Perioperative Myocardial Infarction Rate Research Articles

Outcomes and predictors of amputation-free survival in patients undergoing below-knee popliteal-distal bypass

ObjectiveThe infrageniculate popliteal artery is a potential source for inflow in lower extremity bypass surgery in patients with isolated tibial artery disease. The objective of our study was to assess the short- and long-term outcomes of popliteal-distal bypasses using data from the Vascular Quality Initiative (VQI). MethodsThe VQI registry was queried between 2003 and 2021 for patients undergoing surgical revascularizations with the below-knee popliteal artery serving as inflow. Demographics, comorbidities, intraoperative characteristics, and postoperative complications were analyzed. Kaplan-Meier models were used to estimate amputation-free survival, survival, and freedom from amputation. Cox regression analysis was conducted to determine factors associated with major amputation or death. ResultsA total of 1884 procedures were analyzed. The mean age of the included patients was 67.7 years. The most frequently observed preoperative comorbidities included insulin-dependent diabetes (52.3%), coronary disease (32.4%), and end-stage renal disease (14.4%). Of all the patients, 670 (35.6%) had a history of ipsilateral endovascular intervention. The procedures were performed for a variety of indications, including tissue loss (84.3%), rest pain (10.9%), and claudication (4.8%). Intraoperatively, the outflow targets were the dorsalis pedis (31.4%), the posterior tibial (24.4%), and the anterior tibial arteries (15.6%). Vein conduit was used in 92.1% of cases. The rate of perioperative myocardial infarction (MI) was 2.4%, and the 30-day mortality was 1.9%. The median length of follow up was 371 days. Amputation-free survival was found to be 85.6% (95% confidence interval [CI], 84.0%-87.2%) at 6 months and 78.6% (95% CI, 76.6%-80.4%) at 12 months. Survival was found to be 93.4% (95% CI, 92.2%-94.5%) at 6 months and 88.6% (95% CI, 87.1%-90.0%) at 12 months. Freedom from amputation was found to be 92.0% (95% CI, 90.7%-93.3%) at 6 months and 89.0% (95% CI, 87.3%-90.4%) at 12 months. Cox regression analysis demonstrated that age greater than 65 years, congestive heart failure, coronary artery disease, and end-stage renal disease were associated with a higher risk of major amputation or death (P < .05). ConclusionsBelow-knee popliteal-distal bypass is a safe and effective approach to treat severe tibial vessel occlusive disease in this challenging patient cohort. Patients exhibited low perioperative complication rates and good amputation-free survival at 1 year.

Perioperative Outcomes of Same-Session Bilateral vs Unilateral Ureteroscopy for Stone Removal: Results from the GRAND Study.

Background: Same-session bilateral ureteroscopy may reduce the number of surgeries for stone removal but can lead to higher overall complication rates. We aimed to compare same-session bilateral ureteroscopy with unilateral ureteroscopy in terms of perioperative outcomes. Methods: We used the GeRmAn Nationwide inpatient Data (GRAND), provided by the Research Data Center of the Federal Bureau of Statistics (2005-2021). We assessed, through multiple patient-level analyses, severe perioperative complications, mortality, length of hospital stay, hospital revenues, intensive care unit admission, and the evolution of ureteroscopy during the last years in Germany. Results: We included 833,609 patients undergoing either same-session bilateral (n = 6914, 0.8%) or unilateral (n = 826,695, 99.2%) ureteroscopy for stone management. Patients undergoing bilateral ureteroscopy presented worse baseline characteristics. After adjusting for these characteristics, same-session bilateral ureteroscopy, compared to unilateral ureteroscopy, was significantly associated with higher odds of postoperative sepsis (odds ratio [OR]: 2.4, 95% confidence interval [CI]: 2-2.8, p < 0.001), myocardial infarction (OR: 2, 95% CI: 1.03-3.5, p = 0.024), acute kidney disease (OR: 2.8, 95% CI: 2.5-3.2, p < 0.001), transfusion (OR: 4.2, 95% CI: 3.6-4.8, p < 0.001), urinary tract infection (OR: 1.6, 95% CI: 1.5-1.7, p < 0.001), intensive care unit admission (OR: 1.9, 95% CI: 1.6-2.3, p < 0.001), and mortality (OR: 3.1, 95% CI: 2.1-4.5, p < 0.001). Similarly, the length of hospital stay was longer, and the in-hospital costs were higher (p < 0.001) after same-session bilateral ureteroscopy. Interestingly, the annual cases of ureteroscopy have undergone about a threefold increase in the last 17 years. Conclusions: The present real-world data demonstrate that same-session bilateral ureteroscopy leads to higher rates of perioperative myocardial infarction, acute kidney disease, transfusion, urinary tract infections, sepsis, and intensive care unit admission, as well as to increased length of hospital stay, costs, and inpatient mortality compared to unilateral ureteroscopy.

Carotid Endarterectomy With Simultaneous Proximal Common Carotid Endovascular Intervention is Beneficial for Symptomatic Stenosis and Likely Confers No Advantage for Asymptomatic Lesions.

Carotid bifurcation stenosis may co-exist simultaneously with more proximal common carotid artery (CCA) atherosclerotic plaquing, primarily at the vessel origin in the aortic arch. This scenario is relatively infrequent and its' management does not have quality randomized data to support medical vs surgical treatment. It is logical to treat any high grade common carotid lesions proximal to a carotid bifurcation endarterectomy (CEA) site both to prevent perioperative emboli or thrombosis as well as future embolization. Prior long-term investigations of the combined treatment paradigm have been low volume analysis. Further, prior studies focus on perioperative outcomes with respect to stroke prevention. The only prior VQI study investigating mid-term outcomes following simultaneous CEA with proximal CCA endovascular therapy provided data on less than 10 patients beyond 1.5years. The long-term follow-up (LFTU) component initiative within VQI has been emphasized in recent years, now allowing for much more robust LTFU analysis. Four cohorts were created for perioperative outcome analysis and Kaplan Meier freedom from event analysis: CEA in isolation for asymptomatic disease; CEA in isolation for symptomatic patients; CEA with proximal CCA endovascular intervention for asymptomatic; and, CEA with proximal CCA intervention for symptomatic patients. Binary logistic multivariable regression was performed for perioperative neurological event and 90-day mortality risk determination and Cox multivariable regression analysis was performed for long term freedom from cumulative ischemic neurological event and long-term mortality analysis. Symptomatology and type of surgery (CEA with or without CCA intervention) were individual variables in the multivariable analysis. Neurological ischemic event in this study encompassed transient ischemic attack (TIA) and stroke combined. We noted a statistically significant (P < .001) escalation in rates of perioperative neurological event, myocardial infarction (MI), carotid re-exploration, 90day mortality and combined neurological event and 90day mortality moving from: A) asymptomatic CEA in isolation to B) symptomatic CEA in isolation to C) asymptomatic CEA combined with proximal CCA intervention to D) symptomatic CEA in combination with proximal CCA intervention. The positivity rate for the combined outcome of perioperative ischemic neurological event and 90 day mortality was 2.2% amongst asymptomatic CEA in isolation, 4.1% amongst symptomatic CEA in isolation, 4.4% amongst asymptomatic CEA in combination with proximal CCA intervention; and 8.8% in patients with symptomatic lesions undergoing combined CEA with proximal CCA intervention. On multivariable analysis patients undergoing CEA with proximal CCA endovascular intervention experienced greater risk for perioperative neurological ischemic event (aOR 2.03, 1.43-2.90, P < .001), combined perioperative neurological ischemic event and 90day mortality (aOR 2.13, 1.62-2.80, P < .001), long term mortality (HR 1.62, 1.12-2.29, P < .001), and cumulative neurological ischemic event in long term follow up (HR 1.62, 1.12-2.29, P = .007). Amongst 4395 cumulative ischemic neurological events in all study patients, 34% were TIA. Carotid bifurcation endarterectomy in combination with proximal endovascular common carotid artery intervention caries an over two fold higher perioperative risk of neurologic ischemic event and 90 day mortality relative to CEA in isolation for asymptomatic and symptomatic cohorts respectively. After surgery, freedom from cerebral ischemia and mortality for patients undergoing dual intervention is closely aligned with patients undergoing CEA in isolation. Despite high adverse perioperative event rates for the combined CEA and CCA treatment, there is likely long term stroke reduction and mortality benefit to this approach in symptomatic patients based on the event free rates seen herein after initial hospital discharge. The benefit of treating asymptomatic tandem ICA and CCA lesions remains vague but the 4.4% perioperative neurologic event and death rate suggests that these patients would be better managed with medical therapy.

Systematic review and meta-analysis of the treatment strategies for coronary artery bypass graft patients with concomitant carotid artery atherosclerotic disease

ObjectiveStroke is one of the devastating complications after coronary artery bypass graft (CABG). Underlying carotid artery atherosclerotic disease is reported to be an independent risk factor. The optimal treatment strategy for these patients remains under debate. MethodsWe aimed to perform a network meta-analysis to evaluate the safety and efficacy of additional carotid interventions for patients with concomitant carotid artery atherosclerotic disease who require CABG by comparing perioperative adverse event rates. All articles through February 2022 were searched using MEDLINE and EMBASE to identify studies that investigated outcomes of CABG only as well as additional staged vs combined carotid interventions by both carotid endarterectomy (CEA) and carotid artery stenting (CAS). ResultsTwo randomized controlled trials and 23 observational studies were included, yielding a total of 32,473 patients who underwent combined CEA and CABG (n = 20,204), CEA and staged CABG (n = 6882), CABG and staged CEA (n = 340), CAS and CABG regardless of timing and sequences (n = 1224), and CABG only (n = 3823). No strategy showed a significant advantage over CABG only in all perioperative outcomes. CEA and staged CABG was associated with the lowest perioperative stroke/transient ischemic attack (TIA) rate, significantly lower compared with CAS and CABG (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.36-0.76) as well as CABG and staged CEA (OR, 0.41; 95% CI, 0.23-0.74), but was also associated with the highest perioperative mortality (OR, 2.50; 95% CI, 1.67-3.85, vs CAS and CABG) and myocardial infarction rate (OR, 3.70 [95% CI, 1.16-12.5] and OR, 2.50 [95% CI, 1.35-4.55] vs CAS and CABG, vs combined CEA and CABG, respectively). ConclusionsCEA and staged CABG are associated with low perioperative stroke/transient ischemic attack rates with a tradeoff of higher mortality and myocardial infarction rate. No strategy showed a significant advantage over the CABG-only strategy in all perioperative outcomes, outlining the importance of a tailored approach and determining proper indications for carotid intervention in these patients.

Characteristics and 1-year outcomes of patients with rupture of small abdominal aortic aneurysms

ObjectivesRuptured abdominal aortic aneurysms (rAAA) are associated typically with a large sac diameter; however, some patients experience rupture before reaching operative thresholds for elective repair. We aim to investigate the characteristics and outcomes of patients who experience small rAAA. MethodsThe Vascular Quality Initiative database for open AAA repair and endovascular aneurysm repair from 2003 to 2020 were reviewed for all rAAA cases. Based on the 2018 Society for Vascular Surgery guidelines on operative size thresholds for elective repair, patients with infrarenal aneurysms of less than 5.0 cm in women or less than 5.5 cm in men were categorized as a small rAAA. Patients who met operative thresholds or had a concomitant iliac diameter 3.5 cm or greater were categorized as a large rAAA. Patient characteristics and perioperative as well as long-term outcomes were compared via univariate regression. Inverse probability of treatment weighting using propensity scores was used to examine the relationship between rAAA size and adverse outcomes. ResultsThere were 3962 cases that met inclusion criteria, with 12.2% small rAAA. The mean aneurysm diameter was 42.3 mm and 78.5 mm in the small and large rAAA groups, respectively. Patients in the small rAAA group were significantly more likely to be younger, African American, have a lower body mass index, and had significantly higher rates of hypertension. Small rAAA were more likely to be repaired via endovascular aneurysm repair (P = .001). Hypotension was significantly less likely in patients with small rAAA (P<.001). Rates of perioperative myocardial infarction (P < .001), total morbidity (P < .004) and mortality (P < .001) were significantly higher for large rAAA cases. After propensity matching, there was no significant difference in mortality between the two groups, but smaller rAAA was associated with lower rates of myocardial infarction (odds ratio, 0.50; 95% confidence interval, 0.31-0.82). On long-term follow-up, no difference in mortality was noted between the two groups. ConclusionsPatients presenting with small rAAA represent 12.2% of all rAAA and are more likely to be African American. Small rAAA is associated with similar risk of perioperative and long-term mortality compared with rupture at larger size after risk adjustment.

One-Stop Hybrid Coronary Revascularization Versus Off-Pump Coronary Artery Bypass Grafting.

One-stop hybrid coronary revascularization (HCR) is a promising revascularization strategy for treating multivessel coronary artery disease (MVCAD). However, its safety and feasibility remain controversial. Therefore, we introduced our experience with midterm follow-up of HCR in patients with MVCAD and compared it with conventional off-pump coronary artery bypass grafting (CABG).Patients with MVCAD undergoing one-stop HCR at Beijing Chaoyang Hospital between March 2018 and December 2020 were retrospectively enrolled. These patients were matched in a 1:2 ratio to patients treated with off-pump CABG at the same period via a propensity score analysis with the nearest neighbor matching algorithm.In the adjusted analysis, no significant difference was found in the rate of perioperative myocardial infarction, stroke, death, prolonged ventilation, reoperation for bleeding, and renal failure between the HCR group and the CABG group. No in-hospital repeated revascularization occurred in either group. HCR was associated with lower blood transfusion rate (HCR 11.0% versus CABG 22.8%; P = 0.006) and shorter postoperative length of stay (> 10 days: 31.5% versus 81.0%; P < 0.001) compared with CABG. After the median 21-month follow-up, no significant difference was found in the major adverse cardiac and cerebrovascular events (MACCE), death, myocardial infarction, repeated revascularization, and stroke rate. Besides, the freedom-from MACCE survival rate was similar between the two groups.One-stop HCR seemed to be a safe and feasible revascularization strategy in patients with MVCAD, with faster recovery and similar outcomes when compared with off-pump CABG.

One-year outcomes after transcarotid artery revascularization (TCAR) in the ROADSTER 2 trial

ObjectivesTranscarotid artery revascularization (TCAR) is a carotid stenting technique that utilizes reversal of cerebral arterial flow to confer cerebral protection. Although carotid endarterectomy (CEA) remains the standard for treatment of symptomatic and asymptomatic carotid stenosis, the search for the optimal minimally invasive option for the high-risk surgical patient continues. The goal of the current study is to evaluate the 1-year safety and efficacy of TCAR in a prospective clinical trial. MethodsROADSTER 2 is a prospective, open-label, single-arm, multicenter, post-approval registry for patients undergoing TCAR. All patients were considered high risk for CEA and underwent independent neurological assessments preoperatively, postoperatively, and had long-term clinical follow-up. The primary end point was incidence of ipsilateral stroke after treatment with the ENROUTE Transcarotid Stent System. Secondary end points included individual/composite rates of stroke, death, and perioperative myocardial infarction. ResultsBetween June 2016 and November 2018, 155 patients at 21 centers in the United States and one in the European Union were enrolled and represented a subset of the overall trial. Asymptomatic (n = 119; 77%) and symptomatic patients (n = 36; 23%) with high-risk anatomic (ie, high lesion, restenosis, radiation injury; 43%), physiologic (32%), or combined factors (25%) were enrolled. No patient suffered a perioperative myocardial infarction or stroke. Over the year, no patient had an ipsilateral stroke, but four patients died (2.6%), all from non-neurological causes. Additionally, a technical success rate of 98.7% with a low cranial nerve deficit rate of 1.3% was achieved. ConclusionsIn patients with high risk factors, TCAR yields high technical success with a low stroke and death rate at 1 year. Further comparative studies with CEA are warranted.

National Institutes of Health stroke scale score at admission can predict functional outcomes in patients with ischemic stroke undergoing carotid endarterectomy

ObjectiveThe aim of present study was to evaluate the prognostic effect of the National Institutes of Health stroke scale (NIHSS) score for patients who had undergone acute carotid endarterectomy (CEA) and assess the clinical and morphologic factors that could predict for worse outcomes. MethodsThe data from 183 consecutive patients who had undergone CEA after ischemic stroke were analyzed from January 2015 to January 2021. The patients were divided into two groups using the NIHSS score cutoff of 4. Functional dependence was assessed at hospital discharge and 90 days after discharge. ResultsOf the 183 patients, 102 (55.7%) had had a minor stroke (group A; NIHSS score of ≤4) and 81 (44.3%) had had a moderate to major stroke (group B; NIHSS score >4). Groups A and B showed significant differences in their intracranial anatomic features, including the presence of an incomplete circle of Willis (7.8% vs 17.3%; P = .05), cerebral ischemic lesion volume ≥4000 mm3 (5.9% vs 24.7%; P ≤ .001), and a high Alberta stroke program early computed tomography score of 8 to 10 (75.5% vs 44.4%; P ≤ .001). The overall rate of combined perioperative stroke, myocardial infarction, and death was 1.1%, with no strokes recorded during the interval to CEA. Patients in group A had a lower rate of functional dependence at discharge (4.9% vs 35.8%; P ≤ .001) and at 90 days after the index stroke event (2.5% vs 19.6%; P ≤ .001) compared with those in group B. Using multivariate binary logistic regression, an admission NIHSS score >4 was significantly associated with higher odds of functional dependence at discharge (odds ratio, 7.9; 95% confidence interval, 2.7-18.5; P ≤ .001) and at 90 days (odds ratio, 10.4; 95% confidence interval, 2.7-19.3; P = .002). ConclusionsAn NIHSS score >4 at admission increased the risk of a higher modified Rankin scale score at both hospital discharge and 90 days after the index stroke event. Acute CEA was safe and feasible for patients with ischemic stroke, even if they had previously undergone intravenous thrombolysis.

Contemporary outcomes of concomitant suprainguinal bypass with infrainguinal revascularization procedures in patients with chronic limb-threatening ischemia

ObjectiveCombined suprainguinal and infrainguinal revascularization is sometimes necessary in the treatment of patients with chronic limb-threatening ischemia (CLTI). However, data on outcomes of concomitant revascularization procedures are lacking. We studied the outcomes of patients with CLTI who underwent suprainguinal bypass (SIB) alone, SIB with concomitant infrainguinal bypass (IIB), and SIB with concomitant infrainguinal peripheral endovascular intervention (IIPVI). MethodsWe reviewed all patients in the Vascular Quality Initiative with CLTI who underwent SIB from January 2010 to June 2020. Logistic regression, Kaplan-Meier survival estimates, log-rank tests, and Cox regression were used to analyze outcomes. Outcomes were 30-day mortality, perioperative myocardial infarction, perioperative major amputation, 1-year amputation-free survival, and 5-year survival. ResultsOf 8037 patients included, 81.3% (n = 6537) underwent SIB alone, 9.7% (n = 783) underwent SIB+IIB, and 8.9% (n = 717) underwent SIB+IIPVI. The indication for surgery was rest pain in 5040 (62.5%) and tissue loss in 3031 (37.6%). There were no significant differences in 30-day mortality and perioperative myocardial infarction rates. However, there was 2.8-fold increased odds of perioperative major amputation in both SIB+IIPVI (odds ratio [OR], 2.76; 95% confidence interval [CI], 1.30-5.88; P = .008) and SIB+IIB (OR, 2.79; 95% CI, 1.38-5.54; P = .004) among patients with rest pain as compared with SIB alone. Comparing SIB+IIPVI with SIB alone, there were no significant differences in 1-year freedom from amputation and amputation-free survival. SIB+IIPVI was associated with a 27% increased risk of 5-year mortality (hazard ratio [HR], 1.27; 95% CI, 1.03-1.55; P = .035). Compared with SIB alone, SIB+IIB was associated with 97% increased risk of 1-year major amputation among patients with rest pain (HR, 1.97; 95% CI, 1.06-3.69; P = .033), but a 47% decreased risk of 1-year major amputation or death for patients with tissue loss (HR, 0.53; 95% CI, 0.37-0.78; P = .001). SIB+IIPVI, compared with SIB+IIB, was associated with a two-fold increased risk of 1-year major amputation or death (HR, 2.04; 95% CI, 1.04-2.23), P = .003) and a 52% increased risk of 5-year mortality (HR,1.52; 95% CI, 1.04-2.24; P = .032) among patients with tissue loss. ConclusionsThis study shows that SIB with concomitant infrainguinal revascularization in patients with rest pain is associated with an increased risk of amputation, whereas SIB+IIB in patients with tissue loss is associated with decreased risk of amputation or death. SIB+IIB outperformed SIB+IIPVI in patients with tissue loss. SIB with infrainguinal revascularization should be limited in patients with rest pain in line with current guidelines, but SIB+IIB may be preferred in patients with tissue loss.

Incidence and Clinical Outcomes of Hypothyroidism in Patients Undergoing Spinal Fusion.

BackgroundHypothyroidism has been independently associated with the development of several comorbidities and is known to increase complication rates in non-spinal surgeries. However, there are limited data regarding the effects of hypothyroidism in major spine surgery. Therefore, we present the largest retrospective analysis evaluating outcomes in hypothyroid patients undergoing spinal fusion.MethodsA retrospective review of the National Inpatient Sample (NIS) from 2004-2014 was performed. Patients with an International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) procedure code indicating spinal fusion (81.04-81.08, 81.34-81.38, 81.0x, 81.3x) were included. Patients with an ICD-9-CM diagnosis code indicating hypothyroidism (244.x) were compared to those without. Cervical and lumbar fusions were evaluated independently. Significant covariates in univariable logistic regression were utilized to construct multivariable models to analyze the effect of hypothyroidism on perioperative morbidity and mortality.ResultsA total of 4,149,125 patients were identified, of which 9.4% were hypothyroid. Although, hypothyroid patients had a higher risk of hematologic complications (lumbar - odds ratio [OR] 1.176, p < 0.0001; cervical - OR 1.162, p < 0.0001), they exhibited decreased in-hospital mortality (lumbar - OR .643, p < 0.0001; cervical - OR .606, p < 0.0001). Hypothyroid lumbar fusion patients also demonstrated decreased rates of perioperative myocardial infarction (MI) (OR .851, p < 0.0001). All these results were independent of patient gender.ConclusionsHypothyroid patients undergoing spinal fusion demonstrated lower rates of inpatient mortality and, in lumbar fusions, also had lower rates of acute MI when compared to their euthyroid counterparts. This suggests that hypothyroidism may offer protection against all-cause mortality and may be cardioprotective in the postoperative period for lumbar spinal fusions independent of patient gender.

Early postoperative results of on-pump coronary endarterectomy: is it still a controversy?

Objectives: The coronary endarterectomy combined with coronary artery bypass grafting (CABG) is an useful but still controversial surgical technique in diffuse coronary artery disease. The aim of this study was to analyze the operative and early postoperative outcomes of the patients who underwent CABG with and without coronary endarterectomy. Methods: This retrospective study included a total of 312 consequtive patients undergoing on-pump CABG from December 2018 to December 2020 in the Department of Cardiovascular Surgery, Bursa Yüksek İhtisas Training and Research Hospital. Patients were divided into 2 groups as those who underwent coronary endarterectomy combined with on-pump CABG (Group 1, n = 48) and those who underwent isolated on-pump CABG (Group 2, n = 264). Peroperative variables were obtained from our hospital's computerized database and retrospectively analyzed. Results: Previous percutaneus coronary intervention rate and the number of patients with diabetes mellitus was significantly higher in the endarterectomy group. The demographics and characteristics of the patients were similar between the two groups. The median number of distal anastomoses was 4 (2-5) in Group 1 and 2 (1-5) in Group 2. Median cross-clamp duration and perfusion times in Group 1 were longer than Group 2 (82 min vs. 63 min; p &amp;lt; 0.001 and 120 min vs. 95 min; p = 0.003, respectively). A total of 54 coronary endarterectomy practices were performed on 48 patients, and the LAD artery (73%) was the most endarterectomized vessel. In Group 1, postoperative 24 hours high-sensitive troponin I levels were significantly higher than in Group 2 (p &amp;lt; 0.001). There was no significant difference between the groups in terms of operative mortality, low cardiac output rates and perioperative myocardial infarction rates. Postoperative atrial fibrillation was significantly higher in Group 1 (p = 0.023). Conclusions: Although coronary endarterectomy is a complex procedure, in patients with diffuse coronary artery disease, it is an essential and sometimes mandotary method in order to achieve complete revacularization and can be performed safely with acceptable operative and early postoperative outcomes.

Screening for coronary artery disease in early surgical treatment of acute aortic valve infective endocarditis.

In patients with unknown coronary status undergoing surgery for acute infective endocarditis (IE), the need to screen for coronary artery disease (CAD) and the risk of embolization during invasive coronary angiography (ICA) are debated. Coronary computed tomography angiography (CCTA) is a non-invasive alternative in these patients. We aimed to evaluate the safety and feasibility of ICA and CCTA to diagnose CAD, and the necessity to treat CAD to prevent CAD-related postoperative complications. In this single-centre retrospective cohort study, all patients with acute aortic IE between 2009 and 2019 undergoing surgery were selected. Outcomes were any clinically evident embolization after preoperative ICA, in-hospital mortality, perioperative myocardial infarction or unplanned revascularization and postoperative renal function. Of the 159 included patients, CAD status was already known in 14. No preoperative diagnostics for CAD was done in 46/145, a CCTA was performed in 54/145 patients and an ICA in 52/145 patients. Significant CAD was found after CCTA in 22% and after ICA in 21% of patients. In 1 of the 52 (2%) patients undergoing preoperative ICA, a cerebral embolism occurred. The rate of perioperative myocardial infarction or unplanned revascularization in patients not screened for CAD was 2% (1 out of 46 patients). Although the risk of embolism after preoperative ICA is low, it should be carefully weighed against the estimated risk of CAD-related perioperative complications. CCTA can serve as a gatekeeper for ICA in most patients with acute aortic IE.

Outcomes of Transcarotid Artery Revascularization and Carotid Endarterectomy at a Single Institution

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are accepted revascularization modalities to treat carotid artery stenosis. Higher incidences of perioperative adverse neurological events and death have been reported in patients with transfemoral CAS. Transcarotid artery revascularization (TCAR) is a newer operative technique that involves direct transcervical carotid access, mitigating aortic arch manipulation and minimizing the risk of embolic stroke via cerebral blood flow reversal. Perioperative stroke, myocardial infarction (MI), and death rates have been shown to be similar between TCAR and CEA, with TCAR having fewer complications. The objective of this study was to ascertain the safety and viability of TCAR by evaluating perioperative outcomes. We hypothesized that patients undergoing TCAR and CEA have equivalent outcomes. We performed a single-institution retrospective review of a prospectively maintained Vascular Quality Initiative database on patients who underwent TCAR or CEA between 2012 and 2019. A total of 66 TCAR cases from February 2018 to December 2019 and 501 CEA cases from January 2012 to December 2019 were reviewed. Preoperative, intraoperative, and postoperative characteristics as well as perioperative outcomes were captured for the statistical analyses. From 2012 to 2019, 567 patients underwent TCAR or CEA. Patients who underwent TCAR were found to have higher rates of comorbidities compared with CEA. There were no procedure-related strokes in patients who underwent TCAR. There was no statistically significant difference between TCAR and CEA procedure-related strokes (0% vs. 1.0%, P=0.42). There were 5 CEA procedure-related strokes because of technical problems resulting in thrombosis of the target vessels. Three patients who underwent CEA had strokes unrelated to the operations. Overall, there were no perioperative deaths, MI, cranial nerve injury (CNI), or hematoma in patients who underwent TCAR. There were no complications of surgical site infection, pseudoaneurysm, or arteriovenous fistula among patients who underwent TCAR or CEA. This single-center retrospective analysis of TCAR and CEA for the treatment of carotid artery disease suggests TCAR can result in equivalent perioperative procedure-related stroke as CEA as well as equivalent incidence of perioperative complications including MI, CNI, hematoma, and death in selected patients or patients with proper anatomy. TCAR may be considered a safe, feasible carotid revascularization option for carotid artery stenosis.

Diagnosis and management of coronary artery disease in early surgical treatment of acute infective endocarditis of the aortic valve

Abstract Background The need to routinely screen for coronary artery disease (CAD) in asymptomatic patients undergoing surgery for acute aortic valve infective endocarditis (IE) is debated. There is concern about the risk of embolization during invasive coronary angiography (ICA), especially in patients with vegetations. Coronary computed tomography angiography (cCTA) is a non-invasive alternative. Purpose To evaluate the prevalence of CAD in patients with acute aortic valve IE, the safety and feasibility of ICA and cCTA for diagnosis of CAD, and CAD related postoperative outcomes. Methods In this single center retrospective cohort study, all patients with acute infective aortic valve endocarditis between 2009–2019 undergoing surgery were selected. Outcomes were embolization after preoperative ICA, in-hospital mortality, perioperative myocardial infarction or unplanned revascularization. Results 159 patients (mean age 58±15, 81% male) underwent surgery. No CAD screening was done in 46/145, a cCTA was performed in 54/145 patients and an ICA in 52/145 patients. In 1 of the 52 patients undergoing preoperative ICA a cerebral embolism occurred. cCTA was not assessable on a patient level in 2 patients and 7 patients underwent both cCTA and ICA. Significant CAD was found in about 20% of patients both after cCTA and ICA. Even though just a minority of patients with CAD was treated with concomitant CABG, only 1 patient with known but untreated CAD needed unplanned revascularization postoperatively. The rate of perioperative myocardial infarction or unplanned revascularization in patients not screened for CAD was 5% (3 patients). Conclusion In patients with acute aortic valve IE the prevalence of CAD is low (14%). The risk of embolism after preoperative ICA is not negligible and should be carefully weighed against the estimated risk of CAD-related perioperative complications. cCTA might serve as a gatekeeper for ICA in many patients with acute aortic IE. Funding Acknowledgement Type of funding source: None

Tibial bypass in patients with intermittent claudication is associated with poor outcomes

ObjectiveGiven that intermittent claudication (IC) rarely progresses to chronic limb-threatening ischemia and limb loss, safety and durability of elective interventions for IC are essential. Whether patients with IC benefit from tibial intervention is controversial, and data supporting its utility are limited. Despite endovascular therapy expansion, surgical bypass is still commonly performed. We sought to assess outcomes of bypass to tibial arteries for IC. MethodsThe Vascular Quality Initiative (2003-2018) was queried for infrainguinal bypasses performed for IC. Perioperative and 1-year outcomes were compared between bypasses constructed to tibial and popliteal arteries. ResultsOf 5347 infrainguinal bypasses, 1173 (22%) and 4184 (78%) were tibial and popliteal bypasses, respectively. Overall, mean age was 65 ± 10 years, and patients were often men (72%) and current smokers (42%). Tibial bypasses commonly targeted posterior tibial (40%), tibioperoneal trunk (23%), and anterior tibial (19%) arteries. Great saphenous vein was more often used for tibial bypass than for popliteal bypass (78% vs 54%; P < .001). Patients undergoing tibial compared with popliteal bypass more often had impaired ambulation and prior ipsilateral bypasses and were less often taking antiplatelets and statins (all P < .05). In the perioperative period, tibial bypass patients had longer postoperative length of stay (4.5 ± 3.5 vs 3.5 ± 2.8 days), more pulmonary complications (1.3% vs 0.6%), and higher return to the operating room (7% vs 4%; all P < .05). Perioperative myocardial infarction (1.2% vs 0.8%; P = .19), stroke (0.4% vs 0.4%; P = .91), and mortality (0.3 vs 0.3%; P = .86) rates were similar between the cohorts. At 1 year, tibial compared with popliteal bypasses exhibited lower freedom from occlusion/death (81% vs 89%; P < .001), ipsilateral major amputation/death (90% vs 94%; P < .001), and reintervention/amputation/death (73% vs 80%; P < .001), but patient survival was similar (96% vs 97%; P = .07). On multivariable analysis, tibial compared with popliteal bypass was independently associated with increased occlusion/death (hazard ratio [HR], 1.65; 95% confidence interval [CI], 1.28-2.11; P < .001), major ipsilateral amputation/death (HR, 1.6; 95% CI, 1.12-2.19; P = .003), and ipsilateral reintervention/amputation/death (HR, 1.51; 95% CI, 1.28-1.79; P < .001), with similar patient survival. ConclusionsIn patients with IC, tibial bypass was associated with poor outcomes, including major amputation. Surgeons should exhaust nonoperative therapies and present realistic outcome expectations to their patients before offering such intervention.

Cardiovascular Risk Factors and Perioperative Myocardial Infarction After Noncardiac Surgery

BackgroundPerioperative cardiovascular events are a leading cause of morbidity and mortality after noncardiac surgery. We propose a simplified method for perioperative risk stratification. MethodsIn a retrospective cohort study we identified patients who underwent noncardiac surgery between 2009 and 2015 in the US National Surgical Quality Improvement Program. Multivariable logistic regression models adjusted for age, sex, race, and surgery type were generated to estimate the effect of traditional cardiovascular risk factors (hypertension, diabetes mellitus, current smoking) on odds of perioperative myocardial infarction (MI). Time to event analysis was conducted using competing risk analysis, with MI as the outcome event and death as the competing risk. ResultsA total of 3,848,501 noncardiac surgeries were identified. Postoperative MI occurred in 0.37% of patients and 1.04% of patients died. The 30-day event rate of perioperative MI increased in a stepwise fashion with additional risk factors (0.42% for 1, 0.82% for 2, and 1.08% for 3; P for trend < 0.001) after accounting for the competing risk of death. Compared with those with no risk factors, patients with 1, 2, and 3 risk factors had increased odds of MI (adjusted odds ratio [aOR], 2.07 [95% confidence interval (CI), 1.96-2.19]; aOR, 3.63 [95% CI, 3.43-3.85]; and aOR, 5.54 [95% CI, 5.09-6.04], respectively). Perioperative MI was rare (0.10%) in patients without risk factors. ConclusionsPatients with cardiovascular risk factors are at increased risk of perioperative MI, those without risk factors are at low risk. Further evaluation is needed to determine the effect of a simplified risk score in the perioperative setting.

Immediate Carotid Endarterectomy Is Associated with Higher Risk in Symptomatic Patients

Guidelines recommend that patients with carotid artery stenosis ≥50% (Sx-CAS) undergo carotid endarterectomy (CEA) within 14days of symptoms. However, perioperative risks, especially stroke, may be increased when CEA is performed within 48hours. This study seeks to more fully evaluate the effect of timing of surgery on outcomes for Sx-CAS. All CEAs in the Southern California Vascular Outcomes Improvement Collaborative (SoCal VOICe) from 2012 to 18 were reviewed. Ipsilateral cortical or visual symptoms within 6months defined Sx-CAS. Timing from symptom occurrence to CEA was classified as immediate (0-2days), early (3-14days), or delayed (>14days). Perioperative stroke, myocardial infarction (MI), and 30-day mortality rates were compared by time to surgery. Of 2203 CEAs, 436 (20%) were for Sx-CAS (52% stroke, 48% transient ischemic attack). Mean time from symptoms to CEA was 28.3days (range, 0-172; median, 14days). Sixty-one cases (14%) were immediate, 166 (38%) early, and 209 (48%) delayed. Perioperative stroke occurred in 2.8% and stroke/MI/30-day mortality in 5.7%. Stroke rate was significantly higher in the immediate group (vs. early and delayed): 8.2%, versus 3.0%, and 0.96%, respectively (P=0.009). Stroke/MI/30-day mortality was also higher in the immediate group: 13.1%, versus 6.0%, and 3.3%, respectively (P=0.001). Immediate surgery was associated with greater postoperative events (P=0.009), and logistic regression confirmed decreased risk of postoperative stroke and stroke/MI/30-day mortality in delayed surgery using immediate surgery as a reference. Wide variability existed among centers in the timing of CEA (immediate-range, 0-50%; delayed-range, 41-83%; P=0.01). In the SoCal VOICe, 52% of patients undergo CEA within 2weeks of symptoms. Increased stroke rates occur when CEA is performed within 2days, whereas stroke and death rates are decreased at 3-14days and beyond. These data support avoidance of immediate CEA. Opportunity exists to standardize timing of CEA for Sx-CAS among SoCal VOICe participants. Further study is required to define the role of immediate CEA.

The effect of combining coronary bypass with carotid endarterectomy in patients with unrevascularized severe coronary disease

ObjectiveManagement of significant carotid stenosis in those with symptomatic coronary disease remains controversial. Staged and combined carotid endarterectomy (CEA) with coronary artery bypass grafting has been described. Yet, an understanding of the additive risks of these approaches is poor. This study sought to assess outcomes in patients with clinically relevant coronary disease undergoing either isolated CEA (ICEA) or combined CEA and coronary artery bypass (concurrent coronary artery bypass [CCAB]). MethodsAll CEAs in the Vascular Quality Initiative from 2003 to 2017 were reviewed. CCABs were identified, as were ICEAs in patients with unrevascularized stable angina, unstable angina, or myocardial infarction (MI) within 6 months of operation. CCABs were compared with ICEAs as well as with a risk-matched cohort of ICEAs. Primary outcomes included perioperative stroke, all-cause death, MI, and these as composite (SDM). Univariate analysis and logistic regression were performed. ResultsThere were 4042 patients identified, including 2582 ICEA patients (64%) and 1460 CCAB patients (36%); 61% were male, 91% were white, and 39% had symptomatic carotid disease. Overall stroke was 3.5%, death 1.8%, and SDM 6.0%. ICEA had higher rates of postoperative MI (1.9% vs 0.9%; P = .01) but lower rates of stroke (2.8% vs 4.7%; P = .002), death (1.0% vs 3.0%; P < .001), and SDM (5.1% vs 7.5%; P = .002). After regression, predictors of SDM were congestive heart failure (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.3-2.4; P < .001), urgent operation (OR, 1.6; 95% CI, 1.2-2.2; P = .001), and CCAB (OR, 1.3; 95% CI, 1.01-1.7; P = .04). After propensity matching, ICEA continued to have higher rates of perioperative MI (2.6% vs 1.0%; P = .01) and lower rates of death (1.0% vs 3.0%; P = .001). However, there were no longer differences in stroke (3.2% vs 4.6%; P = .10) or SDM (6.3% vs 7.8%; P = .18). Within the matched cohort, predictors of SDM included chronic obstructive pulmonary disease (OR, 1.6; 95% CI, 1.1-2.2; P = .01), congestive heart failure (OR, 1.7; 95% CI, 1.1-2.5; P = .01), and symptomatic carotid disease (OR, 1.5; 95% CI, 1.03-2.1; P = .03). CCAB was not significant (OR, 1.3; 95% CI, 0.9-1.8; P = .18). ConclusionsIn patients with unrevascularized, clinically relevant coronary disease, CCAB reduces operative MI but increases risk of stroke and death. After risk adjustment, MI remains higher in ICEA, but differences in 30-day stroke and SDM between ICEA and CCAB are no longer appreciated. These data suggest that CEA risk undertaken in patients with unrevascularized coronary disease is not inconsequential, and outcomes are similar to those of CCAB.

Perioperative acute myocardial infarction rate in chronic renal disease patients undergoing orthopedic surgery: Is there any difference between dialyzed and nondialyzed patients?

BackgroundThe incidence of acute myocardial infarction (AMI) in healthy patients undergoing noncardiac surgery is <1%. When patients with chronic kidney disease (CKD) undergo orthopedic surgery, AMI incidence can be expected to be relatively high. However, data on a population-wide scale is lacking.ObjectiveTo investigate AMI incidence in patients with CKD (with and without dialysis) undergoing orthopedic surgery.DesignA population-based study covering the period from January 1, 1997, to December 31, 2011.SettingData from the Taiwan National Health Insurance Research Database.ParticipantsParticipants were 219,195 patients with CKD who underwent surgery between January 1, 1997, and December 31, 2011.ResultsAMI occurred in 2,708 participants (1.24%). The AMI incidence rate in the dialyzed group was 1.52%, which was higher than that in the nondialyzed group after propensity score matching. Dialysis (odds ratio [OR]: 1.79; 95% confidence interval [CI]: 1.62–1.98), male (OR: 1.42; 95% CI: 1.28–1.57), diabetes mellitus (OR: 1.61; 95% CI: 1.44–1.80), hyperlipidemia (OR: 1.88; 95% CI: 1.68–2.11), old myocardial infarction (OR: 18.87; 95% CI: 16.26–1.21.90), and cerebral vascular disease (CVA) (OR: 1.29; 95% CI: 1.30–1.47) were all associated with AMI in the patients with CKD.ConclusionsThe AMI risk was higher in the patients with CKD undergoing orthopedic surgery than in the general population, and the dialyzed group had a higher risk of AMI than did the nondialyzed group.

Outcomes and Durability of Endovascular Aneurysm Repair in Octogenarians

Endovascular aneurysm repair (EVAR) accounts for the majority of all abdominal aortic aneurysm (AAA) repairs in the United States. EVAR utilization in the aging population is increasing due to the minimally invasive nature of the procedure, the low associated perioperative morbidity, and early survival benefit over open repair. The objective of this study is to compare the outcomes of octogenarians after elective EVAR to theiryounger counterparts, a question that can be answered by a long-term, institutional data set. This was a retrospective series of 255 patients, who underwent elective EVAR within our institution from 2008 to 2015. A comparative analysis of patients aged 80years and older and less than 80years was performed. Outcomes measured included perioperative death and myocardial infarction (MI), length of stay, and readmission within 30days. Aneurysm reintervention, long-term surveillance imaging, and aneurysm-related deaths were also evaluated. In addition, subset analyses of octogenarians were compared for survival at 24months. Overall, 255 patients were included in our analysis. Fifty-nine patients were octogenarians, and 196 patients were nonoctogenarians. The mean age difference between the two groups was significant (84.5years [SD, ±3.44] vs. 69.6years [SD, ±6.13] in the ≥80 and <80 groups, respectively; P<0.0001). There was no significant difference in the mean aneurysm size (6.03cm [SD, ±1.12] vs. 5.535cm [SD, ±0.9]; P<0.06) between the ≥80 and<80 groups. Octogenarians had higher rates of perioperative MI (5% vs. 1%, P<0.04), thirty-day mortality (7% vs. 0%, P<0.003), a higher number of perioperative complications (0.64 incidence per patient [SD, ±1.11] vs. 0.31 [SD, ±0.69], P<0.005), and a longer mean hospital stay (5.34 [SD, ±5.75] days vs. 3.16 [SD, ±3.23] days, P<0.0003), and they were also less likely to be discharged home after surgery (75% vs. 91%, P<0.002). In the evaluated long-term outcomes, the two groups were similar with regard to aneurysm reintervention (10% vs. 9%, P<0.06) and the stability of aneurysm sac size on imaging at last follow-up (71% vs. 80%, P<0.27). The overall aortic related cause of death was different between the groups (8% vs. 1%, P<0.003); however, the long-term aortic related mortality was not different between the two groups (2% vs. 1%, P<0.4). Finally, a subset analysis of the octogenarian group was performed comparing patients based on survival status at 24months. Higher preoperative creatinine (1.73mg/dL [SD, ±1.54] vs. 1.15mg/dL [SD, ±0.46]) and lower preoperative hematocrit (33.9% [SD, ±3.43] vs. 37.2% [SD, ±4.9]) along with number of perioperative complications (1.2 incidence per patient [SD, ±1.74] vs. 0.45 [SD, ±0.73]) were associated with death at 24months after the index operation. Elective endovascular repair of AAA in octogenarians carries a higher risk of perioperative mortality but acceptable long-term outcomes. Appropriateness of elective EVAR in octogenarians should be answered based on this potential short-lived survival benefit, taking into account that advanced age should not be the sole basis of exclusion for otherwise suitable candidates for elective EVAR.