Vascular Quality Initiative Data Research Articles

National Vascular Quality Initiative Data Finds Disparities in Aortic Aneurysm Care in Rural Patients

National Vascular Quality Initiative Data Finds Disparities in Aortic Aneurysm Care in Rural Patients

Preoperative Risk Factors Impacting Length of Stay After Transcarotid Artery Revascularization

Transcarotid artery revascularization (TCAR), using interoperative flow reversal is a unique, hybrid operation utilized in treating critical carotid artery stenosis. Over the past decade, TCAR has been increasingly used to treat asymptomatic carotid artery disease and has a similar risk profile to traditional carotid endarterectomy. Postoperative length of stay (LOS) has a significant impact on cost-effectiveness and quality outcomes in this expanded setting. The objective of this study is to develop a multivariate regression model to identify key preoperative variables and their impact factor on LOS after TCAR for asymptomatic carotid artery stenosis. We hypothesized that high-risk preoperative patient factors historically identified in carotid endarterectomy would similarly impact LOS after TCAR. A multi-institution, retrospective study of all adult patients undergoing TCAR with flow-reversal for intraoperative neuroprotection was performed using the Society for Vascular Surgery Vascular Quality Initiative (VQI) from January 2016 to August 2021. Patients with prolonged preoperative hospitalization (preoperative LOS ≥1day) were excluded to enhance the capture of carotid artery stenosis as the index admission. Univariate analysis was done on preoperative factors against LOS using nonparametric statistical tests. A multivariate model was then constructed using a negative binomial regression. The study population was split into 80% "training" data for model formulation and 20% "test" data for model validation. Thirteen thousand four hundred eighty-three patients undergoing TCAR for asymptomatic carotid stenosis met the study's inclusion criteria with a median postoperative LOS of 1.82days. Factors in VQI found to have a significant effect on LOS and retained in the multivariate model were lesion type (restenosis versus atherosclerotic), age, gender, chronic obstructive pulmonary disease, preoperative beta blocker, calcific lesion burden, hypertension status, and race (P<0.05). The model accurately predicted LOS after TCAR within 1day for 86.04% and within 2days for 94.51% of patients in the test population. This large-scale analysis from 2016 to 2021 spans a considerable expansion in the practice of TCAR for asymptomatic carotid disease. All preoperative variables shown to significantly increase the postoperative LOS were derived from the VQI data set. As LOS is a measure of health-care efficiency and cost-effectiveness, this model can be used to identify patients at risk for increased postoperative LOS. It has the potential to be incorporated into a patient/physician decision support tool to optimize resource planning and patient selection for elective TCAR.

Comparison of endovascular therapies for chronic limb-threatening ischemia and claudication

ObjectiveAnalysis of regional data from the Vascular Quality Initiative (VQI) suggested improved survival for patients undergoing stent placement compared with balloon angioplasty and atherectomy. Using national data from the VQI linked to Medicare claims data through the Vascular Implant Surveillance and Interventional Outcomes Network program, this study aimed to compare the rates of mortality, reintervention, and amputation after endovascular interventions (atherectomy, stenting, and balloon angioplasty) for two separate cohorts: patients with chronic limb-threatening ischemia (CLTI) and patients with claudication. MethodsThis was a secondary data analysis of Society for Vascular Surgery National VQI data linked to Medicare claims, between October 2016 and December 2019. Patients aged ≥65 years with symptoms of claudication or CLTI and a diagnosis of occlusive disease were included. Urgent or emergent interventions or those with concurrent procedures (endarterectomy, bypass, or bilateral intervention) were excluded. Interventions were grouped into (1) balloon angioplasty only; (2) stent (with or without balloon angioplasty); or (3) atherectomy (alone, with or without stent, with or without balloon angioplasty). Propensity score-matched cohorts were constructed to conduct pairwise intervention comparisons of mortality, reintervention, and amputation rates. Multivariable logistic regression was used to derive propensity scores for each patient. Kaplan-Meier estimates and Cox proportional hazards ratios (HRs) (95% confidence interval [CI]) analyses were performed. ResultsA total of 9785 (2665 claudication, 7120 CLTI) eligible patients were identified. After propensity score matching for the CLTI group, 2826, 3608, and 2796 pairs of cases were used to compare balloon angioplasty vs atherectomy, balloon angioplasty vs stent, and stent vs atherectomy, respectively. No statistically significant difference in mortality was observed among all interventions. However, atherectomy was associated with a significant increase in reintervention rate compared with balloon angioplasty (HR, 1.22; 95% CI, 1.06-1.39; P = .01) and compared with stenting (HR, 1.27; 95% CI, 1.10-1.46; P < .01) within the first year after the index procedure. Of note, both atherectomy (HR, 0.82; 95% CI, 0.68-0.98; P < .05) and stenting (HR, 0.76; 95% CI, 0.64-0.90; P < .01) showed lower rates of major amputation when compared with balloon angioplasty within 1 year after the index procedure. In the claudication group, there were no significant differences observed among interventions for peripheral arterial disease for mortality, reintervention, or amputation rates. ConclusionsFurther studies are needed to identify appropriate indications for atherectomy, because there may be a subset of patients with CLTI who benefit from this therapy with respect to amputation rates. Until then, caution should be exercised when using atherectomy because it is also associated with higher reintervention rates.

Upper Extremity Access Has Worse Outcomes in F/BEVAR Using the VQI Dataset

Physician-modified endografts and custom-manufactured devices use branched and fenestrated techniques (F/BEVAR) to repair complex aneurysms. Traditionally, many of these are deployed through a combination of upper and lower extremity access. However, with newer steerable sheaths, you can now simulate upper extremity (UEM) access from a transfemoral approach. Single-institution studies have demonstrated increased risks of access site complications and stroke when UEM access is used. This study compares outcomes after F/BEVAR in a national database between total transfemoral (TTF) access and mixed UEM access. This study is an analysis of the Vascular Quality Initiative for all patients who underwent F/BEVAR from 2014 to 2021. Patients were stratified based on a TTF delivery of all devices versus any UEM access for deployment of target vessel stents. Primary outcomes included stroke, myocardial infarction (MI), and perioperative death. Secondary outcomes included access site hematoma, occlusion or embolization, operative time, fluoroscopy time, and technical success. Multivariable linear and logistic regression analyses were performed. Three thousand one hundred forty six patients underwent an F/BEVAR: 2,309 (73.4%) TTF and 837 (26.6%) UEM. Logistic regression analysis indicated a two-fold increased risk of death and MI and a three-fold increased risk of stroke in the UEM group. Furthermore, there is decreased operative time (221 vs. 297min, P<0.001) and fluoroscopy time (62 vs. 80min, P<0.001) in the TTF group and no difference in technical success between groups (96% vs. 97%, P=0.159). Finally, there was a decrease in access site hematoma 2.54% vs. 4.31% (P=0.013), access site occlusion 0.61% vs. 1.91% (P=0.001), and extremity embolization 2.17% vs. 3.58% (P=0.026) in the TTF versus UEM group. This study using Vascular Quality Initiative data demonstrates that patients who undergo an F/BEVAR using UEM access have an increased risk of perioperative MI, death, and stroke compared to TTF access.

The association of major adverse limb events and combination stent and atherectomy in patients undergoing revascularization for lower extremity peripheral artery disease.

The effectiveness of combined atherectomy and stenting relative to use of each procedure alone for the treatment of lower extremity peripheral artery disease has not been evaluated. The objective of this study was to evaluate the short- and long-term major adverse limb event (MALE) following the receipt of stenting, atherectomy, and the combination of stent and atherectomy. A retrospective cohort of patients undergoing atherectomy, stent, and combination stent atherectomy for lower extremity peripheral artery disease was derived from the Vascular Quality Initiative (VQI) data set. The primary outcome was MALE and was assessed in the short-term and long-term. Short-term MALE was assessed immediately following the procedure to discharge and estimated using logistic regression. Long-term MALE was assessed after discharge to end of follow-up and estimated using the Fine-Gray subdistribution hazard model. Among the 46,108 included patients, 6896 (14.95%) underwent atherectomy alone, 35,774 (77.59%) received a stent, and 3438 (7.5%) underwent a combination of stenting and atherectomy. The adjusted model indicated a significantly higher odds of short-term MALE in the atherectomy group (OR = 1.35; 95% confidence interval [CI]:1.16-1.57), and not significantly different odds (OR = 0.93; 95%CI:0.77-1.13) in the combination stent and atherectomy group when compared to stenting alone. With regard to long-term MALE, the model indicated that the likelihood of experiencing the outcome was slightly lower (HR = 0.90;95%CI:0.82-0.98) in the atherectomy group, and not significantly different (HR = 0.92; 95%CI:0.82-1.04) in the combination stent and atherectomy group when compared to the stent group. Patients in the VQI data set who received combination stenting and atherectomy did not experience significantly different rates of MALE when compared with stenting alone. It is crucial to consider and further evaluate the influence of anatomical characteristics on treatment strategies and potential differential effects of comorbidities and other demographic factors on the short and long-term MALE risks.

Association Between Conduit Type and Outcomes After Open Repair of Popliteal Artery Aneurysms

IntroductionPrior studies have demonstrated acceptable midterm outcomes with prosthetic conduits for above-knee bypass for occlusive disease in patients with inadequate segment great saphenous vein (GSV). In this study we aimed to investigate whether this holds true for open repair of popliteal artery aneurysms (PAA). MethodsWe queried the Vascular Quality Initiative data for patients who underwent open PAA repair (OPAR). We divided the cohort into three groups based on the conduit used: GSV, other autologous veins, or prosthetic graft. Study outcomes included primary patency, freedom from major amputation, amputation-free survival, and overall survival at 1 y. Kaplan–Meier survival estimates, log-rank tests and multivariable Cox regression were used to compare outcomes between study groups. ResultsA total of 4016 patients underwent bypass for PAA from January 2010 to October 2021. The three cohorts were significantly different in many demographic and clinical characteristics. The adjusted odds of postoperative amputation among symptomatic patients were 3-fold higher for prosthetic conduits compared to the GSV (odds ratio, 3.20; 95% CI, 1.72-5.92; P < 0.001). For the 1-y outcomes, the adjusted risk of major amputation was almost 3-fold higher for patients with symptomatic disease undergoing bypass with prosthetic conduits (hazard ratio [HR], 2.97; 95% CI, 1.35-6.52; P = 0.007). When compared with GSV, prosthetic conduits were associated with 96% increased risk of death when used for repair in symptomatic patients (adjusted hazard ratio (aHR), 1.96; 95% CI, 1.29-2.97; P = 0.002) but no significant association with mortality in asymptomatic patients (aHR, 0.83; 95% CI, 0.37-1.87; P = 0.652). When compared with GSV, prosthetic conduits were associated with a 2-fold increased risk of 1-y major amputation or death when used for repair in symptomatic patients (aHR, 2.03; 95% CI, 1.40-2.94; P < 0.001) but no significant association with mortality in asymptomatic patients (aHR, 0.91; 95% CI, 0.42-1.98; P = 0.816). Comparing bypass with other veins to the GSV among patients with symptomatic disease, there was no statistically significant difference in major amputation risk (HR; 2.44; 95% CI, 0.55-10.82; P = 0.242) and no difference in the adjusted risk of all-cause mortality (aHR, 0.77; 95% CI, 0.26-2.44; P = 0.653). There were no differences in the adjusted risk of loss of primary patency comparing other veins to GSV (HR, 1.53; 95% CI, 0.85-2.76; P = 0.154) and prosthetic conduits to GSV (HR, 0.85; 95% CI, 0.57-1.26; P = 0.422). ConclusionsThis large study shows that among patients undergoing OPAR, 1-y primary patency does not differ between conduit types. However, prosthetic conduits are associated with significantly higher risk of amputation and death compared to GSV among symptomatic patients. Though non-GSV autologous veins are less often used for OPAR, they have comparably acceptable outcomes as GSV.

Black or African American patients undergo great saphenous vein ablation procedures for advanced venous disease and have the least improvement in their symptoms after these procedures

ObjectiveChronic venous insufficiency is an increasingly prevalent problem in the United States, with >25 million individuals currently affected. Previous work has shown that racial minorities and low socioeconomic status are associated with a worse clinical presentation and response to treatment. The present study aimed to determine the relationship between race, patient variables, hospital outcomes, and response to treatment for patients presenting for chronic venous insufficiency intervention. MethodsWe performed a retrospective analysis of all patients who underwent endovenous ablation (radiofrequency or laser) of the great saphenous vein to treat symptomatic, chronic venous insufficiency using Vascular Quality Initiative data from 2014 to 2020. Patient characteristics and outcomes were analyzed stratified by patient race. The χ2 test and the Kruskal-Wallis equality-of-populations rank test were used to measure the study outcomes. The primary outcomes were an improved venous clinical severity score and improvement in patient-reported outcomes. Patient characteristics, CEAP (clinical, etiologic, anatomic, pathophysiologic) classification, prior venous interventions, length of stay, and time to follow-up were compared between races. ResultsThe database consisted of 9009 predominantly female patients (n = 6041; 67.1%), with a mean age distribution of 56 years. Of the 9009 patients, 7892 are White (87.6%), 627 Hispanic (6.9%), and 490 Black or African American (18.3%). The Hispanic cohort was younger than their White and Black/African American counterparts. Black/African American patients presented with more advanced clinical stages than did the White and Hispanic groups. The clinical stage according to race was as follows: C3—Black/African American, 32.9%; Hispanic, 38.9%; White, 46%; C5—Black/African American, 4.7%; Hispanic, 2.1%; White, 2.3%; and C6—Black/African American, 12.7%; Hispanic, 3.2%; White, 6.2%. Black/African American patients were more likely to present as overweight or obese (66%; P < .001) and less likely to be taking anticoagulation medication preoperatively (11%; P < .001). Non-White race was associated with a higher probability of treatment in the hospital setting (Black/African American, 63.6%; Hispanic, 87.5%; P < .001). Black/African American patients (3.25 ± 4.4; P < .001) demonstrated lower mean improvement postoperatively in both the venous clinical severity score and patient-reported outcomes than their White (4.25 ± 4.13, P <.001) and Hispanic (4.42 ± 3.78; P < .001) counterparts. ConclusionsDifferences exist in the clinical severity and symptom presentation based on race. Black/African American patients present with more advanced chronic venous insufficiency than do their White and Hispanic counterparts. Furthermore, the postprocedural analysis showed inferior clinical and self-reported improvement in chronic venous insufficiency for the Black/African American patients. Although the Hispanic population was younger, the White and Hispanic patients experienced similar responses to treatment.

Machine Learning Model Predicts Open Bypass Outcomes in VQI Claudicants

Peripheral artery disease (PAD) studies have largely focused on patients with acute or critical limb ischemia, although one in five patients with PAD are claudicants. New endovascular technology has fallen into favor for use in patients with claudication. However, there is debate surrounding the longevity of these interventions that may ultimately still result in a patient requiring an open bypass that could possible last a patient's lifetime. The aim of this prospective study was to leverage existing data in the Vascular Quality Initiative (VQI) database and preoperatively risk stratify patients with lifestyle-limiting claudication who may be eligible for an open bypass. The VQI was queried for all patients who underwent infrainguinal lower extremity bypass between December 2004 and December 2017. Of the 71,561 procedures, 15,633 of these procedures were initial open procedures performed for patients with lifestyle-limiting claudication. Our outcomes of interest included 30-day survival, major adverse limb events (MALE), and major cardiac events (MCE). The machine learning algorithm Random Forrest was used to identify univariate significant predictors after multiple testing correction. Generalized liner models with all significant predictors were then trained on 80% of the existing data set and tested on 20% of the dataset for accuracy of predicting outcomes. Eleven percent of patients survived after 30 days, 3.2% had an MALE, and 14% had an MCE. The best performing prediction model created was for 30-day survival, where we included the following predictors identified on univariate analysis in addition to age, race, and gender: utilizing a conduit other than great saphenous vein (GSV) (odds ratio [OR], 0.79; 95% confidence interval [CI], 0.72-0.88; P corrected = .05), uncontrolled hypertension (OR, 0.50; 95% CI, 0.42-0.60; P corrected = 8.96 × 10−11), preoperative ambulation with assistance (OR, 1.75; 95% CI, 1.53-2.01; P corrected = 8.39 × 10−12), quitting smoking before the surgery (OR, 0.72; 95% CI, 0.61-0.85; P corrected = .05), and having a preoperative computed tomography angiography available (OR, 1.28; 95% CI, 1.16-1.43; P corrected = .02). Model characteristics for each of the three outcome are listed in Table I. The model for 30-day readmission had an area under the curve of 0.79 (95% CI, 0.74-0.82) (Fig). We developed a model to predict 30-day survival in claudicants undergoing infrainguenal bypass using clinical characteristics commonly available to physicians. This computational machine learning model was developed using real world VQI data and can possibly be used in a general clinic setting for preoperative risk stratification.TableModel characteristics used to predict 30-day survival, major adverse limb event (MALE) created from a composite of any limb amputation and any return to the operating room for revision, and major cardiac event (MCE) created from a composite of stroke, myocardial infarction, or death30-day survivalMALEMCEAUC (95% CI)0.79 (0.74-0.82)0.68 (0.57-0.72)0.71 (0.69-0.74)TPR (IQR)0.79 (0.66-0.91)0.55 (0.27-0.83)0.76 (0.50-0.90)FPR (IQR)0.46 (0.20-0.73)0.39 (0.10-0.69)0.47 (0.22-0.73)Cutoff0.10.030.1Sensitivity0.810.680.65Specificity0.640.510.65AUC, Area under the curve; CI, confidence interval; FPR, false positive rate; IQR, interquartile range; TPR, true positive rate. Open table in a new tab

Protamine Sulfate Following Carotid Artery Stenting: Does the Patient’s Gender Matter?

Protamine sulfate can be administrated to decrease the risk of bleeding after the carotid artery stenting (CAS) procedure. Although a few studies reported data regarding the efficacy and safety of protamine, the existing literature assessing its impact under more personalized patient circumstances is limited. Therefore, in this study, we aimed to identify the potential factors where the patients are more likely to benefit from protamine sulfate after CAS procedures. A retrospective review of Vascular Quality Initiative data between 2016 and 2022 to identify all patients who underwent CAS procedures was performed. The patients were divided into two groups based on the surgical approach: transfemoral CAS (TF-CAS) and transcarotid artery revascularization (TCAR). A multivariate model was conducted to identify the perioperative predictors of bleeding complications in each cohort. In addition, a propensity score matching was performed to compare the rates of thrombotic events between protamine vs no protamine groups in both cohorts. A total of 61,686 patients were identified; 36.6% were female. Approximately 53% of the patients underwent TCAR (protamine: 85.6%; no protamine: 14.4%), whereas TF-CAS was performed in 46.8% (protamine: 18.9%; no protamine: 81.1%). Protamine use was associated with a decreased risk of bleeding complications after TCAR (0.26 [0.2-0.3]; P < .001) but not TF-CAS (1.06 [0.8-1.3]; P = .6164). However, the protamine beneficial impact is more apparent among the female patients regardless of the surgical approach (Table). In addition, no significant increase was noted in the thrombotic complications in both TF-CAS (protamine vs no protamine: death, 7.9% vs 11.5%; myocardial infarction, 0.5% vs 0.9%; stroke/transient ischemic attack, 2.8% vs 2.9%; P > .05 for all, except death P < .001) and TCAR (protamine vs no protamine: death, 7.7% vs 7.3%; myocardial infarction, 0.4% vs 0.3%; stroke/transient ischemic attack, 2.4% vs 2.9%; P > .05 for all) groups. Protamine sulfate appears to be effective in reducing the bleeding complications in patients who undergo TCAR but not TF-CAS, without an increase in the thrombotic complications. However, this beneficial impact is more significant among female patients regardless of the CAS approach.TablePerioperative predictors of bleeding complications after TCAR and TF-CASaCovariatebNo protamineProtamineAdjusted odds ratio (95% CI)P valueAdjusted odds ratio (95% CI)P value(A) TCAR Sex (female)1.45 (1.2-1.9).00501.08 (0.9-1.3).4639 Race (Asian) (Ref: White)4.29 (1.4-13.1).01041.31 (0.6-3.0).5139 Symptomatic CHF1.67 (1.1-2.6).02451.21 (0.8-1.7).3206(B) TF-CAS Sex (female)1.76 (1.4 – 2.2)<.0011.14 (0.8 – 1.7).5277ACEI, Angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CHF, congestive heart failure; CI, confidence interval; COPD, chronic obstructive pulmonary disease; TCAR, transcarotid artery revascularization; TF-CAS, transfemoral carotid artery stenting.aOnly the perioperative predictors that were statistically significant on the univariate and multivariate analysis are shown in this table.bOther covariates: age ≥65, Hispanic ethnicity, comorbidities (hypertension, diabetes, dialysis status, smoking, and COPD), perioperative medications (aspirin, antiplatelet, statin, β-blockers, ACEIs/ARBs), and type of anesthesia. Open table in a new tab

Doctors, not facilities, perform procedures

Chow et al 1 Chow C.Y. Mathlouthi A. Zarrintan S. Swafford E. Siracuse J.J. Malas M.B. Outcomes of elective peripheral endovascular interventions for peripheral arterial disease performed in hospital outpatient departments versus ambulatory surgical centers versus office-based labs. J Vasc Surg. 2023; 77: 1732-1740 Google Scholar have provided us with an interesting paper that details differences in equipment utilization, risk factors, complications, and technical outcomes in outpatient facilities where patients with peripheral arterial disease are treated. Typical of a paper from a Vascular Quality Initiative data review, we are overwhelmed with facts and figures. However, in this forest of data, there is one tree that stands out. Patients’ demographics, comorbidities, indications, and treatment will differ depending on whether they are treated in a hospital outpatient department (HOPD), ambulatory surgical center (ASC), or outpatient-based lab (OBL). Outcomes of elective peripheral endovascular interventions for peripheral arterial disease performed in hospital outpatient departments, ambulatory surgical centers and office-based labsJournal of Vascular SurgeryVol. 77Issue 6PreviewA recent shift in the location where peripheral endovascular interventions (PVI) are performed has occurred, from traditional settings such as hospital outpatient departments (HOPD), to ambulatory surgical centers (ASC) and outpatient-based laboratories (OBL). Different settings may influence the safety and efficacy of the PVI, as well as how it is done. This study aims to compare the postprocedural outcomes and intraprocedural details between the three settings. Full-Text PDF

Open Versus Endovascular Left Subclavian Artery Revascularization Outcomes in Thoracic Endovascular Aortic Repair: A National Study

Left subclavian artery (LSA) revascularization is recommended in patients undergoing elective thoracic endovascular aortic repair (TEVAR) with LSA coverage. However, the outcomes of open vs endovascular techniques for LSA revascularization remain poorly studied due to lack of high-quality evidence. The aim of this study is to use a large national database to compare the effects of open vs endovascular LSA revascularization for LSA coverage during TEVAR on the perioperative outcomes of stroke, arm ischemia (AI), spinal cord ischemia (SCI), 30-day mortality, and reintervention. Patients who had undergone LSA revascularization for LSA coverage in the Vascular Quality Initiative TEVAR database between 2011 and 2022 were identified. Patients with no coverage of the LSA, no LSA revascularization after LSA coverage, conversion to open repair, proximal disease > zone 5, distal zone disease < zone 3, and genetic history of connective tissue disease were excluded. We divided our cohort into two groups: open and endovascular revascularization of LSA. Open LSA revascularization was defined as treatment with surgical bypass. Endovascular LSA revascularization was defined as treatment with stent, stent graft, chimney, scallop, stented scallop, fenestration, stented fenestration, fenestrated branch, side-arm branch, and iliac device. Outcomes were perioperative stroke, AI, SCI, 30-day mortality, and reintervention. A total of 3052 patients met our inclusion criteria. There were 2396 (78.5%) patients in the open LSA revascularization group and 656 (21.5%) patients in the endovascular LSA revascularization group. The results are summarized in the Table. When compared with open LSA revascularization, endovascular LSA revascularization showed no significant difference in the risk of stroke (adjusted odds ratio [aOR]: 1.1, 95% confidence interval [CI]: 0.8-1.5; P = .498), AI (aOR: 1.5, 95% CI: 0.7-3.1; P = .273), SCI (aOR: 0.7, 95% CI: 0.3-1.5; P = .337), and 30-day mortality (aOR: 1.3, 95% CI: 0.8-2.0; P = .254). Furthermore, there was no significant difference in the risk of reintervention (aOR: 0.7, 95% CI: 0.4-1.2; P = .166). In this analysis of Vascular Quality Initiative data, both open and endovascular LSA revascularization for LSA coverage during TEVAR were equally effective and durable with no significant difference in outcomes of stroke, AI, SCI, 30-day mortality, and reintervention. Thus, endovascular LSA revascularization is a viable alternative to open LSA revascularization that could reduce the need for staged carotid-subclavian bypass or transposition procedures. Further studies are warranted to compare the long-term outcomes of open vs endovascular LSA revascularization, in addition to comparing the outcomes of specific endovascular techniques to each other.TableMultivariate logistic regression of stroke, arm ischemia (AI), spinal cord ischemia (SCI), 30-day mortality, and reintervention outcomesOutcomeEndovascular LSA revascularization vs open LSA revascularizationaOR (95% CI) (reference = open LSA revascularization)P valueStroke1.1 (0.8-1.5).498AI1.5 (0.7-3.1).273SCI0.7 (0.3-1.5).33730-day mortality1.3 (0.8-2.0).254Reintervention0.7 (0.4-1.2).166aOR, adjusted odds ratio; CI, confidence interval; LSA, left subclavian artery. Open table in a new tab

Vascular Quality Initiative assessment of compliance with Society for Vascular Surgery clinical practice guidelines on the management of extracranial cerebrovascular disease

ObjectivesCompliance with Society for Vascular Surgery (SVS) clinical practice guidelines (CPGs) is associated with improved outcomes for the treatment of abdominal aortic aneurysm, but this has not been assessed for carotid artery disease. The Vascular Quality Initiative (VQI) registry was used to examine compliance with the SVS CPGs for the management of extracranial cerebrovascular disease and its impact on outcomes. MethodsThe 2021 SVS extracranial cerebrovascular disease CPGs were reviewed for evaluation by VQI data. Compliance rates by the center and provider were calculated, and the impact of compliance on outcomes was assessed using logistic regression with inverse probability-weighted risk adjustment for each CPG recommendation, allowing for clustering by the center. Our primary outcome was a composite end point of in-hospital stroke/death. As a secondary analysis, compliance with the 2021 SVS carotid implementation document recommendations and associated outcomes were also assessed. ResultsOf the 11 carotid CPG recommendations, 4 (36%) could be evaluated using VQI registry data. Median center-specific CPG compliance ranged from 38% to 95%, and median provider-specific compliance ranged from 36% to 100%. After adjustment, compliance with 2 of the recommendations was associated with lower rates of in-hospital stroke/death: first, the use of best medical therapy (antiplatelet and statin therapy) in low/standard surgical risk patients undergoing carotid endarterectomy for >70% asymptomatic stenosis (event rate in compliant vs noncompliant cases 0.59% vs 1.3%; adjusted odds ratio: 0.44, 95% confidence interval: 0.29-0.66); and second, carotid endarterectomy over transfemoral carotid artery stenting in low/standard surgical risk patients with >50% symptomatic stenosis (1.9% vs 3.4%; adjusted odds ratio: 0.55, 95% confidence interval: 0.43-0.71). Of the 132 implementation document recommendations, only 10 (7.6%) could be assessed using VQI data, with median center- and provider-specific compliance rates ranging from 67% to 100%. The impact of compliance on outcomes could only be assessed for 6 (4.5%) of these recommendations, and compliance with all 6 recommendations was associated with lower stroke/death. ConclusionsFew SVS recommendations could be assessed in the VQI because of incongruity between the recommendations and the VQI data variables collected. Although guideline compliance was extremely variable among VQI centers and providers, compliance with most of these recommendations was associated with improved outcomes after carotid revascularization. This finding confirms the value of guideline compliance, which should be encouraged for centers and providers. Optimization of VQI data to promote evaluation of guideline compliance and distribution of these findings to VQI centers and providers will help facilitate quality improvement efforts in the care of vascular patients.

Trends and outcomes associated with intravascular ultrasound use during femoropopliteal revascularization in the Vascular Quality Initiative

ObjectiveIntravascular ultrasound (IVUS) use in lower extremity interventions is growing in popularity owing to its imaging in the axial plane, superior detail in imaging lesion characteristics, and its enhanced ability to delineate lesion severity and extent compared with catheter angiograms. However, there are conflicting data regarding whether IVUS affects outcomes. The purpose of this study was to assess the effect associated with IVUS implementation in femoropopliteal interventions. MethodsThis retrospective cohort study used Vascular Quality Initiative data. Patients undergoing an index endovascular femoropopliteal revascularization from 2016 to 2021 were included. Patients were differentiated by whether or not IVUS was used to assess the femoropopliteal segment during intervention (no IVUS, IVUS). Propensity score matching, based on preoperative demographics and measures of disease severity was used. Primary outcomes were major amputation-free survival (AFS), femoropopliteal reintervention-free survival (RFS), and primarily patent survival (PPS) at 12 months. ResultsIVUS use grew steadily throughout the study period, comprising 0.6% of interventions in 2016 and increasing to 8.2% of interventions by 2021; growth was most dramatic in ambulatory surgical center or office-based laboratory settings where IVUS use grew from 4.4% to 43% to 47% of interventions. In unmatched cohorts, patients receiving interventions using IVUS tended to have lower prevalence of multiple cardiovascular comorbidities (eg, congestive heart failure, hypertension, diabetes, and dialysis dependence) and presented more often with claudication and less often with chronic limb-threatening ischemia (CLTI). Intraoperatively, IVUS was used more often in complex femoropopliteal lesions (Transatlantic Intersociety grade D vs A), and more often in conjunction with stenting and/or atherectomy. IVUS use was associated with improved AFS, but similar RFS and PPS at 12 months. However, in multivariable analysis IVUS was not associated with any of the primary outcomes independently; rather, all outcomes were influenced primarily by CLTI, dialysis dependence, and prior major amputation status; technical outcomes (ie, RFS and PPS loss) were further driven by complexity of lesion (worse in Transatlantic Intersociety grade D vs A lesions) and treatment setting (ie, ambulatory surgical center or office-based laboratory setting associated with increased hazard for RFS and PPS loss). ConclusionsIVUS implementation in femoropopliteal interventions is growing, with rapid adoption among interventions in ambulatory surgical centers and office-based laboratories. IVUS was not associated with an effect on technical outcomes at 12 months; improvement in major AFS was observed; however, multivariable analysis suggests this finding may be an effect of confounding by multiple factors highly associated with IVUS use, namely, in patients with lower prevalence of CLTI, dialysis dependence, and prior major amputations, thus conveying baseline lower risk for major amputation and death.

Impact of calcified plaque volume on technical and 3-year outcomes after transcarotid artery revascularization

ObjectiveWe sought to quantify the percent calcification within carotid artery plaques and assess its impact on percent residual stenosis and rate of restenosis in patients undergoing transcarotid artery revascularization for symptomatic and asymptomatic carotid artery stenosis. MethodsA retrospective review of prospectively collected institutional Vascular Quality Initiative data was performed to identify all patients undergoing transcarotid artery revascularization from December 2015 to June 2021 (n = 210). Patient and lesion characteristics were extracted. Using a semiautomated workflow, preoperative computed tomography head and neck angiograms were analyzed to determine the calcified plaque volume in distal common carotid artery and internal carotid artery plaques. Intraoperative digital subtraction angiograms were reviewed to calculate the percent residual stenosis post-intervention according to North American Symptomatic Carotid Endarterectomy Trial criteria. Peak systolic velocity and end-diastolic velocity were extracted from outpatient carotid duplex ultrasound examinations. Univariate logistic regression was performed to analyze the relationship of calcium volume percent and Vascular Quality Initiative lesion calcification to percent residual stenosis in completion angiograms. Kaplan-Meier analysis examined the relationship between calcium volume percent and in-stent stenosis over 36 months. ResultsOne hundred ninety-seven carotid arteries were preliminarily examined. Predilation was performed in 87.4% of cases with a mean balloon diameter of 5.1 ± 0.7 mm and a mean stent diameter was 8.8 ± 1.1 mm. The mean calcium volume percent was 11.9 ± 12.4% and the mean percent residual stenosis was 16.1 ± 15.6%. Univariate logistic regression demonstrated a statistically significant difference between calcium volume percent and percent residual stenosis (odds ratio [OR], 1.324; 95% confidence interval [CI], 1.005-1.746; P = .046). Stratified by quartile, only the top 25% of calcified plaques (>18.7% calcification) demonstrated a statistically significant association with higher percent residual stenosis (OR, 2.532; 95% CI, 1.049-6.115; P =.039). There was no statistical significance with lesion calcification (OR, 1.298; 95% C,: 0.980-1.718; P = .069). A Kaplan-Meier analysis demonstrated a statistically significant increase in the rate of in-stent stenosis during a 36-month follow-up for lesions containing >8.2% calcium volume (P = .0069). ConclusionsA calcium volume percent of >18.7% was associated with a higher percent residual stenosis, and a calcium volume percent of >8.2% was associated with higher in-stent stenosis at 36 months. There was one clinically diagnosed stroke during the follow-up period, demonstrating the overall safety of the procedure.

Assessing the quality of reporting of studies using Vascular Quality Initiative (VQI) data.

The Society for Vascular Surgery Vascular Quality Initiative (VQI) has become an increasingly popular data source for retrospective observational vascular surgery studies. There are published guidelines on the reporting of data in such studies to promote transparency and rigor, but these have not been used to evaluate studies using VQI data. Our objective was to appraise the methodological reporting quality of studies using VQI data by evaluating their adherence to these guidelines. The Society for Vascular Surgery VQI publication repository was queried for all articles published in 2020. The REporting of studies Conducted using Observational Routinely-collected Health Data (RECORD) statement and the Journal of American Medical Association-Surgical Section (JAMA-Surgery) checklist were utilized to assess the quality of each article's reporting. Five and three items from the RECORD statement and JAMA-Surgery checklist were excluded, respectively, because they were either inapplicable or nonassessable. Journal impact factor (IF) was queried for each article to elucidate any difference in reporting standards between high and low IF journals. Ninety studies were identified and analyzed. The median score on the RECORD checklist was 6 (of 8). The most commonly missed item was discussing data cleaning methods (93% missed). The median score on the JAMA-Surgery checklist was 3 (of 7). The most commonly missed items were the identification of competing risks (98% missed), the use of a flow chart to clearly define sample exclusion and inclusion criteria (84% missed), and the inclusion of a solid research question and hypothesis (81% missed). There were no differences in JAMA-Surgery checklist or RECORD statement median scores among studies published in low vs high IF journals. Studies using VQI data demonstrate a poor to moderate adherence to reporting standards. Key areas for improvement in research reporting include articulating a clear hypothesis, using flow charts to clearly define inclusion and exclusion criteria, identifying competing risks, and discussing data cleaning methods. Additionally, future efforts should center on creating tailored instruments to better guide reporting in studies using VQI data.

Examining Care Fragmentation After PAD Interventions: The Readmission Event

Lower extremity revascularization (LER) for peripheral artery disease (PAD) is complicated by the frequent need for readmission either at the same facility or a different one than where the index LER was performed. Prior work using Vascular Quality Initiative data linked to Medicare claims has demonstrated that readmission rates after LER are 18% and 31% at 30 days and 90 days, respectively. It is unclear, however, if readmission at a nonindex LER facility compared with the index LER facility is associated with worse outcomes.

Effects of abdominal aortic aneurysm appropriateness dashboard on clinical practice

ObjectiveThe Society for Vascular Surgery published abdominal aortic aneurysm (AAA) practice guidelines in 2003, 2009, and 2018 to improve the management and treatment of AAAs. In 2014, our vascular surgery department implemented a quarterly AAA dashboard (AAAdb) to record the perioperative outcomes and guideline compliance with a focus on intervention appropriateness and procedural follow-up, which supplemented our Vascular Quality Initiative data. From the available reported evidence and expert consensus opinions, nine additional criteria for the appropriate treatment of AAAs <5 cm in women and <5.5 cm in men were noted, when applicable. The purpose of our study was to assess the effects of AAAdb implementation on adherence to society and institutional guidelines, documentation of treatment rationale, and the quality of follow-up. MethodsWe performed a retrospective review of elective open and endovascular AAA repair at a single institution from 2010 to 2018. The AAAdb was implemented in the middle of this period in 2014. The patient demographics, aortic size, repair indication, repair type, 30-day mortality, and postoperative and 1-year follow-up imaging findings were analyzed. The primary outcome was adherence to intervention appropriateness and the follow-up guidelines. The categorical factors were summarized using frequencies and percentages and compared using the Pearson χ2 test or Fisher exact test. Continuous measures were summarized using the mean ± standard deviation and compared between study periods using two-sample t tests. ResultsFrom 2010 to 2018, 1549 patients had undergone elective AAA repair: 657 before and 892 after AAAdb implementation. No differences were found in AAA size after AAAdb (5.6 ± 1.2 cm vs 5.6 ± 1.1 cm; P = .88). However, the proportion of size-appropriate repairs increased (64.1% vs 71.3%; P = .003). The proportion of small AAA repairs with a documented rationale had increased (64.4% vs 80.5%; P < .001), with rapid disease progression cited most often. No difference was found in 30-day mortality (1.2% vs 1.5%; P = .69). Follow-up imaging after endovascular abdominal aortic aneurysm repair increased at <60 days postoperatively (76% vs 84%; P = .004) and at 1 year of follow-up (78% vs 86%; P = .0005). The proportion of patients with endoleak at <60 days postoperatively had increased in the post-AAAdb cohort (21% vs 29%; P = .012). ConclusionsThe AAAdb served as a centerpiece for improving the appropriateness of care and compliance with national and institutional guidelines, including treatment of small AAAs in special circumstances. Its implementation was associated with higher quality follow-up and surveillance in a high-volume, regional aortic center. Consideration should be given to adding additional criteria to the Society for Vascular Surgery guidelines and Vascular Quality Initiative reporting.

Atherectomy overuse is a real problem

Atherectomy overuse is a real problem

Modern Analysis of Stroke After Carotid Stenting in Octogenarians Using the Virginia Vascular Study Group Vascular Quality Initiative Data

Carotid artery stenting (CAS) is a safe and effective alternative to carotid endarterectomy in appropriate patients. However, there remains debate over the safety of stenting in octogenarians. This is due to previous studies demonstrating higher stroke risk in this population. Since those studies were published, transcarotid artery revascularization (TCAR) has become available, allowing surgeons to stent without crossing the aortic arch. Using a modern database, we sought to evaluate whether CAS is associated with increased odds of stroke in octogenarians compared to younger patients and to determine whether there is a difference in stroke odds between the age groups depending on device used (tfCAS vs TCAR).

Derivation and Validation of a Risk Score for Abdominal Compartment Syndrome after Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysms

Abdominal compartment syndrome (ACoS) is a devastating complication after endovascular aneurysm repair for ruptured abdominal aortic aneurysms (rEVAR). This study sought to develop a risk score for ACoS to identify patients who would benefit from early decompressive laparotomy. Model derivation was performed with Vascular Quality Initiative data for rEVAR from 2013 to 2020. The primary outcome was evacuation of abdominal hematoma. A multivariable logistic regression was used to create and validate a scoring system to predict ACoS. The model was validated using institutional data for rEVAR from 1998 to2019. The derivation cohort included 2,310 patients with rEVAR. Abdominal hematoma evacuation occurred in 265 patients (11.5%). Factors associated with abdominal hematoma evacuation on a multivariable analysis included transfer from an outside hospital, preoperative creatinine ≥1.4 mg/dL, preoperative systolic blood pressure ≤85 mmHg, preoperative altered mental status, ≥3.0 liters intraoperative crystalloid, and ≥4 units of red blood cells transfused intraoperatively. The validation cohort consisted of 67 rEVAR; ACoS occurred in 8 patients (11.9%). The c-statistic was 0.84 in the derivation and 0.87 in the validation cohort, whereas Hosmer-Lemeshow was P = 0.15 in the derivation and 0.84 in the validation cohorts, suggesting good model discrimination and calibration. Points were applied based on β-coefficients to produce a risk score ranging from -1 to 13. A cutoff of risk score ≥8 resulted in a sensitivity and specificity of 87.5% and 83.1% for detecting patients with ACoS, respectively. ACoS conveyed a significantly higher mortality in both the derivation (ACoS: 49.8% vs. No ACoS: 17.8%; P < 0.001) and validation cohorts (ACoS: 75.0% vs. No ACoS: 15.2%; P < 0.001). In patients with equivocal signs/symptoms of ACoS, this scoring system can be used to guide surgeons on when to perform decompressive laparotomy prior to leaving the operating room for rEVAR. Patients with a risk score ≥8 would benefit from decompressive laparotomy at index rEVAR.