Publications by authors named "Jeffrey J Siracuse"

171 Publications

Exploring the Rapid Expansion of Office-Based Laboratories and Peripheral Vascular Interventions Across the United States.

J Vasc Surg 2021 Feb 19. Epub 2021 Feb 19.

Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, MI.

Objective: To characterize the relationship between office-based laboratory utilization and Medicare payments for peripheral vascular interventions.

Methods: Using Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Public Use Files from 2014 to 2017, we identified providers who performed percutaneous transluminal angioplasty (PTA), stent placement (stent), and atherectomy. Procedures were aggregated at the provider and hospital referral region (HRR) level.

Results: Between 2014 and 2017, 2,641 providers performed 308,247 procedures. Mean payment for OBL stent in 2017 was $4383.39, while mean payment for OBL atherectomy was $13079.63. Change in mean payment varied significantly, from a decrease of $16.97 in HRR 146 to an increase of $43.77 per beneficiary over the study period in HRR 11. Change in the rate of PVI also varied substantially, and moderately correlated with change in payment across HRRs (R=0.40, p<0.001). The majority of HRRs experienced an increase in rate of PVI within OBLs, which strongly correlated with changes in payments (R=0.85, p<0.001). Furthermore, 85% of the variance in change in payment was explained by increases in OBL atherectomy (p<0.001).

Conclusion: A rapid shift into the office setting for PVIs occurred within some HRRs which was highly geographically variable and was strongly correlated with payments. Policymakers should revisit the current payment structure for OBL utilization, and, in particular atherectomy, to better align the policy with the intended goals.
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http://dx.doi.org/10.1016/j.jvs.2021.01.061DOI Listing
February 2021

Impact of Impaired Ambulatory Capacity on The Outcomes of Peripheral Vascular Interventions Among Patients with Chronic Limb Threating Ischemia.

J Vasc Surg 2021 Feb 3. Epub 2021 Feb 3.

Department of Surgery, Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA. Electronic address:

Objective: Despite prior literature recommending against limb salvage in patients with poor functional status such as non-ambulatory patients with chronic limb-threatening ischemia (CLTI), peripheral endovascular interventions (PVI) continue to be carried out in this group of patients. Clinical outcomes following these interventions are however not well characterized.

Methods: A retrospective review was conducted on all patients treated for CLTI in the Vascular Quality Initiative from September, 2016 to December, 2019. Logistic regression, Kaplan-Meier survival estimates, log rank tests, cox regression analyses were used as appropriate to study outcomes. Primary outcomes were 30-day mortality and 1-year amputation free survival. Secondary outcomes were in-hospital death and postoperative complications, 1-year freedom from major amputation and 2-year survival.

Results: Of a total of 49,807 patients studied, 28,469 (57.2%) were ambulatory, 15,148 (31.0%) were ambulatory with assistance, 5395(10.8%) were wheelchair bound and 525 (1.1%) were bedridden. There was a 2-fold increase in the odds of 30-day death in patients who were ambulatory with assistance (OR, 2.03; 95%CI, 1.77-2.34; P<0.001) and wheelchair bound patients (OR, 2.09; 95%CI, 1.74-2.51; P<0.001), and over 6-fold increase in bedridden patients (OR, 6.28; 95%CI, 4.55-8.65; P<0.001) compared to ambulatory patients. There was a significantly higher odds of postoperative complications in patients who were ambulatory with assistance or bedridden but no difference with wheelchair bound patients. Among ambulatory patients, the risks of major amputation and death within one year were only 10% and 12% respectively while that of bedridden patients were as high as 30% and 38% respectively. A stepwise decrease in amputation free survival from 81% with full ambulatory capacity to less than 50% (47.7%) in bedridden patients was observed. The risk of major amputation or death within 1 year was 35% higher for ambulatory with assistance (HR, 1.35; 95% CI, 1.26-1.44; P<0.001), 65% higher for wheelchair bound (HR, 1.65; 95% CI, 1.51-1.79; P<0.001) and 2.6-fold higher for bedridden (HR, 2.64; 95% CI, 2.17-3.21; P<0.001) compared to ambulatory. A similar association was seen for 1-year freedom from major amputation and 2-year survival.

Conclusion: Ambulatory impairment in patients with CLTI is associated with a significant increase in 30-day mortality and significant decrease in amputation free survival after PVI. Bedridden patients had a 6-fold increase in 30-day death whereas their amputation free survival dropped to less than 50% in 1-year. These risks should be considered during shared decision-making regarding management options for non-ambulatory patients with CLTI.
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http://dx.doi.org/10.1016/j.jvs.2020.12.088DOI Listing
February 2021

Intermittent Claudication Treatment Patterns in the Commercially Insured Non-Medicare Population.

J Vasc Surg 2021 Feb 3. Epub 2021 Feb 3.

Institute for Health System Innovation and Policy, Boston University, Boston, MA; Questrom School of Business, Boston University, Boston, MA.

Objectives: Despite published guidelines and data for Medicare patients, it is uncertain how younger patients with intermittent claudication (IC) are treated. Additionally, the degree to which treatment patterns have changed over time with the expansion of endovascular interventions and outpatient centers is unclear. Our goal was to characterize IC treatment patterns in the commercially insured non-Medicare population.

Methods: The IBM MarketScan Commercial Database, which comprises over 8 billion U.S. commercial insurance claims, was queried for patients newly diagnosed with IC from 2007 to 2016. Patient demographics, medication profiles, and open/endovascular interventions were evaluated. Time trends were modeled using simple linear regression and goodness-of-fit was assessed with coefficients of determination (R). A patient-centered cohort sample and a procedure-focused dataset were analyzed.

Results: Among 152,935,013 unique patients in the database, there were 300,590 newly diagnosed IC patients. Mean insurance coverage was 4.4 years. Median age was 58 years and 56% of patients were male. The prevalence of statin use was 48% among patients at the time of IC diagnosis and increased to 52% among patients after one year from diagnosis. Interventions were performed in 14.3% of whom 20% and 6% underwent > 2 and > 3 interventions, respectively. Median time from diagnosis to intervention decreased from 230 days in 2008 days to 49 days in 2016 (R=.98). There were 16,406 inpatient and 102,925 ambulatory interventions for IC over the study period. Among ambulatory interventions, 7.9% were performed in office-based/surgical centers. The proportion of atherectomies performed in the ambulatory setting increased from 9.7% in 2007 to 29% in 2016 (R=.94). In office-based/surgical centers, 57.6% of interventions for IC utilized atherectomy in 2016. Atherectomy was used in ambulatory interventions by cardiologists in 22.6%, surgeons in 15.2%, and radiologists in 13.6% of interventions. Inpatient atherectomy rates remained stable over the study period. Open and endovascular tibial interventions were performed in 7.9% and 7.8% of ambulatory and inpatient IC interventions, respectively. Tibial bypasses were performed in 8.2% of all open IC interventions.

Conclusions: There was been shorter time to intervention in the treatment of younger commercially insured patients with IC, with many receiving multiple interventions. Statin utilization was low. Ambulatory procedures, especially in office-based/surgical centers, increasingly used atherectomy, which was not observed in inpatient settings.
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http://dx.doi.org/10.1016/j.jvs.2020.10.090DOI Listing
February 2021

Vascular Surgery Related Violations of the Emergency Medical Treatment and Labor Act.

J Vasc Surg 2021 Feb 3. Epub 2021 Feb 3.

Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA. Electronic address:

Objectives: The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law established in 1986 to ensure that patients who present to an emergency department (ED) receive medical care regardless of means. Violations are reported to the Centers for Medicare and Medicaid Services (CMS) and can result in significant financial penalties. Our objective was to assess all available EMTALA violations for vascular-related issues.

Methods: EMTALA violations in the CMS publicly-available hospital violations database from 2011 to 2018 were evaluated for vascular-related issues. Details recorded were case type, hospital type, hospital region, reasons for violation, disposition, and mortality.

Results: There were 7001 patients identified with any EMTALA violation and 98 (1.4%) were deemed vascular-related. The majority (82.7%) of EMTALA violations occurred at urban/suburban hospitals. Based on the Association of American Medical Colleges United States (US) region, vascular-related EMTALA violations occurred in the Northeast (7.1%), Southern (56.1%), Central (18.4%), and Western (18.4%) United States. Case types included cerebrovascular (28.6%), aortic-related (22.4%; which consisted of ruptured aortic aneurysms [8.2%], aortic dissection [11.2%], and other aortic [3.1%]), vascular trauma (15.3%), venous-thromboembolic (15.3%), peripheral arterial disease (9.2%), dialysis access (5.1%), bowel ischemia (3.1%), and other (1%) cases. Patients were transferred to another facility in 41.8% of cases. The most common reasons for violation were specialty refusal/unavailability (30.6%), inappropriate documentation (29.6%), misdiagnosis (18.4%), poor communication (17.3%), inappropriate triage (13.3%), failure to obtain diagnostic labs or imaging (12.2%), and ancillary/nursing staff issues (7.1%). The overall mortality was 19.4% of which 31.6% died during the index ED visit. Vascular conditions associated with death were venous thromboembolism (31.6%), ruptured aortic aneurysm (21.1%), aortic dissection (21.1%), other aortic causes (10.5%), vascular trauma (10.5%), and bowel ischemia (5.3%).

Conclusions: Although the frequency of vascular-related EMTALA violations was low, improvement in communication, awareness of vascular disease among staff, specialty staffing, and development of referral networks and processes are needed to ensure that patients receive adequate care and that institutions are not placed at undue risk.
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http://dx.doi.org/10.1016/j.jvs.2020.12.110DOI Listing
February 2021

The Majority of Major Amputations After Resuscitative Endovascular Balloon Occlusion of the Aorta Are Associated with Pre-Admission Trauma.

J Vasc Surg 2021 Feb 3. Epub 2021 Feb 3.

Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA. Electronic address:

Objectives: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potentially life-saving intervention. However, recent reports of associations with limb loss and mortality have called its safety into question. We aimed to evaluate patient and hospital characteristics associated with major amputation and in-hospital mortality among patients undergoing REBOA for trauma.

Methods: The National Trauma Data Bank (2015-2017) was queried for patients presenting to trauma centers and treated with REBOA. We included REBOA performed on hospital day one in patients who survived > 6 hours from presentation. Univariable and multivariable analyses evaluated associations with major amputation and in-hospital mortality.

Results: A total of 316 patients underwent REBOA and survived in the acute period after presentation. Overall, mean age was 45 ± 20 years and the majority were male (73%) and white (56%). Most patients presented to Level I trauma centers (72%) after blunt injuries (79%) with an average injury severity score (ISS) of 31 ± 15, indicating major trauma. In 15 patients (5%), there were 18 major amputations - 7 above-knee and 11 below-knee. A subgroup of 11 amputations were either traumatic amputations (73%) or mangled limbs requiring amputation within 24 hours (27%). Of the remaining amputations, 71% were associated with ipsilateral vascular or orthopedic lower extremity injuries of serious-to-severe Abbreviated Injury Scale severity. Comparing patients with amputations to those without amputations, there were no significant differences in patient demographics, comorbidities or hospital characteristics. During hospitalization, patients requiring amputation more frequently received open peripheral vascular interventions (40% vs. 10%, P=.002), underwent similar numbers of endovascular interventions (6.7% vs. 4.7%, P=.5), and more often developed compartment syndrome (13% vs. 2%, P=.04). Overall, there were 110 deaths (35%). Major amputation prevalence was similar between patients who died vs. survived (3.6% vs. 5.3%, P=.5). In multivariable analysis, prehospital cardiac arrest (OR 8.47, 95% CI 1.47-48.66, P=.02), penetrating vs. blunt trauma (OR 5.5, 95% CI 1.05-28.82, P=.04), decreased Glasgow Coma Scale score (OR 1.18, 95% CI 1.05-1.32, P=.01), increased age (OR 1.06, 95% CI 1.03-1.1, P<.001), and increased ISS (OR 1.05, 95% CI 1-1.1, P=.03) were associated with higher mortality.

Conclusions: The majority of major amputations in patients undergoing REBOA were secondary to the initial traumatic mechanism. Injury type and severity, as well as initial hemodynamic derangements are associated with mortality after REBOA. Despite concerns about prohibitive limb complications of REBOA, baseline injuries appear to be the primary cause of limb loss, but further prospective analysis is needed.
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http://dx.doi.org/10.1016/j.jvs.2020.12.107DOI Listing
February 2021

Inadequate Adherence to Imaging Surveillance and Medical Management in Patients with Duplex Ultrasound-Detected Carotid Artery Stenosis.

Ann Vasc Surg 2021 Jan 27. Epub 2021 Jan 27.

Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston MA. Electronic address:

Background: It is recommended that patients with ≥50% carotid artery stenosis undergo surveillance imaging and atherosclerotic risk reduction medical therapies, regardless of whether revascularization is performed. The objective of this study was to determine rates of adherence to these recommended measures and to identify risk factors for nonadherence.

Methods: A retrospective analysis was performed of all carotid duplex ultrasound (DUS) from 2016 to 2017 at a single institution. Patients with unilateral or bilateral ≥50% carotid stenosis were included. Primary outcomes were rates and timing of surveillance imaging and medication regimen. Patient and study characteristics were compared using univariate and multivariable analyses. A subgroup analysis of patients with a new finding of carotid stenosis was also performed.

Results: Carotid stenosis >50% was detected in 340 patients. Overall, 182 patients (54%) had follow-up imaging (median 261 days [IQR 166-366]) and 158 patients (46%) had no imaging follow-up (NIFU). NIFU patients had similar rates of aspirin use (86% vs. 88%, P = 0.6) and tobacco cessation counseling (71% vs. 71%, P = 0.8) but had less statin use (85% vs. 94%, P = 0.01) compared to those with imaging follow-up. Subsequent carotid revascularization was more common in patients with imaging follow-up (18% vs. 3%, P < 0.001). NIFU patients were less likely to have Medicare or commercial insurance (54% vs. 75%, P < 0.001). The indication for DUS in NIFU patients, compared to those in follow up, was less commonly neurologic symptoms (11% vs. 14%), more commonly other clinical findings (35% vs. 16%), and more commonly as work up before nonvascular surgery (25% vs. 4%, P < 0.001), respectively. NIFU rates decreased with increasing degree of carotid stenosis. Prior carotid intervention, prior DUS, or DUS ordered by a vascular surgeon were characteristics associated with imaging follow-up (P < 0.05 for all). In a subgroup of 160 patients with new carotid stenosis, a majority (64%) had NIFU and statin use was lower in these patients (82% vs. 96%, P = 0.007). On multivariable analysis, preop indication was predictive of NIFU (odds ratio [OR] 8.1 [95% confidence interval, CI 2.5-26.4], P < 0.001) whereas protective factors included: 70-80% stenosis (OR 0.33 [95% CI 0.14-0.76], P = 0.01), study ordered by vascular surgeon (OR 0.40 [95% CI 0.19-0.83], P = 0.01), and Medicare/commercial insurance (OR 0.36 [95% CI 0.2-0.66], P = 0.001).

Conclusions: Nearly half of patients found to have ≥50% carotid stenosis on DUS had no imaging follow-up; these patients were less likely to be on recommended statin therapy. The benefits of nonrevascularization-based treatments for carotid disease require adherence to therapy. Forgoing surveillance imaging in patients with hemodynamically significant carotid stenosis should be a shared decision between provider and patient and does not obviate the need for medical therapies.
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http://dx.doi.org/10.1016/j.avsg.2020.12.027DOI Listing
January 2021

Association of Medicaid Expansion with Tunneled Dialysis Catheter Use at the Time of First Arteriovenous Access Creation.

Ann Vasc Surg 2021 Jan 26. Epub 2021 Jan 26.

Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA. Electronic address:

Background: In the United States, many low-income patients initiating hemodialysis are uninsured before qualifying for Medicare. Inadequate access to predialysis care may delay their arteriovenous (AV) access creation and increase tunneled dialysis catheter (TDC) use. The 2014 Affordable Care Act expanded eligibility for Medicaid among low-income adults, but not every state adopted this measure. We evaluated whether Medicaid expansion was associated with decreased TDC use for hemodialysis initiation.

Methods: We queried the United States Vascular Quality Initiative state-level database for non-Medicare patients undergoing initial AV access creation from 2011 to 2018. We evaluated associations of receiving initial AV access in states that expanded Medicaid with concurrent TDC use, survival, and insurance coverage.

Results: Data were available for patients in 31 states: 19 states expanded Medicaid from January 2014 to February 2015. Among 8462 patients in the postexpansion period from March 2015 to December 2018, 58% were in Medicaid expansion states. Patients in Medicaid expansion states less often had concurrent TDCs (40% vs. 48%, P < 0.001). In multivariable analysis, Medicaid expansion was independently associated with fewer TDCs (OR 0.7, 95% CI 0.6-0.8, P < 0.001). Three-year survival was similar between patients in Medicaid expansion and nonexpansion states (84.7% vs. 85.2%, P = 0.053). Multivariable cox-regression confirmed the finding (HR 0.95, 95% CI 0.82-1.1, P = 0.482). In difference-in-differences analysis, Medicaid expansion was associated with a 9.2-percentage point increase in Medicaid coverage (95% CI 2.7-15.8, P = 0.009). Hispanic patients exhibited a 30.1-percentage point increase in any insurance coverage (95% CI 0.3-59.9, P = 0.048).

Conclusions: Patients in Medicaid expansion states were less likely to have TDCs during initial AV access creation, suggesting earlier predialysis care. Hispanic patients benefited from increased insurance coverage. Expanding insurance options for the underserved may improve quality metrics and cost-savings for hemodialysis patients.
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http://dx.doi.org/10.1016/j.avsg.2021.01.063DOI Listing
January 2021

The need for a comprehensive vascular trauma registry.

J Vasc Surg 2021 Feb;73(2):738

Department of Surgery, Boston University, School of Medicine, Boston, Mass.

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http://dx.doi.org/10.1016/j.jvs.2020.08.113DOI Listing
February 2021

Prevalence and hospital charges from firearm injuries treated in US emergency departments from 2006 to 2016.

Surgery 2020 Dec 28. Epub 2020 Dec 28.

Dean's Office, Boston University School of Public Health, MA.

Background: Age- and intent-related differences in the burden and costs of firearm injury treated in emergency departments are not well-documented.

Methods: We performed a serial cross-sectional study of the Healthcare Cost and Utilization Program Nationwide Emergency Department Survey from 2006 to 2016. We used International Classification of Diseases diagnoses codes revisions 9 and 10 to identify firearm injuries. We calculated survey-weighted counts, proportions, means, and rates and confidence intervals of national, age-specific (0-4, 5-9, 10-14, 15-17, 18-44, 45-64, 65-84, >84) and intent-specific (assault, unintentional, suicide, undetermined) emergency department discharges for firearm injuries. We used survey-weighted regression to assess temporal trends.

Results: There was a total of 868,483 (25.5 per 100,000) emergency department visits for firearm injuries from 2006 to 2016, and 7.8% died in the emergency department. Overall, firearm injury rates remained steady (P = .78). The largest burden was among those 25 to 44 years of age, but their rates remained stable (10.8 per 100,000). Overall assault injuries declined from 39.7% to 36.4%, and overall unintentional injuries increased from 46.4% to 54.7%. Legal-intervention injuries declined from 0.6 to 0.3 per 100,000. The charges (total $4,059,070,364, $369,006,396/year) increased across time in age and intent groups. The mean predicted charges increased from $1,922 to $3,348 in those alive versus $3,741 to $6,515 among those who died.

Conclusion: Interventions and programs to manage the consequences of firearm injury in persons who live with ongoing morbidity and economic burden are warranted.
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http://dx.doi.org/10.1016/j.surg.2020.11.009DOI Listing
December 2020

The Association of the Day of the Week with Outcomes of Infrainguinal Lower Extremity Bypass.

Ann Vasc Surg 2020 Dec 25. Epub 2020 Dec 25.

Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA. Electronic address:

Background: The day of the week (DOW) for performing procedures and operations has been shown to affect clinical and resource utilization outcomes. Limited published data are available on vascular surgery operations. Our primary objective was to assess outcomes by DOW for infrainguinal lower extremity bypass (LEB) performed for claudication or rest pain. The secondary objective was to assess outcomes by DOW for LEBs performed for tissue loss.

Methods: The Vascular Quality Initiative was queried from 2003 to 2018 for all elective index infrainguinal LEBs performed for claudication or rest pain. Cases performed for acute limb ischemia as well as concomitant peripheral vascular intervention, nonelective LEBs, sequential grafts, and weekend cases were excluded. LEBs were grouped by DOW: Monday-Tuesday (early weekdays) versus Wednesday-Friday (later weekdays). Baseline data, operative details, and outcomes were collected. Univariate and multivariable analyses were performed. LEBs performed for claudication/rest pain were analyzed together while tissue loss was assessed separately.

Results: There were 12,084 LEBs identified-44.5% performed on Monday-Tuesday and 55.5% on Wednesday-Friday. Overall, the mean age was 65.6 years, 68.6% were male, and 82.8% were Caucasian. LEBs were performed for claudication in 57.4% of cases. An autogenous great saphenous vein was used in 58.8% of cases, whereas a prosthetic graft was used in 35.1% of cases. The most common bypass origin was the femoral artery (94.1%), and target was the popliteal artery (70.1%). Significant differences between Monday-Tuesday versus Wednesday-Friday, respectively, were mean body mass index (27.8 kg/m vs. 28 kg/m), preoperative aspirin use (74.2% vs. 72.5%), continuous vein harvest technique (41.9% vs. 44%), and mean operative time (mins) (216.2 vs. 222.6) (all P < 0.05). Univariate postoperative outcomes were significantly different between Monday-Tuesday versus Wednesday-Friday, respectively, for mean length of stay (LOS) (days) (3.9 vs. 4.3), cardiac complications (myocardial infarction/dysrhythmia/congestive heart failure) (3.5% vs. 4.9%), stroke (0.3% vs. 0.6%), and respiratory complications (0.8% vs. 1.3%) (all P < 0.05). Multivariable analysis demonstrated that LEBs performed on Wednesday-Friday versus Monday-Tuesday for claudication/rest pain were independently associated with cardiac complications and prolonged LOS. There were also 8,491 LEBs performed for tissue loss which overall had similar findings to LEBs performed for claudication/rest pain such as increased LOS for LEBs performed for tissue loss on Wednesday-Friday (P < 0.001) and similar likeliness for respiratory complication, wound complication, return to the operating room, and mortality (all P > 0.05). However, LEBs performed for tissue loss on Wednesday-Friday versus Monday-Tuesday had similar cardiac complications (P > 0.05).

Conclusions: Elective LEBs performed on later weekdays for claudication/rest pain were associated with cardiac complications and prolonged LOS, whereas tissue loss confirmed association with prolonged LOS. Further investigations are needed to identify whether increased resources or allocation of resources should be focused on later weekdays to optimize patient outcomes.
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http://dx.doi.org/10.1016/j.avsg.2020.11.025DOI Listing
December 2020

Selective Nonoperative and Delayed Management of Severe Asymptomatic Carotid Artery Stenosis.

Ann Vasc Surg 2020 Dec 18. Epub 2020 Dec 18.

Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA. Electronic address:

Objectives: Although intervention is generally the standard of care for severe (80-99%) asymptomatic carotid stenosis, conservative management may be appropriate for a subset of patients. Our goal was to assess reasons for and outcomes of nonoperative/delayed operative management of asymptomatic severe carotid stenosis.

Methods: Institutional vascular laboratory data from 2010 to 2018 was queried for all patients who underwent a carotid duplex ultrasonography. Patients with severe asymptomatic carotid stenosis (80-99%) were included. Such stenosis was defined by an end diastolic velocity >140 cm/sec on duplex ultrasound in patients without transient ischemic attacks (TIA)/strokes ≤6 months prior to imaging. Nonoperative/delayed operative management was defined as not undergone carotid endarterectomy (CEA) or carotid artery stent (CAS) ≤6 months after imaging. Reasons for nonoperative management or delayed intervention as well as subsequent TIA/stroke and survival were determined. Kaplan-Meier analysis was performed to evaluate survival.

Results: Among 211 patients with severe carotid stenosis, 35 (16.6%) were managed nonoperatively or with delayed operation. Mean age in this subset was 72.6 ± 11.4 years and the majority were female (57.1%), had a smoking history (74.3%), and were on statins (91.4%) at the time of index duplex ultrasound. Reasons for no/delayed intervention were classified as severe medical comorbidities (37.1%), advanced age (17.1%), no referral for intervention (14.3%), patient refusal (14.3%), other severe concomitant cerebrovascular disease (11.4%), and active/advanced cancer (5.7%). Over a median follow-up of 35.2 months, no patients experienced TIAs/strokes attributable to carotid stenosis. One patient had a multifocal bilateral stroke after a cardiac arrest and prolonged resuscitation. A subset of patients underwent delayed CEA (8.6%) or CAS (2.9%). Four-year survival after initial imaging was 79%.

Conclusions: Reasons for nonoperative and delayed operative management in our cohort of asymptomatic carotid stenosis were commonly due to comorbidities and advanced age. However, a subset of patients was never referred to vascular surgeons/interventionalists. Adverse neurologic events due to carotid stenosis were not observed during follow-up and patients had relatively high long-term survival.
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http://dx.doi.org/10.1016/j.avsg.2020.10.045DOI Listing
December 2020

Outcomes after transfemoral carotid artery stenting stratified by preprocedural symptom status.

J Vasc Surg 2020 Dec 2. Epub 2020 Dec 2.

Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. Electronic address:

Objective: The available data on outcomes after transfemoral carotid artery stenting (TFCAS) originate from the early experience with TFCAS. Although most previous studies stratified outcomes according to a symptomatic or asymptomatic presentation, they often did not specify the degree of presenting neurologic injury. We previously reported that the outcomes after carotid endarterectomy differed according to neurologic injury severity, the contemporary perioperative outcomes of TFCAS stratified by the specific presenting symptom status are unknown.

Methods: Patients with data in the Vascular Quality Initiative database who had undergone TFCAS from 2016 to 2020 were included. We stratified patients according to their preprocedural symptom status as asymptomatic, formerly symptomatic (last symptoms >180 days before the procedure), or recently symptomatic (symptoms <180 days before the procedure). The symptoms included stroke, hemispheric transient ischemic attack (TIA), and ocular TIA. We compared the occurrence of in-hospital stroke or death (stroke/death) among the asymptomatic, formerly symptomatic, and specific subtypes of recently symptomatic patients. Multivariable logistic regression models were constructed to adjust for the baseline differences among the groups.

Results: Of the 9807 included patients, 2650 (27%) had had recent stroke, 842 (9%), recent hemispheric TIA, and 360 (4%), recent ocular TIA. In addition, 795 patients (8%) were formerly symptomatic and 5160 (53%) were asymptomatic. The patients with recent stroke had a perioperative stroke/death rate of 5.5%, higher than that of patients with recent hemispheric TIA (2.4%; P < .001) or recent ocular TIA (2.8%; P = .03) and asymptomatic patients (1.4%; P < .001). The stroke/death rate was greater for patients with recent ocular TIA than for asymptomatic patients (2.8% vs 1.4%; P = .04). Formerly symptomatic patients had higher stroke/death rates compared with asymptomatic patients (3.5% vs 1.4%; P < .001). On multivariable-adjusted analysis, recent stroke was associated with higher stroke/death compared with recent hemispheric TIA (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.6-4.3; P < .001) and asymptomatic status (OR, 4.1; 95% CI, 3.0-5.6; P < .001) and demonstrated a trend toward higher stroke/death compared with recent ocular TIA (OR, 2.0; 95% CI, 1.0-3.9; P = .06). Furthermore, asymptomatic status was associated with lower stroke/death compared with formerly symptomatic status (OR, 0.4; 95% CI, 0.2-0.6; P < .001).

Conclusions: For patients undergoing TFCAS, recent stroke was associated with greater odds of in-hospital stroke/death after TFCAS compared with recent hemispheric TIA. Also, formerly symptomatic status was associated with greater odds of stroke/death compared with asymptomatic status. These findings support further symptom stratification by the degree of the presenting neurologic injury in the preoperative risk assessment.
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http://dx.doi.org/10.1016/j.jvs.2020.11.031DOI Listing
December 2020

Tapered and non-tapered prosthetic grafts in upper extremity dialysis access: A systematic review and meta-analysis.

J Vasc Access 2020 Nov 20:1129729820974177. Epub 2020 Nov 20.

College of Medicine, University of Arizona, Tucson, AZ, USA.

Objective: It is unclear whether tapered arteriovenous grafts (AVGs) are superior to non-tapered AVGs when it comes to preventing upper extremity ischemic steal syndrome. We aimed to evaluate the outcomes of tapered and non-tapered AVGs using systematic review and meta-analysis.

Methods: A literature search was systemically performed to identify all English publications from 1999 to 2019 that directly compared the outcomes of upper extremity tapered and non-tapered AVGs. Outcomes evaluated were the primary patency at 1-year (number of studies () = 4), secondary patency at 1-year ( = 3), and risk of ischemic steal ( = 5) and infection ( = 4). Effect sizes of individual studies were pooled using random-effects model, and between-study variability was assessed using the I statistic.

Results: Of 5808 studies screened, five studies involving 4397 patients have met the inclusion criteria and included in the analysis. Meta-analyses revealed no significant difference for the risk of ischemic steal syndrome (pooled odds ratio (OR) 0.92, 95% Confidence Incidence (CI) 0.29-2.91,  = 0.89, I = 48%) between the tapered and non-tapered upper extremity AVG. The primary patency (OR 1.33, 95% CI 0.93-1.90,  = 0.12, I = 10%) and secondary patency at 1-year (OR 1.49, 95% CI 0.84-2.63,  = 0.17, I = 13%), and rate of infection (OR 0.62, 95% CI 0.30-1.27,  = 0.19, I = 29%) were also similar between the tapered and non-tapered AVG.

Conclusions: The risk of ischemic steal syndrome and patency rate are comparable for upper extremity tapered and non-tapered AVGs. This meta-analysis does not support the routine use of tapered graft over non-tapered graft to prevent ischemic steal syndrome in upper extremity dialysis access. However, due to small number of studies and sample sizes as well as limited stratification of outcomes based on risk factors, future studies should take such limitations into account while designing more robust protocols to elucidate this issue.
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http://dx.doi.org/10.1177/1129729820974177DOI Listing
November 2020

Carotid endarterectomy for asymptomatic carotid stenosis has a higher risk of morbidity and mortality in octogenarians.

J Vasc Surg 2020 11;72(5):1833-1834

Division of Vascular and Endovascular Surgery, Boston University, Boston Medical Center, Boston, Mass.

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http://dx.doi.org/10.1016/j.jvs.2020.02.054DOI Listing
November 2020

Association of state tobacco control policies with active smoking at the time of intervention for intermittent claudication.

J Vasc Surg 2020 Oct 21. Epub 2020 Oct 21.

Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass. Electronic address:

Objective: Active smoking among patients undergoing interventions for intermittent claudication (IC) is associated with poor outcomes. Notwithstanding, current levels of active smoking in these patients are high. State-level tobacco control policies have been shown to reduce smoking in the general US population. We evaluated whether state cigarette taxes and 100% smoke-free workplace legislation are associated with active smoking among patients undergoing interventions for IC.

Methods: We queried the Vascular Quality Initiative database for peripheral endovascular interventions, infrainguinal bypasses, and suprainguinal bypasses for IC. Active smoking at the time of intervention was defined as smoking within one month of intervention. We implemented difference-in-differences analysis to isolate changes in active smoking owing to cigarette taxes (adjusted for inflation) and implementation of smoke-free workplace legislation. The difference-in-differences models estimated the causal effects of tobacco policies by adjusting for concurrent temporal trends in active smoking unrelated to cigarette taxes or smoke-free workplace legislation. The models controlled for age, sex, race/ethnicity, insurance type, diabetes, chronic obstructive pulmonary disease, state, and year. We tested interactions of taxes with age and insurance.

Results: Data were available for 59,847 patients undergoing interventions for IC in 25 states from 2011 to 2019. Across the study period, active smoking at the time of intervention decreased from 48% to 40%. Every $1.00 cigarette tax increase was associated with a 6-percentage point decrease in active smoking (95% confidence interval, -10 to -1 percentage points; P = .02), representing an 11% decrease relative to the baseline proportion of patients actively smoking. The effect of cigarettes taxes was greater in older patients and those on Medicare. Among patients aged 60 to 69 and 70 to 79 years, every $1.00 tax increase resulted in 14% and 21% reductions in active smoking relative to baseline subgroup prevalences of 53% and 29%, respectively (P < .05 for both); however, younger age groups were not affected by tax increases. Among insurance groups, only patients on Medicare exhibited a significant change in active smoking with every $1.00 tax increase (an 18% decrease relative to a 33% baseline prevalence; P = .01). The number of states implementing smoke-free workplace legislation increased from 9 to 14 by 2019; however, this policy was not significantly associated with active smoking prevalence. At follow-up (median, 12.9 months), $1.00 tax increases were still associated with decreased smoking prevalence (a 25% decrease relative to a 33% baseline prevalence; P < .001).

Conclusions: Cigarette tax increases seem to be an effective strategy to decrease active smoking among patients undergoing interventions for IC. Older patients and Medicare recipients are the most responsive to tax increases.
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http://dx.doi.org/10.1016/j.jvs.2020.08.156DOI Listing
October 2020

Factors associated with a tunneled dialysis catheter in place at initial arteriovenous access creation.

J Vasc Surg 2020 Oct 15. Epub 2020 Oct 15.

Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass. Electronic address:

Objective: Arteriovenous (AV) access is the preferred hemodialysis modality to avoid the complications associated with tunneled dialysis catheters (TDCs). Despite efforts to create timely AV access, many patients still initiate hemodialysis through TDCs. Our goal was to determine the patient factors associated with having a TDC present at initial AV access creation and how this affects survival.

Methods: We performed a single-center, retrospective review of all patients who had undergone initial AV fistula creation from 2014 to 2019. Patients with previous peritoneal or AV access were excluded. Univariable and multivariable analyses were used to identify associations with a TDC present at initial AV access creation and patient survival.

Results: Of 509 patients who had undergone initial AV access creation, a TDC was present in 280 (55%). The mean patient age was 59.7 ± 14.1 years. The access types were brachiocephalic (47.2%), brachiobasilic (22.4%), radiocephalic (15.5%), and prosthetic (12.6%). The patients with a TDC compared with those without a TDC were less likely to be obese (68.9% vs 54.2%), more likely to be homeless (10.4% vs 4.8%), and more likely to be an inpatient (44.6% vs 18.8%). They were less likely to have seen a primary care physician within 1 year preoperatively (54.3% vs 88.6%) and a nephrologist within 3 months preoperatively (39.3% vs 93%; P < .05 for all). On multivariable analysis, the presence of a TDC at initial AV access creation was associated with no nephrology visit within 3 months preoperatively (odds ratio [OR], 25; 95% confidence interval [CI], 12.5-50; P < .001), homeless status (OR, 2.6; 95% CI, 1.1-6.2; P = .03), and the absence of obesity (OR, 1.8; 95% CI, 1.1-2.9; P = .02). The 1-year survival was similar for patients with (95%) and without (94.8%) a TDC (P = .36) as confirmed by multivariable analysis (hazard ratio, 1.2; 95% CI, 0.65-2.1; P = .63).

Conclusions: The absence of a preoperative nephrology visit, homeless status, and the absence of obesity were associated with a TDC present at initial AV access creation. However, the presence of a TDC did not appear to confer changes in short-term survival. Targeted improvements in high-risk populations such as increasing the frequency of preoperative subspecialty evaluation might be warranted to reduce TDC placement before AV access creation at urban safety-net hospitals.
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http://dx.doi.org/10.1016/j.jvs.2020.09.020DOI Listing
October 2020

Effects of Timing on In-hospital and One-year Outcomes after TransCarotid Artery Revascularization.

J Vasc Surg 2020 Oct 7. Epub 2020 Oct 7.

University of California San Diego, San Diego, CA, USA. Electronic address:

Objective: Current recommendations are to perform carotid endarterectomy (CEA) within two weeks of symptoms due to superior long-term stroke prevention, although urgent CEA within 48-hours has been associated with increased perioperative stroke. With the development and rapid adoption of TransCarotid Artery Revascularization (TCAR), we aim to study the impact of timing on outcomes after TCAR.

Methods: Symptomatic patients undergoing TCAR in the Vascular Quality Initiative between September 2016 and November 2019 were stratified by time to procedure: urgent (TCAR within 48-hours), early (TCAR between 3-14 days after symptoms), and late (TCAR greater than 14 days after symptoms). Primary outcome was in-hospital rates of stroke/death and evaluated using logistic regression. Secondary outcome was one-year rate of recurrent ipsilateral stroke and mortality, analyzed using Kaplan Meier Survival Analysis.

Results: A total of 2608 symptomatic patients undergoing TCAR were included: 144 urgent (5.52%), 928 early (35.58%), and 1536 (58.90%) late. Patients undergoing urgent intervention had increased risk of in-hospital stroke/death that was driven primarily by increased risk of stroke. No differences were seen in in-hospital death. On adjusted analysis, urgent intervention had a 3-fold increased odds of stroke [OR:2.8, 95%CI:1.3-6.2, p=0.01] and a 3-fold increased odds of stroke/death [OR:2.9, 95%CI:1.3-6.4, p=0.01] when compared to late intervention. Patients undergoing early intervention had comparable risks of stroke [OR:1.3, 95%CI:0.7-2.3, p=0.40] and stroke/death [OR:1.2, 9%CI:0.7-2.1, p=0.48] when compared to late intervention. On subset analysis, the type of presenting symptoms was an effect modifier. Both patients presenting with stroke and patients presenting with transient ischemic attacks (TIA) or amaurosis fugax (AF) had increased risk of stroke/death when undergoing urgent compared to late TCAR: [OR:2.7, 95%CI:1.1-6.6, p=0.04] and [OR:4.1, 95%CI:1.1-15.0, p=0.03] respectively. However only patients presenting with TIA or AF had experienced increased risk of stroke when undergoing urgent compared to late TCAR: [OR:5.0, 95%CI:1.4-17.5, p<0.01]. At one-year follow-up, no differences were seen in recurrent ipsilateral stroke (urgent:0.7%, early:0.2%, late:0.1%, p=0.13) or post-discharge mortality (urgent:0.7%, early:1.6%, late:1.8%, p=0.71).

Conclusion: TCAR has a reduced incidence of stroke when performed 48-hours after onset of symptoms. Urgent TCAR within 48 hours of onset of stroke is associated with a three-fold increased risk of in-hospital stroke/death with no added benefit up to one year after the intervention. Further studies are needed on long-term outcomes of TCAR stratified by timing of the procedure.
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http://dx.doi.org/10.1016/j.jvs.2020.08.148DOI Listing
October 2020

Younger patients have worse outcomes after peripheral endovascular interventions for suprainguinal arterial occlusive disease.

J Vasc Surg 2020 Sep 26. Epub 2020 Sep 26.

Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical School, Pittsburgh, Pa. Electronic address:

Objective: The choice of intervention for treating suprainguinal arterial disease, open bypass vs endovascular intervention, is often tempered by patient age and comorbidities. In the present study, we compared the association of patient age with 1-year major adverse limb events (MALE)-free survival and reintervention-free survival (RFS) rates among patients undergoing intervention for suprainguinal arterial disease.

Methods: The Vascular Quality Initiative datasets for bypass and peripheral endovascular intervention (PVI; aorta and iliac only) were queried from 2010 to 2017. The patients were divided into two age groups: <60 and ≥60 years at the procedure. Age-stratified propensity matching of patients in bypass and endovascular procedure groups by demographic characteristics, comorbidities, and disease severity was used to identify the analysis samples. The 1-year MALE-free survival and RFS rates were compared using the log-rank test and Kaplan-Meier plots. Proportional hazard Cox regression was used to perform propensity score-adjusted comparisons of MALE-free survival and RFS.

Results: A total of 14,301 cases from the Vascular Quality Initiative datasets were included in the present study. Propensity matching led to 3062 cases in the ≥60-year group (1021 bypass; 2041 PVI) and 2548 cases in the <60-year group (1697 bypass; 851 PVI). In the crude comparison of the matched samples, the older patients undergoing bypass had had significantly greater in-hospital (4.6% vs 0.9%; P < .001) and 1-year (10.5% vs 7.5%; P = .005) mortality compared with those who had undergone endovascular intervention. The rates of MALE (7.5% vs 14.3%; P < .001) and reintervention (6.7% vs 12.7%; P < .001) or death were significantly higher for the younger group undergoing PVI than bypass at 1 year. However, the rates of MALE (12.9% vs 14.3%; P = .298) and reintervention (12.7% vs 12.9%; P = .881) or death for were similar both procedures for the older group. Both log-rank analyses and the adjusted propensity score analyses of MALE-free survival and RFS in the two age groups confirmed these findings. The adjusted comparison of outcomes using propensity score matching favored PVI at 1-year survival (hazard ratio, 1.4; 95% confidence interval, 1.1-1.9; P = .003) for the older group but was not different for the younger group (hazard ratio, 0.6; 95% confidence interval, 0.3-1.0; P = .054).

Conclusions: Among the patients aged <60 years undergoing intervention for suprainguinal arterial disease, the choice of therapy should be open surgical intervention given the higher risk of reintervention and MALE with endovascular intervention. Endovascular intervention should be favored for patients aged ≥60 years because of reduced perioperative mortality.
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http://dx.doi.org/10.1016/j.jvs.2020.08.139DOI Listing
September 2020

Novel bypass risk predictive tool is superior to the 5-Factor Modified Frailty Index in predicting postoperative outcomes.

J Vasc Surg 2020 10;72(4):1427-1435.e1

Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa. Electronic address:

Objective: This study aimed to develop risk predictive models of 30-day mortality, morbidity, and major adverse limb events (MALE) after bypass surgery for aortoiliac occlusive disease (AIOD) and to compare their performances with a 5-Factor Frailty Index.

Methods: The American College of Surgeons National Surgical Quality Improvement Program 2012-2017 Procedure Targeted Aortoiliac (Open) Participant Use Data Files were queried to identify all patients who had elective bypass for AIOD: femorofemoral bypass, aortofemoral bypass, and axillofemoral bypass (AXB). Outcomes assessed included mortality, major morbidity, and MALE within 30 days postoperatively. Major morbidity was defined as pneumonia, unplanned intubation, ventilator support for >48 hours, progressive or acute renal failure, cerebrovascular accident, cardiac arrest, or myocardial infarction. Demographics, comorbidities, procedure type, and laboratory values were considered for inclusion in the risk predictive models. Logistic regression models for mortality, major morbidity and MALE were developed. The discriminative ability of these models (C-indices) were compared with that of the 5-Factor Modified Frailty Index (mFI-5): a general frailty tool determined from diabetes, functional status, history of chronic obstructive pulmonary disease, history of congestive heart failure, and hypertension. Calculators were derived using the most significant variables for each of the three risk predictive models.

Results: A total of 2612 cases (mean age 65.0, 60% male) were identified, of which 1149 (44.0%) were femorofemoral bypass, 1138 (43.6%) were aortofemoral bypass, and 325 (12.4%) were axillofemoral bypass. Overall, the rates of mortality, major morbidity, and MALE were 2.0%, 8.5%, and 4.9%, respectively. Twenty preoperative risk factors were considered for incorporation in the risk tools. Apart from procedure type, age was the most statistically significant predictor of both mortality and morbidity. Preoperative anemia and critical limb ischemia were the most significant predictors of MALE. All three constructed models demonstrated significantly better discriminative ability (P < .001) on the outcomes of interest as compared with the mFI-5.

Conclusions: Our models outperformed the mFI-5 in predicting 30-day mortality, major morbidity, and adverse limb events in patients with AIOD undergoing elective bypass surgery. Calculators were created using the most statistically significant variables to help calculate individual patient's postoperative risks and allow for better informed consent and risk-adjusted comparison of provider outcomes.
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http://dx.doi.org/10.1016/j.jvs.2019.11.050DOI Listing
October 2020

Clinical diagnostic phenotypes in hospitalizations due to self-inflicted firearm injury.

J Affect Disord 2021 Jan 15;278:172-180. Epub 2020 Sep 15.

Department of Medicine and Community Health Sciences, Boston University, 72 E Concord St L-516, Boston, MA 02118, USA. Electronic address:

Background: . Hospitalized self-inflicted firearm injuries have not been extensively studied, particularly regarding clinical diagnoses at the index admission. The objective of this study was to discover the diagnostic phenotypes (DPs) or clusters of hospitalized self-inflicted firearm injuries.

Methods: . Using Nationwide Inpatient Sample data in the US from 1993 to 2014, we used International Classification of Diseases, Ninth Revision codes to identify self-inflicted firearm injuries among those ≥18 years of age. The 25 most frequent diagnostic codes were used to compute a dissimilarity matrix and the optimal number of clusters. We used hierarchical clustering to identify the main DPs.

Results: . The overall cohort included 14072 hospitalizations, with self-inflicted firearm injuries occurring mainly in those between 16 to 45 years of age, black, with co-occurring tobacco and alcohol use, and mental illness. Out of the three identified DPs, DP1 was the largest (n=10,110), and included most common diagnoses similar to overall cohort, including major depressive disorders (27.7%), hypertension (16.8%), acute post hemorrhagic anemia (16.7%), tobacco (15.7%) and alcohol use (12.6%). DP2 (n=3,725) was not characterized by any of the top 25 ICD-9 diagnoses codes, and included children and peripartum women. DP3, the smallest phenotype (n=237), had high prevalence of depression similar to DP1, and defined by fewer fatal injuries of chest and abdomen.

Limitations: . Claims data.

Conclusions: . There were three distinct diagnostic phenotypes in hospitalizations due to self-inflicted firearm injuries. Further research is needed to determine how DPs can be used to tailor clinical care and prevention efforts.
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http://dx.doi.org/10.1016/j.jad.2020.09.067DOI Listing
January 2021

Hospital-Level Medicaid Prevalence Is Associated with Increased Length of Stay after Asymptomatic Carotid Endarterectomy and Stenting Despite no Increase in Major Complications.

Ann Vasc Surg 2021 Feb 16;71:65-73. Epub 2020 Sep 16.

Center for Clinical Translational Epidemiology and Comparative Effectiveness Research, Preventative Medicine & Epidemiology, Department of Medicine, Boston University School of Medicine, Boston, MA.

Background: Length of stay (LOS) after carotid endarterectomy (CEA) and carotid artery stenting (CAS) for asymptomatic disease is used as a quality measure and affects hospital operating margins. Patient-level Medicaid status has traditionally been associated with longer hospital LOS. Our goal was to assess the association between hospital-level Medicaid prevalence and postoperative LOS after CEA and CAS.

Methods: The National Inpatient Sample was queried from 2006-2014 for CEA and CAS performed for asymptomatic carotid stenosis. Overall hospital-level Medicaid prevalence was divided into quartiles. The quartiles were further categorized into low Medicaid prevalence (LM) (lowest quartile), medium Medicaid prevalence (MM) (second and third quartiles), and high Medicaid prevalence (HM) (fourth quartile) cohorts. The primary outcome evaluated was postoperative LOS >1 day. The secondary outcomes included perioperative/in-hospital complications and mortality.

Results: There were 984,283 patients with asymptomatic carotid stenosis who underwent CEA (88%) or CAS (12%). Mean postoperative LOS after CEA at hospitals with LM, MM, and HM prevalence was 1.4 ± 1.5, 2.1 ± 2.5, and 2.2 ± 2.8 days (P = 0.0001), respectively, and after CAS were 1.7 ± 2.6, 1.8 ± 2.1, and 2 ± 2.6 days (P < 0.0001), respectively. After CEA, relative to LM prevalence, MM (OR 1.62, 95% CI 1.17-2.24) and HM (OR 1.66, 95% CI 1.2-2.28) prevalence were associated with a higher likelihood of LOS > 1 day (P = 0.009). After CAS, relative to LM prevalence, HM prevalence was associated with a higher likelihood of LOS >1 day (OR 1.42, 95% CI 1.06-1.91) (P = 0.003). After CEA, neurologic (0.8% vs. 0.9% vs. 0.9%, P = 0.83) and cardiac complications (0.9% vs. 1.2% vs. 1.2%, P = 0.24) were similar among hospitals with LM, MM, and HM prevalence, respectively. After CAS, the prevalence of neurological (1.1% vs. 1% vs. 1.2%, P = 0.42) and cardiac complications (2% vs. 1.3% vs. 1.5%, P = 0.46) were also similar. After both CEA and CAS, mortality was similar among Medicaid prevalence cohorts.

Conclusions: Higher hospital-level Medicaid prevalence was associated with longer LOS after CEA and CAS for asymptomatic carotid stenosis. Value-based payment models should adjust for hospital-level Medicaid prevalence to appropriately reimburse providers and hospital with higher Medicaid prevalence as well as investigate care pathways and systems improvement to help reduce LOS.
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http://dx.doi.org/10.1016/j.avsg.2020.09.008DOI Listing
February 2021

The Long-Term Implications of Access Complications during EVAR.

J Vasc Surg 2020 Sep 1. Epub 2020 Sep 1.

Division of Cardiac, Thoracic, and Vascular Surgery, NewYork-Presbyterian / Columbia University Irving Medical Center / Columbia University Vagelos College of Physicians & Surgeons, New York, NY 10032. Electronic address:

Background: Access issues are one of the most common complications of endovascular aneurysm repair (EVAR). However, contemporary rates as well as risk factors for complications and the subsequent impact of access complications on mortality are poorly described.

Methods: We studied all EVAR for intact AAA without prior aortic surgery in the Vascular Quality Initiative between 2011 and 2018. We studied factors associated with access complications (thrombosis, embolus, wound infection, hematoma, conversion to cutdown), as well as the interaction with female sex and the impact on survival using multilevel logistic regression and propensity weighting. Multiple imputation was used for missing data.

Results: There were 33,951 EVAR during the study period (91% elective, 9% symptomatic); most cases (70%) involved an attempt at percutaneous access on at least one side, with 30% bilateral cutdowns and 0.1% iliac conduits. 1,553 patients (4.6%) experienced at least one access complication. Access complications were almost twice as common in female patients (7.5% vs 3.9%, P<.001). The factors associated with access complications included female sex (OR 2.7 [2.0-3.6], P<.001), age (OR 1.05 per 5 years [1.02-1.1], P<.01), aortouniiliac device (OR 1.6 [1.1-2.3], P<.01), smoking (OR 1.4 [1.1-1.7], P<.01), BMI < 16 (OR 1.8 [1.3-2.5], P=.001), dual antiplatelet therapy (1.3 [1.02-1.6], P=.03), prior infrainguinal bypass (OR 1.8 [1.3-2.7], P<.01), and beta blocker usage (OR 1.2 [1.03-1.4], P=.02). Conversion from percutaneous access to open cutdown was associated with higher rates of complications than planned open cutdown (8.6% vs 2.9%, P<.001). In propensity-weighted analysis, percutaneous access was associated with significantly lower odds of access complications in women (OR 0.6 [0.4-0.96], P=.03). Patients who experienced an access complication had over four times the odds of perioperative death (OR 4.2 [2.5-7.1], P<.001), and 60% higher risk of long-term mortality (HR 1.6 [1.2-2.1], P=.001). In addition to death, patients with access site complications had higher rates of other major complications, including reoperation during the index hospitalization (19% vs 1.2%, P < .001), myocardial infarction (3.5% vs 0.7%, P < .001), stroke (0.8% vs 0.2%, P < .001), acute kidney injury (12% vs 3%, P < .001), and reintubation (5.7% vs 0.8%).

Conclusion: Although access complications are infrequent in the current era, they are associated with both perioperative and long-term morbidity and mortality. Female patients in particular are at high risk of access complications but may benefit from percutaneous access.
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http://dx.doi.org/10.1016/j.jvs.2020.08.033DOI Listing
September 2020

Prevalence and Outcomes of Endovascular Infrapopliteal Interventions for Intermittent Claudication.

Ann Vasc Surg 2021 Jan 29;70:79-86. Epub 2020 Aug 29.

Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL. Electronic address:

Background: Although endovascular peripheral vascular interventions (PVI) are typically limited to vessels above the knee in intermittent claudication (IC), some patients have concomitant or isolated infrapopliteal disease with IC. The benefits and risks of undergoing tibial intervention remain unclear in IC patients. The purpose of this study is to evaluate the prevalence and outcomes of infrapopliteal PVI for IC.

Methods: The Vascular Quality Initiative was queried for PVI procedures performed for IC between 2003 and 2018. Patients were divided into 3 groups: isolated femoropopliteal (FP), isolated infrapopliteal (IP), and combined above and below knee interventions (COM). Multivariable logistic regression models identified predictors of minor and major amputation, as well as freedom from reintervention. Kaplan-Meier plots estimate amputation-free survival.

Results: We identified 34,944 PVI procedures for IC. There were 31,110 (89.0%) FP interventions, 1,045 (3.0%) IP interventions, and 2,789 (8.0%) COM interventions. Kaplan-Meier plots of amputation-free survival revealed that patients with any IP intervention had significantly higher rates of both minor and major amputation (log rank <0.001). Freedom from reintervention at 1-year was 89.2% for the FP group, 91.3% for the IP group, and 85.3% for the COM group (P < 0.0001). In multivariable analysis, factors associated with an increased risk of major amputation included isolated IP intervention (OR 6.47, 95% CI, 6.45-6.49; P < 0.0001), COM interventions (OR 2.32, 95% CI, 2.31-2.33; P < 0.0001), dialysis dependence (OR 3.34, 95% CI, 3.33-3.35; P < 0.0001), CHF (OR 1.86, 95% CI, 1.85-1.86; P = 0.021) and, nonwhite race (OR 1.64, 95% CI, 1.63-1.64; P = 0.013).

Conclusions: PVI in the infrapopliteal vessels for IC is associated with higher amputation rates. This observation may suggest the need for more careful patient selection when performing PVI in patients with IC where disease extends into the infrapopliteal level.
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http://dx.doi.org/10.1016/j.avsg.2020.08.097DOI Listing
January 2021

Upper Arm Arteriovenous Grafts are Superior over Forearm Arteriovenous Grafts in Upper Extremity Dialysis Access.

Ann Vasc Surg 2021 Jan 29;70:131-136. Epub 2020 Jul 29.

Department of Surgery, University of Arizona, Tucson, AZ. Electronic address:

Background: In this study, we compared the outcomes of forearm arteriovenous grafts (AVGs) and upper arm AVGs in a large, prospectively collected data set, which represents real-world experience with upper extremity prosthetic dialysis access, to determine if there are clinically significant differences in the upper arm and forearm positions.

Methods: We identified 2,063 patients who received upper extremity AVGs within the Vascular Quality Initiative data set (2010-2018). Axillary to axillary upper arm AVGs were excluded (n = 394) from the analysis. The main outcome measures were primary and secondary patency rates at 12 months. Other outcomes were 6-month wound infection, steal syndrome, and arm swelling. The log-rank test was used to evaluate patency loss using a Kaplan-Meier analysis. Cox proportional hazards models were used to examine adjusted association between locations (forearm and upper arm) and outcomes.

Results: There were 1,160 forearm AVGs and 509 upper arm brachial artery AVGs in the study cohort. Patients with forearm AVGs were more likely to have a body mass index > 30 (45% vs. 38%, P = 0.013), no history of previous access (73% vs. 63%, P < 0.001), and underwent local-regional anesthesia (56% vs. 43%, P < 0.001). The 12-month primary patency (51.5% vs. 62.9%, P < 0.001) and secondary patency (76.4% vs. 89.1%, P < 0.001) were significantly lower for forearm AVGs. Wound infection, steal syndrome, and arm swelling were similar between forearm AVGs and upper arm AVGs at the 6-month follow-up. In multivariable analysis, the primary patency loss (adjusted hazard ratio (aHR) 1.66, 95% confidence interval (CI) 1.33-2.01, P < 0.001) and 12-month secondary patency loss (aHR 2.71, 95% CI 1.84-3.98, P < 0.001) were significantly higher for forearm AVGs at 12 months.

Conclusions: From this observational study of the Vascular Quality Initiative data set, the primary and secondary patency rates were superior for upper arm brachial artery AVGs compared with forearm AVGs.
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http://dx.doi.org/10.1016/j.avsg.2020.07.009DOI Listing
January 2021

Reasons for long-term tunneled dialysis catheter use and associated morbidity.

J Vasc Surg 2021 Feb 21;73(2):588-592. Epub 2020 Jul 21.

Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Mass. Electronic address:

Objective: Tunneled dialysis catheters (TDCs) are generally used as a temporary means to provide hemodialysis until permanent arteriovenous (AV) access is established. However, some patients may have long-term catheter-based hemodialysis because of the lack of alternatives for other dialysis access. Our objective was to evaluate characteristics of patients with, reasons for, and mortality associated with long-term TDC use.

Methods: A retrospective single-institution analysis was performed. Long-term TDC use was defined as >180 days without more than a 7-day temporary removal time. Reasons for long-term TDC use and complications were recorded. Summary statistics were performed. Kaplan-Meier analysis compared mortality between patients with long-term TDC use and a comparison cohort who underwent AV access creation with subsequent TDC removal.

Results: We identified 50 patients with long-term TDC use from 2013 to 2018. The average age was 63 years, 44% were male, and 76% were African American. Previous TDC use was found in 42% of patients with subsequent removal after alternative access was established. Median TDC duration was 333 days (range, 185-2029 days). The primary reasons for long-term TDC use were failed (occluded) AV access (34%), nonmaturing AV (nonoccluded) access (32%), delayed AV access placement (14%), no AV access options (10%), patient refusal for AV access placement (6%), and medically high risk for AV access placement (4%). In 46% of patients, TDC complications including central venous stenosis (33.4%), TDC-related infections (29.6%), TDC displacement (27.8%), and thrombosis (7.9%) occurred. Overall, 47.6% required a catheter exchange during the prolonged TDC period. The majority (76.4%) had the catheter removed because of established alternative access during follow-up. The long-term TDC group, in relation to the comparator group (n = 201), had fewer male patients (44% vs 61.2%; P = .028) and higher proportion of congestive heart failure (66% vs 40.3%; P = .001). Kaplan-Meier analysis showed no significant difference in survival at 24 months for the long-term TDC group compared with the comparator group (93.6% vs 92.7%; P = .28).

Conclusions: Patients with long-term TDCs experienced significant TDC-related morbidity. Whereas permanent access is preferable, some patients may require long-term TDC use because of difficulty in establishing a permanent access, limited access options, and patient preference. There was no difference in survival between the groups.
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http://dx.doi.org/10.1016/j.jvs.2020.06.121DOI Listing
February 2021

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

J Vasc Surg 2021 Feb 21;73(2):564-571.e1. Epub 2020 Jul 21.

Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass. Electronic address:

Objective: Given that intermittent claudication (IC) rarely progresses to chronic limb-threatening ischemia and limb loss, safety and durability of elective interventions for IC are essential. Whether patients with IC benefit from tibial intervention is controversial, and data supporting its utility are limited. Despite endovascular therapy expansion, surgical bypass is still commonly performed. We sought to assess outcomes of bypass to tibial arteries for IC.

Methods: The Vascular Quality Initiative (2003-2018) was queried for infrainguinal bypasses performed for IC. Perioperative and 1-year outcomes were compared between bypasses constructed to tibial and popliteal arteries.

Results: Of 5347 infrainguinal bypasses, 1173 (22%) and 4184 (78%) were tibial and popliteal bypasses, respectively. Overall, mean age was 65 ± 10 years, and patients were often men (72%) and current smokers (42%). Tibial bypasses commonly targeted posterior tibial (40%), tibioperoneal trunk (23%), and anterior tibial (19%) arteries. Great saphenous vein was more often used for tibial bypass than for popliteal bypass (78% vs 54%; P < .001). Patients undergoing tibial compared with popliteal bypass more often had impaired ambulation and prior ipsilateral bypasses and were less often taking antiplatelets and statins (all P < .05). In the perioperative period, tibial bypass patients had longer postoperative length of stay (4.5 ± 3.5 vs 3.5 ± 2.8 days), more pulmonary complications (1.3% vs 0.6%), and higher return to the operating room (7% vs 4%; all P < .05). Perioperative myocardial infarction (1.2% vs 0.8%; P = .19), stroke (0.4% vs 0.4%; P = .91), and mortality (0.3 vs 0.3%; P = .86) rates were similar between the cohorts. At 1 year, tibial compared with popliteal bypasses exhibited lower freedom from occlusion/death (81% vs 89%; P < .001), ipsilateral major amputation/death (90% vs 94%; P < .001), and reintervention/amputation/death (73% vs 80%; P < .001), but patient survival was similar (96% vs 97%; P = .07). On multivariable analysis, tibial compared with popliteal bypass was independently associated with increased occlusion/death (hazard ratio [HR], 1.65; 95% confidence interval [CI], 1.28-2.11; P < .001), major ipsilateral amputation/death (HR, 1.6; 95% CI, 1.12-2.19; P = .003), and ipsilateral reintervention/amputation/death (HR, 1.51; 95% CI, 1.28-1.79; P < .001), with similar patient survival.

Conclusions: In patients with IC, tibial bypass was associated with poor outcomes, including major amputation. Surgeons should exhaust nonoperative therapies and present realistic outcome expectations to their patients before offering such intervention.
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February 2021

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

J Vasc Surg 2021 Feb 21;73(2):564-571.e1. Epub 2020 Jul 21.

Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass. Electronic address:

Objective: Given that intermittent claudication (IC) rarely progresses to chronic limb-threatening ischemia and limb loss, safety and durability of elective interventions for IC are essential. Whether patients with IC benefit from tibial intervention is controversial, and data supporting its utility are limited. Despite endovascular therapy expansion, surgical bypass is still commonly performed. We sought to assess outcomes of bypass to tibial arteries for IC.

Methods: The Vascular Quality Initiative (2003-2018) was queried for infrainguinal bypasses performed for IC. Perioperative and 1-year outcomes were compared between bypasses constructed to tibial and popliteal arteries.

Results: Of 5347 infrainguinal bypasses, 1173 (22%) and 4184 (78%) were tibial and popliteal bypasses, respectively. Overall, mean age was 65 ± 10 years, and patients were often men (72%) and current smokers (42%). Tibial bypasses commonly targeted posterior tibial (40%), tibioperoneal trunk (23%), and anterior tibial (19%) arteries. Great saphenous vein was more often used for tibial bypass than for popliteal bypass (78% vs 54%; P < .001). Patients undergoing tibial compared with popliteal bypass more often had impaired ambulation and prior ipsilateral bypasses and were less often taking antiplatelets and statins (all P < .05). In the perioperative period, tibial bypass patients had longer postoperative length of stay (4.5 ± 3.5 vs 3.5 ± 2.8 days), more pulmonary complications (1.3% vs 0.6%), and higher return to the operating room (7% vs 4%; all P < .05). Perioperative myocardial infarction (1.2% vs 0.8%; P = .19), stroke (0.4% vs 0.4%; P = .91), and mortality (0.3 vs 0.3%; P = .86) rates were similar between the cohorts. At 1 year, tibial compared with popliteal bypasses exhibited lower freedom from occlusion/death (81% vs 89%; P < .001), ipsilateral major amputation/death (90% vs 94%; P < .001), and reintervention/amputation/death (73% vs 80%; P < .001), but patient survival was similar (96% vs 97%; P = .07). On multivariable analysis, tibial compared with popliteal bypass was independently associated with increased occlusion/death (hazard ratio [HR], 1.65; 95% confidence interval [CI], 1.28-2.11; P < .001), major ipsilateral amputation/death (HR, 1.6; 95% CI, 1.12-2.19; P = .003), and ipsilateral reintervention/amputation/death (HR, 1.51; 95% CI, 1.28-1.79; P < .001), with similar patient survival.

Conclusions: In patients with IC, tibial bypass was associated with poor outcomes, including major amputation. Surgeons should exhaust nonoperative therapies and present realistic outcome expectations to their patients before offering such intervention.
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February 2021

Managing central venous access during a health care crisis.

Authors:
Tristen T Chun Dejah R Judelson David Rigberg Peter F Lawrence Robert Cuff Sherene Shalhub Max Wohlauer Christopher J Abularrage Papapetrou Anastasios Shipra Arya Bernadette Aulivola Melissa Baldwin Donald Baril Carlos F Bechara William E Beckerman Christian-Alexander Behrendt Filippo Benedetto Lisa F Bennett Kristofer M Charlton-Ouw Amit Chawla Matthew C Chia Sungsin Cho Andrew M T L Choong Elizabeth L Chou Anastasiadou Christiana Raphael Coscas Giovanni De Caridi Sharif Ellozy Yana Etkin Peter Faries Adrian T Fung Andrew Gonzalez Claire L Griffin London Guidry Nalaka Gunawansa Gary Gwertzman Daniel K Han Caitlin W Hicks Carlos A Hinojosa York Hsiang Nicole Ilonzo Lalithapriya Jayakumar Jin Hyun Joh Adam P Johnson Loay S Kabbani Melissa R Keller Manar Khashram Issam Koleilat Bernard Krueger Akshay Kumar Cheong Jun Lee Alice Lee Mark M Levy C Taylor Lewis Benjamin Lind Gabriel Lopez-Pena Jahan Mohebali Robert G Molnar Nicholas J Morrissey Raghu L Motaganahalli Nicolas J Mouawad Daniel H Newton Jun Jie Ng Leigh Ann O'Banion John Phair Zoran Rancic Ajit Rao Hunter M Ray Aksim G Rivera Limael Rodriguez Clifford M Sales Garrett Salzman Mark Sarfati Ajay Savlania Andres Schanzer Mel J Sharafuddin Malachi Sheahan Sammy Siada Jeffrey J Siracuse Brigitte K Smith Matthew Smith Ina Soh Rebecca Sorber Varuna Sundaram Scott Sundick Tadaki M Tomita Bradley Trinidad Shirling Tsai Ageliki G Vouyouka Gregory G Westin Michael S Williams Sherry M Wren Jane K Yang Jeniann Yi Wei Zhou Saqib Zia Karen Woo

J Vasc Surg 2020 Oct 15;72(4):1184-1195.e3. Epub 2020 Jul 15.

Division of Vascular Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, Calif. Electronic address:

Objective: During the COVID-19 pandemic, central venous access line teams were implemented at many hospitals throughout the world to provide access for critically ill patients. The objective of this study was to describe the structure, practice patterns, and outcomes of these vascular access teams during the COVID-19 pandemic.

Methods: We conducted a cross-sectional, self-reported study of central venous access line teams in hospitals afflicted with the COVID-19 pandemic. To participate in the study, hospitals were required to meet one of the following criteria: development of a formal plan for a central venous access line team during the pandemic; implementation of a central venous access line team during the pandemic; placement of central venous access by a designated practice group during the pandemic as part of routine clinical practice; or management of an iatrogenic complication related to central venous access in a patient with COVID-19.

Results: Participants from 60 hospitals in 13 countries contributed data to the study. Central venous line teams were most commonly composed of vascular surgery and general surgery attending physicians and trainees. Twenty sites had 2657 lines placed by their central venous access line team or designated practice group. During that time, there were 11 (0.4%) iatrogenic complications associated with central venous access procedures performed by the line team or group at those 20 sites. Triple lumen catheters, Cordis (Santa Clara, Calif) catheters, and nontunneled hemodialysis catheters were the most common types of central venous lines placed by the teams. Eight (14%) sites reported experience in placing central venous lines in prone, ventilated patients with COVID-19. A dedicated line cart was used by 35 (59%) of the hospitals. Less than 50% (24 [41%]) of the participating sites reported managing thrombosed central lines in COVID-19 patients. Twenty-three of the sites managed 48 iatrogenic complications in patients with COVID-19 (including complications caused by providers outside of the line team or designated practice group).

Conclusions: Implementation of a dedicated central venous access line team during a pandemic or other health care crisis is a way by which physicians trained in central venous access can contribute their expertise to a stressed health care system. A line team composed of physicians with vascular skill sets provides relief to resource-constrained intensive care unit, ward, and emergency medicine teams with a low rate of iatrogenic complications relative to historical reports. We recommend that a plan for central venous access line team implementation be in place for future health care crises.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7362805PMC
October 2020

Natural History of Non-operative Management in Asymptomatic Patients with 70%-80% Internal Carotid Artery Stenosis by Duplex Criteria.

Eur J Vasc Endovasc Surg 2020 Sep 11;60(3):339-346. Epub 2020 Jul 11.

Division of Vascular and Endovascular Surgery, Boston Medical Centre, Boston University School of Medicine, Boston, MA, USA. Electronic address:

Objective: Treatment of asymptomatic internal carotid artery (ICA) stenosis, particularly for moderate to severe (70%-80%) disease, is controversial. The goal was to assess the clinical course of patients with moderate to severe carotid stenosis.

Methods: A single institution retrospective analysis of patients with asymptomatic ICA stenosis identified on duplex ultrasound as moderate to severe (70%-80%) from 2003 to 2018 were analysed. Duplex criteria for 70%-80% stenosis was a systolic velocity of ≥325 cm/s or an ICA:common carotid artery ratio of ≥4, and an end diastolic velocity of <140 cm/s. Asymptomatic status was defined as no stroke/transient ischaemic attack (TIA) within six months of index duplex. Primary outcomes were progression of stenosis to >80%, ipsilateral stroke/TIA without documented progression, and death.

Results: In total, 206 carotid arteries were identified in 182 patients meeting the inclusion criteria. Mean patient age was 71.5 years, 57.7% were male, and 67% were white. There were 19 stenoses removed from analysis except for survival analysis as they initially underwent carotid endarterectomy or carotid artery stent based on surgeon/patient preference. Documented progression occurred in 24.1% of stenoses. There were 5.3% of stenoses associated with an ipsilateral stroke/TIA without documented progression, which occurred at a mean of 26.4 months. Kaplan-Meier analysis demonstrated a 60.3% five year freedom from stenosis progression, 92.5% five year freedom from stroke/TIA without documented progression, and 83.7% five year survival. Risk factors associated with stroke/TIA without documented progression at five years were atrial fibrillation (hazard ratio [HR] 14.87, 95% confidence interval [CI] 2.72-81.16; p = .002) and clopidogrel use at index duplex (HR 6.19, 95% CI 1.33-28.83; p = .020). Risk factors associated with death at five years were end stage renal disease (HR 9.67, 95% CI 2.05-45.6; p = .004), atrial fibrillation (HR 7.55, 95% CI 2.48-23; p < .001), prior head/neck radiation (HR 6.37, 95% CI 1.39-29.31; p = .017), non-obese patients (HR 5.49, 95% CI 1.52-20; p = .009), and non-aspirin use at index duplex (HR 3.05, 95% CI 1.12-8.33; p = .030).

Conclusion: Patients with asymptomatic moderate to severe carotid stenosis had a low rate of stroke/TIA without documented progression. However, there was a high rate of stenosis progression reinforcing the need to follow these patients closely.
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September 2020

Access Type for Endovascular Repair in Ruptured Abdominal Aortic Aneurysms Does Not Affect Major Morbidity or Mortality.

Ann Vasc Surg 2021 Jan 10;70:181-189. Epub 2020 Jul 10.

Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA. Electronic address:

Background: There are limited data on access type when treating ruptured abdominal aortic aneurysms (AAAs) with endovascular aneurysm repair (EVAR). Our study's objective was to evaluate if the type of access in ruptured AAAs affected outcomes.

Methods: The Vascular Quality Initiative was queried from 2009 to 2018 for all ruptured AAAs treated with an index EVAR. Procedures were grouped by access type: percutaneous, open, and failed percutaneous that converted to open access. Patients with iliac access, both percutaneous and open access, and concurrent bypass were excluded. Baseline characteristics, procedure details, and outcomes were collected. Univariable and multivariable analyses were performed.

Results: There were 1,206 ruptured AAAs identified-739 (61.3%) was performed by percutaneous access, 416 (34.5%) by open access, and 51 (4.2%) by failed percutaneous that converted to open access. Percutaneous access, compared with open access and failed percutaneous access, respectively, had the shortest operative time (min, median) (111 vs. 138 vs. 180, P < 0.001) and was most often performed under local anesthesia (16.7% vs. 5% vs. 9.8%, P < 0.001). The amount of contrast used was similar between the approaches. Univariable analysis comparing percutaneous access, open access, and failed percutaneous access showed differences in 30-day mortality (19.9% vs. 24.8% vs. 39.2%, P = 0.002), postoperative complications (33.7% vs. 40.2% vs. 54%, P = 0.003), and cardiac complications (18.2% vs. 19.8% vs. 34.7%, P = 0.018). However, multivariable analysis did not show access type to have a significant effect on cardiac complications, pulmonary complications, any complications, return to the operating room, or perioperative mortality. Open access was independently associated with a prolonged length of stay (means ratio 1.17, 95% confidence interval (CI) 1.04-1.33, P = 0.012). Factors independently associated with failed percutaneous were prior bypass (odds ratio (OR) 9.77, 95% CI 2.44-39.16, P = 0.001) and altered mental status (OR 2.45, 95% CI 1.17-5.15, P = 0.018).

Conclusions: Access type for ruptured AAAs was not independently associated with major morbidity or mortality but did have a differential effect on length of stay. Access during these emergent procedures should be based on surgeon preference and experience.
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http://dx.doi.org/10.1016/j.avsg.2020.07.004DOI Listing
January 2021