Results Of Endarterectomy Research Articles

A Retrospective Cohort Study on Coronary Endarterectomy Outcomes in Coronary Artery Bypass Graft Patients.

Introduction: The aim of this study is to determine the outcomes following coronary endarterectomy (CE) in patients who underwent coronary artery bypass grafting (CABG) for revascularization in our hospital.Methods: We retrospectively reviewed patients who underwent CABG over a six-month period, from November 1, 2016 to May 31, 2017 and examined their outcomes in regards to CE.Results: A total of (n=361) CABG procedures were performed in our study period, though complete records were available for only (n=254) patients. Amongst these, (n=37) patients (14.5%) required CE. Ages ranged from 43 to 75 years for these patients, (n=7) were females and (n=30) males. Comorbidities included hypertension in (n=19) patients, diabetes in (n=12) patients and hepatitis B in (n=11) patients. The right coronary artery (RCA) was the most common artery endarterectomized (n= 15), followed by the left anterior descending (LAD) (n= 10), obtuse marginal (n= 6 patients), diagonals (n=5) and ramus (n=2). Two vessels were endarterectomized in (n=4) patients. A total of (n=9) patients had two-vessel CABG, (n=16) had three-vessel CABG and (n=8) had four-vessel CABG. The left internal mammary artery (LIMA) was used in (n=25) patients. Two patients required intra-aortic balloon pump post-operatively. All the patients had received inotropic support postoperatively in the intensive care unit (ICU). There were no reports of postoperative mortality. One patient remained in the ICU for four days postoperatively, the rest of the patients were stepped down to the ward in less than four days.Conclusions: CE is a safe and viable option as an adjunct to CABG in long segment totally occluded vessels needing revascularization and reconstruction.

Perfusion strategy and mid-term results of 58 consecutive pulmonary endarterectomy.

The aim of this retrospective study was to review and report short-term and mid-term outcomes of pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension at our institute in the recent 2 years and to describe perfusion strategy. A total of 58 consecutive patients with chronic thromboembolic pulmonary hypertension underwent pulmonary endarterectomy under deep hypothermia circulatory arrest with an established perfusion practice between November 2015 and December 2017. Peri-operative data and patients' outcome were retrospectively analyzed. Mean pulmonary artery pressure was decreased (49 (40-56) mmHg vs 27 (20-31) mmHg, p < 0.001), and pulmonary vascular resistance (724 (538-1108) vs 206 (141-284) dyn second cm-5, p < 0.001) improved significantly after surgery. In-hospital mortality was 1.7% and postoperative complication rate was 27.6%. Antipsychotic medication of olanzapine was prescribed for 36 patients (62.1%), which was independently related to total deep hypothermic circulatory arrest time, postoperative blood potassium concentration, and hematocrit. The majority of patients recovered uneventfully with good mid-term cardiac function (New York Heart Association I-II: 98.1%) and neurological outcome (Glasgow Outcome Scale-Extended Upper Good Recovery: 74.1% and Lower Good Recovery: 20.3%). Mid-term neurological outcome was associated with post-pulmonary endarterectomy antipsychotic medication. Short-term and mid-term outcome after pulmonary endarterectomy was comparable to high-volume centers. Incidence of post-pulmonary endarterectomy delirium was relatively high and associated with mid-term neurological outcome. Total deep hypothermic circulatory arrest time, postoperative blood potassium concentration, and hematocrit were independent risk factors of postoperative olanzapine medication. More efforts and further research are required to optimize the neuroprotection of perfusion practice.

Outcomes of Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension at a Single Center in Taiwan.

Chronic thromboembolic pulmonary hypertension (CTEPH) is classified as group IV pulmonary hypertension. This study aimed to report our institutional experience in managing CTEPH. We prospectively collected the data of 23 patients diagnosed with CTEPH between August 2001 and August 2017 in Linkou Chang Gung Memorial Hospital. Baseline characteristics including functional class (FC), 6-minute walk distance (6MWD), comorbidities, hematological and biochemical data, echocardiography, cardiac catheterization, and selective pulmonary angiography were recorded at diagnosis. All patients were referred to a cardiac surgeon for pulmonary endarterectomy (PEA) assessment. The mean age at diagnosis was 48.4 ± 16.1 years. Nineteen patients (83%) underwent PEA with mean postoperative follow-up of 37.7 ± 42.8 months. The in-hospital mortality rate of PEA was 11%. The 1-, 2-, 3- and 5-year overall survival rates were 89%, 89%, 81%, and 50%, respectively. After 3 months of PEA, all patients had improvements in FC, 6MWD (from 326 ± 62 to 420 ± 63 m), B-type natriuretic peptide level (from 602 ± 599 to 268 ± 565 pg/mL), and systolic pulmonary artery pressure (from 79 ± 19 to 48 ± 19 mmHg). The patients with proximal disease (Jamieson type 1 or 2) had better survival than those with distal disease (Jamieson type 3 or 4), but there was no significant difference in mortality between FC III and IV. All of the four patients who did not undergo PEA survived for more than 3 years. Significant improvements in symptoms, functional capacity, and hemodynamics were achieved in the CTEPH patients after PEA. However, the overall survival was still unsatisfactory.

Carotid Endarterectomy Outcomes in the Elderly: A Canadian Institutional Experience

Carotid endarterectomy (CEA) is a well-established surgical intervention for stroke prevention in patients with carotid stenosis of all ages. However, the decision to proceed to operate in the elderly involves a more complicated risk-benefit assessment due in part to increased comorbidities and reduced life expectancy. Some studies suggest that CEA is more risky in the elderly with worse outcomes, whereas others have found no difference. Our objective was to evaluate and compare outcomes of CEA between elderly and younger patients at our institution. All hospital charts were reviewed for consecutive patients undergoing CEA from the Jewish General Hospital and the Royal Victoria Hospital from October 2009 to December 2015. Primary outcomes were ipsilateral stroke, death, and restenosis at 30 days and 1 year. Secondary outcomes were cranial nerve injury, myocardial infarction (MI), hematoma, wound infection, cerebral hyperperfusion, and transient ischemic attacks within 30days. Primary and secondary outcomes were compared between patients aged ≥80years and <80years. A total of 361 patients were included in this study with a mean age of 70.2±9.5 years (n=247 [68.4%] male and n=272 [75.8%] symptomatic). Elderly patients were more often symptomatic (93.8% vs. 71.6%, P<0.0001) and had an increased length of stay (2.8±5.3 vs. 1.6±1.8, P=0.001). There was no statistically significant difference in primary outcomes between patients aged <80years and ≥80years, including 30-day stroke (1.7% vs. 0%), death (no deaths in either group), restenosis (8.8% vs. 12.3%), 1-year stroke (1.7% vs. 0%), death (0.7% vs. 0%), or restenosis (14.9% vs. 13.8%). However, elderly patients had significantly increased MI risk postoperatively (4.6% vs. 0.7%, P=0.01). Other complications, including cranial nerve injury (3.7% in <80years vs. 4.6% in the elderly group), were similar between the groups. We found that CEA in the elderly does not have an increased risk of stroke or death up to one year postoperatively. However, the postoperative length of stay is increased and complicated by significantly more MIs, which should weigh into the decision of whether to perform CEA on an elderly patient.

Long-term outcomes of stenting and endarterectomy for symptomatic carotid stenosis: a preplanned pooled analysis of individual patient data

The risk of periprocedural stroke or death is higher after carotid artery stenting (CAS) than carotid endarterectomy (CEA) for the treatment of symptomatic carotid stenosis. However, long-term outcomes have not been sufficiently assessed. We sought to combine individual patient-level data from the four major randomised controlled trials of CAS versus CEA for the treatment of symptomatic carotid stenosis to assess long-term outcomes. We did a pooled analysis of individual patient-level data, acquired from the four largest randomised controlled trials assessing the relative efficacy of CAS and CEA for treatment of symptomatic carotid stenosis (Endarterectomy versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis trial, Stent-Protected Percutaneous Angioplasty of the Carotid Artery versus Endarterectomy trial, International Carotid Stenting Study, and Carotid Revascularization Endarterectomy versus Stenting Trial). The risk of ipsilateral stroke was assessed between 121 days and 1, 3, 5, 7, 9, and 10 years after randomisation. The primary outcome was the composite risk of stroke or death within 120 days after randomisation (periprocedural risk) or subsequent ipsilateral stroke up to 10 years after randomisation (postprocedural risk). Analyses were intention-to-treat, with the risk of events calculated using Kaplan-Meier methods and Cox proportional hazards analysis with adjustment for trial. In the four trials included, 4775 patients were randomly assigned, of whom a total of 4754 (99·6%) patients were followed up for a maximum of 12·4 years. 21 (0·4%) patients immediately withdrew consent after randomisation and were excluded. Median length of follow-up across the studies ranged from 2·0 to 6·9 years. 129 periprocedural and 55 postprocedural outcome events occurred in patients allocated CEA, and 206 and 57 for those allocated CAS. After the periprocedural period, the annual rates of ipsilateral stroke per person-year were similar for the two treatments: 0·60% (95% CI 0·46-0·79) for CEA and 0·64% (0·49-0·83) for CAS. Nonetheless, the periprocedural and postprocedural risks combined favoured CEA, with treatment differences at 1, 3, 5, 7, and 9 years all ranging between 2·8% (1·1-4·4) and 4·1% (2·0-6·3). Outcomes in the postprocedural period after CAS and CEA were similar, suggesting robust clinical durability for both treatments. Although long-term outcomes (periprocedural and postprocedural risks combined) continue to favour CEA, the similarity of the postprocedural rates suggest that improvements in the periprocedural safety of CAS could provide similar outcomes of the two procedures in the future. None.

Longterm Outcomes of Eversion Endarterectomy for Iliac Artery Occlusive Disease

Longterm Outcomes of Eversion Endarterectomy for Iliac Artery Occlusive Disease

Outcome of drug-eluting balloon angioplasty versus endarterectomy in common femoral artery occlusive disease

ObjectiveCommon femoral artery (CFA) occlusive disease remains a debatable site for endovascular therapy, and the outcome of drug-eluting balloon (DEB) angioplasty in treating CFA occlusive disease is largely unknown. This study compared the efficacy, safety, and short-term patency rate of DEB angioplasty and femoral endarterectomy for treatment of CFA occlusive disease. MethodsFrom March 2013 to June 2016, there were 100 patients with symptomatic CFA occlusive disease who were retrospectively reviewed. Forty patients were treated with DEB angioplasty and 60 were treated with femoral endarterectomy. Each patient received regular follow-up. Patency rate, ankle-brachial index, target lesion revascularization, and adverse events were assessed. ResultsTechnical success was 100% in all patients. The DEB group had a lower 1-year primary patency rate (75.0% vs 96.7%; P = .003), but the secondary patency rate was similar between the two groups (97.5% vs 98.3%; P = 1.000). At 2-year follow-up, the primary patency was lower in the DEB group (57.1%) than in the endarterectomy group (94.1%; P = .001), whereas the secondary patency rate had no significant difference (90.5% vs 97.1%; P = 1.000). Both groups had significant improvement in ankle-brachial index. Freedom from target lesion revascularization was lower in the DEB group both at 1 year (75.0% vs 96.7%; P = .003) and at 2 years (57.1% vs 94.1%; P = .001). There was no significant difference in the incidence of complications and adverse events. ConclusionsFemoral endarterectomy has a better primary patency rate compared with DEB angioplasty in treating CFA occlusive disease without significant increase in complications. In patients not suitable for endarterectomy, DEB angioplasty provides a similar secondary patency rate and could be considered an alternative treatment.

Invited commentary

This study analyzed the effect of black race on carotid endarterectomy (CEA) outcomes in the United States from the Vascular Quality Initiative (VQI) registry. It included 57,622 CEA patients, 2909 (5%) of whom were black. Of the 54,713 white patients, 30% were symptomatic vs 34% of black patients. Blacks had a higher vascular disease burden and were less likely to be operated on in high-volume hospitals and by high-volume surgeons. Black symptomatic patients underwent surgery more often in <2 weeks after the index neurologic event (47% vs 40%). The perioperative stroke/death rates were comparable between blacks and whites. A multivariant analysis showed that black race was not an independent risk factor for poor outcomes with a shortened survival after CEA, although many conditions were more common in blacks (eg, CEA without patch, insulin-dependent diabetes mellitus, prior stroke, lower volume surgeons and centers, and congestive heart failure were associated with poor outcomes). What is also interesting is that black patients experienced better adjusted long-term survival. Some of the findings are very interesting. Specifically, although a good percentage of the black population live in large metropolitan areas, they were less likely to be operated on by high-volume surgeons and in high-volume centers. Similarly, the authors state that symptomatic blacks were more likely to be operated on in <2 weeks vs ≥2 weeks. Can this explain why the perioperative outcomes were similar between blacks and whites who had procedures done beyond 2 weeks, since most authorities advocate surgery in <2 weeks of a neurologic event to optimize benefits of CEA? Why were blacks operated on earlier? Was it easier to convince them to proceed with surgery? Black patients also had a longer length of hospital stay and higher rate of failed discharge home, which may be explained by the extent of their vascular disease. Several studies have evaluated the impact of race on outcomes of CEA, with conflicting results. In an interesting study by Brown et al,1Brown H.A. Sullivan M.C. Gusberg R.G. Dardik A. Sosa J.A. Indes J.E. Race as a predictor of morbidity, mortality, and neurologic events after carotid endarterectomy.J Vasc Surg. 2013; 57: 1325-1330Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar data from the American College of Surgeons National Surgical Quality Improvement Program identified CEAs in 29,114 whites (96%) and 1316 blacks (4%). The stroke rate was 1.6% for whites and 2.5% for blacks (P = .009). The 30-day mortality was 0.7% for whites and 1.4% for blacks (P = .002). There was also a longer operating time and length of stay (P < .001) in blacks. A multivariant logistic regression showed black race as an independent risk factor for 30-day mortality (odds ratio, 1.9; P = .007). Blacks also had a greater proportion of in-hospital death (74% vs 43%; P = .01). Another study by Wayangankar et al2Wayangankar S.A. Kennedy K.F. Aronow H.D. Rundback J. Tafur A. Drachman D. et al.Rachial/ethnic variation in carotid artery revascularization utilization and outcomes: analysis from the National Cardiovascular Data Registry.Stroke. 2015; 46: 1525-1532Crossref PubMed Scopus (17) Google Scholar compared the utilization and outcome of carotid artery stenting and CEA across racial ethnic groups within the Carotid Artery Revascularization and Endarterectomy (CARE) registry (2007-2012). There were 10,953 patients who underwent CEA (93% white, 4% black, 3% Hispanic). There was a trend toward increased carotid artery stenting utilization among whites and increased CEA utilization among Hispanics and blacks. In-hospital major adverse cardiac and cerebrovascular events were comparable between the groups, whereas the 30-day major cardiac and cerebrovascular events were significantly higher in blacks. It is feasible that the difference between these studies and the present study can be explained by the data, which were obtained by the VQI vs the National Surgical Quality Improvement Program, which may reflect different populations and operating surgeons because the VQI data are mainly related to vascular surgeons and may not include other nonvascular surgeons who perform CEAs. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. The impact of race on outcomes after carotid endarterectomy in the United StatesJournal of Vascular SurgeryVol. 68Issue 2PreviewBlack patients undergoing carotid endarterectomy (CEA) in the United States are more often symptomatic at presentation and have more comorbidities compared with white patients. However, the impact of race on outcomes after CEA is largely unknown. Full-Text PDF Open Archive

Coronary Endarterectomy with off Pump Coronary Artery Bypass Surgery- A Review

Coronary endarterectomy is first described as an alternative surgical procedure for myocardial revascularization against diffuse coronary artery disease by Baily et al. in 1956. Coronary endarterectomy provides complete surgical revascularization of the myocardium in diffuse and calcified coronary arteries with adequate blood flow to distal part of occluded arteries, thus improving ventricular function. However, the initial outcomes of coronary endarterectomy were not satisfactory but now-a-days different studies have shown that coronary endarterectomy with coronary artery bypass grafting can be done safely with acceptable morbidity and mortality. Moreover, the graft patency rate on angiographic evaluation is also good following coronary endarterectomy. So, it’s time to reevaluate this old techniques, and reanalysis the current outcomes of coronary endarterectomy and readdress its indication in diffuse coronary artery diseaseCardiovasc. j. 2017; 10(1): 84-90

Outcome of coronary endarterectomy with off-pump coronary artery bypass grafting: A retrospective study

In this study, we assessed the outcome of surgical revascularization technique, coronary artery bypass grafting (CABG) with or without coronary endarterectomy for patients with diffuse coronary artery disease in a single surgeon’s practice on 2,189 patients from January 2009 and December 2016. The variables like intubation time, ICU stay, postoperative myocardial infarction, arrhythmia, renal impairment, stroke and ICU mortality were compared. Among these patients, 1,000 patients required coronary endarterectomy in addition to off-pump coronary artery bypass grafting (OPCABG). Initially, the mortality and incidence of postoperative blood transfusion were higher in the group of patients who had coronary endarterectomy in addition to CABG. However, postoperative combined use of heparin, warfarin and double anti-platelet agent was associated with decreased mortality significantly in our study. In comparison to other group, the patients in the combined coronary endarterectomy with CABG group had a higher incidence of male sex, past myocardial infarction and poor left ventricular function. Total myocardial revascularization is attainable when coronary endarterectomy is performed in addition to off-pump coronary artery bypass graft surgery in diffuse coronary artery disease.

Preoperative SYNTAX score to assess the late outcomes after coronary endarterectomy for the diffusely diseased left anterior descending artery†

To evaluate whether the preoperative Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) score was associated with late outcomes of coronary endarterectomy (CE) for the diffusely diseased left anterior descending artery (LAD). We retrospectively analysed 205 of 212 patients undergoing CE for the diffusely diseased LAD between September 2004 and May 2016, excluding 2 patients without preoperative angiographic data and 5 redo cases. The mean SYNTAX score was 34.6. Patients were divided into 3 groups according to their SYNTAX score: low (≤22, n = 26), intermediate (23-32, n = 58) and high (≥33, n = 121). The study end-points were cardiac death and major adverse cardiac and cerebrovascular events, defined as all-cause death, cerebrovascular accidents, non-fatal myocardial infarction and repeat revascularization. All CEs involved long arteriotomy and the reconstruction of the endarterectomized LAD using the skeletonized internal thoracic artery. Postoperative mortality and morbidity were similar between the groups. The median follow-up period was 5.4 years. We found no significant difference in the cumulative cardiac death-free survival rate at 5 years (91.1% vs 100% vs 98.3%; log-rank, P = 0.196) or major adverse cardiac and cerebrovascular events (61.6% vs 71.5% vs 76.7%; log-rank, P = 0.258) in the low, intermediate and high SYNTAX score groups, respectively. Univariate and multivariate Cox proportional hazard analyses revealed no significant association between the study end-points and individual components of the SYNTAX score for the LAD. The preoperative SYNTAX score and its individual components for the LAD were not associated with late outcomes following CE for the diffusely diseased LAD.

A contemporary evaluation of carotid endarterectomy outcomes in patients with chronic kidney disease in the United States.

Objectives Chronic kidney disease (CKD) has been identified as a significant risk factor for poor post-surgical outcomes. This study was designed to provide a contemporary analysis of carotid endarterectomy (CEA) outcomes in patients with CKD, end-stage renal disease (ESRD), and normal renal function (NF). Methods The Nationwide Inpatient Sample data 2006-2012 was queried to select patients aging 40 years old and above who underwent CEA during two days after admission and had a diagnosis of ESRD on long-term hemodialysis, patients with non-dialysis-dependent CKD, or NF. Patients with acute renal failure were excluded. We subsequently compared procedure outcomes and hospital resource utilization in these patients. Results Totally 573,723 CEA procedures were estimated: 4801 (ESRD)' 32,988 (CKD)' and 535,934 (NF). Mean age was 71.0 years, 57.7% were males, and 73.7% were white. Overall hospital mortality was 0.20%: 0.69% (ESRD), 0.35% (CKD), and 0.19% (NF), p < 0.0005 between groups. The overall stroke rate was 1.6%: 1.8% (ESRD), 2.0% (CKD), and 1.6% (NF). Comparing NF to CKD there was a significant difference: p < 0.0001. For CKD patients, compared to NF patients, there was an increased risk in cardiac complications (odds ratio = 1.2; 95% CI 1.15-1.32), respiratory complications (odds ratio = 1.2; 95% CI 1.15-1.32), and stroke (odds ratio = 1.1; 95% CI 1.04-1.23). For ESRD patients compared to NF patients there was an increased risk in respiratory complications (odds ratio = 1.3; 95% CI 1.08-1.47) and sepsis (odds ratio = 4.4; 95% CI 3.23-5.94). Mean length of stay and cost were: 2.8 d and $13,903 (ESRD), 2.2 d and $12,057 (CKD), and 1.8 d and $10,130 (NF), all p < 0.0001. Conclusions Patients with ESRD undergoing CEA had an increased risk of respiratory and septic complications, but not a higher risk of stroke compared to patients with normal renal function. The greatest risks of postoperative stroke, respiratory, and cardiac complications were found in patients with CKD. A diagnosis of ESRD and CKD were both found to significantly increase hospital mortality, length of stay and cost. Where clinicians typically consider ESRD patients the highest risk for CEA, further consideration should be given to patients with CKD not yet on dialysis as they had the higher risk of cardiac complications and stroke compared to the others evaluated.

Outcome of coronary endarterectomy with coronary artery bypass grafting in patients with diffuse coronary artery disease in Bangladesh: A retrospective cohort study.

BackgroundIn this study, we aimed to review the consequences of coronary endarterectomy with coronary artery bypass grafting, and assess outcomes of this combined surgical technique for patients with diffuse coronary artery disease in a single surgeon’s practice.MethodsWe retrospectively reviewed outcome of 1198 endarterectomized coronary artery in 1000 patients with diffuse coronary artery disease, who have had experienced coronary endarterectomy with off pump coronary artery bypass grafting in between 2009 and 2016.ResultsThe mean age was 61.5 ± 5.5 years. Coronary endarterectomy was performed on 74.7% in the left coronary territory (43.2% left anterior descending, 26.6% diagonal, 4.9% Obtuse Marginal), and 25.3% in the right coronary territory. Post-operative intensive care unit mortality rate was 1.9%, and there were 11 (1.1%) late deaths. Mean intensive care unit stay was 36.6 ± 6.7 hours. Patients were extubated following a mean of 9.8 ± 1.25 hours. The mean duration of hospital stay was 10 ± 1 days. One-year survival rate was 97.8% and 89.5% survival rate was at 5 years follow up. However, 91.8% of patients were angina free at median follow-up of 2.5 years.ConclusionCoronary endarterectomy with off pump coronary artery bypass grafting is attainable and accomplishes surgical revascularization in coronary artery disease patients when there is no other alternative for sufficient revascularization.

SS22. Outcomes of Endarterectomy vs Stenting in Patients With Prior Ipsilateral Carotid Artery Stenting

SS22. Outcomes of Endarterectomy vs Stenting in Patients With Prior Ipsilateral Carotid Artery Stenting

Influence of gender and use of regional anesthesia on carotid endarterectomy outcomes

Carotid endarterectomy (CEA) is the most commonly performed surgical procedure to reduce the risk of stroke. The operation may be performed under general anesthesia (GA) or regional anesthesia (RA). We used a national database to determine how postoperative outcomes were influenced by gender and type of anesthesia used. All patients who underwent CEA between 2005 and 2011 were identified from the American College of Surgeons National Surgical Quality Improvement Program database (N= 41,442). Incidence of stroke and myocardial infarction (MI) within 30days as well as other postoperative complications, operative time, and hospital length of stay were examined in groups separated by gender and anesthesia type. Multivariable logistic regression with effect modification was used to determine significant risk-adjusted differences between genders and type of anesthesia to assess outcomes after CEA. The male-to-female ratio among CEA cases performed was approximately 3:2. Most cases were performed under GA (85% male patients, 86% female patients). Adjusted multivariable analysis showed no statistical difference in rates of MI and stroke based on gender or type of anesthesia used. There were, however, higher 30-day postoperative local complications and MI (both P< .05) in those who had GA vs RA regardless of gender before adjustment. Total operative time was decreased (mean difference,-8.15minutes; 95% confidence interval,-10.09 to-6.21; P< .001) and length of stay was increased (mean difference, 0.34day; 95% confidence interval, 0.14-0.54; P< .02) in women, with statistical significance, whether RA or GA was used. On adjusted multivariate analysis, there is no statistically significant difference in postoperative incidence of MI or stroke between men and women undergoing CEA. Use of RA vs GA did not affect this finding. Furthermore, there was no correlation between gender and the type of anesthesia chosen. Women, however, experienced decreased operative times and increased length of stay regardless of anesthesia type.

Early Outcomes of Coronary Endarterectomy in Patients Undergoing Coronary Artery Bypass Surgery.

Coronary endarterectomy (CE) is performed as an adjunct to coronary artery bypass surgery (CABG); however, the efficacy of this technique is still controversial. We aimed to evaluate the impact of CE combined with CABG when compared with isolated CABG. Patients who underwent CABG between July 2007 and June 2014 were included. 70 of 2452 patients (2.8%) underwent CE in addition to CABG. Early results were compared with isolated CABG and predictors of adverse outcome were measured in stepwise multivariate logistic regression analyses. The incidence of comorbidities including prior myocardial infarction, diabetes mellitus, and three-vessel coronary disease in CE patients was higher; however, mortality (4.3% versus control 3.6%; P = .762) and postoperative complications were not significantly increased in this group of patients (except supraventricular arrhythmia). Although age greater than 70 years, impaired ejection fraction, intraoperative intraaortic balloon pump, and prolonged cardiopulmonary bypass time were important predictors of adverse outcomes, CE was not associated with increased mortality or postoperative morbidities. Despite the higher risk profile of patients who underwent CE, this technique was not identified as an independent risk factor for adverse postoperative outcomes.

Clinical Outcome of Surgical Endarterectomy for Common Femoral Artery Occlusive Disease.

Although common femoral artery endarterectomy (CFE) is the standard treatment for occlusive disease of the common femoral artery (CFA), several studies have noted encouraging results for endovascular therapy in this anatomical area. A retrospective multi-center study of 118 consecutive limbs from 111 symptomatic patients undergoing CFE between April 1998 and December 2014 was performed. Seventy-five CFE were performed on limbs for intermittent claudication and 43 CFE were performed for critical limb ischemia (CLI). The prevalence of perioperative complications was higher in patients with CLI than in the claudication patients. The technical success rate was 99% in all cases. The 1- and 5-year primary patency rates were 100% and 100% for claudication and 95% and 95% for CLI, respectively. The assisted-primary patency rates were 100% at both time points in both groups. Freedom from major amputation at 1 and 5 years was 100% and 100% in the claudication patients and 93% and 82% in the CLI patients, respectively. The 1- and 5-year overall survival rates were 97% and 89% in the claudication patients and 69% and 33% in the CLI patients, respectively. CFE is a safe, effective and durable procedure for occlusive disease of the CFA. This procedure should remain the standard treatment for this anatomical region.

Operative and Functional Outcome After Pulmonary Endarterectomy for Advanced Thromboembolic Pulmonary Hypertension.

To evaluate the midterm hemodynamic and functional outcome of pulmonary endarterectomy (PEA) for patients with advanced chronic thromboembolic pulmonary hypertension (CTEPH). Thirty-eight consecutive patients underwent PEA for CTEPH from May 2004 to March 2012. All patients were followed prospectively at six months postoperatively and annually thereafter. Each patient underwent serial cardiopulmonary exercise testing (CPET) and transthoracic echocardiography, and were followed for up to four years. Overall, 31.5% (12/38) of patients had Jamieson class II disease while 65.8% (25/38) had class III disease. There were three in-hospital mortalities (7.9%), all of which had baseline pulmonary vasculature resistance (PVR) greater than 1400 dynes-sec-cm(-5) . Preoperative PVR and mean pulmonary artery pressure were 1209 ± 723 dynes-sec-cm(-5) and 50 ± 14 mmHg, respectively, signifying a high-risk operative group. Ninety-seven percent of patients were in NYHA class III or IV preoperatively. At median follow-up of 29 months 89.5% (17/19) of patients were in NYHA class I or II. CPET revealed a progressive increase in peak oxygen consumption from 16.5 ± 4.1 ml/kg/min at first follow-up, to a plateau of 20.2 ± 5.6 ml/kg/min (p = 0.032) at two years. CPET can be used to quantify progress in functional capacity post-CTEPH, although improvements in peak oxygen consumption plateau at two years.

Off-pump coronary endarterectomy with stent removal for in-stent restenosis in the left anterior descending artery.

In-stent restenosis (ISR) remains a major complication of percutaneous coronary intervention, even in the current era of drug-eluting stents (DESs). We reviewed the clinical and angiographic outcomes of coronary endarterectomy with stent removal using an off-pump technique in patients with ISR in the left anterior descending artery (LAD). Twelve patients with long-segment ISR in the LAD underwent off-pump coronary artery bypass grafting with coronary endarterectomy and stent removal at our institution from November 2005 to August 2012. Their mean age was 65.0 ± 6.3 years, and 11 were male. DESs were used in 10 patients and bare-metal stents were used in the remaining 2 patients. The interval from the latest intervention ranged from 4 to 102 months (median, 12 months). None of the procedures were converted to on-pump surgery, and there were no operative deaths. The left internal thoracic artery (LITA) was used to reconstruct the endarterectomized LAD in all patients, and the mean length of the arteriotomy in the LAD was 5.3 ± 1.0 cm. The LITA and LAD were patent in all patients on both early postoperative and follow-up angiography. At the median 24-month follow-up (range, 12-78 months), there were no late deaths and all patients were at a Canadian Cardiovascular Society class of 0 or I. Coronary endarterectomy with stent removal can be safely performed using an off-pump technique and provides favourable clinical and angiographic outcomes in patients with long-segment ISR in the LAD.

Does Gender or Use of Regional Anesthesia Have Influence on Carotid Endarterectomy Outcomes?

Carotid endarterectomy (CEA) is the most commonly performed surgical procedure to reduce risk of stroke. The operation may be performed under regional (RA) or general anesthesia (GA). Despite perceived advantages of RA, previous trials have found no difference in incidence of transient ischemic attack, stroke, myocardial infarction (MI), and death with RA compared with GA. A retrospective review was performed to determine if postoperative outcomes were influenced by gender or the type of anesthesia used, or both. Patients who underwent CEA between 2005 and 2011 were extracted from the American College of Surgeons National Surgical Quality Improvement Program database. The cohort was separated by sex and anesthesia type. Primary end points included 30-day incidence of stroke and MI. Secondary end points included 30-day postoperative local complications, operative time, and surgical length of stay. Most of the 41,442 CEA patients were men (24,568 male, 16,874 female), and most cases were performed under GA (85% male, 86% female). Adjusted multivariate analysis showed no statistical difference between primary end point outcomes based on gender or type of anesthesia used. There was, however, a trend for increased risk of 30-day postoperative local complications and 30-day incidence of MI in operations conducted under GA compared with RA. Operative time and length of stay was decreased in women, regardless of anesthesia used (mean difference, −8.15 [10.09, −6.21] P < .0001; 0.34 [0.14, 0.54] P < .02). GA was associated with increased operative time and increased total surgical length of stay, regardless of sex, with statistical significance. There is no significant difference in postoperative outcomes between women and men regardless of type of anesthesia used for CEA. GA was associated with increased length of stay and operative time compared with RA in women and men, suggesting that choice of anesthesia may have significant economic effect for patients and institutions. The trend of increased 30-day postoperative local complications and 30-day MI among GA cases also supports the use of RA for CEA. These factors warrant further evaluation to improve patient outcomes and the economic effect of this commonly performed procedure.