Revascularization For Aortoiliac Occlusive Disease Research Articles

Predicting outcomes following open revascularization for aortoiliac occlusive disease using machine learning: Presented at the 2023 Vascular Annual Meeting of the Society for Vascular Surgery, National Harbor, Maryland, June 14-17, 2023.

Predicting outcomes following open revascularization for aortoiliac occlusive disease using machine learning: Presented at the 2023 Vascular Annual Meeting of the Society for Vascular Surgery, National Harbor, Maryland, June 14-17, 2023.

Predicting outcomes following open revascularization for aortoiliac occlusive disease using machine learning

ObjectiveOpen surgical treatment options for aortoiliac occlusive disease carry significant perioperative risks; however, outcome prediction tools remain limited. Using machine learning (ML), we developed automated algorithms that predict 30-day outcomes following open aortoiliac revascularization. MethodsThe National Surgical Quality Improvement Program (NSQIP) targeted vascular database was used to identify patients who underwent open aortoiliac revascularization for atherosclerotic disease between 2011 and 2021. Input features included 38 preoperative demographic/clinical variables. The primary outcome was 30-day major adverse limb event (MALE; composite of untreated loss of patency, major reintervention, or major amputation) or death. The 30-day secondary outcomes were individual components of the primary outcome, major adverse cardiovascular event (MACE; composite of myocardial infarction, stroke, or death), individual components of MACE, wound complication, bleeding, other morbidity, non-home discharge, and unplanned readmission. Our data were split into training (70%) and test (30%) sets. Using 10-fold cross-validation, we trained six ML models using preoperative features. The primary model evaluation metric was area under the receiver operating characteristic curve (AUROC). Model robustness was evaluated with calibration plot and Brier score. Variable importance scores were calculated to determine the top 10 predictive features. Performance was assessed on subgroups based on age, sex, race, ethnicity, symptom status, procedure type, and urgency. ResultsOverall, 9649 patients were included. The primary outcome of 30-day MALE or death occurred in 1021 patients (10.6%). Our best performing prediction model for 30-day MALE or death was XGBoost, achieving an AUROC of 0.95 (95% confidence interval [CI], 0.94-0.96). In comparison, logistic regression had an AUROC of 0.79 (95% CI, 0.77-0.81). For 30-day secondary outcomes, XGBoost achieved AUROCs between 0.87 and 0.97 (untreated loss of patency [0.95], major reintervention [0.88], major amputation [0.96], death [0.97], MACE [0.95], myocardial infarction [0.88], stroke [0.93], wound complication [0.94], bleeding [0.87], other morbidity [0.96], non-home discharge [0.90], and unplanned readmission [0.91]). The calibration plot showed good agreement between predicted and observed event probabilities with a Brier score of 0.05. The strongest predictive feature in our algorithm was chronic limb-threatening ischemia. Model performance remained robust on all subgroup analyses of specific demographic/clinical populations. ConclusionsOur ML models accurately predict 30-day outcomes following open aortoiliac revascularization using preoperative data, performing better than logistic regression. They have potential for important utility in guiding risk-mitigation strategies for patients being considered for open aortoiliac revascularization to improve outcomes.

Outcomes of Aortobifemoral Bypass Based on Configuration of the Proximal Anastomosis

Aortobifemoral bypass (ABF) remains an important treatment modality in the revascularization of aortoiliac occlusive disease. Despite ABF being performed for decades, questions remain regarding the preferred technique for the proximal anastomosis, specifically whether an end-to-end (EE) or an end-to-side (ES) configuration is superior. The goal of this study was to compare the outcomes of ABF based on proximal configuration. We queried the Vascular Quality Initiative (VQI) registry for ABF procedures performed between 2009 and 2020. Univariate and multivariate logistic regression analyses were used to compare peri-operative and 1-year outcomes between EE and ES configurations. Of the 6782 patients (median (interquartile range) age, 60.0 (54-66 years) who underwent ABF, 3524 (52%) had an EE proximal anastomosis and 3258 (48%) had an ES proximal anastomosis. Post-operatively, the ES cohort had a higher frequency of extubation in the operating room (80.3% vs 77.4%; p<0.01), lower change in renal function (8.8% vs 11.5%; p <0.01), and lower use of vasopressors (15.6% vs 19.1%; p<0.01), but higher rates of unanticipated return to the operating room (10.2% vs 8.7%; p=0.037) compared with the EE configuration. At 1-year follow up, the ES cohort had a significantly lower primary graft patency rate (87.5% vs 90.2%; p<0.01) and higher rates of graft revision (4.8% vs 3.1%; p<0.01), and claudication symptoms (11.6% vs 9.9%; p<0.01). The ES configuration was significantly associated with a higher rate of 1-year major limb amputations in univariate (1.6% vs 0.9%; p<0.01) and multivariate (OR, 1.95, CI, 1.18-3.23, p=<0.01) analyses. While the ES cohort seemed to have less physiologic insult immediately post-operatively, the EE configuration appeared to have improved 1-year outcomes. To our knowledge, this study is one of the largest population-based studies comparing the outcomes of the proximal anastomotic configurations. Longer-term follow-up is needed to determine which configuration is optimal.

Outcomes Of Aortobifemoral Bypass Based On Configuration Of The Proximal Anastomosis

Aortobifemoral bypass (ABF) remains an important treatment modality in the revascularization of aortoiliac occlusive disease. Despite ABF being performed for decades, questions remain regarding the preferred arrangement of the proximal anastomosis, specifically whether an end-to-end (EE) or an end-to-side (ES) configuration is superior. The goal of this study was to compare the outcomes of ABF based on proximal configuration.

Hybrid Revascularization for Aorto-Iliac Occlusive Disease with Common Femoral Artery Involvement: Early Outcomes of a Single Centre.

To study the early outcomes of aorto-iliac occlusive disease with common femoral artery involvement by hybrid methods of revascularization - iliac stenting with femoral endarterectomy. We report the initial experiences of a single centre and discuss issues that arose. Ninety-eight critical limb ischaemia (CLI) patients with aorto-iliac occlusive lesions TASC-II C and D were treated using HR between January 2017 and September 2020 in the Ivano-Frankivsk Regional Clinical Hospital. Prospective data were recorded and analysed including demographics, technical success, 30-day and early patency outcomes, re-intervention, and death. The mean age of patients was 65 ± 7.2 years (61 men and 37 women). Using classification by TASC-II, 77% of the lesions were class D. Technical success was seen in 98% of patients. Two patients underwent a crossover femoro-femoral bypass due to failure to re-enter the true lumen of the aorta during endovascular lesion crossing. There were no deaths during the 30-day period. No re-interventions for thrombosis were needed. Additional delayed bypass procedures were required in 19 patients (19.3%) with distal occlusions and minor and major tissue loss. The overall complication rate was 16.3% (16 patients). The 30-day patency rate was 100%. The median follow-up period was 18 months (range 1-36 months) with a primary patency rate of 87.2%, and cumulative primary assisted and secondary patency rate of 93.4%. Four patients died during the study period. Hybrid revascularization is a safe and less traumatic method of managing aorto-iliac occlusive disease with common femoral artery involvement. Good early patency results and low major complication rates indicate that HR is an excellent alternative to traditional open surgery, especially for high-risk patients.

Open Surgical Revascularization for Aortoiliac Occlusive Disease Across Surgical Eras and Surgeon Experience

We compared the contemporary outcomes of open surgical revascularization (OSR) for aortoiliac occlusive disease with a historical cohort (HC) and between surgeons with varying experience (junior, <5 years of practice; senior, >5 years of practice).

Carbon dioxide versus iodine contrast medium for endovascular revascularization of aortoiliac occlusive disease: a two-center randomized controlled trial

Objectives The objective of this study was to compare the quality of radiographic imaging obtained intraoperatively using carbon dioxide (CO2) as a contrast medium with iodinated contrast media in patients undergoing endovascular revascularization of aortoiliac occlusive disease Trans-Atlantic Inter-Society Consensus A, B, and C in patients without renal impairment. Patients and methods Recruitment started from July 2015 and ended July 2018. Patients with aortoiliac occlusive disease who were eligible for endovascular treatment and lacked contraindications to either iodine contrast or CO2 were offered to participate. After informed consent, they were randomized into the CO2 arm (32) patients or iodine contrast medium (ICM) arm (32) patients. They underwent aortoiliac angioplasty blinded to the type of contrast type used. The primary outcome was the quality of image using one type of contrast agent to perform the needed interventions. The secondary outcomes were technical success rate and the safety of procedure. Imaging from all cases were analyzed within 12 weeks of conclusion of the study by two independent observers blinded to treatment arm. Results CO2 angiography images were classified as very good in 27.4% (25.8 and 29%), whereas 39% (40.6 and 37.5%) of iodine arteriograms were classified as very good by two observers, with no statistical significance (P=0.158 and 0.176). Interoperator agreement analysis showed substantial agreement (kappa=0.712). Technical success was 100%, with no procedure-related deaths. The treatment time was longer when CO2 was used as contrast medium (87±22 min) versus using ICM (77±28 min). The use of ICM was required in three (9%) CO2 patients to complete the procedure. Conclusion Using CO2 as a contrast medium in aortoiliac arterial occlusive disease in normal kidney function patients produces good-quality images and is practical and safe. It is a comparable alternative to ICM with minimum risk of affecting kidney function and complications.

Prediction of postoperative myocardial infarction after suprainguinal bypass using the Vascular Quality Initiative Cardiac Risk Index

BackgroundThe Vascular Quality Initiative (VQI) Cardiac Risk Index (CRI) was developed to estimate the risk of postoperative myocardial infarction (POMI) for noncardiac vascular procedures. Whereas suprainguinal bypass carried the second highest odds of POMI, the performance of the all-procedure model declined when it was applied to the suprainguinal subset. We sought to improve the VQI CRI for application in this high-risk group undergoing open revascularization for aortoiliac occlusive disease. MethodsThe VQI Suprainguinal Bypass Registry was queried for elective procedures performed between January 2010 and March 2017. Logistic regression was used to create a model for estimating the risk of in-hospital POMI with preoperative variables including demographics, comorbidities, and planned inflow source. After adjustment for overfitting, internal validation was performed using both bootstrapping and 10-fold cross-validation methods. ResultsAmong 8157 procedures, the incidence of POMI was 3.2% (n = 258). After bootstrapping variable selection, age, graft inflow, preoperative stress test, American Society of Anesthesiologists class, indication for procedure, and coronary artery disease were chosen for inclusion as predictors in the final risk model. The final model demonstrated good discrimination (area under the curve = 0.725). On internal validation, the model discriminated well (area under the curve = 0.713), with good calibration (plot intercept = 0.0006 and slope = 1.001). Using this model, POMI risk estimates ranged from 0.6% to 30.4%. ConclusionsWhereas the incidence of POMI among all suprainguinal bypasses was 3%, model-based estimates ranged 50-fold, from 0.6% to 30.4%. This underscores the heterogeneity of this cohort and the need for patient-specific risk estimation. Although some of the strongest predictors were nonmodifiable (eg, age), the model provided specific estimates according to graft inflow and stress testing. This supraspecific VQI CRI module risk predictor may enhance preoperative counseling by influencing the decision to pursue preoperative stress testing and ultimately the type of revascularization strategy chosen.

Predictors of Myocardial Infarction after Suprainguinal Bypass Using the Vascular Quality Initiative Cardiac Risk Index

Several models have been developed to estimate the risk of postoperative myocardial infarction (POMI). The Vascular Quality Initiative (VQI) Cardiac Risk Index (CRI) was developed specifically for vascular procedures; while suprainguinal bypass carried the second highest odds of POMI, the all-procedure-based model performance declined when applied to the suprainguinal subset. We sought to refine the VQI CRI for application in this high-risk group undergoing open revascularization for aortoiliac occlusive disease.

Impact of coexisting aneurysms on open revascularization for aortoiliac occlusive disease

National data evaluating outcomes for occlusive abdominal aortic reconstructions are well described. The relative effect of operative indication as well as the presence of concomitant abdominal aortic aneurysm (AAA) on in-hospital mortality is not well defined. The Nationwide Inpatient Sample was queried to identify patients who underwent open aortic surgery (2003-2010). Indication for surgery was classified by International Classification of Diseases, Ninth Revision diagnostic codes to identify isolated occlusive indications as well as combined occlusive disease and AAA. Primary outcome was in-hospital mortality. Secondary outcomes were complications and discharge disposition. Overall, 56,374 underwent aortic reconstruction, 48,591 for occlusive disease (86.2%) and 7783 for combined occlusive disease with AAA (13.8%). Intermittent claudication was the most common indication for intervention (60.9%), whereas 39.7% underwent intervention for critical limb ischemia (22.2% rest pain, 17.6% gangrene). Patients with intermittent claudication had more concomitant AAAs (17.3%) than did patients with critical limb ischemia (8.4%). Thebaseline characteristics for those with occlusive disease and combined occlusive with AAA disease were similar in terms of obesity (4.8% vs 4.2%; P= .27) and congestive heart failure (6.6% vs 6.3%; P= .65) but differed by age (62.2years vs 68.4years; P<.0001) and hypertension (65.4% vs 69.1%; P= .005). Patients with combined occlusive and AAA disease had higher mortality than those with occlusive disease alone (3.9% vs 2.7%; P= .01). On multivariable regression, factors associated with in-hospital mortality included gangrene with AAA compared with gangrene alone (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.6-4.7; P< .0002), age >65years age (OR, 3.1; 95% CI, 2.4-4.1; P<.0001), renal failure (OR, 2.7; 95% CI, 1.9-3.8; P< .0001), and concurrent lower extremity revascularization (OR,1.3; 95% CI, 1.1-1.7; P< .02). Intermittent claudication or critical limb ischemia with concomitant AAA carries a higher mortality than intermittent claudication or critical limb ischemia alone, especially in older patients with gangrene requiring revascularization and renal insufficiency. Preoperative risk stratification strategies should focus on the indication for surgery as well as the presence of concomitant AAA.

Paramedian retroperitoneal approach for revascularization of aortoiliac occlusive disease

Paramedian retroperitoneal approach for revascularization of aortoiliac occlusive disease

Midline abdominal wall incisional hernia after aortic reconstructive surgery: A prospective study

To evaluate rate of formation of midline abdominal wall incisional hernia (MAIH) after elective open repair of abdominal aortic aneurysm (AAA) and revascularization for aortoiliac occlusive disease (AOD). AAA and AOD patients operated electively via a primary midline abdominal incision at our institution over a decade were entered in this prospective study. Patients who had already undergone midline laparotomy or had an MAIH after previous celiotomy were excluded. Patients were examined for MAIH 6-monthly for 2 years, then yearly. We included 1,065 patients who underwent aortic reconstructive surgery (412 with AAA and 653 with AOD). The follow-up (mean ± standard deviation) was 6.4 ± 3.8 years (range, 0.5-12.7). Wounds were closed with a suture length-to-wound length (SL:WL) ratio of at least 4:1 in 58% (239 of 653) of AAA patients and 66% (431 of 653) of AOD patients (P = .01). There were 124 (11.6%) MAIHs, with an incidence of 12.4% (51 of 412) in the AAA group and 11.2% (73 of 653) in the AOD group (P = .62), and 3 (0.4%) wound infections (all among the AOD patients), none of which resulted in MAIH. At multivariate analysis, a SL:WL ratio of <4:1 was the only independent predictor of MAIH in AAA (P = .004) and AOD patients (P < .001). AAA and AOD patients had a similar incidence of MAIH, which seems related to the wound closure technique. A SL:WL ratio of at least 4:1 is recommended. Further clinical studies are required to determine possible technical and perioperative variables that may be modified to decrease the incidence of MAIH development after aortic reconstructive surgery.

PVSS4. Surgical Revascularization for Aorto-Iliac Occlusive Disease (AIOD): Current Indications and Outcomes

PVSS4. Surgical Revascularization for Aorto-Iliac Occlusive Disease (AIOD): Current Indications and Outcomes

Totally videoendoscopic descending thoracic aorta-to-femoral artery bypass

Descending thoracic aorta to femoral artery bypass is an effective and safe procedure for the treatment of aortoiliac occlusive disease when an approach to the abdominal aorta is undesirable. The major limitation of this technique has resulted from the morbidity rate associated with thoracotomy in a relatively high-risk vascular surgery population. As a minimally invasive procedure, videoendoscopy has been shown to improve the patient postoperative course and comfort in the field of general and thoracic surgery. The same benefits could be expected from a videoendoscopic surgery involving the thoracic aorta. In 2003 we reported the first case of a totally videoendoscopic descending thoracic aorta-to-femoral artery bypass procedure. In this article we report our additional experience with and the modifications we have made to this technique.

Collagen- versus gelatine-coated Dacron versus stretch PTFE bifurcation grafts for aortoiliac occlusive disease: Long-term results of a prospective, randomized multicenter trial

Background. In this prospective randomized multicenter trial, knitted gelatine-coated Dacron, knitted collagen-coated Dacron, and stretch polytetrafluoroethylene (PTFE) aortic bifurcation grafts were compared for their long-term results. Methods. Between 1991 and 1998, 149 patients undergoing elective revascularization for aortoiliac occlusive disease were prospectively randomized at 3 tertiary referral centers of vascular surgery. The patients received either gelatine-coated Dacron (GEL-D) grafts (n = 52), collagen-coated Dacron (COL-D) grafts (n = 49), or stretch PTFE grafts (n = 48). Results. No intraoperative deaths were recorded. The 30-day mortality was 4%. The mean follow-up time was 97 months. Primary patency rates were 77% for GEL-D, 78% for COL-D, and 79% for PTFE at 8 years. The differences were not different (P >.8). Secondary corrected 8-year patency rates were also not significantly different (P >.5): 91% for GEL-D, 96% for COL-Dm and 90% for PTFE. Five Dacron and 1 PTFE grafts were affected by infections. Conclusions. Bifurcation grafts for revascularization of aortoiliac occlusive disease using these 3 materials were comparable in terms of primary and secondary patency and long-term complication rates. (Surgery 2003;134:80-5.)

LONG-TERM RESULTS OF VASCULAR GRAFTS SEALED WITH FRAGMENTED AUTOLOGOUS ADIPOSE TISSUE FOR AORTOILIAC OCCLUSIVE DISEASE

Purpose: The aim of this study was to test the safety and efficacy of fragmented autologous adipose tissue (FAT) grafts for revascularization in aortoiliac occlusive disease. Methods: We subjected 27 patients with atherosclerotic aortoiliac occlusive disease to surgical treatment with fragmented autologous adipose tissue (FAT) grafts. Age at operation ranged from 44 to 90 years. There were 25 males and 2 females. A piece of adipose connective tissue was obtained from the operative wound and chopped up and pressed into the wall of a Dacron prosthesis. An aortobilateral iliac or femoral bypass (Y graft) was done in 13 cases, and an aortounilateral iliac or femoral bypass (straight graft) was done in 14 cases. Results: Cumulative primary patency rates were 92% at 3 years, 86% at 5 years, and 86% at 8 years. Cumulative secondary patency rates were 96, 90, and 90% at the same intervals. In comparison with reported patency rates, the long-term patency of our FAT grafts was not inferior to that of conventional grafts. We conclude that application of the FAT graft is acceptable and safe as a vascular prosthesis for the revascularization of aortoiliac occlusive disease.

Factors affecting late survival after elective abdominal aortic aneurysm repair.

The late prognosis after repair of an abdominal aortic aneurysm (AAA) may be affected by atherosclerosis, which involves various organs including the aorta. The influence of organ dysfunction and atherosclerosis on the long-term survival of 338 consecutive patients undergoing successful elective AAA repair between 1980 and 1997 was analysed using Cox hazards model. Survival rate was compared with that of 349 patients undergoing successful revascularization for aortoiliac occlusive disease (AIOD) during the same interval. Renal dysfunction and a previous history of cerebrovascular events were important variables predicting late death (risk ratio 1.980 and 1.903 respectively), while a history of cardiac disease predicted only cardiac-related death. The survival rate in patients with normal renal function was significantly better than that in those with renal dysfunction (P = 0.0371). Similarly, the survival rate was significantly better in patients without a history of previous cerebrovascular events (P = 0.0414). The survival rate after AAA repair was nearly identical to that of age- and sex-matched patients with grade II or III symptoms who had surgery for AIOD. Advanced atherosclerosis with underlying organ dysfunction is a true determinant of long-term survival following elective repair of AAA.

Descending thoracic aorta to iliofemoral artery bypass grafting: A role for primary revascularization for aortoiliac occlusive disease?

Purpose: Bypass grafts that originate from the descending thoracic aorta to the iliac or femoral arteries are well described but are not commonly used as primary procedures, and the long-term results remain unknown. A 15-year experience with 50 descending thoracic aorta to iliofemoral artery bypass grafts for aortoiliac occlusive disease is the basis of this report. Methods: From January 1983 to December 1997, patients who underwent bypass grafting procedures from the descending thoracic aorta to the iliac or femoral arteries were identified. Surgical indications, morbidity and mortality rates, primary and secondary patency rates, limb salvage rates, and survival rates were determined. Results: Fifty descending thoracic aorta to iliofemoral artery bypass grafting procedures were performed—24 (48%) for severe claudication, 22 (44%) for rest pain, and 4 (8%) for ischemic ulceration. A primary procedure was performed in 31 patients (62%) for complete occlusion (21 patients) and severe atherosclerotic disease (10 patients) of the infrarenal aorta. The indications for 19 secondary revascularizations (38%) were prior aortic or extra-anatomic graft failure in 17 cases and aortic graft infection in 2 cases. The follow-up periods ranged from 1 to 150 months (mean, 39 months). The cumulative life-table 5-year primary patency, secondary patency, limb salvage, and survival rates were 79%, 84%, 93%, and 67%, respectively. An improved patency trend was observed for patients who underwent operation for severe claudication as compared with limb-threatening ischemia (92% and 69%; P = .07). However, there was no difference between primary and secondary operations in primary patency rates (81% and 79%; P = NS) or survival rates (72% and 62%; P = NS). Conclusion: Descending thoracic aorta to iliofemoral artery bypass grafting has excellent overall long-term results. These results support its more liberal use for primary revascularization, especially for patients with severe atherosclerotic disease or complete occlusion of the infrarenal aorta. (J Vasc Surg 1999;29:249-58.)

Descending thoracic aorta to iliofemoral artery bypass grafting: A role for primary revascularization for aortoiliac occlusive disease?

Descending thoracic aorta to iliofemoral artery bypass grafting: A role for primary revascularization for aortoiliac occlusive disease?

大動脈腸骨動脈閉塞疾患６２例７７肢に対する血行再建術の検討

大動脈腸骨動脈閉塞疾患６２例７７肢に対する血行再建術の検討