Publications by authors named "Livia de Guerre"

15 Publications

  • Page 1 of 1

Racial Differences in Isolated Aortic, Concomitant Aortoiliac, and Isolated Iliac Aneurysms: This is a Retrospective Observational Study.

Ann Surg 2020 Dec 29. Epub 2020 Dec 29.

*The Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA †The Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands ‡The Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA §The Department of Surgery, Howard University and Hospital, Washington, D.C.

Objective: Our aim was to describe the racial and ethnic differences in presentation, baseline and operative characteristics, and outcomes after aortoiliac aneurysm repair.

Summary Of Background Data: Previous studies have demonstrated racial and ethnic differences in prevalence of abdominal aortic aneurysms and showed more complex iliac anatomy in Asian patients.

Methods: We identified all White, Black, Asian, and Hispanic patients undergoing aortoiliac aneurysm repair in the VQI from 2003 to 2019. We compared baseline comorbidities, operative characteristics, and perioperative outcomes by race and ethnicity.

Results: In our 60,435 patient cohort, Black patients, followed by Asian patients, were most likely to undergo repair for aortoiliac (W:23%, B:38%, A:31%, H:22%, P < 0.001) and isolated iliac aneurysms (W:1.0%, B:3.1%, A:1.5%, H:1.6%, P < 0.001), and White and Hispanic patients were most likely to undergo isolated aortic aneurysm repair (W:76%, B:59%, A:68%, H:76%, P < 0.001). Black patients were more likely to undergo symptomatic repair and underwent rupture repair at a smaller aortic diameter. The iliac aneurysm diameter was largest in Black and Asian patients. Asian patients were most likely to have aortic neck angulation above 60 degree, graft oversizing above 20%, and completion endoleaks. Also, Asian patients were more likely to have a hypogastric artery aneurysm and to undergo hypogastric coiling.

Conclusion: Asian and Black patients were more likely to undergo repair for aortoiliac and isolated iliac aneurysms compared to White and Hispanic patients who were more likely to undergo repair for isolated aortic aneurysms. Moreover, there were significant racial differences in the demographics and anatomic characteristics that could be used to inform operative approach and device development.
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http://dx.doi.org/10.1097/SLA.0000000000004731DOI Listing
December 2020

Epidemiology of Endovascular and Open Repair for Abdominal Aortic Aneurysms in the United States from 2004-2015 and Implications for Screening.

J Vasc Surg 2021 Feb 13. Epub 2021 Feb 13.

Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston MA. Electronic address:

Introduction: Contemporary national trends in repair of ruptured abdominal aortic aneurysms and intact abdominal aortic aneurysms are relatively unknown. Furthermore, screening is only covered for patient's 65 to 75 years old with a family history or men with a smoking history. It is unclear what proportion of patients who present with a ruptured aneurysm would have been candidates for screening.

Methods: Using the National Inpatient Sample from 2004 to 2015, we identified rupture and intact AAA admissions and repairs based on International Classification of Diseases codes. We generated the screening eligible cohort using previously identified proportions of male smokers (87%) and all patients with a family history of aneurysm (10%) and applied these proportions to patients aged 65-75. We accounted for those who may have had a prior AAA diagnosis (17%) either from screening or incidental detection in patients over age 75 presenting with rupture. The primary outcomes were treatment and in-hospital mortality stratified by patients meeting criteria for screening versus those who did not.

Results: We evaluated 65,125 admissions for ruptured AAA and 461,191 repairs for intact AAA. Overall, an estimated 45,037 (68%) of patients admitted and 25,777 (59%) of patients undergoing repair for ruptured AAA did not meet criteria for screening. Of the patients who did not qualify; 27,653 (63%) were older than 75 years old; 10,603 (24%) were younger than 65 years old; and 16,103 (36%) were females. EVAR use increased for ruptured AAA from 10% in 2004 to 55% in 2015 (P<0.001) with an operative mortality of 35%, and for intact AAA from 45% in 2004 to 83% in 2015 (P<0.001) with an operative mortality of 2.0%.

Conclusions: The majority of patients who underwent repair for ruptured AAA did not qualify for screening. EVAR is the primary treatment for both ruptured AAA and intact AAA with a relatively low in-hospital mortality. Therefore, expansion of screening criteria to include selected women and a wider age range should be considered.
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http://dx.doi.org/10.1016/j.jvs.2021.01.044DOI Listing
February 2021

Association Between Intraoperative Hypotension and Postoperative Adverse Outcomes in Patients Undergoing Vascular Surgery - A Retrospective Observational Study.

J Cardiothorac Vasc Anesth 2020 Nov 5. Epub 2020 Nov 5.

Center for Anesthesia Research Excellence (CARE), Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. Electronic address:

Objective: Intraoperative hypotension (IOH) is associated with adverse outcomes. It could be challenging to define IOH in vascular surgical patients with increased baseline blood pressure (BP). The authors studied the relationship between (1) absolute and relative BP thresholds of IOH, (2) preoperative pulse pressure (PP) and isolated systolic hypertension, and (3) endovascular versus open surgical approach with adverse outcomes in vascular surgical patients.

Design: Retrospective observational study.

Setting: Teaching hospital.

Patients: A total of 566 vascular surgical patients from 2011 to 2018.

Intervention: None.

Measurements And Main Results: BP thresholds were as follows: IOH - absolute mean arterial pressure (MAP) <65 mmHg, relative MAP >20% decrease from baseline, preoperative PP hypertension - PP >40 mmHg, isolated systolic hypertension - baseline systolic BP ≥140 mmHg with diastolic BP <90 mmHg. Thresholds were characterized by (1) total duration and (2) area under the curve. Primary outcome was a composite of postoperative in-hospital complications (acute kidney injury, stroke, myocardial infarction, congestive heart failure, and mortality). Forty-six (8.1%) patients had in-hospital complications. Only IOH duration-MAP <65 mmHg (odds ratio 1.01; 95% confidence interval 1.00-1.02; p = 0.004) was significantly associated with outcome. No associations were found with MAP >20% decrease from baseline and preoperative BP. Significant interaction was observed with the surgical approach and outcome (p = 0.031), which was stronger after 60 minutes of IOH in endovascular approach.

Conclusion: Longer periods of IOH (MAP <65 mmHg for >60 minutes) during endovascular surgery were associated with adverse outcomes. Relative fall in BP from baseline, preoperative isolated systolic, and PP hypertension were not associated with postoperative complications.
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http://dx.doi.org/10.1053/j.jvca.2020.11.005DOI Listing
November 2020

A comparison of administrative data and quality improvement registries for abdominal aortic aneurysm repair.

J Vasc Surg 2021 Mar 16;73(3):874-888. Epub 2020 Jul 16.

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

Objective: Databases are essential in evaluating surgical outcomes and gauging the implementation of new techniques. However, there are important differences in how data from administrative databases and surgical quality improvement (QI) registries are collected and interpreted. Therefore, we aimed to compare trends, demographics, and outcomes of open and endovascular abdominal aortic aneurysm (AAA) repair in an administrative database and two QI registries.

Methods: We identified patients undergoing open and endovascular repair of intact and ruptured AAAs between 2012 and 2015 within the National Inpatient Sample (NIS), the National Surgical Quality Improvement Program (NSQIP), and the Vascular Quality Initiative (VQI). We described the differences and trends in overall AAA repairs for each data set. Moreover, patient demographics, comorbidities, mortality, and complications were compared between the data sets using Pearson χ test.

Results: A total of 140,240 NIS patients, 10,898 NSQIP patients, and 26,794 VQI patients were included. Ruptured repairs composed 8.7% of NIS, 11% of NSQIP, and 7.9% of VQI. Endovascular aneurysm repair (EVAR) rates for intact repair (range, 83%-84%) and ruptured repair (range, 51%-59%) were similar in the three databases. In general, rates of comorbidities were lower in NIS than in the QI registries. After intact EVAR, in-hospital mortality rates were similar in all three databases (NIS 0.8%, NSQIP 1.0%, and VQI 0.8%; P = .06). However, after intact open repair and ruptured repair, in-hospital mortality was highest in NIS and lowest in VQI (intact open: NIS 5.4%, NSQIP 4.7%, and VQI 3.5% [P < .001]; ruptured EVAR: NIS 24%, NSQIP 20%, and VQI 16% [P < .001]; ruptured open: NIS 36%, NSQIP 31%, and VQI 26% [P < .001]). After stratification by intact and ruptured presentation and repair strategy, several discrepancies in morbidity rates remained between the databases. Overall, the number of cases in NSQIP represents 7% to 8% of the repairs in NIS, and the number of cases in VQI grew from 12% in 2012 to represent 23% of the national sample in 2015.

Conclusions: NIS had the largest number of patients as it represents the nationwide experience and is an essential tool to evaluate trends over time. The lower in-hospital mortality seen in NSQIP and VQI questions the generalizability of the studies that use these QI registries. However, with a growing number of hospitals engaging in granular QI initiatives, these QI registries provide a valuable resource to potentially improve the quality of care provided to all patients.
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http://dx.doi.org/10.1016/j.jvs.2020.06.105DOI Listing
March 2021

Protamine use in transfemoral carotid artery stenting is not associated with an increased risk of thromboembolic events.

J Vasc Surg 2021 Jan 12;73(1):142-150.e4. Epub 2020 Jun 12.

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

Background: Protamine use in carotid endarterectomy has been shown to be associated with fewer perioperative bleeding complications without higher rates of thromboembolic events. However, the effect of protamine use on complications after transfemoral carotid artery stenting (CAS) is unclear, and concerns remain about thromboembolic events.

Methods: A retrospective review was performed for patients undergoing transfemoral CAS in the Vascular Quality Initiative from March 2005 to December 2018. We assessed in-hospital outcomes using propensity score-matched cohorts of patients who did and did not receive protamine. The primary outcome was in-hospital stroke or death. Secondary outcomes included bleeding complications, stroke, death, transient ischemic attack, myocardial infarction, and congestive heart failure exacerbation. Bleeding complications were categorized as bleeding resulting in intervention or blood transfusions.

Results: Of the 17,429 patients undergoing transfemoral CAS, 2697 (15%) patients received protamine. We created 2300 propensity score-matched pairs of patients who did and did not receive protamine. There were no statistically significant differences in stroke or death between the two cohorts (protamine, 2.5%; no protamine, 2.9%; relative risk [RR], 0.85; 95% confidence interval [CI], 0.60-1.21; P = .37). Protamine use was not associated with statistically significant differences in perioperative bleeding complications resulting in interventional treatment (0.9% vs 0.5%; RR, 2.10; 95% CI, 0.99-4.46; P = .05) or blood transfusion (1.2% vs 1.2%; RR, 0.92; 95% CI, 0.53-1.61; P = .78). There were also no statistically significant differences for the individual outcomes of stroke (1.8% vs 2.3%; RR, 0.78; 95% CI, 0.52-1.16; P = .22), death (0.9% vs 0.8%; RR, 1.17; 95% CI, 0.62-2.19; P = .63), transient ischemic attack (1.4% vs 1.3%; RR, 1.10; 95% CI, 0.67-1.82; P = .70), myocardial infarction (0.5% vs 0.4%; RR, 1.20; 95% CI, 0.52-2.78; P = .67), or heart failure exacerbation (1.0% vs 0.9%; RR, 1.05; 95% CI, 0.58-1.90; P = .88). Protamine use in patients presenting with symptomatic carotid stenosis was associated with lower risk of stroke or death (3.0% vs 4.3%; RR, 0.69; 95% CI, 0.47-0.998; P = .048), whereas there were no statistically significant differences in stroke or death with protamine use in asymptomatic patients (1.6% vs 1.0%; RR, 1.63; 95% CI, 0.67-3.92; P = .28).

Conclusions: Heparin reversal with protamine after transfemoral CAS is not associated with an increased risk of thromboembolic events, and its use in symptomatic carotid disease is associated with a lower risk of stroke or death.
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http://dx.doi.org/10.1016/j.jvs.2020.04.526DOI Listing
January 2021

Thoracic Endovascular Aortic Repair With Left Subclavian Artery Coverage Is Associated With a High 30-Day Stroke Incidence With or Without Concomitant Revascularization.

J Endovasc Ther 2020 10 21;27(5):769-776. Epub 2020 May 21.

Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

To evaluate the perioperative stroke incidence following thoracic endovascular aortic repair (TEVAR) with differing left subclavian artery (LSA) coverage and revascularization approaches in a real-world setting of a nationwide clinical registry. The National Surgical Quality Improvement Program registry was interrogated from 2005 to 2017 to identify all nonemergent TEVAR and/or open LSA revascularization procedures. In this time frame, 2346 TEVAR cases met the selection criteria for analysis. The 30-day stroke incidence was compared between patients undergoing TEVAR with (n=888) vs without (n=1458) LSA coverage, for those with (n=228) vs without (n=660) concomitant LSA revascularization among those with coverage, and following isolated LSA revascularization for occlusive disease (n=768). Multivariable logistic regression was employed for risk-adjusted analyses and to identify factors associated with stroke following TEVAR. Results of the regression analyses are presented as the adjusted odds ratio (OR) with 95% confidence interval (CI). The stroke incidence was 2.3% following TEVAR without vs 5.2% with LSA coverage (p<0.001). In TEVARs with LSA coverage, the stroke incidence was 7.5% when the LSA was concomitantly revascularized and 4.4% without concomitant revascularization, while stroke occurred in 0.5% of isolated LSA revascularizations. Of 33 TEVAR patients experiencing a perioperative stroke, 8 (24%) died within 30 days. LSA coverage was associated with stroke both with concomitant revascularization (OR 4.0, 95% CI 2.2 to 7.5, p<0.001) and without concomitant revascularization (OR 2.2, 95% CI 1.3 to 3.8, p=0.002). Other preoperative factors associated with stroke were dyspnea (OR 1.8, 95% CI 1.1 to 3.0, p=0.014), renal dysfunction (OR 2.2, 95% CI 1.0 to 3.8, p=0.049), and international normalized ratio ≥2.0 (OR 3.6, 95% CI 1.0 to 13, p=0.045). Stroke following TEVAR with LSA coverage occurs frequently in the real-world setting, and concurrent LSA revascularization was not associated with a lower stroke incidence.
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http://dx.doi.org/10.1177/1526602820923044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7804158PMC
October 2020

Stroke rate after endovascular aortic interventions in the Society for Vascular Surgery Vascular Quality Initiative.

J Vasc Surg 2020 11 2;72(5):1593-1601. Epub 2020 Apr 2.

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

Objective: The stroke rate after endovascular aneurysm repair (EVAR), particularly complex EVAR such as fenestrated EVAR (FEVAR) and chimney EVAR (chEVAR), is not well defined. Whereas stroke is a well-established risk of thoracic endovascular aortic repair (TEVAR), the impact of procedural characteristics on stroke remains unclear. Therefore, we characterized the risk of stroke after endovascular aortic interventions in the Vascular Quality Initiative database and identified procedural characteristics associated with stroke.

Methods: We performed a retrospective cohort study of patients undergoing infrarenal EVAR, complex EVAR, and TEVAR within the Vascular Quality Initiative between 2011 and 2019. Complex EVAR included FEVAR (with either a Food and Drug Administration-approved custom-manufactured device or physician-modified endovascular graft) and chEVAR. We excluded emergent procedures. The primary outcome was in-hospital stroke. We used multivariable logistic regression to identify procedural characteristics associated with stroke.

Results: We identified 41,540 EVARs, 1371 complex EVARs, and 4600 TEVARs. The in-hospital stroke rate was 0.1% after EVAR, 0.9% after complex EVAR, and 2.9% after TEVAR. In patients undergoing EVAR, aneurysm diameter >6.5 mm (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.1-2.7; P = .03) and use of a proximal extension cuff (OR, 3.3; 95% CI, 1.4-7.9; P < .01) were independently associated with stroke. Among complex EVARs, stroke rate was 0.7% after FEVAR with a custom-manufactured device, 0.4% after FEVAR with a physician-modified endovascular graft, and 2.1% after chEVAR (P = .08). In multivariable analysis, arm access was associated with 8.4-fold higher odds of stroke (95% CI, 1.7-41; P < .01). Whereas chEVAR was associated with higher odds of stroke in crude analysis, this association did not persist after adjustment for arm access (OR, 1.0; 95% CI, 0.2-4.4; P = .99). In patients undergoing TEVAR, more proximal landing zones were associated with higher risk of stroke compared with zone 4/5 (zone 3: OR, 2.0 [95% CI, 0.9-4.2]; zone 2: OR, 3.8 [95% CI, 1.8-8.2]; zone 0/1: OR, 6.3 [95% CI, 2.8-14]). In terms of procedural characteristics, any involvement of the left subclavian artery was associated with stroke (bypass: OR, 2.5 [95% CI, 1.5-4.0]; stent: OR, 2.7 [95% CI, 0.9-8.5]; covered or occluded: OR, 2.5 [95% CI, 1.5-4.1]).

Conclusions: Stroke, although rare after elective EVAR, is substantially more common after complex EVAR and TEVAR. Increasing procedural complexity in complex EVAR and TEVAR is associated with a higher stroke rate, a risk that should be factored into clinical decision-making. The strong association between stroke and upper extremity access during complex EVAR is alarming and warrants further study.
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http://dx.doi.org/10.1016/j.jvs.2020.02.015DOI Listing
November 2020

Midterm survival after endovascular repair of intact abdominal aortic aneurysms is improving over time.

J Vasc Surg 2020 08 21;72(2):556-565.e6. Epub 2020 Feb 21.

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

Objective: There is a growing body of literature raising concerns about the long-term durability of endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAAs), suggesting that long-term outcomes may be better after open AAA repair. However, the data investigating these long-term outcomes largely originate from early in the endovascular era and therefore do not account for increasing clinical experience and technologic improvements. We investigated whether 4-year outcomes after EVAR and open repair have improved over time.

Methods: We identified all EVARs and open repairs for intact infrarenal AAA within the Vascular Quality Initiative database (2003-2018). We then stratified patients by procedure year into treatment cohorts of four years: 2003-2006, 2007-2010, 2011-2014, and 2015-2018. We used Kaplan-Meier analysis and Cox proportional hazards models to assess whether the survival after EVAR or open repair changed over time. In addition, we propensity matched EVAR and open repairs for each time cohort to investigate whether the relative survival benefit of EVAR over open repair changed over time.

Results: We included 42,293 EVARs (increasing from 549 performed between 2003 and 2006 to 25,433 between 2015 and 2018) and 5189 open AAA repairs (increasing from 561 to 2306). Four-year survival increased for the periods 2003-2006, 2007-2010, 2011-2014, and 2015-2018 after both EVAR (76.6% vs 79.7% vs 83.5% vs 87.3%; P < .001) and open repair (82.2% vs 85.8% vs 87.7% vs 88.9%; P = .026). After risk adjustment, compared with 2003-2006, hazard of mortality up to 4 years after EVAR was lower for those performed between 2011 and 2014 (hazard ratio [HR], 0.72; 95% confidence interval [CI], 0.59-0.87; P = .001) and for those performed between 2015 and 2018 (HR, 0.56; 95% CI, 0.46-0.68; P < .001). In contrast, the risk-adjusted hazard of mortality was similar between open repair cohorts (2011-2014: HR, 0.81 [95% CI, 0.61-1.08; P = .15]; and 2015-2018: HR, 0.86 [95% CI, 0.64-1.17; P = .34]). Finally, in matched EVAR and open repairs, there was no difference in mortality in the first three cohorts, whereas the hazard of mortality was lower for the 2015-2018 cohort (HR, 0.65; 95% CI, 0.51-0.84; P = .001).

Conclusions: Four-year survival improved in more recent years after EVAR but not after open repair. This finding suggests that midterm outcomes after EVAR are improving, perhaps because of technologic improvements and increased experience, information that should be considered by surgeons and policymakers alike in evaluating the value of contemporary EVAR and open AAA repair.
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http://dx.doi.org/10.1016/j.jvs.2019.10.082DOI Listing
August 2020

Five-year survival following endovascular repair of ruptured abdominal aortic aneurysms is improving.

J Vasc Surg 2020 07 21;72(1):105-113.e4. Epub 2020 Feb 21.

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

Objective: Increasing experience and improving technology have led to the expansion of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysms (AAA). We investigated whether the 5-year survival after both EVAR and open repair for ruptured AAA changed over the last 14 years.

Methods: We identified repairs for ruptured infrarenal AAA within the Vascular Quality Initiative registry between 2004 and 2018. We compared the 5-year survival of both EVAR and open repair between the early (2004-2012) and late (2013-2018) cohorts. In addition, we compared EVAR with open repair in the early and late cohorts. We used propensity score modeling to create matching cohorts for each analysis. Kaplan-Meier analysis was used to estimate survival proportions and univariate Cox proportional hazards analysis was used to compare differences in hazard of mortality in the matched cohorts.

Results: We identified 4638 ruptured AAA repairs. This included 409 EVARs in the early cohort and 2250 in the late cohort, as well as 558 open repairs in the early cohort and 1421 in the late cohort. Propensity matching resulted in 366 matched pairs of late vs early EVAR and 391 matched-pairs of late vs early open repair. When comparing EVAR with open repair, propensity matching resulted in 277 matched pairs of early EVAR versus open, and 1177 matched pairs of late EVAR versus open. In matched EVAR patients, 5-year survival was higher in the late cohort (63% vs 49%; hazard ratio [HR], 0.77; 95% confidence interval [CI], 0.61-0.97; P = .027), whereas there was no difference between matched late vs early for open repair patients (52% vs 59%; HR, 1.04; 95% CI, 0.85-1.28; P = .69). In the early cohort, there was no survival difference between EVAR and open repair (51% vs 46%; HR, 0.88; 95% CI, 0.69-1.11; P = .28). However, in the late cohort EVAR was associated with higher survival compared with open repair (63% vs 54%; HR, 0.69; 95% CI, 0.60-0.79; P < .001).

Conclusions: The 5-year survival after EVAR for ruptured AAA has improved over time, whereas survival after open repair remained constant. Consequently, the relative survival benefit of EVAR over open repair has increased over time, which should encourage further adoption of EVAR for ruptured AAA.
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http://dx.doi.org/10.1016/j.jvs.2019.10.074DOI Listing
July 2020

In-hospital outcomes alone underestimate rates of 30-day major adverse events after carotid artery stenting.

J Vasc Surg 2020 04 13;71(4):1233-1241. Epub 2020 Feb 13.

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

Objective: Outcome studies using databases collecting only hospital discharge data underestimate morbidity and mortality because of failure to capture postdischarge events. The proportion of postdischarge major adverse events is well characterized in patients undergoing carotid endarterectomy (CEA) but has yet to be characterized after carotid artery stenting (CAS).

Methods: We retrospectively reviewed all patients undergoing CAS from 2011 to 2017 using the American College of Surgeons National Surgical Quality Improvement Program procedure targeted database to evaluate rates of 30-day major adverse events, stratified by in-hospital and postdischarge occurrences. The primary outcome was 30-day stroke/death. Multivariable analysis using purposeful selection was used to identify independent factors associated with in-hospital, postdischarge, and 30-day stroke/death events.

Results: Of the 899 patients undergoing CAS, reporting of in-hospital outcomes alone would yield a stroke/death rate of 2.7%, substantially underestimating the 30-day stroke/death rate of 4.0%. In fact, 35% of stroke/deaths, 27% of strokes, 73% of deaths, 35% of cardiac events, and 35% of stroke/death/cardiac events occurred after discharge. More postdischarge stroke/death events occurred after treatment of symptomatic compared with asymptomatic patients (47% vs 27%; P < .001). During this same study period, the 30-day stroke/death rate after CEA was 2.6%, with similar proportions of postdischarge strokes (28% vs 27%; P = .51) compared with CAS but lower proportions of postdischarge deaths (55% vs 73%; P < .001). After CAS, patients experiencing postdischarge stroke/death events had a shorter postoperative length of stay compared with patients with in-hospital stroke/death (1 [1-2] vs 5 [3-10] days; P < .001). Chronic obstructive pulmonary disease was independently associated with postdischarge stroke/death (odds ratio [OR], 4.4; 95% confidence interval [CI], 1.2-16; P = .02) after CAS. Nonwhite ethnicity was independently associated with overall 30-day stroke/death (OR, 3.4; 95% CI, 1.4-7.9; P < .01), whereas statin use was associated with not having stroke/death within 30 days (OR, 0.5; 95% CI, 0.2-1.0; P = .049).

Conclusions: More than one-quarter of perioperative strokes occur following discharge after both CAS and CEA. A higher proportion of postdischarge deaths occur after CAS in symptomatic patients, which may reflect treatment of a population of higher risk patients. Further investigation is needed to elucidate the cause of postdischarge stroke to develop methods to reduce these complications.
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http://dx.doi.org/10.1016/j.jvs.2019.06.201DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7096257PMC
April 2020

The Impact of Proximal Clamp Location on Peri-Operative Outcomes Following Open Surgical Repair of Juxtarenal Abdominal Aortic Aneurysms.

Eur J Vasc Endovasc Surg 2020 Mar 18;59(3):411-418. Epub 2019 Dec 18.

Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA. Electronic address:

Objective: Open surgical repair of juxtarenal abdominal aortic aneurysms (AAA) requires an aortic cross clamp location above at least one renal artery. This study investigated the impact of clamp location on peri-operative outcomes using a United States based nationwide clinical registry.

Methods: The National Surgical Quality Improvement Program targetted vascular module was used to identify all elective open juxtarenal AAA repairs (2011-2017). Outcomes were compared between clamping above one vs. above both renal arteries, and above one or both renal arteries vs. supracoeliac clamping. The primary outcome was 30 day mortality and secondary outcomes included post-operative renal dysfunction (creatinine increase ≥ 177 μmol/L or new dialysis) and unplanned re-operations. Multivariable logistic regression models were constructed to perform risk adjusted analyses.

Results: A total of 615 repairs were identified, with a clamp location above one renal artery in 42%, above both renal arteries in 40%, and supracoeliac in 18% of cases. Procedures with a clamp location above one vs. above both renal arteries showed no difference in mortality (3.5% vs. 2.1%, p = .34) or renal dysfunction (6.9% vs. 4.9%, p = .34). In contrast, supracoeliac clamping compared with clamping above one or both renal arteries was associated with a higher mortality rate (8.0% vs. 2.8%, p = .023), renal dysfunction (12% vs. 6.0%, p = .017), and unplanned re-operations (24% vs. 10%, p < .001). In the multivariable adjusted models, outcomes were similar between clamping above both vs. above one renal artery, while supracoeliac clamping vs. clamping above one or both renal arteries was associated with higher mortality (odds ratio [OR]: 3.4; 95% CI: 1.3-8.8; p = .013) and unplanned re-operation (OR: 2.4; 95% CI: 1.4-4.1; p = .002).

Conclusion: Although there is no difference between clamping above one vs. both renal arteries during open juxtarenal AAA repair, a supracoeliac clamp location is associated with worse peri-operative outcomes. Surgeons should avoid supracoeliac clamping when clamping above one or both renal arteries is technically possible.
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http://dx.doi.org/10.1016/j.ejvs.2019.10.004DOI Listing
March 2020

Sex differences in perioperative outcomes after complex abdominal aortic aneurysm repair.

J Vasc Surg 2020 02 4;71(2):374-381. Epub 2019 Jul 4.

Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass. Electronic address:

Objective: Female sex is associated with worse outcomes after infrarenal abdominal aortic aneurysm (AAA) repair. However, the impact of female sex on complex AAA repair is poorly characterized. Therefore, we compared outcomes between female and male patients after open and endovascular treatment of complex AAA.

Methods: We identified all patients who underwent complex aneurysm repair between 2011 and 2017 in the American College of Surgeons National Surgical Quality Improvement Program targeted vascular module. Complex repairs were defined as those for juxtarenal, pararenal, or suprarenal aneurysms. We compared rates of perioperative adverse events between female and male patients stratified by open AAA repair and endovascular aneurysm repair (EVAR). We calculated propensity scores and used inverse probability-weighted logistic regression to identify independent associations between female sex and our outcomes.

Results: We identified 2270 complex aneurysm repairs, of which 1260 were EVARs (21.4% female) and 1010 were open repairs (30.7% female). After EVAR, female patients had higher rates of perioperative mortality (6.3% vs 2.4%; P = .001) and major complications (15.9% vs 7.6%; P < .001) compared with male patients. In contrast, after open repair, perioperative mortality was not significantly different (7.4% vs 5.6%; P = .3), and the rate of major complications was similar (29.4% vs 27.4%; P = .53) between female and male patients. Furthermore, even though perioperative mortality was significantly lower after EVAR compared with open repair for male patients (2.4% vs 5.6%; P = .001), this difference was not significant for women (6.3% vs 7.4%; P = .60). On multivariable analysis, female sex remained independently associated with higher perioperative mortality (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.3-4.9; P = .007) and major complications (OR, 2.0; 95% CI, 1.3-3.2; P = .002) in patients treated with EVAR but showed no significant association with mortality (OR, 0.9; 95% CI, 0.5-1.6; P = .69) or major complications (OR, 1.1; 95% CI, 0.8-1.5; P = .74) after open repair. However, the association of female sex with higher perioperative mortality in patients undergoing complex EVAR was attenuated when diameter was replaced with aortic size index in the multivariable analysis (OR, 1.9; 95% CI, 0.9-3.9; P = .091).

Conclusions: Female sex is associated with higher perioperative mortality and more major complications than for male patients after complex EVAR but not after complex open repair. Continuous efforts are warranted to improve the sex discrepancies in patients undergoing endovascular repair of complex AAA.
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http://dx.doi.org/10.1016/j.jvs.2019.04.479DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6942245PMC
February 2020

Fenestrated endovascular aneurysm repair is associated with lower perioperative morbidity and mortality compared with open repair for complex abdominal aortic aneurysms.

J Vasc Surg 2019 06 13;69(6):1670-1678. Epub 2018 Dec 13.

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

Objective: The Zenith Fenestrated Endovascular Graft (ZFEN; Cook Medical, Bloomington, Ind) has expanded the anatomic eligibility of endovascular aneurysm repair (EVAR) for complex abdominal aortic aneurysms (AAAs). Current data on ZFEN mainly consist of single-institution experiences and show conflicting results. Therefore, we compared perioperative outcomes after repair using ZFEN with open complex AAA repair and infrarenal EVAR in a nationwide multicenter registry.

Methods: We identified all patients undergoing elective AAA repair using ZFEN, open complex AAA repair, and standard infrarenal EVAR between 2012 and 2016 within the American College of Surgeons National Surgical Quality Improvement Program targeted vascular module. Open complex AAA repairs were defined as those with a juxtarenal or suprarenal proximal AAA extent in combination with an aortic cross-clamping position that was above at least one renal artery. The primary outcome was perioperative mortality, defined as death within 30 days or within the index hospitalization. Secondary outcomes included postoperative renal dysfunction (creatinine concentration increase of >2 mg/dL from preoperative value or new dialysis), occurrence of any complication, procedure times, blood transfusion rates, and length of stay. To account for baseline differences, we calculated propensity scores and employed inverse probability-weighted logistic regression.

Results: We identified 6825 AAA repairs-220 ZFENs, 181 open complex AAA repairs, and 6424 infrarenal EVARs. Univariate analysis of ZFEN compared with open complex AAA repair demonstrated lower rates of perioperative mortality (1.8% vs 8.8%; P = .001), postoperative renal dysfunction (1.4% vs 7.7%; P = .002), and overall complications (11% vs 33%; P < .001). In addition, fewer patients undergoing ZFEN received blood transfusions (22% vs 73%; P < .001), and median length of stay was shorter (2 vs 7 days; P < .001). After adjustment, open complex AAA repair was associated with higher odds of perioperative mortality (odds ratio [OR], 4.9; 95% confidence interval [CI], 1.4-18), postoperative renal dysfunction (OR, 13; 95% CI, 3.6-49), and overall complication rates (OR, 4.2; 95% CI, 2.3-7.5) compared with ZFEN. Compared with infrarenal EVAR, ZFEN presented comparable rates of perioperative mortality (1.8% vs 0.8%; P = .084), renal dysfunction (1.4% vs 0.7%; P = .19), and any complication (11% vs 7.7%; P = .09). Furthermore, after adjustment, there was no significant difference between the odds of perioperative mortality, postoperative renal dysfunction, or any complication between infrarenal EVAR and ZFEN.

Conclusions: ZFEN is associated with lower perioperative morbidity and mortality compared with open complex AAA repair, and outcomes are comparable to those of infrarenal EVAR. Long-term durability of ZFEN compared with open complex AAA repair warrants future research.
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http://dx.doi.org/10.1016/j.jvs.2018.08.192DOI Listing
June 2019

Pseudomyxoma Peritonei After a Total Pancreatectomy for Intraductal Papillary Mucinous Neoplasm With Colloid Carcinoma in Lynch Syndrome.

Pancreas 2019 01;48(1):135-138

Radiology, St Antonius Hospital, Nieuwegein, the Netherlands.

We report a case of pseudomyxoma peritonei (PMP) arising in a 62-year-old male patient with Lynch syndrome (LS). The patient's medical history included an adenocarcinoma of the colon for which a right hemicolectomy was performed and a pancreatectomy due to an intraductal papillary mucinous neoplasm (IPMN) with invasive colloid carcinoma. It was considered that the PMP could be a metastasis of the earlier colonic or pancreatic carcinoma. The pancreatic carcinoma, colon carcinoma, and PMP tissues were examined, and immunohistochemical and molecular analyses were performed to determine the PMP origin. Histopathologic examination revealed morphological similarities with the pancreatic colloid carcinoma, and further immunohistochemical and molecular analyses, including a shared GNAS mutation, confirmed the pancreatic origin of the PMP. In conclusion, this is a unique case of a patient with LS presenting with PMP originating from an IPMN with invasive colloid carcinoma, several years after pancreatectomy. The present case has important diagnostic implications. The IPMN should be considered as a rare extracolonic manifestation of LS, and pancreatic carcinoma origin should be considered in patients presenting with PMP. This case report highlights the added value of molecular diagnostics in daily pathology practice.
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http://dx.doi.org/10.1097/MPA.0000000000001201DOI Listing
January 2019

Injuries related to bicycle accidents: an epidemiological study in The Netherlands.

Eur J Trauma Emerg Surg 2020 Apr 15;46(2):413-418. Epub 2018 Oct 15.

Departement of Orthopaedics, Diakonessenhuis Utrecht/Zeist, Utrecht/Zeist, The Netherlands.

Background: This study aims to analyze the incidence and outcomes of bicycle-related injuries in hospitalized patients in The Netherlands.

Methods: Bicycle accidents resulting in hospitalization in a level-I trauma center in The Netherlands between 2007 and 2017 were retrospectively identified. We subcategorized data of patients involved in a regular bicycle, race bike, off-road bike or e-bike accident. The primary outcomes were mortality rate and incidence of multitrauma. Secondary outcomes were differences between bicycle subcategories. Independent risk factors were identified using multivariable logistic regression. All variables with a p value < 0.20 in univariable analysis were entered in multivariable analysis.

Results: We identified 1986 patients. The mortality rate after emergency room admission was 5.7%, and 41.0% were multitraumas. A higher age, multitrauma and cerebral haemorrhages were independent risk factors for in hospital mortality. Independent risk factors found for multitrauma were a higher age, two-sided trauma, e-bike accidents and cerebral haemorrhage.

Conclusion: Bicycle accidents resulting in hospitalization have a high mortality rate. Furthermore, a high incidence of multitrauma, fractures and cerebral haemorrhages were found. Considering the increasing incidence of bicycle accident victims needing hospital admission, new and more efficient prevention strategies are essential.
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http://dx.doi.org/10.1007/s00068-018-1033-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7113215PMC
April 2020