point-based scoring system was developed with the use of factors predictive for readmission, including procedure type; discharge destination; race; non-elective presentation; pulmonary, renal, and cardiac comorbidities; diabetes; steroid use; hypoalbuminemia; anemia; venothromboembolism before discharge; graft failure before discharge; and bleeding disorder. The point score stratified patients into 3 groups: low risk (0-3 points) with a readmission rate of 5.4%, moderate risk (4-7 points) with a readmission rate of 8.6%, and high risk (≥ 8 points) with a readmission rate of 16.4%. The model had a C-statistic = 0.67. Through the use of patient, operative, and predischarge events, this novel vascular surgery-specific readmission score accurately identified patients at high risk for 30-day unplanned readmission. This model could help direct discharge and home health care resources to patients at high risk, ultimately reducing readmissions and improving efficiency.

Acute Aortic Occlusion Presenting as Paraplegia

Acute aortic occlusion by massive thoracoabdominal thrombi has been reported as a serious complication in patients undergoing major vascular or cardiac surgical procedures. However, this complication occurs rarely after ambulatory procedures. In this case report, we describe a patient who experienced paraplegia after an elective laparoscopic cholecystectomy in whom acute aortic thromboembolic occlusion was subsequently diagnosed. We emphasize the importance of accurate neurologic and cardiovascular history taking and examination throughout the perioperative period along with the appropriate diagnostic studies to expeditiously arrive at a diagnosis of such a rare complication.

Risk Score for Unplanned 30-Day Readmissions after Major Vascular Surgery Procedures

Risk Score for Unplanned 30-Day Readmissions after Major Vascular Surgery Procedures

Characterization of readmissions after major vascular procedures

Ju, Mila H. MD; Merkow, Ryan P. MD, MS; Eskandari, Mark K. MD, FACS; Ko, Clifford Y. MD, MSHS, MS, FACS; Bilimoria, Karl Y. MD, MS Author Information

Evolving Patterns of Vascular Surgery Care in the United States: A Report From the American Board of Surgery

Most general surgeons do not perform any major vascular procedures. Younger general surgeons are performing fewer such procedures than their older counterparts. The opposite is true for vascular surgeons.

Elevated Postoperative Troponin Levels As a Predictor of Increased 30-Day, 1 and 2 year Mortality Following Major Vascular Surgical Interventions

To determine the utility of routine post-operative troponin (PO Tn) measurements in patients undergoing major vascular surgical reconstructions (VSRs). Data from consecutive patients undergoing VSRs and routine PO Tn measurement over one year, January 1 to December 31, 2010, were retrospectively analyzed. A positive troponin (Tn) panel included a baseline level immediately after the procedure of ≥ .20 ng/mL, or a delta at 3 and/or 6 hours of ≥ .30 ng/mL/≥ 20%. Patients without complete Tn panels and research authorization were excluded. Cox Proportional hazards model was used to evaluate the effect of preoperative risk factors and postoperative Tn levels on early and mid-term mortality. Of 725 patients undergoing VSRs 678 (462 males, 216 females; mean age 69 years) satisfied criteria for inclusion. Procedures included 408 open, 196 endovascular and 73 hybrid (306 abdominal, 197 infrainguinal, 40 thoracoabdominal, 117 cerebrovascular and 18 upper extremity). Tn levels were elevated in 67 patients (10%; M: 42, F: 25) and after consultation with a cardiologist were ascribed to non-ST elevation myocardial infarction (NSTEMI) in 26, STEMI in six, demand ischemia in 29 and renal insufficiency in six. Sixty-one patients were managed medically; six underwent cardiac catheterization and intervention. Thirty-day mortality was significantly higher in Tn+ compared to Tn- patients (7.6% vs 1.7%; P = .08). On multivariate analysis abnormal delta Tn (P = .008; HR, 2.0; 95% CI, 1.2-3.4) and SVS/AAVS co-morbidity score >9 were associated with mortality. The cumulative probability of death in Tn+ patients remained significantly higher at 1 (27.6% vs 10.6%; P = .004) and 2 years (40.8% vs 18.5%; P = .002). Elevated delta troponin levels following major vascular surgical procedures are independently associated with higher 30 day and mid-term mortality, and this marker should be considered an important prognostic indicator.

The Risk of Major Elective Vascular Surgical Procedures in Patients With End-Stage Renal Disease

To examine the postoperative complications and death rate of major elective vascular surgery procedures in patients with end-stage renal disease (ESRD). Patients with ESRD undergoing elective major vascular surgical procedures are thought to have a high rate of postoperative complications and death. The American College of Surgeons-National Surgical Quality Improvement Program database was used to select ESRD and non-ESRD patients who had elective major vascular surgical procedures between 2004 and 2008. Multivariable logistic regression analysis was used to examine the impact of ESRD on 30-day surgical outcomes adjusted for age, race, sex, work relative value units, American Society of Anesthesiology class, and recent operations (within the past 30 days). ESRD patients undergoing elective major vascular surgery were significantly more likely than non-ESRD patients to develop surgical site infection, unplanned intubation, ventilator dependence, combined pulmonary outcome, and a need for reoperation within 30 days of surgery. Importantly, ESRD patients undergoing elective major vascular surgery were also at higher risk for composite outcome and death within 30 days from surgery. ESRD patients above age 65 years undergoing elective major vascular surgery had far worse 30-day outcomes when compared with the younger ESRD cohort. Examining these data by their anatomic site (carotid, aortic, and peripheral) demonstrated elevated rates of postoperative complications and death in patients with ESRD undergoing open abdominal aortic aneurysm repair, carotid endarterectomies, and peripheral vascular operations compared with the non-ESRD cohort. Endovascular abdominal aortic aneurysm repair in ESRD patients had complications and death rates comparable with non-ESRD patients. Patients with ESRD undergoing elective vascular surgery have a significantly elevated risk of postoperative complications and death after major vascular surgical operations--particularly in patients over age 65. These data, in combination with well-established reduced survival for the older ESRD population, call into question the utility of most carotid and aortic operations in these patients in the absence of symptoms or a rapidly enlarging aneurysm.

Evolving Patterns of Vascular Surgery Care in the United States: A Report from the American Board of Surgery

The purpose of this study was to analyze the distribution of major vascular procedures among general and vascular surgeons and to compare the evolution of vascular surgical practice of general and vascular surgeons at specific points in their careers. Case logs of surgeons seeking recertification in surgery from 2007 to 2009 were reviewed. Data from 3,362 physicians certified only in surgery (GS) were compared with 363 additionally certified in vascular surgery (VS). Independent variables were compared using factorial ANOVA. The mean numbers of major vascular procedures (±SD) were 10 ± 51 for GS and 192 ± 209 for VS (p < 0.001). Thirty-three percent of the total vascular procedures reported were performed by GS. Compared with VS, GS performed significantly fewer vascular procedures in all major procedure categories, and GS certifying at 10 years performed fewer vascular procedures (6.7 ± 47) than those recertifying at 20 years (11.5 ± 48) and 30 years (13.6 ± 59) (p < 0.01). In contrast, VS certifying at 10 years performed more vascular procedures (235 ± 237) compared with those recertifying at 20 years (157 ± 173) and 30 years (104 ± 115). The mean number of vascular procedures was not different for sex, geographic location, or practice type, after controlling for other variables in the study. The majority of GS currently do not perform any major vascular procedures, and younger GS are performing fewer such procedures than their older counterparts. The opposite is true for VS. These opposing trends indicate that vascular procedures are shifting from GS to VS in modern surgical practice, and this may have important implications for patient access to vascular surgery care, considering the limited capacity for VS to assume the excess case load.

Preoperative Statin Use and Postoperative Acute Kidney Injury

BackgroundAcute kidney injury is a frequent postoperative complication that confers increased mortality, morbidity, and costs. The purpose of this study was to evaluate whether preoperative statin use is associated with a decreased risk of postoperative acute kidney injury. MethodsWe assembled a retrospective cohort of 98,939 patients who underwent a major open abdominal, cardiac, thoracic, or vascular procedure between 2000 and 2010. Statin users were pair-matched to nonusers on the basis of surgery type, baseline kidney function, days from admission until surgery, and propensity score based on demographics, comorbid conditions, and concomitant medications. Acute kidney injury was defined based on changes in serum creatinine measurements applying Acute Kidney Injury Network and Risk-Injury-Failure staging systems, and on the need for renal replacement therapy. Associations between statin use and acute kidney injury were estimated by conditional logistic regression. ResultsAcross various acute kidney injury definitions, statin use was consistently associated with a decreased risk: adjusted odds ratios (95% confidence intervals) varied from 0.74 (0.58-0.95) to 0.80 (0.71-0.90). Associations were similar among diabetics and nondiabetics, and across strata of baseline kidney function. The protective association of statins was most pronounced among patients undergoing vascular surgery and least among patients undergoing cardiac surgery. ConclusionsPreoperative statin use is associated with a decreased risk of postoperative acute kidney injury. Future randomized clinical trials are needed to determine causality.