Revascularization Procedures In Patients Research Articles

Hemoglobin A1c Levels Are Related to Patency and Adverse Limb Events in Diabetics After Revascularization

Poor glycemic control in the perioperative period has been reported to be associated with early and late major adverse limb events (MALEs). However, these studies were mostly from large databases or lacked long-term outcomes. We examined the long-term effects of high hemoglobin A1c (HbA1c) level on patency, MALE, limb salvage (LS) and survival after lower extremity revascularization procedures in patients with diabetes. Patients with diabetes who underwent revascularization for Rutherford class 3 to 6 ischemia between May 2002 and December 2018 were identified. Patients with an HbA1c of ≤7% were compared with those with an HbA1c of >7% for patency, MALE, survival, LS, and amputation-free survival. Of 706 patients, 699 had HbA1c data (775 limbs), with 311 (357 limbs) in the HbA1c ≤7% and 388 (418 limbs) in the HbA1c >7% groups. Patients with an HbA1c of >7% were younger (69.9± 10.2 years vs 71.7± 9.5 years; P= .011), had higher lipid levels, insulin use (70% vs 49%; P< .01), American Society of Anesthesiologists classification of 4, and had a lower prevalence of chronic kidney disease (32% v s41%; P= .023). Patients with an HbA1c of >7% were more likely to present with chronic limb-threatening ischemia (CLTI) (79% vs 72%; P= .019) and undergo infrapopliteal interventions (49% vs 42%; P= .005), with no difference in anatomical complexity (TransAtlantic Inter Society Consensus class C/D, 75% vs 77%; P= .72) or type of revascularization (24% vs 18% open, 66% vs 70% endovascular, 10% vs 12% hybrid; P= .236). Patency and freedom from MALE were significantly lower in patients with an HbA1c of >7% for infrainguinal revascularizations, whereas amputation-free survival and overall survival were similar. In patients with chronic limb-threatening ischemia, LS rates at 5 years were significantly lower in patients undergoing open revascularization (HbA1c > 7%: 64%± 6% vs HbA1c<7%:86%± 5%; P= .020), whereas it was similar after endovascular interventions (HbA1c > 7%:79%± 4% vs HbA1c< 7%:77%± 3%; P= .631). Seventy patients with an HbA1c of >7% lost limbs vs 38 patients with an HbA1c of ≤7% (P= .007). In multivariate analysis, HbA1c was associated significantly with primary patency. HbA1c, insulin use, level of intervention, and angiotensin-converting enzyme inhibitor use were associated with MALE. A perioperative HbA1c of >7% is associated with poorer patency rates and increased MALE, especially at the infrainguinal level revascularization in patients with diabetes, with no significant impact on survival. LS is impacted after open, but not after endovascular revascularization.

Outcomes of Carotid Artery Revascularization Procedures in Patients with High-grade Bilateral Stenosis

Outcomes of Carotid Artery Revascularization Procedures in Patients with High-grade Bilateral Stenosis

Development and validation of machine learning models to predict postoperative infarction in moyamoya disease.

Cerebral infarction is a common complication in patients undergoing revascularization surgery for moyamoya disease (MMD). Although previous statistical evaluations have identified several risk factors for postoperative brain ischemia, the ability to predict its occurrence based on these limited predictors remains inadequately explored. This study aimed to assess the feasibility of machine learning algorithms for predicting cerebral infarction after revascularization surgery in patients with MMD. This retrospective study was conducted across two centers and harnessed data from 512 patients with MMD who had undergone revascularization surgery. The patient cohort was partitioned into internal and external datasets. Using perioperative clinical data from the internal cohort, three distinct machine learning algorithms-namely the support vector machine, random forest, and light gradient-boosting machine models-were trained and cross-validated to predict the occurrence of postoperative cerebral infarction. Predictive performance validity was subsequently assessed using an external dataset. Shapley additive explanations (SHAP) analysis was conducted to augment the prediction model's transparency and to quantify the impact of each input variable on shaping both the aggregate and individual patient predictions. In the cohort of 512 patients, 33 (6.4%) experienced postrevascularization cerebral infarction. The cross-validation outcomes revealed that, among the three models, the support vector machine model achieved the largest area under the receiver operating characteristic curve (ROC-AUC) at mean ± SD 0.785 ± 0.052. Notably, during external validation, the light gradient-boosting machine model exhibited the highest accuracy at 0.903 and the largest ROC-AUC at 0.710. The top-performing prediction model utilized five input variables: postoperative serum gamma-glutamyl transpeptidase value, positive posterior cerebral artery (PCA) involvement on preoperative MRA, infarction as the rationale for surgery, presence of an infarction scar on preoperative MRI, and preoperative modified Rankin Scale score. Furthermore, the SHAP analysis identified presence of PCA involvement, infarction as the rationale for surgery, and presence of an infarction scar on preoperative MRI as positive influences on postoperative cerebral infarction. This study indicates the usefulness of employing machine learning techniques with routine perioperative data to predict the occurrence of cerebral infarction after revascularization procedures in patients with MMD.

Smartphone-Based Infrared Thermography as an Option for Evaluating the Treatment Effect of Revascularization Procedure in Patients With Peripheral Arterial Disease, a Prospective Study

Infrared imaging has been used to assess peripheral perfusion; however, large, heavy, and prohibitively expensive cameras have precluded its adoption for widespread clinical applications. With advent of more affordable and portable infrared cameras in recent years, they have become more accessible for clinical use. In this study, we aim to introduce the use of smart phone based thermal camera using thermal ankle-brachial index (TABI) to assess the perfusion in peripheral arterial disease (PAD)-affected lower extremities both preintervention and postintervention and simultaneously comparing with ABI. To our knowledge, this is the first study in the Indian scenario. We included 52 patients with 67 lower limbs with PAD requiring revascularization who presented to our institute between July 2020 and December 2021 in the study. Revascularization procedures included endovascular or open surgical bypass. ABI was measured in affected lower limb using Handheld Doppler device before revascularization, after revascularization at discharge and at 1-month follow-up after revascularization. Thermal images of upper and lower limbs were obtained using FLIR ONE PRO (a smartphone-based infrared thermal camera) at the time of measuring ABI. TABI was calculated by dividing maximum lower limb temperature by maximum upper limb temperature. ABI and TABI were compared for correlation using Pearson analysis. After revascularization, there was statistically significant improvement in ABI, 0.38 ± 0.20, t(66) = 15.1; P < .001, and TABI, 0.09 ± 0.053, t(66)=14.2; P < .001, at discharge when compared with before intervention (Table). Before intervention, positive correlation was found between ABI and Lower limb temperature (r = 0.973; P < .001) and ABI and TABI (r = 0.810; P < .001). After intervention at discharge, positive correlation was found between ABI and Lower limb temperature (r = 0.682; P < .001) and ABI and TABI (r = 0.662; P < .001). At the 1-month follow-up after intervention, positive correlation was found between ABI and Lower limb temperature (r = 0.874; P < .001) and ABI and TABI (r = 0.663; P < .001). Smart phone-based thermal imaging can be used to assess perfusion status in PAD in clinical settings as non-invasive, portable, cost effective and reproducible alternative to ABI. It has shown improvement in perfusion status corresponding to standard Doppler ABI.TableShowing descriptive analysis of revascularized lower limbsBefore interventionAfter intervention at dischargeAt the 1-month follow-upABITABILower extremity temperature (℉)Ambient temperature (℉)ABITABILower extremity temperature (℉)Ambient temperature (℉)ABITABILower extremity temperature (℉)Ambient temperature (℉)Mean.28.8382.786.4.67.9392.986.8.68.9492.987.7Median.27.8382.988.4.67.9592.688.4.67.9692.688.2Std deviation.21.044.219.40.22.065.779.54.17.055.348.64Minimum.00.7574.864.0.00.7879.560.8.00.7878.664.2Maximum.83.9796.6101.41.11.02103.6102.31.11.02103.1102.3Range.83.2221.837.41.1.2424.141.51.1.2424.538.1Interquartile range.28.045.37.90.21.1010.137.35.19.099.456.67TABI, Thermal ankle-brachial index. Open table in a new tab

Treatment outcomes between bypass surgery and endovascular therapy in patients with chronic limb-threatening ischemia classified as bypass-preferred category based on Global Vascular Guidelines

ObjectiveThe aim of this study was to examine outcomes between bypass surgery and endovascular therapy (EVT) in patients with chronic limb-threatening ischemia (CLTI), classified as bypass-preferred according to the Global Vascular Guidelines (GVG). MethodsWe retrospectively analyzed the multi-center data of patients who underwent infrainguinal revascularization for CLTI with Wound, Ischemia, and foot Infection (WIfI) Stage 3 to 4 and Global Limb Anatomical Staging System (GLASS) Stage III, which is classified as bypass-preferred category by the GVG between 2015 and 2020. The endpoints were limb salvage and wound healing. ResultsWe analyzed 301 patients and 339 limbs following 156 bypass surgeries and 183 EVTs. The 2-year limb salvage rates were 92.2% in the bypass surgery group and 76.3% in the EVT group, respectively (P < .01). The 1-year wound healing rates were 86.7% in the bypass surgery group and 67.8% in the EVT group (P < .01). Multivariate analysis shows decreased serum albumin level (P < .01), increased wound grade (P = .04), and EVT (P < .01) were risk factors for major amputation. Decreased serum albumin level (P < .01), increased wound grade (P < .01), GLASS infrapopliteal grade (P = .02), inframalleolar (IM) P grade (P = .01), and EVT (P < .01) were risk factors for impaired wound healing. Subgroup analysis of limb salvage in patients after EVT, decreased serum albumin level (P < .01), increased wound grade (P = .03), increased IM P grade (P = .04), and congestive heart failure (P < .01) were risk factors for major amputation. According to scoring by existence of these risk factors, 2-year limb salvage rates following EVT were 83.0% and 42.8% for the total score of 0 to 2 and of 3 to 4, respectively (P < .01). ConclusionsBypass surgery provides better limb salvage and wound healing in patients with WIfI Stage 3 to 4 and GLASS Stage III, which is classified as bypass-preferred category by the GVG. In patients after EVT, serum albumin level, wound grade, IM P grade, and congestive heart failure were related to major amputation. Although bypass surgery may be considered as initial revascularization procedure in patients classified as bypass-preferred category, in case that EVT has to be selected, relatively acceptable outcomes can be expected in patients with less of these risk factors.

Evaluation of the ICD-10 system in coding revascularisation procedures in patients with peripheral arterial disease in England: A retrospective cohort study using national administrative and clinical databases.

Many studies evaluating care in hospitals in England use the Hospital Episode Statistics (HES) administrative database. The aim of this study was to explore whether the International Classification of Diseases 10th Revision (ICD-10) system used by HES supported the evaluation of care received by patients with peripheral arterial disease (PAD) who had revascularisation. This retrospective cohort study used records on patients who had revascularisation for PAD between 1st January 2017 and 31st December 2019 in England, collected prospectively in the National Vascular Registry (NVR) and linked to HES. Patients were excluded if their NVR record did not have a match in HES, due to lack of consent or different admission and procedure dates. Agreement between different presentations of PAD recorded in the NVR and the ICD-10 diagnostic codes recorded in HES was evaluated using the unweighted Kappa statistic and sensitivity and specificity. Agreement between the NVR and HES was also assessed for gender, age, comorbidities, mode of admission, and procedure type and side. In total, 20,603 patients who had 24,621 admissions were included in the study. Agreement between NVR and HES on patient gender (Kappa=0.98), age (Kappa=0.98), mode of admission (Kappa=0.80), and procedure type and side (Kappa=0.92 and 0.87, respectively) was excellent. When all diagnostic fields in HES were explored, substantial agreement was observed for chronic ischaemia with tissue loss (Kappa=0.63), but it was lower for chronic ischaemia without tissue loss (Kappa=0.32) and acute limb ischaemia (Kappa=0.15). Agreement on comorbidities was mixed; excellent for diabetes (Kappa=0.82), moderate for chronic lung disease (Kappa=0.56), chronic kidney disease (Kappa=0.56), and ischaemic heart disease (Kappa=0.45) and fair for chronic heart failure (Kappa=0.35). The diagnostic ICD-10 codes currently used in HES cannot accurately differentiate between stages of PAD. Therefore, studies using HES to examine patterns of care and outcomes for patients with PAD are likely to suffer from misclassification bias. Adopting an extended ICD-10 system or the ICD-11 version released to the World Health Organisation member states in 2022, may overcome this problem. Healthcare Quality Improvement Partnership (HQIP).

Is it possible that angioplasty does not improve the quality of life in patients with stable angina?

The scientific evidence in favour of percutaneous transcatheter coronary angioplasty (PTCA) in chronic ischaemic heart disease in terms of reduction of myocardial infarction and mortality is very scarce and controversial. However, for many years, the cardiology community has believed in the dogma that PTCA in chronic ischaemic heart disease could improve symptoms, especially when combined with effective medical therapy. A recent randomized controlled trial (ORBIT) has completely overturned this dogma, questioning much of what we have been taught about revascularization procedures in patients with stable coronary artery disease. In this article, the ORBITA study is discussed in depth, highlighting the lights and shadows of the study itself.

Imaging Techniques to Assess Cerebral Perfusion and Metabolism in Chronic Cerebral Ischemia

The assessment of cerebral perfusion and metabolism is crucial in evaluating the indications for bypass surgery and other revascularization procedures in patients with chronic hemodynamic cerebral ischemia. In particular, it is necessary to detect misery perfusion(Powers' stage II), which is defined as an increased oxygen extraction fraction and increased cerebral blood volume or impaired cerebrovascular reactivity, with a constant cerebral metabolic rate of oxygen. Among the imaging techniques available for this purpose, 15O-positron emission tomography(PET)and acetazolamide-challenge single-photon emission computed tomography(SPECT)remain the de facto standards; however, these have substantial limitations such as invasiveness and the risk of severe adverse effects. Recently, several less invasive, easy-to-use techniques, such as perfusion computed tomography and magnetic resonance(MR)imaging, arterial spin labeling, quantitative susceptibility mapping, intravoxel incoherent motion, MR spectroscopy, and single-slab MR angiography, have also been introduced. These techniques may serve as alternatives to PET or SPECT if validation studies are successful and standardization among vendors is achieved.

Incident cardiovascular events and early mortality in patients with revascularized critical limb ischemia.

Patients with critical limb ischemia (CLI) present a high risk of cardiovascular events and death. This study aimed to investigate the incidence of major adverse cardiovascular events (MACE) and one-year mortality in patients undergoing percutaneous revascularization procedure for CLI. This investigation is a retrospective analysis of an ongoing cohort study in patients with CLI undergoing endovascular revascularization, hospitalized in the vascular medicine department from November 2013 to December 2018. Major cardiovascular events were collected during the first year after revascularization procedure and were defined as heart failure, acute coronary syndrome, ischemic stroke and sudden death. Mortality and major limb amputations, defined as above-the-ankle amputation, were determined during the one-year follow-up period. Multivariate logistic regression analyses were performed to identify factors independently associated with the occurrence of MACE and one-year mortality after revascularization procedure. A P≤0.05 was considered as statistically significant. The study included 285 consecutive patients, 157 men (55%) and 128 women (45%), with a mean age of 77.8±12 years. Treated hypertension was present in 222 (78%) patients; diabetes was present in 137 (48%) patients; 112 (39%) patients had known coronary heart disease and 20 (7%) patients were dialysis dependent. During the one-year follow-up after revascularization procedure, 75 (26.3%) patients presented an incident cardiovascular event, of whom 19 (6.7%) patients in the perioperative period. Cumulative mortality rate was 26.7% (76 patients) mostly from cardiovascular causes. Twenty-five patients (8.8%) experienced major amputation. In multivariate analysis, the occurrence of MACE was associated with an increased mortality risk (HR 6.96 (2.99-16.94), P<0.001). Other variables associated with an increased mortality were living in a nursing home and malnutrition. Decompensated heart failure and coronary heart disease were both associated with incident MACE in multivariate analysis, independently of confounders. In the present study population, incident MACE were prevalent in the year following endovascular revascularization procedure in patients with CLI and were associated with an increased risk of mortality. Coronary heart disease and decompensated heart failure are important contributors for the occurrence of MACE. In this elderly patient population with CLI, these results should be taken into account during the multidisciplinary team meeting before consideration of revascularization procedure.

Prognosis and Clinical Results after Coronary Artery Bypass Operation in Young Patients Aged

Coronary artery bypass grafting (CABG) is the recommended type of revascularization procedure in patients with left main or three-vessel disease and is considered an alternative when percutaneous coronary intervention is not feasible. We evaluated registry data to obtain long-term outcome data.All patients ≤45 years in whom CABG was performed between 2009 and 2019 were selected from the Heart and Diabetes Center NRW, Germany. Cox regression analysis was applied to estimate the incidence risk of events after surgery.A total of 209 patients (81.8% male) were included. Mean (standard deviation) follow-up duration was 5.8 (3.1) years. The combined outcome of death, stroke, myocardial infarction, or repeated revascularization occurred in 31 patients (14.8%). Estimated mean time to event was 8.5 (standard error: 0.22) years. By the end of the follow-up period, 8 patients (3.8%) had died, among whom 2 (1.0%) died within 1 month after surgery, 1 (0.5%) within 1 year, 1 (0.5%) within 2 years, and 4 (1.9%) after 2 years.Risk factors independently associated with postsurgery events were angina pectoris CCS (Canadian Cardiovascular Society) class IV (adjusted hazard ratio [HR]: 4.954; 95% confidence interval [CI]: 1.322-18.563; p = 0.018) and STS (Society of Thoracic Surgeons) score (adjusted HR: 1.152 per scoring point; 95% CI: 1.040-1.276; p = 0.007).After performing CABG in patients ≤45 years, event-free long-term outcomes were observed in the majority of patients. Presence of angina pectoris CCS class IV and higher STS scores were independently associated with adverse postsurgery events.

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.

Abstract P518: Intravascular Ultrasound Assisted Endovascular Revascularization in Patients With Subacute and Chronic Internal Carotid Artery Occlusions

Background: Revascularization of subacute or chronic internal carotid artery occlusion is technically feasible in some patients but carotid revascularization procedure needs to be optimized to improve the clinical success of the procedure. Objective: To describe our experience using intravascular ultrasound (IVUS) as adjunct to carotid revascularization procedure in patients with subacute or chronic internal carotid artery occlusion. Materials and Methods: Endovascular recanalization was attempted in 7 patients with symptomatic internal carotid artery occlusions between 3 and 11 days of symptoms onset. Distal protection device was deployed in all the patients followed by advancement of IVUS catheter (Eagle Eye Gold, 20 MHZ Digital, s5 Imaging System, Volcano Corp.) to obtain gray-scale and virtual histology (VH) images at regions of interest. IVUS images used to categorize occlusion content as: dark green- fibrous; yellow/green- fibrofatty; white- calcified; red- necrotic lipid core plaque on images. Intravascular thrombus was diagnosed an echolucent, homogeneous, well-delineated, diaphragm-like intraluminal structure. Results: The occlusion was recanalized successfully in all of 7 patients with median age 67.4±7.5 years. IVUS demonstrated intravascular thrombus in 5 of 7 patients. Fibrous and fibrofatty constituents of plaque were seen in 5 of the 7 patients in whom VH was done. Calcification and lipid necrotic core each were seen in 3 of 5 patients.5 patients with large thrombus burden on IVUS were treated using aspiration thrombectomy. Six of seven patients underwent stent placement and one patient underwent primary angioplasty. 5 of 7 patients had modified Rankin Scale of 0-2 at follow up (3 weeks to 4 months post procedure). Conclusions: IVUS provided valuable information to optimize carotid revascularization procedure in patients with subacute or chronic internal carotid artery occlusion.

Outcomes of Carotid Revascularization in Patients with Contralateral Carotid Artery Occlusion

Little is known about the best revascularization procedure for patients with contralateral carotid artery occlusion (CCO). We aim to compare the outcomes of transcarotid artery revascularization (TCAR), carotid endarterectomy (CEA), and transfemoral carotid artery stenting (TFCAS) in patients with CCO. Patients in the Vascular Quality Initiative dataset who underwent CEA, TFCAS, or TCAR, and had CCO between September 2016 and April 2020, were included. Multivariable logistic analysis was used to evaluate in-hospital outcomes. The final cohort included 1,144 TCARs, 1,182 TFCAS, and 2,527 CEA procedures performed in patients with CCO. Compared with TFCAS, TCAR was associated with a significant reduction in the odds of in-hospital stroke or death (odds ratio [OR] 0.26; 95% CI: 0.12-0.59; p < 0.01). However, no significant difference in stroke was noted (OR 0.71; 95% CI 0.34-1.51; p= 0.38). These results persisted after stratifying with respect to symptomatic status (p values of interaction= 0.92 and 0.74, respectively). There was no significant difference between TCAR and CEA in odds of in-hospital stroke or death on multivariable adjustment (OR 0.57; 95% CI: 0.29-1.10, p= 0.10). The interaction between procedure type and symptomatic status in predicting in-hospital stroke was statistically significant (p= 0.04). In asymptomatic patients, TCAR was associated with a 50% to 60% reduction in the odds of stroke (p= 0.04). Yet, no significant differences were observed in symptomatic patients. TCAR has lower odds of in-hospital stroke or death compared to TFCAS, independent of symptomatic status. Compared to CEA, TCAR seems to be a better option in asymptomatic patients, with lower odds of in-hospital stroke. Yet, no significant difference is observed in symptomatic patients.

Coronary Artery Bypass Grafting vs Percutaneous Coronary Intervention in Patients With Diabetes

As percutaneous coronary intervention (PCI) continues to evolve, comparative outcomes for PCI vs coronary artery bypass grafting (CABG) remain relevant in diabetic patients. All revascularization procedures in patients with coronary artery disease and diabetes mellitus from 2010 to 2018 were included. Propensity matching was used to identify equivalent cohorts to compare revascularization strategies. Primary outcomes included 30-day, 1-year, and 5-year mortality. Multivariable analysis was used to define factors associated with major adverse cardiovascular and cerebrovascular events (MACCE). A total of 2869 patients with diabetes were divided into PCI (n = 653) and CABG (n = 2216) cohorts. Propensity matching yielded a 1:1 match consisting of 552 patients in each cohort (CABG vs PCI). Total median follow-up was 3.28 years (range: 1.83-5.00). Following propensity matching in patients with no prior PCI (1:1; n = 279), mortality remained significantly higher in the PCI cohort at 1 year (13.98% vs 7.53%; P = 0.014) and 5 years (26.88% vs 16.85%; P < 0.004). Hospital readmissions were higher for PCI patients at 1 year (16.49% vs 9.32%; P < 0.0122) and 5 years (19.71% vs 11.83%; P = 0.011). MACCE occurred more frequently in the PCI cohort (32.97% vs 21.51%; P = 0.002). Need for subsequent revascularization (6.45% vs 2.51%; P = 0.024) were significantly higher in the PCI cohort, and time interval to revascularization was significantly longer in the CABG cohort (3.48 [2.11-5.17] vs 2.62 [1.33-4.25] years; P < 0.001). The current study reports improved survival, fewer long-term hospital readmissions, and reduced MACCE and need for repeat revascularization in the CABG cohort. Given these data, patients with diabetes mellitus and coronary artery disease may fare better with surgical revascularization, compared to PCI.

Systematic Literature Review of Randomized Trials Comparing Antithrombotic Therapy Following Revascularization Procedures in Patients With Peripheral Artery Disease.

A systematic literature review was conducted to identify and summarize the clinical efficacy and safety of available antithrombotic therapies after peripheral endovascular or surgical revascularization in patients with peripheral artery disease (PAD). Five databases were searched using free-text and Emtree/Mesh terms for PAD, randomized controlled trials (RCTs), and antithrombotic therapies of interest (ie, single antiplatelet therapy, dual antiplatelet therapy, and vitamin K antagonists). Randomized controlled trials were eligible for inclusion if they assessed the risk of thrombotic events (ie, myocardial infarction, ischemic stroke, cardiovascular death, limb ischemia, or limb amputation) or safety profile (ie, minor, moderate, major, or fatal bleeding events) after revascularization. In total, 16 RCTs were identified. Only a few studies reported on treatment effects of the investigated therapies. Myocardial infarction, ischemic stroke, cardiovascular death, and amputation were reported in up to 2.3%, 2.3%, 5.6%, and 7.3% of patients, respectively. Bleeding events were observed in up to 8.4% (major) and 1.5% (fatal) of patients. Despite available treatments, patients with PAD undergoing revascularization remain at risk of thrombotic events. There is a need for new treatments that will help to optimize care for patients with symptomatic PAD undergoing revascularization.

Significance of Prior Endovascular Intervention on Contemporary Outcomes of Open Mesenteric Revascularization

Endovascular treatment has emerged as the primary modality of revascularization in patients with chronic mesenteric ischemia (CMI). The purpose of this study was to determine whether patients undergoing open mesenteric revascularization in the setting of failed prior endovascular intervention had worse outcomes compared to those without prior endovascular intervention. A single-center retrospective review of patients with CMI treated with open mesenteric bypass from 2000 to 2019 was conducted. Demographic, comorbidities, perioperative variables, and outcomes were collected. Patients were categorized into those with prior endovascular intervention and those without. Categorical factors were compared with Pearson χ2 tests or Fisher exact tests, and the life-table method for survival analysis was used to estimate event rates at predefined time frame. From 2000 to 2019, there were 236 patients who underwent open mesenteric bypasses, of which 92 were performed for CMI. Antegrade aortomesenteric bypasses constituted 95% (87/92) of cases. Total of 145 vessels were revascularized: celiac artery (33 vessels), hepatic artery (25 vessels), and superior mesenteric artery (87 vessels). Seventy-six percent (70/92) of patients had undergone a prior endovascular intervention, which subsequently failed. In 91% (84/92) of patients, one or more visceral vessel was chronically occluded on imaging prior to bypass procedure. Patients with prior endovascular intervention were older (64 ± 15 years vs 54 ± 11 years; P = .006). Demographics and comorbidities were otherwise similar between the groups. Primary patency for celiac artery bypass was 93% and 89% at 1 and 3 years, respectively. Primary patency for superior mesenteric artery bypass was 92% and 84% at 1 and 3 years, respectively. There was no statistically significant difference in primary bypass patency rates of those with or without prior endovascular intervention (P > .05). Patients with prior endovascular intervention had a higher all-cause mortality trend at 30 days, 1 year, and 3 years (5.8% vs 0%; 13.7% vs 5.4%; and 30% vs 5.4%; P = .1); however, this did not reach statistical significance. Open mesenteric bypass remains a durable revascularization procedure in patients with CMI. Failed endovascular intervention does not significantly impact open mesenteric revascularization outcomes; however, it likely signifies an overall higher atherosclerotic disease burden.

Safety of carotid artery revascularization procedures in patients with atrial fibrillation

BackgroundAtrial fibrillation (Afib) is a major contributor to cerebrovascular events. Coexisting carotid artery disease is not uncommon in Afib patients, yet they have been excluded from major randomized clinical trials. Therefore, the aim of this study was to evaluate the safety of carotid endarterectomy (CEA) and carotid artery stenting (CAS) in Afib patients. MethodsThe Premier Healthcare Database was queried (2009-2015). Patients who underwent CEA or CAS were captured by International Classification of Diseases, Ninth Revision, Clinical Modification codes. Multivariable logistic modeling was implemented to examine the outcomes: in-hospital stroke, intracerebral hemorrhage (ICH), mortality, and stroke/death. ResultsThere were 86,778 patients included. The majority were asymptomatic (n = 82,128 [94.6%]). Afib was reported in 6743 patients (7.8%). In terms of absolute outcomes in both asymptomatic and symptomatic patients, Afib patients (vs non-Afib patients) had higher mortality and stroke/death (asymptomatic: mortality, 0.4% vs 0.2%; stroke/death, 1.7% vs 1.2%; symptomatic: mortality, 6.9% vs 2.1%; stroke/death, 10.6% vs 4.5%; all P < .05). Adjusted analysis yielded higher odds of ICH (adjusted odds ratio [aOR], 1.29; 95% confidence interval [CI], 1.00-1.67), mortality (aOR, 1.59; 95% CI, 1.11-2.26), and stroke/death (aOR, 1.30; 95% CI, 1.08-1.58) in Afib patients. Although univariable analysis found Afib to be a statistically significant predictor of ischemic stroke, similar results could not be elucidated in the multivariable analysis (aOR, 1.17; 95% CI, 0.93-1.47). In Afib patients, important predictors of stroke/death included CAS (aOR, 1.80; 95% CI, 1.21-2.68) and symptomatic presentation (aOR, 5.00; 95% CI, 3.20-7.83). Other important predictors were type of preoperative medication use, age, and hospital size. ConclusionsAfib was associated with worse postoperative outcomes in patients with carotid artery disease. Symptomatic status in Afib patients is associated with a stroke/death risk that is higher than in recommended guidelines for CEA and particularly for CAS. Overall, CEA was associated with lower periprocedural ICH, mortality, and stroke/death in Afib patients compared with CAS.

MANAGEMENT OF COVID-19 IN PERSPECTIVE OF CARDIOLOGISTS

MANAGEMENT OF COVID-19 IN PERSPECTIVE OF CARDIOLOGISTS

Functional Outcomes After Revascularization Procedures in Patients With Hemorrhagic Moyamoya Disease.

Poor natural history of hemorrhagic Moyamoya disease (MMD) is related to high rehemorrhage rates between 32% and 61%. Postrevascularization, rehemorrhage rates reportedly decrease to 12% to 17%. To evaluate long-term functional outcomes and rehemorrhage rates of hemorrhagic MMD patients treated with surgical revascularization and examine these in relation to clinical and radiological factors. Patients treated surgically for hemorrhagic MMD over a 26-yr period were identified. Modified Rankin scale (mRS) was used to assess clinical status at presentation and functional outcomes. Multivariable regression analyses were performed to evaluate the risk factors associated with rehemorrhage rates and functional outcomes. A total of 104 patients (mean age: 38.04 yr) were identified. The mean mRS score at baseline was 1.3. Of 172 revascularized hemispheres, 157 (91.3%) were direct superficial temporal artery (STA)-middle cerebral artery (MCA) bypasses and the rest indirect. Over the mean follow-up of 61.4 mo, 8 of 104 patients (7.7%) experienced rehemorrhage with rehemorrhage rate per person-years of 1.9%. A total of 4 patients died with 1 related to rehemorrhage. At the last follow-up, mean mRS score improved to 1.1. No significant risk factors were identified in relation to the rehemorrhage rates (P<.05). The patients' initial mRS score was positively associated with mRS scores at the final follow-up (P<.001). STA-MCA direct bypass was associated with better performance status (P=.033). Rehemorrhage rate following surgical revascularization of the hemorrhagic MMD patients at 7.7% is lower compared with much higher natural history rates. Surgical revascularization improved patients' performance status. These outcomes support performing revascularization procedure with a preference for direct STA-MCA bypasses.

P6144Trends of mortality in patients with acute coronary syndromes submitted to urgent myocardial revascularization procedures in Brazil

Abstract Background Acute Coronary Syndromes (ACS) are the most common and life-threatening manifestation of cardiovascular diseases. This disease burden along with progress in cardiovascular technology has led to substantial growth in the number of cardiovascular procedures performed in ACS management. In Brazil, there are no contemporary data about in-hospital mortality related to urgent myocardial revascularization procedures. Purpose To describe trends in mortality in patients with ACS who underwent urgent myocardial revascularization procedures in Brazil, between 2008 and 2016. Methods Data on hospital admission and in-hospital mortality were obtained from the database of the Brazilian Public Health System (DATASUS) over a nine-years period (2008–2016). All admissions due to ACS were identified using standard ICD codes. Additionally, data about percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG) performed as an urgency were retrieved. Trend analyses over the period were performed using Poisson regression. Results Between 2008 and 2016, 472,810 urgent myocardial revascularization procedures were performed, of which 370,018 (78.3%) were PCI and 102,792 (21.7%) were CABG. The in-hospital mortality in patients with ACS submitted to PCI was 3.4%, and 6.8% among those submitted to CABG. There was an increase in the number of PCI procedures from 26,929 in 2008 to 53,542 in 2016 (98%), although the mortality remained stable (3.3% to 3.6%, respectively). CABG procedures also raised 77%, from 9,535 in 2008 to 12,262 in 2016, but the observed related mortality decreased from 8.0% to 6.3%, respectively. However, disparities among Brazilian geographical regions were noted: in 2016, mortality among ACS patients who underwent urgent PCI was lower in Southeast (3.2%) and higher in the Northeast Region (5.9%). The Southeast Region also presented the lowest CABG related mortality (5.7%), whereas the Midwest had the higher death rates (7.8%). Conclusions In this contemporary analysis based on national public health data, there was an increase in the number of urgent myocardial revascularization procedures in patients hospitalized for ACS in Brazil. Despite stable death rates in patients undergoing PCI, CABG-related mortality decreased significantly. Due to the heterogeneity of results among the different geographical Regions of the country, there are still opportunities to improve these national results.