Postoperative Myocardial Infarction Research Articles

Females at a Clear Disadvantage with Postoperative Myocardial Infarction Symptoms.

Cardiovascular disease remains the leading cause of death in women. Gender bias and blindness are coming into focus as relevant risk factors for patients. To date, there have been no studies that target surgeons' potential gender bias in recognizing postoperative myocardial infarction (MI). An online clinical vignette describing a patient with postoperative MI was randomized for gender. Possible diagnoses, the next steps in management, and questions on gender bias were assessed. A total of 205 surveys were analyzed. MI was recognized in 55.6% of the male case studies vs. 32.0% of the female case studies in the first question (p < 0.005). Cardiac diagnostics were initiated significantly more in male case studies (94% vs. 76%, p = 0.001). Female surgeons listed MI as the first diagnosis twice as often as male surgeons overall (43% vs. 23%, p = 0.027). Female surgeons were also more likely to mention MI across the survey at all compared to male surgeons (89% vs. 67%, p = 0.0002). Board-certified surgeons diagnosed MI by the end of the survey significantly more (88.2%) than residents (75.0%) and medical students (75.0%, p = 0.047). Overall, this study was able to demonstrate the presence of both gender bias and gender blindness in surgeons' assessment of postoperative myocardial infarction symptoms with a clear disadvantage for female patients and a superior awareness for female surgeons.

Total arterial revascularization with RIMA-LIMA-Y configuration in patients with left subclavian artery stenosis.

Subclavian artery stenosis (SAS) occurs in 6% of patients undergoing coronary artery bypass grafting (CABG). Complications such as subclavian-coronary steal are common. Revascularization options in such cases remain debatable. In this case series, all patients with angina, had severe triple vessel disease on angiography. All tests including computed tomography (CT) angiography of neck vessels, were done as part of routine workup for CABG. The patients, all males, had a mean age of 66.5 years with three of them having hypertension and diabetes. All were ex-smokers with mean ejection fraction (EF) of 60.1%. CT angiography of neck vessels revealed that two patients had moderate to severe while one had severe left SAS and another had severe proximal left internal mammary artery (LIMA) stenosis. Total arterial revascularization was performed, with an average of 3.5 distal grafts. The LIMA graft was employed in a Y graft configuration, anastomosed to in-situ right internal mammary artery (RIMA). All patients had uneventful postoperative stay and were discharged with a mean hospital stay of 3.8 days. There were no postoperative strokes, myocardial infarction, neurological symptoms, or change in EF. At 6-month follow-up, they were asymptomatic and doing well. The RIMA-LIMA-Y configuration can be a safe, viable option in CABG for patients with left SAS. It is challenging, with re-entry and judicious utilization of the length of LIMA being of paramount importance. The importance of CT angiography of neck vessels to detect SAS cannot be under-emphasized.

Tranexamic Acid Is Safe in Arthroplasty Patients Who Have a History of Venous Thromboembolism: An Analysis Accounting for Surgeon Selection Bias

BackgroundRetrospective data supporting the use of tranexamic acid (TXA) among high-risk total joint arthroplasty (TJA) patients are limited by surgeon selection bias. This study sought to evaluate the thromboembolic risk associated with TXA administration among elective arthroplasty patients who have history of venous thromboembolism while accounting for surgeon selection. MethodsA healthcare database was retrospectively queried from 2015 to 2021 to identify all patients who had a history of deep vein thrombosis or pulmonary embolism who underwent elective TJA. Patients were categorized into two cohorts: (1) patients treated by a surgeon who used TXA in 0 to 30% of cases; and (2) patients treated by a surgeon who used TXA in 90 to 100% of cases. Patients were assessed based on the surgeon who treated them rather than their exposure to TXA. Demographics, comorbidities, and the incidence of 90-day postoperative complications were compared between the two groups. Multivariable and instrumental variable analysis using surgeon as an instrument were conducted to account for confounding factors. ResultsIn total, 70,759 high-risk elective TJA patients were identified, of which 7,190 (10.2%) were performed by surgeons in the infrequent-TXA cohort and 9,478 (13.4%) were performed by surgeons in the frequent-TXA cohort. On instrumental variable analysis, patients treated by surgeons in the frequent-TXA cohort had a lower risk of aggregate bleeding complications (instrumental variable odds ratio 0.94, 95% confidence interval: 0.89 to 0.98, P = 0.005), including transfusion (instrumental variable odds ratio 0.60, 95% confidence interval: 0.54 to 0.66, P < 0.001). However, no significant differences were observed in postoperative deep vein thrombosis, pulmonary embolism, stroke, and myocardial infarction between the two cohorts (P > 0.05). ConclusionsAfter accounting for surgeon selection, TXA administration was associated with a significant reduction in early postoperative bleeding complications with no observed increase in thromboembolic risk. Given the favorable safety profile, surgeons should consider TXA among high-risk arthroplasty patients.

Results of Carotid Endarterectomy Performed at Different Times During the Acute Period of Ischemic Stroke

AIM OF STUDY. To compare the results of carotid endarterectomy performed at different times (1st, 2nd and 3rd week) of the acute period of ischemic stroke.MATERIAL AND METHODS. In the acute period of ischemic stroke (1–21 days), 92 patients with symptomatic stenosis of the internal carotid artery of 50% or more were operated on using carotid endarterectomy . There were 66 men and 26 women. The average age was 65.7±8.4 years. All patients were divided into three groups depending on the timing of the operation: Group 1, where the operation was performed on the 1st week of stroke (n=48); Group 2, where the operation was performed on the 2nd week after stroke (n=28); Group 3, where carotid endarterectomy was performed on the 3rd week after stroke (n=16). In-hospital endpoints of the study in each group were ipsilateral ischemic stroke, any other stroke (contralateral ischemic or hemorrhagic), myocardial infarction, wound hemorrhagic complications requiring repeated operation and surgical hemostasis, death, and major adverse cardiovascular events (stroke + myocardial infarction + fatal outcome).RESULTS. There were no postoperative ipsilateral ischemic strokes, myocardial infarctions, or deaths in the study group (92 patients). In the overall group of patients (n = 92), the incidence of any postoperative stroke was 2.2% (2 patients): one hemorrhagic stroke on the side of carotid endarterectomy (group 3) and one contralateral ischemic stroke on the first postoperative day in a patient with bilateral critical stenosis of the internal carotid artery (group 1). Postoperative wound hematoma, which required revision and bleeding arrest in the early postoperative period, developed in one (1.1%) patient in Group 1. The overall incidence of major adverse cardiovascular events was 2.2% or 2 patients. In all three groups, a statistically significant and positive effect in regression of the initial neurological deficit was obtained at discharge. In patients operated in the first week after stroke, the neurological deficit at discharge according to the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin scale was the lowest. In general, 31.3%, 17.9% and 12.5% of patients in groups 1, 2 and 3 were discharged without neurological deficit (0 points according to the NIHSS scale), respectively.CONCLUSIONS. Carotid endarterectomy performed in the acute period of ischemic stroke is a safe surgical intervention in the prevention of recurrent ipsilateral ischemic events. The most positive neurological dynamics and the least neurological deficit at discharge were achieved after operations performed in the first week of ischemic stroke.

Del Nido versus conventional blood cardioplegia in patients with combined aortic root surgery: A retrospective study.

This study aimed to compare the safety and efficacy of Del Nido cardioplegia (DNC) and conventional blood cardioplegia (CBC) in combined aortic surgery. This retrospective study involved elective patients who underwent combined aortic root surgery between September 2017 and July 2023. Patients were divided into two groups: the DNC and the CBC group. The primary outcome was high-sensitivity cardiac troponin I and creatine kinase-MB levels at the 0, 1, 2, and three postoperative days. The secondary outcomes contained postoperative left ventricular ejection fraction, return to spontaneous rhythm after aortic de-clamping, postoperative myocardial infarction, new-onset atrial fibrillation, postoperative mechanical circulatory support, mechanical ventilation duration, intensive care unit stay, postoperative hospital stay, and the reduction of left ventricle end-diastolic diameter at 3months after surgery. 223 patients were included and divided into the CBC (n = 111) and the DNC group (n = 112). There was no statistical difference in patients' demographics and preoperative parameters between the two groups. No in-hospital mortality. The total cardioplegia volume [35.25 (30.30,43.65) ml/kg versus 21.43 (18.42,25.62) ml/kg, p < 0.001] and infusion times [2 (2,3) times versus 1 (1,2) times, p < 0.001] were less and the incidence of return to spontaneous rhythm after de-clamping was higher in the DNC group [59.5% versus 83%, p < 0.001]. Postoperative high-sensitivity cardiac troponin I and creatine kinase-MB levels were comparable between the two groups. DNC is related to a shorter duration of mechanical ventilation, intensive care unit stay, and hospital stay than CBC. The rate of return to spontaneous rhythm after aortic de-clamping seemed to decrease with the prolongation of aortic cross-clamping (ACC) duration, and there was no difference between the two groups when the time exceeded 120min. The safety and efficacy of using DNC were comparable to CBC in combined aortic surgery. The rate of return to spontaneous rhythm after aortic de-clamping seemed to decrease with the prolongation of ACC time. Further studies may be needed to fully elucidate the advantages of DNC in postoperative recovery and its long-term effects on patient outcomes.

Outcomes of Surgical Versus Transcatheter Aortic Valve Replacement in Obese Patients: A Systematic Review and Meta-Analysis.

Transcatheter aortic valve implantation (TAVI) has been increasingly preferred over surgical aortic valve replacement (SAVR) for treating patients with severe aortic stenosis and intermediate to high surgical risk. Recent studies have indicated that obesity may confer protective benefits in cardiac surgery, known as the obesity paradox. We conducted a systematic review and meta-analysis to explore how obesity influences outcomes of TAVI versus SAVR. We searched and reviewed relevant studies comparing TAVI and SAVR in obese patients with aortic stenosis indexed in PubMed, Embase, and Scopus databases. Data from 5 studies with 16,161 patients (TAVI, n = 2951; SAVR, n = 13,210) were included. There was a lower incidence of postprocedural in-hospital mortality [risk ratio (RR), 0.64; 95% confidence interval (CI), 0.41-0.98; P = 0.04], acute kidney injury (RR, 0.53; 95% CI, 0.38-0.73; P = 0.0001), and shorter duration of in-hospital stay (mean difference: -3.35; 95% CI, -4.93 to -1.76; P = 0.0001) in TAVI versus SAVR. There was no significant difference in the risk of postoperative stroke (RR, 0.93; 95% CI, 0.29-3.02; P = 0.91), major bleeding (RR, 0.71; 95% CI, 0.47-1.07; P = 0.10), and myocardial infarction (RR, 0.64; 95% CI, 0.39-1.06; P = 0.08) between TAVI and SAVR. Higher incidences of PPM implantation (RR, 2.0; 95% CI, 1.38-2.90; P = 0.0003) and major vascular complications (RR, 1.51; 95% CI, 1.01-2.27; P = 0.05) were observed with TAVI. In obese patients, TAVI offers similar results as in the general population when compared with SAVR, except for increased vascular complications. An individualized approach can lead to optimal outcomes in this subpopulation.

Recent advances in Del Nido cardioplegia: A comprehensive analysis of randomized clinical trials in adult cardiac surgery.

Del Nido cardioplegia (DNC) has extensively been used for pediatric population undergoing cardiac surgery. However, its use in adult cardiac surgeries have been limited thus, its benefits are not yet fully known. This analysis was performed to evaluate the impact of DNC versus any other type of cardioplegia in adult patients who are undergoing cardiac surgery. We systematically searched PubMed, Cochrane Library, and Scopus from database inception till March 2023, and moderate to high-quality randomized controlled trials were included which compared DNC to other cardioplegia. The primary outcome was postoperative stroke and/or transient ischemic attack (TIA). Secondary outcomes included spontaneous rhythm return, postoperative myocardial infarction, all-cause mortality, postoperative atrial fibrillation, defibrillation after coronary reperfusion, postoperative intra-aortic balloon pump, postoperative kidney injury, postoperative low cardiac output syndrome, inotropic support, cardiopulmonary bypass time, cross-clamp time, blood transfusion, cardioplegia volume, hospital stay, intensive care unit stay, mechanical ventilation stay, postoperative left ventricular ejection fraction, and cardiac markers. In this meta-analysis, 13 studies were included with a patient population of 2207. Stroke and/or TIA studies (risk ratio [RR]: 0.54, 95% CI [0.29, 1.00]) and all-cause mortality studies (RR: 1.30, 95% CI [0.66, 2.56]) were insignificant. From the secondary outcomes, spontaneous rhythm return (RR: 1.58, 95% CI [1.02, 2.45]), defibrillation after coronary reperfusion (RR: 0.49, 95% CI [0.30, 0.79]), inotropic support (RR: 0.70, 95% CI [0.57, 0.85]), composite risk of stroke and/or TIA and/or acute kidney injury and mortality (RR: 0.72, 95% CI [0.53, 0.99]), cross-clamp time (mean difference [MD]: -6.01, 95% CI [-11.14, -0.89]), blood transfusion (RR: 0.73, 95% CI [0.60, 0.90]), cardioplegia volume (MD: -537.17, 95% CI [-758.89, -315.45]), troponin T (MD: -1.71, 95% CI [-2.11, -1.32]), creatine phosphokinase-MB (MD: -2.96, 95% CI [-5.84, -0.07]) were significant. Whereas all other secondary outcomes were found to be insignificant. No significant difference was observed between patients undergoing Del Nido administration in comparison to other cardioplegia solutions for the primary outcome, stroke or/and TIA.

A systematic review and meta-analysis of differences between men and women in short-term outcomes following coronary artery bypass graft surgery

We provide an update regarding the differences between men and women in short-term postoperative mortality after coronary artery bypass grafting (CABG) and highlight the differences in postoperative risk of stroke, myocardial infarction, and new onset atrial fibrillation. We included 23 studies, with a total of 3,971,267 patients (70.7% men, 29.3% women), and provided results for groups of unbalanced studies and propensity matched studies. For short-term mortality, the pooled odds ratio (OR) from unbalanced studies was 1.71 (with 95% CI 1.69–1.74, I2 = 0%, p = 0.7), and from propensity matched studies was 1.32 (95% CI 1.14–1.52, I2 = 76%, p < 0.01). For postoperative stroke, the pooled effects were OR = 1.50 (95% CI 1.35–1.66, I2 = 83%, p < 0.01) and OR = 1.31 (95% CI 1.02–1.67, I2 = 81%, p < 0.01). For myocardial infarction, the pooled effects were OR = 1.09 (95% CI = 0.78–1.53, I2 = 70%, p < 0.01) and OR = 1.03 (95% CI = 0.86–1.24, I2 = 43%, p = 0.18). For postoperative atrial fibrillation, the pooled effect from unbalanced studies was OR = 0.89 (95% CI = 0.82–0.96, I2 = 34%, p = 0.18). The short-term mortality risk after CABG is higher in women, compared to men. Women are at higher risk of postoperative stroke. There is no significant difference in the likelihood of postoperative myocardial infarction in women compared to men. Men are at higher risk of postoperative atrial fibrillation after CABG.

Clinical outcomes of different revascularization approaches for patients with multi-vessel coronary artery disease: A network meta-analysis.

As surgical techniques continue to evolve, the optimal approach for revascularizing multi-vessel coronary artery disease (CAD) remains a matter of ongoing debate. Accordingly, our objective was to compare and contrast various surgical techniques utilized in the management of multi-vessel CAD. A systematic literature review was performed using PubMed, Embase, and Cochrane central register of controlled trials from inception to May 2022. Random-effects network meta-analysis was performed for the primary outcome; target vessel revascularization (TVR), and secondary outcomes; mortality, major adverse cardiac and cerebrovascular events, postoperative myocardial infarction, new-onset atrial fibrillation, stroke, new-onset dialysis, in patients undergoing percutaneous coronary intervention (PCI) with a stent, off-pump coronary bypass graft, on-pump coronary artery bypass graft (ONCABG), hybrid coronary revascularization, minimally-invasive coronary artery bypass, or robot-assisted coronary artery bypass (RCAB) surgeries. A total of 8841 patients were included from 23 studies. The analysis showed that ONCABG had the highest freedom from TVR, with a mean (SD) absolute risk of 0.027 (0.029); although ONCABG was found to be superior to all other methods, it was only significantly better than first-generation stent PCI. While RCAB did not demonstrate significant superiority over other treatments, it showed a greater probability of preventing postoperative complications. Notably, no significant heterogeneity was calculated for any of the reported outcomes. ONCABG shows a better rank probability compared to all other techniques for preventing TVR, while RCAB offers greater freedom from most postoperative complications. However, given the absence of randomized controlled trials, these results should be interpreted with caution.

Extracorporeal Membrane Oxygenation-Supported Patient Outcome Undergoing Transcatheter Aortic Valve Replacement.

The efficacy and safety of extracorporeal membrane oxygenation (ECMO) support during transcatheter aortic valve replacement (TAVR) remains unknown. We conducted a meta-analysis to compare benefit and risk of ECMO in TAVR patients. Bibliographic databases were searched from inception to January 1, 2024. Included studies involved patients ≥18 years old undergoing TAVR and using ECMO emergently or prophylactically. Mortality and procedure success were primary outcomes. Peri- or postoperative complications were the secondary outcomes. We identified 11 observational studies, including 2,275 participants (415 ECMO and 1,860 non-ECMO). The unadjusted mortality risk in ECMO-supported patient was higher than non-ECMO patients (odds ratio [OR] 1.73). The mortality unadjusted risk remained high (OR 3.89) and statistically significant for prophylactic ECMO. Prophylactic ECMO had lower mortality risk compared with emergent ECMO (OR 0.17). Extracorporeal membrane oxygenation-supported patients had lower procedural success rate (OR 0.10). Extracorporeal membrane oxygenation patients undergoing TAVR had significantly increased risk of bleeding (OR 3.32), renal failure (OR 2.38), postoperative myocardial infarction (OR 1.89), and stroke (OR 2.32) compared with non-ECMO patients. Clinical results are not improved by ECMO support in patients with high-risk TAVR. Prophylactic ECMO outperforms emergent. Overall, ECMO support increases mortality and postoperative complications. Transcatheter aortic valve replacement outcomes may improve with prophylactic ECMO in high-risk situations.

Social Determinants of Health Impact Complications Following Free-Flap Reconstruction for Head and Neck Cancer.

Head and neck cancers (HNCs) have increased in prevalence and often require free-flap reconstruction (FFR) after tumor ablation. Postoperative complications following FFR can be high, occurring in as many as 48% and 71% of cases. HNC patients also have many disparities in Social Determinants of Health (SDOH), but the potential impact of SDOH disparities on postoperative complications following FFR has not been formally assessed. Retrospective cohort review. Academic Tertiary Care Institution in Northeast United States. Patients that underwent head and neck FFR between January2018 and December2021 were analyzed to determine associations between quartiles of the national Area Deprivation Index (ADI), a proxy for SDOH disparity, and various medical and surgical postoperative complications. Associations were assessed using χ2analysis. Two hundred four patients were included in the study, and 61 patients had 97 complications. Significant associations between higher national ADI quartile and incidence of several postoperative complications were identified, including any surgical complication (P = .0419), wound dehiscence (P = .0494), myocardial infarction (MI) (P = .0215), and sepsis (P = .0464). There are significant associations between SDOH disparities and postoperative surgical complications, wound dehiscence, MI, and sepsis following head and neck FFR. Addressing SDOH disparities in HNC is pivotal to enhance postoperative outcomes and promote holistic patient care.

Racial and Ethnic Disparities in Emergency General Surgery Outcomes Among Older Adult Patients

IntroductionRacial and ethnic disparities in emergency general surgery (EGS) patients have been well described in the literature. Nonetheless, the burden of these disparities, specifically within the more vulnerable older adult population, is relatively unknown. This study aims to investigate racial and ethnic disparities in clinical outcomes among older adult patients undergoing EGS. MethodsThis retrospective analysis used data from 2013 to 2019 American College of Surgeons National Surgery Quality Improvement Program database. EGS patients aged 65 y or older were included. Patients were categorized based on their self-reported race and ethnicity. The primary outcomes evaluated were in-hospital mortality, 30-d mortality, and overall morbidity. Multivariable logistic regression was performed to examine the relationship between race/ethnicity and postoperative outcomes while adjusting for relevant factors including age, comorbidities, functional status, preoperative conditions, and surgical procedure. ResultsA total of 54,132 patients were included, of whom 79.8% identified as non-Hispanic White, 9.5% as non-Hispanic Black (NHB), 5.8% as Hispanic, and 4.2% as non-Hispanic Asian. After risk adjustment, compared to non-Hispanic White patients, NHB, non-Hispanic Asian, and Hispanic patients had decreased odds of 30-d mortality. For 30-d readmission and reoperation, differences among groups were comparable. However, NHB patients had significantly increased odds of overall morbidity (adjusted odds ratio, 1.18; 95% confidence interval: 1.10-1.26; P < 0.001) and postoperative complications including sepsis, venous thromboembolism, and unplanned intubation. Hispanic ethnicity was associated with lower odds of postoperative myocardial infarction and stroke. ConclusionsAmong older adult patients undergoing emergency general surgery, minority patients experienced higher morbidity rates, but paradoxical disparities in mortality were detected. Further research is necessary to identify the cause of these disparities and develop targeted interventions to eliminate them.

Surgical Outcomes in Octogenarians with Heart Failure and Reduced Ejection Fraction following Isolated Coronary Artery Bypass Grafting-A Propensity Score Matched Analysis.

Background/Objectives: The demographic shift towards an aging population necessitates a reevaluation of surgical interventions like coronary artery bypass grafting (CABG) in octogenarians. This study aims to elucidate the outcomes of CABG in octogenarians with heart failure and reduced ejection fraction (HFrEF), a group traditionally considered at high risk for such procedures. Methods: Conducted across four academic hospitals in Germany from 2017 to 2023, this retrospective multicenter study assessed 100 patients (50 octogenarians ≥80 years and 50 non-octogenarians <80 years) with HFrEF undergoing isolated CABG. Through propensity score matching, the study aimed to compare the incidence of major adverse cardiac and cerebrovascular events (MACCEs), as well as other clinical endpoints, between the two groups. Statistical analyses included chi-square, ANOVA, Mann-Whitney U test, Cox regression, and logistic regression, aiming to identify significant differences in outcomes. Results: The study revealed no significant difference in the combined incidence of MACCEs between octogenarians and non-octogenarians (OR: 0.790, 95% CI: 0.174-3.576, p = 0.759). Mortality rates were similar across groups (7% each, p = 1.000), as were occurrences of postoperative myocardial infarction (2% each, p = 1.000) and stroke (3% total). Secondary outcomes like delirium (17% total, no significant age group difference, p = 0.755), acute kidney injury (18% total, p = 0.664), and the need for dialysis (14% total, p = 1.000) also showed no differences between age groups. Interestingly, non-octogenarians required more packed red blood cells during their stay (p = 0.008), while other postoperative care metrics, such as hospital and ICU length of stay and ventilation hours, were comparable across groups. Conclusion: This multicenter study highlights that CABG is a viable and safe surgical option for octogenarians with HFrEF, challenging prior assumptions about the elevated risks associated with performing this procedure in older patients. The absence of significant differences in the incidence of MACCEs and other postoperative complications across age groups emphasizes the importance of careful patient selection and perioperative management. These findings advocate for a more inclusive approach to surgical treatment for octogenarians with HFrEF, suggesting that age alone should not be a determinant for CABG eligibility. This study contributes critical insights into optimizing care for a high-risk demographic, indicating a need for tailored guidelines that accommodate the aging population with complex cardiac conditions.

Determining Perioperative Mortality in Patients with Ruptured Abdominal Aortic Aneurysm: Insights from a Retrospective Cohort Study

Objective: Analyzing factors determining perioperative mortality in patients with ruptured abdominal aortic aneurysm (rAAA) undergoing open surgical repair (OSR) and endovascular aneurysm repair (EVAR).Materials and Methods: Inclusion of 147 consecutive rAAA patients who underwent OSR (n=37) or EVAR (n=110) between 2000 and 2017. Assessment of patients' demographic data, intraoperative details, and perioperative complications. Investigation of comparative outcomes between OSR and EVAR. Employing logistic regression analysis to identify factors associated with perioperative mortality.Results: Perioperative mortality rate of 19.04% (28/147), with 8.1% (3/37) for OSR and 22.7% (25/110) for EVAR (p=0.139). Higher prevalence of unfit patients in the non-survived group (82.1% vs. 47.9%, p=0.002). Non-survived group had significantly higher preoperative serum creatinine levels (1.8 ± 1.74 vs. 1.4 ± 5.89, p=0.011). Intraoperatively, non-survived group had higher rates of aortic balloon usage and cardiac arrest (64.3% vs. 22.7% and 28.6% vs. 3.4%, p &lt; 0.001). Multivariable analysis identified age &gt; 80 years old, unfit patient status, aortic balloon usage, postoperative myocardial infarction, postoperative congestive heart failure, and abdominal compartment syndrome as independent predictors of 30-day mortality.Conclusions: No significant difference in perioperative mortality between OSR and EVAR in rAAA patients. Independent predictors of 30-day mortality include age &gt; 80 years old, unfit patient status, aortic balloon usage, postoperative myocardial infarction, congestive heart failure, and abdominal compartment syndrome. Valuable insights for clinicians in predicting outcomes and improving patient care in rAAA cases.

Outcomes following carotid revascularization in patients with prior ipsilateral carotid artery stenting in the Vascular Quality Initiative

ObjectiveThe outcomes of carotid revascularization in patients with prior carotid artery stenting (CAS) remain understudied. Prior research has not reported the outcomes after transcarotid artery revascularization (TCAR) in patients with previous CAS. In this study, we compared the peri-operative outcomes of TCAR, transfemoral CAS (tfCAS) and carotid endarterectomy (CEA) in patients with prior ipsilateral CAS using the Vascular Quality Iniatitive. MethodsUsing Vascular Quality Initiative data from 2016 to 2023, we identified patients who underwent TCAR, tfCAS, or CEA after prior ipsilateral CAS. We included covariates such as age, race, sex, body mass index, comorbidities (hypertension, diabetes, prior coronary artery disease, prior coronary artery bypass grafting/percutaneous coronary intervention, congestive heart failure, renal dysfunction, smoking, chronic obstructive pulmonary disease, and anemia), symptom status, urgency, ipsilateral stenosis, and contralateral occlusion into a regression model to compute propensity scores for treatment assignment. We then used the propensity scores for inverse probability weighting and weighted logistic regression to compare in-hospital stroke, in-hospital death, stroke/death, postoperative myocardial infarction (MI), stroke/death/MI, 30-day mortality, and cranial nerve injury (CNI) after TCAR, tfCAS, and CEA. We also analyzed trends in the proportions of patients undergoing the three revascularization procedures over time using Cochrane-Armitage trend testing. ResultsWe identified 2137 patients undergoing revascularization after prior ipsilateral carotid stenting: 668 TCAR patients (31%), 1128 tfCAS patients (53%), and 341 CEA patients (16%). In asymptomatic patients, TCAR was associated with a lower yet not statistically significant in-hospital stroke/death than tfCAS (TCAR vs tfCAS: 0.7% vs 2.0%; adjusted odds ratio [aOR], 0.33; 95% confidence interval [CI], 0.11-1.05; P = .06), and similar odds of stroke/death with CEA (TCAR vs CEA: 0.7% vs 0.9%; aOR, 0.80; 95% CI, 0.16-3.98; P = .8). Compared with CEA, TCAR was associated with lower odds of postoperative MI (0.1% vs 14%; aOR, 0.02; 95% CI, 0.00-0.10; P < .001), stroke/death/MI (0.8% vs 15%; aOR, 0.05; 95% CI, 0.01-0.25; P < .001), and CNI (0.1% vs 3.8%; aOR, 0.04; 95% CI, 0.00-0.30; P = .002) in this patient population. In symptomatic patients, TCAR had an unacceptably elevated in-hospital stroke/death rate of 5.1%, with lower rates of CNI than CEA. We also found an increasing trend in the proportion of patients undergoing TCAR following prior ipsilateral carotid stenting (2016 to 2023: 14% to 41%), with a relative decrease in proportions of tfCAS (61% to 45%) and CEA (25% to 14%) (P < .001). ConclusionsIn asymptomatic patients with prior ipsilateral CAS, TCAR was associated with lower odds of in-hospital stroke/death compared with tfCAS, with comparable stroke/death but lower postoperative MI and CNI rates compared with CEA. In symptomatic patients, TCAR was associated with unacceptably higher in-hospital stroke/death rates. In line with the postprocedure outcomes, there has been a steady increase in the proportion of patients with prior ipsilateral stenting undergoing TCAR over time.

Comparative effectiveness of antiplatelet therapies for saphenous venous graft occlusion and cardiovascular outcomes: a network meta-analysis.

The ideal antiplatelet therapy to maintain graft patency after coronary artery bypass graft surgery (CABG) remains controversial. This review of randomized controlled trials (RCTs) aims to compare aspirin monotherapy, ticagrelor monotherapy, dual antiplatelet therapy (DAPT) with aspirin and ticagrelor (Asp+Tica) or with aspirin and clopidogrel (Asp+Clopi) to evaluate differences in post-CABG saphenous vein graft (SVG) occlusion, internal mammary artery (IMA) occlusion, myocardial infarction (MI), bleeding, and all-cause mortality (ACM) rates. The literature review was conducted on several electronic databases, including Medline, Embase, and Cochrane Central, from inception to August 10, 2022. Data was extracted using a predefined proforma. A Bayesian random-effects model was used for calculating point effect estimates (odds ratio and standard deviation). Quality assessment was done using the Cochrane RoB-2 tool. Ten RCTs comprising 2139 patients taking anti-platelets post-CABG were included. For preventing SVG occlusion, Asp+Tica showed the lowest mean AR of 0.144±0.068. Asp+Tica also showed a trend toward lesser postoperative MI risk and lower ACM rates, with a mean AR of 0.040±0.053 and 0.018±0.029, respectively. For maintaining IMA graft patency, Asp+Clopi showed the lowest mean AR of 0.092±0.053. Ticagrelor had the lowest mean AR of 0.049±0.075, with Asp+Tica showing a similar mean AR of 0.049±0.045 for postoperative major bleeding risk. Our analysis demonstrates that Asp+Tica can be the ideal therapy for patients undergoing CABG using SVG as it decreases the risk of post-CABG SVG occlusion and is not associated with a significantly higher risk for major bleeding.

Contemporary outcomes after endoscopic vein harvesting for lower extremity bypass in a multicenter subspecialty practice

BackgroundEndoscopic vein harvesting (EVH) is considered the standard of care for coronary bypass procedures given the lower early morbidity from surgical wound complications. However, the use of EVH for lower extremity (LE) bypass remains controversial owing to concerns about decreased graft patency. In 2022, the BEST-CLI Trial (Best Endovascular vs. Best Surgical Therapy in Patients With Critical Limb Ischemia) demonstrated patients undergoing surgical bypass with adequate great saphenous vein quality experienced a lower incidence of major adverse limb events and mortality than those who underwent endovascular repair. Despite these results, wound complications from large harvest site incisions remain a significant barrier preventing surgical bypass as being the preferred initial treatment. To mitigate wound complications, our practice has adopted EVH as the standard approach for harvesting bypass conduit. Here, we report our recent 5-year experience using EVH for LE bypass. MethodsOne hundred sixty-eight LE bypasses with EVH were evaluated from 2017 to 2022. The cohort included 14 vascular surgeons in 8 hospitals. The primary end point was 30-day surgical wound complications. Secondary end points included bypass patency, need for major amputation, 30-day morbidity and mortality, length of operation, and length of hospitalization. Wound complications were measured using Szilagyi's method, with class I characterized by erythema necessitating antibiotics, class II having drainage or superficial dehiscence, and class III threatening graft integrity and requiring surgical intervention. ResultsA total of 168 LE bypasses with EVH were performed on 166 patients. Of these, 65.48% were male with a median age of 68.4 ± 9.7 years. There were no wound complications related to saphenectomy. Surgical site infections occurred in 22 patients (13.10%). Seven patients (4.17%) had class I complications, 12 (7.14%) had class II complications, and 3 (1.79%) had class III complications. Primary patency at 30 days was 96.10% and 86.84% at 1 year). Seven patients (4.17%) required major amputation at 30 days. The 1-year amputation-free survival was 89.39%. The 30-day postoperative stroke, myocardial infarction, and death rates were 0.60%, 0.60%, and 2.38%, respectively. The median operative time was 3.30 ± 1.18 hours. The median length of hospitalization was 3.00 ± 3.56 days. ConclusionsEVH minimizes saphenectomy wound complications without compromising patency and limb salvage rates. Older studies suggesting lower patency rates after EVH may have been limited by older technology and inexperienced operators. Whether EVH should be the standard of care for LE bypass warrants further investigation.

127 Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention in Heart Failure with Reduced Ejection Fraction Patients: A Systematic Review and Meta-Analysis Stratified by Left Ventricular Ejection Fraction

Abstract Aim The primary objectives were to assess differences in mortality, repeat revascularization, new postoperative myocardial infarction (MI), and cerebrovascular accidents (CVA/stroke) between PCI and CABG in HFrEF patients, stratified by the degree of LVEF reduction. Method A comprehensive search of electronic databases was conducted, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria comprised clinical trials or observational cohort studies with ≥20 patients per group, comparing long-term outcomes in HFrEF patients (LVEF &amp;lt;50%) who underwent PCI or CABG. Data was extracted, and quality was assessed using the New Castle Ottawa (NOS) Risk of Bias tool. Hazard ratios (HRs) were pooled for time-to-event outcomes, with subgroup analysis based on LVEF. Heterogeneity was assessed, sensitivity analysis conducted, and publication bias evaluated. Results Twenty studies involving 25,031 patients met the inclusion criteria. In the severe LVEF reduction group (&amp;lt;35%), CABG was associated with significantly higher long-term survival, reduced repeat revascularization, and fewer postoperative MIs compared to PCI. In patients with moderate LVEF reduction (&amp;lt;40%), there was no difference in long-term survival, but repeat revascularization was lower in the CABG group . In the mild LVEF reduction group (&amp;lt;50%), CABG was associated with superior long-term survival and reduced repeat revascularization. Stroke rates were similar between PCI and CABG in all groups. Conclusions Individualized patient care should consider the degree of LVEF reduction when selecting between PCI and CABG, with CABG generally favored for improved outcomes in HFrEF patients. However, clinical presentation, patient characteristics, and cost-effectiveness should also be considered in the decision-making process.

Bilateral internal thoracic artery grafting in robotic beating-heart totally endoscopic coronary artery bypass: 10-year outcomes.

Multi-arterial grafting (MAG) with bilateral internal thoracic arteries (BITAs) is superior to single internal thoracic artery (ITA) and veins, however, sternal wound infection (SWI) is a deterrent to using BITA, especially in diabetic and obese patients. Sternal-sparing approaches, including robotic totally endoscopic coronary artery bypass (TECAB), may mitigate this risk. We reviewed outcomes of robotic TECAB with BITA grafting. A total of 871 patients underwent robotic TECAB at our institution from 7/2013 to 4/2024. Of these, 406 patients received BITA grafts and are the subject of this review. Early and mid-term clinical outcomes were reviewed and angiographic patency in those undergoing hybrid revascularization with percutaneous coronary intervention (PCI) after TECAB. All cases were performed via a beating-heart robotic approach, with standard TECAB port placement. The mean age of the cohort was 67±9 years and 16% were female. The mean Society of Thoracic Surgeons (STS) risk was 1.47%±2.2%. Thirty-nine percent were diabetic (15% insulin-dependent) and 39% had a body mass index (BMI) ≥30 kg/m2. Twenty percent had an ejection fraction (EF) ≤40%. Ninety-eight percent of cases were completed off-pump and there were no conversions to sternotomy. The mean number of grafts per patient was 2.2±0.4. The mean intensive care unit (ICU) and hospital length of stay (LOS) were 1.22±0.62 and 2.44±0.83 days, respectively. Postoperative complications included atrial fibrillation in 13%, acute kidney injury (AKI) in 3.4%, return to theatre for bleeding in 0.7%, postoperative myocardial infarction (MI) in 0.2%, and stroke in 0.2%. Thirty-day mortality was 1.2% [observed/expected (O/E): 0.89]. Return to full activities and work occurred at mean of 14±8.6 and 17±13 days, respectively. Two hundred and two patients (50%) had 'advanced' hybrid revascularization (with at least two arterial grafts and stents). ITA early graft patency in this cohort of patients was 271/278 (98%) with 100% left ITA to left anterior descending artery (LITA-LAD) patency. Mid-term follow-up was complete in all patients at mean of 51±36 months (longest follow-up at 10 years). All-cause mortality was 13% and cardiac-mortality was 2.5%. Freedom from angina was 96%, and freedom from repeat revascularization was 94%. Use of the beating-heart robotic TECAB approach facilitates BITA grafting to achieve multi-vessel arterial revascularization of the left coronary system, with excellent 10-year outcomes.

Perioperative transfusion study (PETS): Does a liberal transfusion protocol improve outcome in high-risk cardiovascular patients undergoing non-cardiac surgery? A randomised controlled pilot study.

Small studies have shown that patients with advanced coronary artery disease might benefit from a more liberal blood transfusion strategy. The goal of this pilot study was to test the feasibility of a blood transfusion intervention in a group of vascular surgery patients who have elevated cardiac troponins in rest. We conducted a single-centre, randomised controlled pilot study. Patients with a preoperative elevated high-sensitive troponin T undergoing non-cardiac vascular surgery were randomised between a liberal transfusion regime (haemoglobin >10.4 g/dL) and a restrictive transfusion regime (haemoglobin 8.0-9.6 g/dL) during the first 3 days after surgery. The primary outcome was defined as a composite endpoint of all-cause mortality, myocardial infarction or unscheduled coronary revascularization. In total 499 patients were screened; 92 were included and 50 patients were randomised. Postoperative haemoglobin was different between the intervention and control group; 10.6 versus 9.8, 10.4 versus 9.4, 10.9 versus 9.4 g/dL on day one, two and three respectively (p < 0.05). The primary outcome occurred in four patients (16%) in the liberal transfusion group and in two patients (8%) in control group. This pilot study shows that the studied transfusion protocol was able to create a clinically significant difference in perioperative haemoglobin levels. Randomisation was possible in 10% of the screened patients. A large definitive trial should be possible to provide evidence whether a liberal transfusion strategy could decrease the incidence of postoperative myocardial infarction in high risk surgical patients.