Perioperative Stroke Rate Research Articles

One-year mortality and costs associated with surgical ablation for atrial fibrillation concomitant to coronary artery bypass grafting.

While surgical ablation (SA) for persistent atrial fibrillation (AF) can reduce recurrence of AF, its impact on longitudinal survival and health-care costs remains controversial. This study defines the clinical outcomes and costs associated with SA in patients with prior AF undergoing coronary artery bypass grafting (CABG). A total of 3745 Medicare beneficiaries with prior AF who underwent CABG in 2013 were divided into 2 groups: those with and those without concomitant SA. Risk-adjusted early (0-90 days) and late (91-364 days) postoperative outcomes and inpatient costs were compared. SA was performed in 17% of CABG patients with prior AF. Preoperative characteristics favoured patients with SA: emergent presentation (15% vs 22%), heart failure in the 2 weeks prior to CABG (31% vs 36%), chronic lung disease (27% vs 33%) and renal failure (4% vs 7%) (all P < 0.05). Risk-adjusted operative mortality and perioperative stroke rates were similar in the 2 groups. Risk-adjusted survival was similar through 90 days, but significantly better with SA after 90 days [hazard ratio (HR) = 0.58; P = 0.03]. At 1 year, the risk-adjusted incidence of cardiovascular implantable electronic device implantation was greater with SA (HR = 1.20; P = 0.01). Risk-adjusted costs for the CABG admission (HR = 1.11; P < 0.01) and inpatient care through 1 year (HR = 1.06; P = 0.02) were also greater with SA. In the US Medicare population, SA was performed in 17% of CABG-AF patients in 2013. Operative risks for mortality and stroke did not increase with SA but costs did. Patients receiving SA, however, had significantly better risk-adjusted late survival.

Abstract 124: Safety of Carotid Endarterectomy and Carotid Stenting in the Early Period After the Neurologic Index Event - Results From the German Quality Assurance Registry on &gt; 50,000 Patients

Objectives: Current guidelines recommend that carotid endarterectomy (CEA) should be performed within two weeks after the neurologic index event in patients with a 50-99% symptomatic carotid artery stenosis (sCS). Safety of early CEA and early carotid artery stenting (CAS) within those two weeks remains unclair. This study aims to analyze the safety of CEA and CAS in sCS in Germany. Methods: By German law all extracranial carotid procedures have to be documented prospectively in a nationwide quality assurance registry. We analysed data on 56,336 CEAs (68% male, mean age 71 years (SD ± 9.6) and 4,726 CAS (68% male, median age 70 years (SD ± 9.8) treated between 2009-2014 for sCS. The patient cohort was divided into four time interval groups (I: 0-2 days, II: 3-7 days, III: 8-14 days and IV: 14-180 days respectively). Primary endpoint was the combined in-hospital stroke and mortality rate. We excluded all emergency CEAs (stroke-in-evolution, acute occlusion) and all procedures for recurrent carotid stenosis from this analysis. We performed chi-squared tests and a multivariable multilevel Poisson-regression analysis to estimate adjusted risk ratios (RR). Results: The procedural combined stroke and mortality rate was 3.0% (157 of 5198)/6.0% (33 of 550) in group I, 2.5% (480 of 19,117)/4.4% (70 of 1579) in group II, 2.6% (427 of 16,205)/2.4% (30 of 1244) in group III and 2.3% (370 of 15,759)/3.0% (40 of 1344) in group IV respectively. In the multivariable regression analysis the time interval was no independent risk factor for patients treated by CEA. However, CAS was associated with a decreased periprocedural risk when performed 8-14 days (group III) after the index event vs. group I (0-2 days) (RR 0.47, 95% CI 0.28-0.79). No significance was found comparing time group II vs. I (RR 0.80, 95% CI0.52-1.24) and IV vs. I (RR 0.64, 95% CI 0.39-1.05). Conclusion: Time interval between neurologic event and CEA has no significant influence on the perioperative stroke and mortality rate. CAS was associated with a higher risk when performed early. In accordance with the guidelines, CEA remains to be the treatment of choice in the early period after cerebral ischemia.

Modified Eversion Carotid Endarterectomy (mECEA): Analysis of Clinical and Financial Outcomes

Several carotid endarterectomy techniques have been described, including conventional carotid endarterectomy (CCEA) performed with patch repair and eversion carotid endarterectomy (ECEA) performed with transection of the internal carotid artery. We describe our simplified technique of modified eversion carotid endarterectomy (mECEA) with longitudinal arteriotomy limited to the carotid bulb, without transection of the internal carotid artery and present our analysis of its safety, efficacy, and cost effectiveness. A retrospective review of all carotid endarterectomies performed by 3 vascular surgeons over a 3-year period was completed. About 197 mECEA were performed during the study period. Follow-up data were obtained on 77.7% of patients. A comparison was made with the contemporary literature with respect to outcomes for both CCEA and ECEA. Between January 2012 and December 2014, a total of 197 mECEA were performed. The perioperative stroke and death rates for those undergoing mECEA was 0.5% and 0.5%, respectively. Late stroke and death rates were 3.0% and 5.1%, respectively. Perioperative rate of myocardial infarction was 1.0%. Early restenosis rates of >70% occurred in 1.4%, whereas late restenosis of >70% occurred in 2.7%. Mean operating time for those undergoing mECEA was 57.9min. Average costs savings for mECEA compared to CCEA were $5,835. This simplified technique has comparable outcomes to those described in the contemporary literature for both CCEA and ECEA with respect to postoperative neurologic events as well as restenosis rates. In our institution, the short mean operative times with mECEA has led to reduced resource utilization.

Abstract 066: Perioperative Stroke as a Predictor of Mortality and Morbidity in Patients Undergoing CABG

Background: Perioperative stroke is a devastating neurological complication of Coronary Artery Bypass Grafting surgery (CABG). It results in significantly increased rates of mortality and morbidity and presents a significant financial burden to our healthcare system. It has not, however, been studied in a large population based sample. We aim to investigate the role of perioperative stroke as an independent risk factor for in-hospital mortality and morbidity following CABG, and to review trends in the early outcomes of CABG from the years 1999-2011. Hypothesis: Perioperative stroke is an independent risk factor for in-hospital mortality and morbidity following CABG. Methods: Data from the 1999-2011 Nationwide Inpatient Sample was analyzed. We identified patients who underwent CABG using ICD-9 and CCS codes, excluding patients undergoing concomitant heart and or vascular procedures, and also excluding patients below the age of 18 and above the age of 100. Results: Analysis on our sample of 668,627 patients yielded an overall rate of perioperative stroke, mortality, and morbidity of 1.87%, 2.13%, and 49.07%, respectively. Along with age, risk category, gender, and other postoperative outcomes, perioperative stroke was found to be a strong predictor of mortality and morbidity, leading to more than a 5-fold risk of death and morbidity. Conclusions: Perioperative stroke remains a serious adverse outcome of CABG and is an independent predictor of mortality and morbidity. While rates of stroke and mortality are decreasing, morbidity continues to trend upwards. This study emphasizes the importance of prevention and early intervention in patients at risk for perioperative stroke.

Abstract WP444: Postoperative Cognitive Dysfunction is Associated with Large Acute Cerebral Infarcts in Older Adults Following Aortic Valve Replacement for Aortic Stenosis

Introduction: Aortic valve replacement (AVR) for calcific aortic stenosis (AS) is associated with high rates of perioperative clinical stroke and “silent” acute cerebral infarcts (SACI) in older adults. The goal of this study was to determine the impact of clinical stroke and acute infarcts on cognitive outcomes. Methods: 129 elderly surgical AVR (age=74.7±6y) participants underwent perioperative evaluations by neurologists and post-surgical diffusion-weighted MRI during the first week post-op. Clinical assessments and MRI’s were reviewed by vascular neurologists, and participants were classified as having clinical stroke, SACI, or no stroke. Trained coders quantified all acute lesions on MRI (lesion number, lesion volume). Participants also completed cognitive testing at baseline, 4-6 weeks, and 1 year. The incidence of post-operative cognitive disorder (POCD) was identified using reliable change index scores calculated in reference to a comparison group of 154 nonsurgical participants with vascular disease. Results: Surgical participants who had a perioperative clinical stroke (n=34) had the largest infarct volume and performed worse than participants with SACI (n=59) and those without stroke on cognitive testing at baseline and at 4-6 weeks post-surgery (p &lt; .05 for all). Among participants who showed an acute infarct on postop MRI (i.e., clinical stroke + silent stroke, n = 93), total acute infarct volume but not infarct number was significantly correlated with cognitive outcomes at 4-6 weeks and 1 year (r &gt; .27 for all). Surgical participants with POCD (12.2% at 4-6 weeks; 9.2% at 1 year) were older, more likely to have had a perioperative clinical stroke, and had more and larger acute infarcts on MRI than surgical participants without POCD (p &lt;.05 for all). Conclusions: Cognitive outcomes and POCD are significantly associated with perioperative clinical stroke and volume of acute infarct on MRI. However, surgical participants who demonstrate small, SACI show good cognitive outcomes that are comparable to participants without perioperative infarct. Low baseline cognitive function may be a risk marker for perioperative stroke and poor cognitive outcomes in the elderly.

Treatment Strategy and Results of Carotid Endarterectomy in Chronic Renal Failure Patients

The number of patients receiving chronic dialysis treatment in Japan currently exceeds 300,000 people. Few reports have described carotid endarterectomy(CEA)for chronic renal failure patients because of the unacceptable rate of perioperative stroke and other morbidities. A strategy for and treatment results of CEA for chronic renal failure patients in our hospital are described herein. The present study included 6 patients who underwent CEA while receiving dialysis treatment between April 2011 and November 2014. Dialysis treatment was initiated due to diabetes in 4 patients and renal sclerosis in 2 patients. All the patients were men, with a mean age of 74.0 years. Two patients were symptomatic, and four were asymptomatic. In all the patients, heart vascular lesions and arteriosclerosis risk factors were present. Postoperatively, pneumonia transient cranial neuropathy, heart failure, and pneumonia in 1 case required extensive treatment. However, by the time of discharge from hospital, no cases had deteriorated compared with their pre-CEA state. The modified Rankin scale score on discharge was 0-2 for all the patients. CEA can be performed safely in patients receiving dialysis, but further operative procedures and careful postoperative management are likely to be needed for patients with CEA who are receiving dialysis.

Carotid artery disease and periprocedural stroke risk after transcatheter aortic valve implantation

Objective/Background:To examine the role of carotid stenosis (CS) and other independent risk factors of perioperative stroke, following transcatheter aortic valve implantation (TAVI).Materials and Methods:Using data from the National Inpatient Sample database for analysis, patients who underwent TAVI were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. Various preoperative and perioperative risk factors and their association with perioperative strokes were studied.Results:Data on 7566 patients who underwent a TAVI procedure from 2012 to 2013 were extracted. The average age of the patient population was 81.2 ± 0.32 years. The overall perioperative stroke rate in our patient cohort was 2.79%. Majority (94.6%) of the strokes were ischemic. Multivariate analysis showed the following independent risk factors for perioperative strokes after TAVI: female gender odds ratio (OR) = 2.25 (95% confidence interval [CI], 1.42–3.57), higher van Walraven score OR = 6.6 (95% CI = 3.71–11.73), bilateral CS OR = 4.46 (95% CI = 2.03–9.82), and TAVI with a cardiac procedure done under cardiopulmonary bypass OR = 2.84 (95% CI = 1.57–5.14).Conclusion:Bilateral carotid disease is a significant risk factor for perioperative strokes following TAVI. Preoperative screening with carotid Doppler to identify high-risk patients appears to be warranted. In addition, patients of female gender were found to have an increased risk for carotid disease.

Cerebral monitoring during carotid endarterectomy by transcranial Doppler ultrasonography.

PurposeTo evaluate the efficacy and safety of cerebral monitoring by transcranial Doppler ultrasonography (TCD) for the detection of cerebral ischemia during carotid endarterectomy (CEA).MethodsFrom August 2004 to December 2013, 159 CEAs were performed in a tertiary hospital. All procedures were performed under general anesthesia. Intraoperative TCD was routinely used to detect cerebral ischemia. Of the 159 patients, 102 patients were included in this study, excluding 27 patients who had a poor transtemporal isonation window and 30 patients who used additional cerebral monitoring systems such as electroencephalography or somatosensory evoked potentials. When mean flow velocity in the ipsilateral middle cerebral artery decreased by >50% versus baseline during carotid clamping carotid shunting was selectively performed. The carotid shunt rate and incidence of perioperative (<30 days) stroke or death were investigated by reviewing medical records.ResultsCarotid shunting was performed in 31 of the 102 patients (30%). Perioperative stroke occurred in 2 patients (2%); a minor ischemic stroke caused by embolism in one and an intracerebral hemorrhage in the other. Perioperative death developed in the latter patient.ConclusionTCD is a safe cerebral monitoring tool to detect cerebral ischemia during CEA. It can reduce use of carotid shunt.

A short time interval between the neurologic index event and carotid endarterectomy is not a risk factor for carotid surgery

ObjectiveCurrent guidelines recommend that carotid endarterectomy (CEA) be performed as early as possible after the neurologic index event in patients with 50% to 99% carotid artery stenosis. However, recent registry data showed that patients treated ≤48 hours had a significantly increased perioperative risk. Therefore, the aim of this single-center study was to determine the effect of the time interval between the neurologic index event and CEA on the periprocedural complication rate at our institution. MethodsProspectively collected data for 401 CEAs performed between 2004 and 2014 for symptomatic carotid stenosis were analyzed. Patients were divided into four groups according to the interval between the last neurologic event and surgery: group I, 0 to 2 days; group II, 3 to 7 days; group III, 8 to 14 days; and group IV, 15 to 180 days. The primary end point was the combined rate of in-hospital stroke or mortality. Data were analyzed by way of χ2 tests and multivariable regression analysis. ResultsThe patients (68% men) had a median age of 70 years (interquartile range, 63-76 years). The index events included transient ischemic attack in 43.4%, amaurosis fugax in 25.4%, and an ipsilateral stroke in 31.2%. CEA was performed using the eversion technique in 61.1% of patients, and 50.1% were treated under locoregional anesthesia. The perioperative combined stroke and mortality rate was 2.5% (10 of 401), representing a perioperative mortality rate of 1.0% and stroke rate of 1.5%. Overall, myocardial infarction, cranial nerve injuries, and postoperative bleeding occurred in 0.7%, 2.2%, and 1.7%, respectively. We detected no significant differences for the combined stroke and mortality rate by time interval: 3% in group I, 3% in group II, 2% in group III, and 2% in group IV. Multivariable regression analysis showed no significant effect of the time interval on the primary end point. ConclusionsThe combined mortality and stroke rate was 2.5% and did not differ significantly between the four different time interval groups. CEA was safe in our cohort, even when performed as soon as possible after the index event.

Results From a Nationwide Registry on Scalloped Thoracic Stent-Grafts for Short Landing Zones

Purpose: To report the perioperative results and short-term follow-up of patients treated with scalloped thoracic stent-grafts. Methods: A multicenter registry in the Netherlands captured data on 30 patients (mean age 68 years; 17 men) with thoracic aortic pathology and a short (<20 mm) proximal or distal landing zone who received a custom-made scalloped stent-graft between January 2013 and February 2016. Patients were treated for saccular (n=13) aneurysms, fusiform (n=9) aneurysms, pseudoaneurysms (n=4), or chronic type B dissections (n=4). The scallop was used to preserve flow in the left subclavian artery (LSA) (n=17), left common carotid artery (n=5), innominate artery (n=1), and celiac trunk (n=7). In 7 (23%) patients, the scallop also included the adjacent artery. Results: Technical success was achieved in 28 (93%) patients. In 1 patient, a minor type Ia endoleak was observed intraoperatively, which was no longer visible on computed tomography angiography at 3 months. In another patient, the LSA was unintentionally obstructed due to migration of the stent-graft on deployment. Concomitant carotid-carotid or carotid-subclavian bypass was performed in 4 patients. There was no retrograde type A dissection or conversion to open surgery. In-hospital mortality was 3%, and the perioperative ischemic stroke rate was 3%. At a mean follow-up of 9.7 months (range <1 to 31), 29 of 30 target vessels were patent. Conclusion: The scalloped stent-graft appears to be a safe and relatively simple alternative for the treatment of thoracic aortic lesions with short landing zones. Larger patient series and long-term follow-up are required to confirm these early results.

Anatomical and Technical Factors Influence the Rate of In-Stent Restenosis following Carotid Artery Stenting for the Treatment of Post-Carotid Endarterectomy Stenosis.

BackgroundCarotid artery stenting (CAS) has been advocated as an alternative to redo surgery for the treatment of post-carotid endarterectomy (CEA) stenosis. This study analyzed the efficacy of CAS for post-CEA restenosis, focusing on an analysis of technical and anatomical predictive factors for in-stent restenosis.MethodsWe performed a retrospective monocentric study. We included all patients who underwent CAS for post-CEA restenosis at our institution from July 1997 to November 2013. The primary endpoints were the technical success, the presence of in-stent restenosis >50% or occlusion, either symptomatic or asymptomatic, during the follow-up period, and risk factors for restenosis. The secondary endpoints were early and late morbidity and mortality (TIA, stroke, myocardial infarction, or death).ResultsA total of 153 CAS procedures were performed for post-CEA restenosis, primarily because of asymptomatic lesions (137/153). The technical success rate was 98%. The 30-day perioperative stroke and death rate was 2.6% (two TIAs and two minor strokes), and rates of 2.2% (3/137) and 6.2% (1/16) were recorded for asymptomatic and symptomatic patients, respectively. The average follow-up time was 36 months (range, 6–171 months). In-stent restenosis or occlusion was observed in 16 patients (10.6%). Symptomatic restenosis was observed in only one patient. We found that young age (P = 0.002), stenosis > 85% (P = 0.018), and a lack of stent coverage of the common carotid artery (P = 0.006) were independent predictors of in-stent restenosis.ConclusionWe identified new risk factors for in-stent restenosis that were specific to this population, and we propose a technical approach that may reduce this risk.

Carotid Revascularization in Asymptomatic Patients after Renal Transplantation

In multiple studies, chronic renal insufficiency has been associated with increased risk of periprocedural stroke, cardiac complications, and death following carotid revascularization. Renal transplantation has been shown to reduce cardiovascular risk and improve survival; outcomes after carotid revascularization in renal transplant patients however are unknown. In this study, we evaluate periprocedural and long-term risks after carotid endarterectomy (CEA) and carotid artery stenting (CAS) in a cohort of renal transplant patients. We studied all renal transplant patients in the United States Renal Data System who underwent CEA or CAS between January 2006 and December 2011. Patient outcomes were determined by linking with the Medicare database. Propensity score matched logistic and cox regression analyses were employed to evaluate perioperative stroke, myocardial infarction (MI), and death and long-term stroke and death. Of the 462 revascularizations for asymptomatic carotid artery stenosis between 2006 and 2011, 387 (84%) were CEA and 75 (16%) were CAS. The 2 groups did not differ in age, gender, sex, race, or baseline medical characteristics. There was no significant difference in perioperative stroke, MI, or death rates in the CEA cohort (4.7%, 4.4%, and 1.3%, respectively) compared with the CAS cohort (5.3%, 2.7%, and 4.0%, respectively). Stroke-free survival for CEA versus CAS was 93% vs. 92% at 1year, 90% vs. 87% at 2years, 88% vs. 87% at 3years, and 84% vs. 82% at 4years (P=0.81). Overall patient survival for CEA versus CAS was 89% vs. 88% at 1year, 77% vs. 75% at 2years, 66% for both at 3years, and 53% vs. 48% at 4years (P=0.68). In propensity score matched Cox regression analysis, there was no difference in risk of perioperative stroke or MI or in long-term stroke or death for CAS compared with CEA. This is the first study to evaluate outcomes following CEA and CAS in renal transplant patients. The incidence of perioperative complications in this group is higher than the maximum recommended by the Society of Vascular Surgery, and the benefits of revascularization may be outweighed by the excess periprocedural morbidity and reduced life expectancy of these patients.

Postoperative Stroke after Debranching with Thoracic Endovascular Aortic Repair

This study aimed to analyze the perioperative stroke rate, stroke lesions, outcome, risk factors, and stroke prevention following debranching with thoracic endovascular aortic repair (TEVAR). Retrospective study. Between February 2011 and February 2015, 74 consecutive patients underwent debranching with TEVAR at our institution. Of these, the TEVAR proximal landing zone was "zone 0" in 23 patients, "zone 1" in 28, and "zone 2" in 23. Left subclavian artery (LSA) occlusion with coil embolization, balloon occlusion, or vascular plugging was performed in 27 patients. Mean follow-up time was 19.2months (range 2-52months). The in-hospital mortality rate was 4.1%. Stroke developed in 7 patients (9.5%), zone 0 in 4 patients, zone 1 in 2, and zone 2 in 1. Six of these patients had stroke lesions arising from the vertebral/basilar artery. Univariate analysis revealed a significant increase in the risk of postoperative stroke in patients with intraluminal atheroma (P=0.001), those who underwent prior percutaneous transluminal coronary angioplasty or coronary artery bypass graft (P=0.002), and those with a long operative duration (P=0.001). Additionally, LSA occlusion significantly decreased the incidence of stroke (P=0.041). The postsurgical 1- and 2-year cumulative survival rates were 87.3% and 77.0%, respectively, in those without stroke, and 68.6% and 22.9%, respectively, in those with stroke (P=0.012). Stroke after debranching with TEVAR was associated with a high mortality. To prevent stroke, careful patient selection and protection of the vertebral artery are important. Prophylactic LSA occlusion at the time of stent-graft deployment might reduce the risk of perioperative stroke.

Comparison of Total Arch and Partial Arch Transposition During Hybrid Endovascular Repair for Aortic Arch Disease

Total arch transposition (TAT) during hybrid endovascular repair for aortic arch disease is believed to allow a better landing zone, but also to be associated with higher peri-operative mortality than partial arch transposition (PAT). Information on this issue is limited. This study was a retrospective analysis. All 53 consecutive patients with aortic arch disease (41 males, mean age 65.0 years) who underwent hybrid endovascular repair with TAT (zone 0, n=20) or PAT (zone 1 or 2, n=33) from 2008 to 2014 were analyzed retrospectively. The peri-operative and late outcomes of these two groups were compared. Baseline characteristics, including EuroSCORE II results, were similar in the two groups. After procedures, peri-operative mortalities and stroke rates were similar in the two groups (5.0% vs. 9.1%, p=1.000, and 10.0% vs. 6.1%, p=.627). Interestingly, all four strokes occurred in patients with a type III aortic arch irrespective of transposition type. Primary success rates (80.0% vs. 69.7%, p=.527) and type I endoleak incidences (20.0% vs. 27.3%, p=.744) were not significantly different. During follow up (mean duration 36.9 months), overall survival (89.7% vs. 87.4% at 1 year and 89.7% vs. 79.3% at 3 years; p=.375) and re-intervention free survival rates (78.6% vs. 92.0% at 1 year; 72.0% vs. 62.2% at 3 years, p=.872) were similar in the two groups. Morbidity and mortality were high within the first year of hybrid endovascular therapy for aortic arch disease, implying that candidates for hybrid procedures need to be selected carefully. Hybrid endovascular repair with TAT was found to have peri-operative mortality, stroke, and long-term survival rates comparable with PAT, so hybrid endovascular repair may be considered, irrespective of type of arch reconstruction, when clinically indicated.

IP119. Correlates of Hypothermic Circulatory Arrest and Risk of Operative Mortality in Thoracoabdominal Aortic Repair

Use of hypothermic circulatory arrest (HCA) as a surgical adjunct in descending thoracic and thoracoabdominal repair (D/TAAA) is associated with variable results. We reviewed our experience using HCA during D/TAAA. Data were collected from medical records into an IRB-approved longitudinal clinical research database. Univariate and multivariable analyses were conducted by standard methods for frequency, continuous, and failure-time data. Preoperative characteristics and in-hospital and long-term outcomes were analyzed to identify correlates of HCA and determine risk factors for early and long-term mortality. Between 1999 and 2014, 1183 patients underwent 1251 thoracic or TAAA repair. HCA was required in 33 patients (2.6%; 23 men, 10 women). The median age was 60 (range, 50-68 years). A total of 29 patients (88%) had repair of the distal arch and descending thoracic and 4 (12%) for thoracoabdominal aorta. Median pump time and circulatory arrest time were 136 (IQR 111-153) and 18 (13-25), respectively. The perioperative stroke rate was 4 of 33 (12%). Three patients (9.1%) had spinal cord ischemia. Postoperative hemodialysis was required in 9.1% of patients. Overall, 30-day mortality was 8 (24%). Long-term survival over a median follow-up period of 1.4 (IQR .01-5.2) years was 47.4% at 5 years. Previous DTA repair, previous arch repair, prior TEVAR, history of coarctation, and emergency presentation had increased propensity for use of HCA (Table). Intraoperative coagulopathy commonly complicated the operative repair in those who required HCA (48.5% vs 13.9%; P < .001). HCA did not increase the risk for any postoperative major complications. Although long-term survival between D/TAAA repairs with and without HCA was not statistically different at 5 years (47.4% vs 58.5%; P = .069; Fig), HCA itself was a significant risk factor for overall mortality (hazard ratio, 1.8; 95% CI, 1.0-2.9; P = .034). HCA was significantly associated with intraoperative coagulopathy and mortality but did not increase the risk for postoperative morbidity or mortality. Careful surgical planning with judicious application of HCA may be associated with acceptable outcomes, especially in patients when proximal aortic control is not easily accessible.TableIndependent correlates determining propensity for hypothermic circulatory arrest in descending thoracic aneurysm (DTA) and descending thoracoabdominal (DTAAA) repairParameterParameter estimateOR95% CLP valueDTAA extent C1.18873.2831.440, 7.482.0047Previous DTA repair1.56744.7941.832, 12.546.0014Prior arch repair1.43204.1871.821, 9.628.0008Prior TEVAR2.30139.9872.694, 37.018.0006Prior coarctation2.07937.9991.701, 37.609.0085Emergency1.20263.3291.313, 8.437.0113CL, Confidence limits; OR, odds ratio; TEVAR, thoracic endovascular aortic repair. Open table in a new tab

EARLY OUTCOMES

Objectives: Off pump TACR/MACR performed in experienced hands hascomparable results to on pump TACR/MACR. Period: January-2012 to December-2015.Material and method: 405 patients with two and three vessel coronary artery disease (two &amp;three VCAD) underwent OPCAB at the department of cardiac surgery, Jinnah hospital, Lahore.73 of them got total or multiple arterial coronary revascularizations. 34 patients (41%) hadtwo VCAD and 47 (59%) had three VCAD. Total arterial revascularization was performed in 70(95.8%) patients using right internal mammary artery and left internal mammary artery and/orradial artery. 3 (4.10%) patients got multiple arterial grafts using BITA, RA and SVG. Results:There was no death reported in first 30 days post operatively. Deep sternal wound infectionoccurred in only one patient. The rate of perioperative stroke and renal failure was zero. Two(2.46%) patients had acute MI and 1 patient was reopened due to bleeding. Conclusion: Weconclude that early outcome of OPCAB total or multiple arterial coronary revascularizations, inexperienced hands, are as safe and effective as ONCAB.

English

5 ORIGINAL PROF-3269 ABSTRACT… Objectives: Off pump TACR/MACR performed in experienced hands has comparable results to on pump TACR/MACR. Period: January-2012 to December-2015. Material and method: 405 patients with two and three vessel coronary artery disease (two & three VCAD) underwent OPCAB at the department of cardiac surgery, Jinnah hospital, Lahore. 73 of them got total or multiple arterial coronary revascularizations. 34 patients (41%) had two VCAD and 47 (59%) had three VCAD. Total arterial revascularization was performed in 70 (95.8%) patients using right internal mammary artery and left internal mammary artery and/or radial artery. 3 (4.10%) patients got multiple arterial grafts using BITA, RA and SVG. Results: There was no death reported in first 30 days post operatively. Deep sternal wound infection occurred in only one patient. The rate of perioperative stroke and renal failure was zero. Two (2.46%) patients had acute MI and 1 patient was reopened due to bleeding. Conclusion: We conclude that early outcome of OPCAB total or multiple arterial coronary revascularizations, in experienced hands, are as safe and effective as ONCAB.

Outcomes after carotid artery stenting in hemodialysis patients

Patients who require hemodialysis are historically excluded from randomized studies of carotid artery stenting (CAS) due to perceived poor outcomes. Observational studies of outcomes after CAS in hemodialysis patients are mostly limited to small, single-institution series. This study evaluated long-term outcomes after CAS in a large nationally representative cohort of hemodialysis patients. We studied all patients who underwent CAS in the United States Renal Disease System database between January 2006 and December 2011. Patient outcomes were determined by matching with the Medicare database. Univariable and multivariable logistic and Cox regression were used to compare perioperative (stroke, death, myocardial infarction) and long-term (stroke, death) outcomes after CAS. The cohort included 1109 patients who underwent CAS. Median follow-up was 2.5years (interquartile range, 1.30-3.71; maximum, 4.97years). Mean age was 67 (standard deviation, 9.9) years, and 61% of patients were male, 75% were white, and 83% were asymptomatic. Overall, 30-day perioperative stroke, myocardial infarction, and death rates were 5.5%, 5.5%, and 3.1%, respectively. Long-term freedom from stroke was 90% at 1year, 85% at 2years, and 76% at 4years. Patient survival was 73% at 1year and 29% at 4years. Symptomatic status was the only significant predictor of stroke in a long-term period of 4years (hazard ratio, 1.92; 95% confidence interval, 1.12-3.29; P< .05). This study, which is the largest population-based study of outcomes after CAS in hemodialysis patients, demonstrates relatively poor long-term survival and prohibitive operative stroke and death risk. We recommend avoidance of CAS in asymptomatic dialysis patients and cautious consideration when planning CAS in symptomatic patients.

Results of Carotid Endarterectomy Using Bovine Pericardium Patch Closure, with a Review of Pertinent Literature

Patch closure after carotid endarterectomy lowers risk of recurrent stenosis and perioperative neurologic events. Although vein patches have theoretic benefits, few differences between vein and nonautologous patches have been noted. Bovine pericardium has been increasingly used in carotid surgery over the last 15 years, with favorable reports. This study reviews a large carotid surgery series using this patch. Data were gathered on 464 consecutive carotid operations using the bovine pericardium patch; all complications were analyzed and pertinent literature review was performed. Of 464 procedures, 218 (47%) were performed for symptomatic disease. Total perioperative ipsilateral stroke rate was 0.65 per cent. A low rate of postoperative bleeding was noted. Recurrence of >70 per cent stenosis was 1.6 per cent at follow-up of 26 months in 410 patients. Handling was subjectively described as excellent. Literature review comprising 3239 carotid operations revealed low risks of stroke, bleeding requiring intervention, or high rates of recurrent stenosis. Bovine pericardium patch angioplasty has low perioperative and late complications and good handling characteristics, making it an acceptable choice for use in carotid surgery.

Abstract 102: Carotid Endarterectomy versus Stenting in Patients on Chronic Hemodialysis

Introduction: There has been an increase in the number of hemodialysis (HD) patients seeking treatment for carotid artery stenosis in recent times. These patients suffer from a unique course of cardiac and vascular disease and are often considered high risk for surgery. In this study, we compare long-term outcomes after carotid endarterectomy (CEA) versus angioplasty and stenting (CAS) in a large contemporary cohort of HD patients. Methods: We studied all HD patients who underwent CEA and CAS in the United States Renal Disease System (USRDS) database between January 2006 and December 2011. Patient data were linked to the Medicare database to capture long-term outcomes. Univariable, multivariable cox regression, and propensity score matched analyses were employed to compare perioperative (stroke, death, MI) and long-term (stroke and death) outcomes following CAS vs. CEA. Results: There were 6183 (CEA: 5121; CAS: 1062) carotid revascularizations performed in this cohort with a mean age of 67 (S.D 10.1) years. The majority of patients were male (60%), white (76%) and asymptomatic (CEA: 83%; CAS: 83%). Mean follow-up was of 1.6±1.3 years. Thirty day stroke (3.2 vs 5.5%) and death (4.6 vs 5.5%) were significantly lower after CEA. However, 30-day MI was similar between groups (3.2 vs 3.5%). Propensity score matched analysis showed a significantly higher risk of perioperative stroke after CAS compared to CEA (Table 1). Symptomatic status was a significant predictor of perioperative stroke (OR: 1.92; 95%CI: 1.33-2.77; P&lt;0.001). Stroke-free survival for CEA vs CAS was 92% vs 90% at 1 year, 87% vs 85% at 2 years, and 81% vs 76% at 4 years. Conclusions: This is the first study to compare long-term outcomes after CEA and CAS in a large cohort of HD patients. CAS is associated with a significantly higher risk of perioperative stroke compared to CEA. Long term stroke free survival is similar between groups, and differences appear to be largely driven by perioperative stroke rates.