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Background: Following new dialysis access creation there is no consensus on the optimal use of anti-thrombotic therapy. Recent studies have suggested that single antiplatelet therapy may improve hospital mortality as well as patency. The aim of this study was to assess the role of different antiplatelet and anticoagulation therapies on outcomes following dialysis access creation., Material and Methods: A retrospective study was conducted utilizing patients from the Vascular Quality Initiative who underwent AV fistula (AVF) and AV graft (AVG) creation from 2011-2023. Patients who were antiplatelet and anticoagulation naive were separated into 4 cohorts: no antiplatelet (No APT), single antiplatelet (SAPT), dual antiplatelet (DAPT), and aspirin with anticoagulation (ASA + AC). Univariate Kaplan-Meier (KM) and multivariable regression analyses were conducted to assess overall survival, primary patency, and secondary patency., Results: 49,980 patients with AVF creation and 12,688 patients with AVG creation were identified. AVG patients had improved 1-year primary patency with SAPT compared to No APT (48% vs. 44%, P = 0.03) on KM analysis. No difference on KM analysis was observed for AVF. Regression analysis showed decreased risk of loss of primary patency for AVF (HR 0.90, CI 0.83-0.97, P = 0.009). AVG with SAPT showed decreased risk of mortality (HR 0.80, CI 0.64-1.00, P = 0.05) and decreased risk of loss of primary patency (HR 0.80, CI 0.67-0.94, P = 0.009). DAPT also showed decreased risk of loss of primary patency for AVG (HR 0.64, CI 0.43-0.95, P = 0.028). Survival was worse for both AVF and AVG patients on ASA + AC on KM analysis., Conclusions: Single antiplatelet therapy following access creation improves primary patency for both AVF and AVG, as well as overall survival for those with AVG. DAPT may further improve primary patency in those with AVG. The use of anticoagulation shows no clear benefit and may be harmful, however is more likely to reflect higher risk patients with other co-morbidities. These results suggest that following an AVF one should consider discharging patients on SAPT, and following an AVG one should consider SAPT or DAPT., (Published by Elsevier Inc.)

Background: Antiplatelet therapies with thromboxane inhibitors and adenosine 5'-diphosphate antagonists have been widely used following carotid artery stenting (CAS). However, these therapies may not apply to patients who are intolerant or present acutely. Glycoprotein IIb/IIIa inhibitors (GPI) are a proposed alternative therapy in these patients; however, their use has been limited due to concerns of increased risk for intracranial bleeding. Thus, this study aims to assess the safety profile of GPI in patients undergoing CAS., Methods: All patients undergoing CAS in the Society of Vascular Surgery - Vascular Quality Initiative database from 2012 to 2021 was included and grouped into GPI versus non-GPI therapy (control). The primary outcome was in-hospital stroke or death, and secondary outcomes included in-hospital stroke/transient ischemic attack (TIA), death, myocardial infarction, and intracranial hemorrhage (ICH)/seizure. Patients were stratified by surgical approach (Transcarotid artery revascularization using flow reversal (TCAR) and transfemoral carotid artery stenting), and stepwise backward logistic regression analysis was conducted to evaluate major primary and secondary outcomes., Results: A total of 50,628 patients underwent carotid revascularization. Of these, 4.4% of the patients received GPI. Mean age was similar between control versus GPI (71.35(9.67) vs. 71.36(10.20) years). Compared to the control group, patients who receive GPI are less likely to be on optimal medical therapy, including aspirin (83.0% vs. 88.1%), P2Y12 inhibitor (73.0% vs. 82.7%), and statin (82.3% vs. 86.0%) (All P < 0.05). In addition, patients in the GPI group were more likely to undergo TCAR for carotid revascularization (52.2% vs. 48.4%) for emergent/urgent (29.4% vs. 16.8%) and symptomatic indications (55.5% vs. 49.7%) (All P < 0.001). After stratifying by surgical approach, if patients underwent TFCAS and received a GPI, they were at increased odds of developing stroke/death (1.77(1.25-2.51)), death (odds ratio (OR) (95% CI): 1.67(1.07-2.61)), stroke/TIA (OR (95% confidence interval (CI)): 1.65(1.09-2.51)), and ICH/seizure (OR (95% CI): 2.13(1.23-3.68)) (All P < 0.05). No difference was seen in outcomes between the 2 groups if undergoing TCAR., Conclusions: Patients who receive GPI were more likely to be symptomatic at presentation and less likely to be medically optimized before their carotid revascularization. Transfemoral access in patients receiving GPI was associated with increased odds of morbidity and mortality. However, this was not observed if undergoing TCAR. TCAR can be considered for its overall favorable results in high-risk patients who are not medically optimized., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: This study aims to evaluate the use of prophylactic intravenous hydration (IV prophylaxis) and carbon dioxide (CO 2 ) angiography in reducing contrast associated-acute kidney injury (CA-AKI) and determine the overall incidence and risk factors of CA-AKI in high-risk patients undergoing peripheral vascular interventions (PVI). Method: Only patients undergoing elective PVI from 2017 to 2021 with chronic kidney disease (CKD) stage 3-5 in the Vascular Quality Initiative (VQI) database were included. Patients were grouped into IV prophylaxis vs no prophylaxis. The study's primary outcome was CA-AKI, defined as a rise in creatinine (>.5 mg/dL) or new dialysis within 48 hours following contrast administration. Standard univariate and multivariable (logistic regression) analyses were conducted. Results: A total of 4497 patients were identified. Of these, 65% received IV prophylaxis. The overall incidence of CA-AKI was .93%. No significant difference was seen in overall contrast volume (mean (SD): 66.89(49.54) vs 65.94(51.97) milliliters, P > .05) between the 2 groups. After adjusting for significant covariates, the use of IV prophylaxis (OR (95% CI): 1.54(.77-3.18), P = .25) and CO 2 angiography (OR (95%CI): .95(.44-2.08), P = .90) was not associated with a significant reduction in CA-AKI compared to the patients with no prophylaxis. The severity of CKD and diabetes were the only predictor of CA-AKI. Compared to patients with no CA-AKI, patients with CA-AKI were at risk of higher 30-day mortality (OR (95% CI): 11.09 (4.25-28.93)) and cardiopulmonary complications (OR (95% CI): 19.03 (8.74-41.39) following PVI (Both P < .001). Conclusion : Using a large national vascular database, our study demonstrates that prophylactic use of IV hydration and CO 2 angiography in high-risk CKD patients is not associated with a reduction in renal injury following PVI. Reduced kidney function and history of diabetes is an independent predictor of CA-AKI and patients that develop post-procedural AKI are at an increased risk of morbidity and mortality.

Background: Anatomic severity grade (ASG) score is utilized to assess preoperative abdominal aortic aneurysms (AAA) and provide a quantitative data on its anatomic complexity. The aim of this study is to determine the anatomical differences and long-term survival between male and female patients undergoing elective AAA repair., Methods: All patients undergoing intact AAA repair from 2007 to 2014 were included. ASG scores were calculated based on preoperative anatomical characteristics including aortic neck, aneurysm, and iliac artery. Standard univariate analysis was used to evaluate patient and anatomical characteristics. Kaplan-Meier survival curves were used to evaluate long-term survival at 1 and 5 years., Results: A total of 379 patients were identified, of which, majority of them were males (80%). Females were on average 3 years older (mean [SD]: 74.32 [8.63] vs. 71.92 [8.64] years) and were more likely to undergo open repair (29.7% vs. 17.5%) (both P < 0.05). Both groups had similar comorbidities. The mean long-term follow-up (S.D.) was 6.21 (3.81) years. No significant difference was seen between males versus females in long-term survival at both 1 year (86.3% vs. 92.8, P = 0.06) and 5 year (68.5% vs. 72.7%, P = 0.38). In regard to the anatomical characteristics, females had shorter aortic neck length (mean in mm [S.D.]: 17.67 [1.41] vs. 27.20 [15.76]), increased tortuosity index [mean (S.D.): 1.11 (0.07) vs. 1.09 (0.07)]) and higher calcification [mean % (S.D.): 17.12 (21.17) vs. 10.59 (16.82)] (All P < 0.05). In contrast, males had larger aortic neck (mean in mm (S.D.): 23.81 (4.17) vs. 22.41 (4.16)] and iliac artery [mean in mm (S.D.): 7.70 (1.91) vs. 6.28 (1.67)] diameter (both P < 0.05). The mean total ASG score was significantly higher among females versus males [mean (S.D.): 17.23 (4.01) vs. 15.67 (3.96), P = 0.003]. After stratifying by ASG score ≥15, females had significantly lower survival at 1 year compared to males (82.6% vs. 92.1%, P = 0.04). However, this difference disappeared at 5 years., Conclusions: The data demonstrate that females present at an older age with more complex AAA anatomy than males. Based on anatomical complexities, females were more likely to undergo open repair, with a corresponding increase in 1-year mortality, but not at 5 year. The data suggest that care processes for optimization of aortic surgery in females are needed to improve 1-year survival., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: Completion cerebral angiography (CCA) after transcarotid artery revascularization (TCAR) has been used to identify distal embolization after stenting and serve as a measure of intraoperative quality control. Nevertheless, no general evidence has been reported regarding the benefit of performing routine CCA. The aim of the present study was to evaluate the potential risks and benefits of routine CCA., Methods: We retrospectively reviewed the Vascular Quality Initiative database for TCAR from 2016 to 2021. The patients were divided into two groups: those with no CCA performed and those with CCA performed. The primary outcome was in-hospital stroke or death. The secondary outcomes included stroke, death, myocardial infarction, and a return to the operating room (RTOR). Clinically relevant and statistically significantly variables on univariable analysis were added to a logistic regression model clustered by center identifier., Results: A total of 18,155 patients who had undergone TCAR were identified, of whom 11,607 (63.7%) had undergone routine CCA. The patients with routine CCA were more likely to have contralateral carotid occlusion and to have received general anesthesia. After adjusting for potential confounders, we found no differences in the risk of stroke/death (adjusted odds ratio [aOR], 1.03; 95% confidence interval [CI], 0.8-1.3; P = .820), stroke/transient ischemic attack (TIA; aOR, 1.00; 95% CI, 0.8-1.3; P = .998), stroke (aOR, 1.1; 95% CI, 0.8-1.4; P = .452), death (aOR, 0.98; 95% CI, 0.6-1.6; P = .953), myocardial infarction (aOR, 0.78; 95% CI, 0.5-1.2; P = .240), or RTOR (aOR, 1.5; 95% CI, 0.6-3.8; P = .412) between patients who had undergone CCA and those who had not. A subanalysis of the patients with new occlusions detected by CCA (69 patients [0.6%]; 19 not treated and 50 treated) indicated a higher risk of stroke/death for the patients with treated new occlusions (aOR, 7.1; 95% CI, 2.9-17.3; P < .001) and stroke/TIA (aOR, 5.8; 95% CI, 2.3-14.7; P < .001) than for the patients who had not undergone CCA. However, no differences were found in stroke/death (aOR, 3.3; 95% CI, 0.37-29.5; P = .283) or stroke/TIA (aOR, 3.1; 95% CI, 0.3-29.4; P = .327) for patients with nontreated new occlusions compared with patients who had not undergone CCA., Conclusions: In the present retrospective study, routine performance of CCA was not beneficial, with no significant differences in in-hospital stroke or death detected. The detection of new lesions on CCA was rare. Moreover, identifying new occlusions using CCA was associated with higher odds of stroke or death when these new lesions were treated. Further studies are needed to define the etiology of the worse outcomes for patients undergoing intervention for lesions discovered using CCA and delineate the optimal timing for further imaging and intervention., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Thoracic endovascular aortic repair (TEVAR) has been increasingly used to treat complex thoracic aortic pathology. In the present study, we assessed the hospital volume's effects on the outcomes of patients who had undergone TEVAR., Methods: Patients who had undergone TEVAR from January 2015 to December 2019 were identified from the Vascular Quality Initiative database. The participating centers were stratified by volume as low-volume hospitals (LVHs) and high-volume hospitals (HVHs). We assessed the effects of hospital volume on 30-day mortality and major postoperative complications using multivariable logistic regression analysis., Results: A total of 3584 TEVAR patients (1720 asymptomatic and 1864 symptomatic or ruptured) were identified at 147 centers. The median average annual number of TEVAR cases at the LVHs and HVHs was 6 and 17 cases, respectively. No significant differences were found in 30-day mortality between the LVHs and HVHs (asymptomatic, 3.7% vs 3.7% [P = .98]; symptomatic or ruptured, 9.3% vs 7.3% [P = .13]). After adjusting for multiple clinical and anatomic factors, treatment at a LVH was not associated with increased 30-day mortality (asymptomatic: odds ratio, 0.98; 95% confidence interval, 0.52-1.87; P = .96; symptomatic or ruptured: odds ratio, 1.15; 95% confidence interval, 0.75-1.77; P = .53) nor an increased risk of major complications, including renal, neurologic, cardiac, pulmonary, and femoral artery access complications (P > .05 for all)., Conclusions: Using a large national database, we have demonstrated that treatment at LVHs is not associated with inferior TEVAR outcomes compared with HVHs. The technical aspect of the procedure might play a role in the similarity of outcomes across the different institutional experiences., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The concept of frailty has been proposed to capture the vulnerability resulting from aging and has been implemented for the prediction of perioperative outcomes. Carotid artery stenting (CAS) is considered an appropriate minimally invasive procedure for patients considered to high risk to undergo carotid endarterectomy. Recently, the predictive accuracy for perioperative outcomes using the five-item modified frailty index (5mFI) has been reported to be relatively poor for cardiovascular surgery compared with other surgeries. The effects of functional status and the 5mFI on the outcomes after CAS remain unknown. Thus, in the present study, we investigated the relationship between 5mFI, functional status, and perioperative outcomes., Methods: All the patients who had undergone CAS in the Vascular Quality Initiative from November 15, 2016 to December 31, 2018 were included. Good functional status was defined as the ability to perform all predisease activities without restriction using a new variable added to the Vascular Quality Initiative from November 15, 2016 onward. The 5mFI was calculated using functional status and a history of diabetes, chronic obstructive pulmonary disease, congestive heart failure, and hypertension. The perioperative outcomes included in-hospital stroke or death within 30 days after CAS, a prolonged postoperative stay (≥2 days), and nonhome discharge. The associations between functional status, 5mFI, and perioperative outcomes were examined using univariate and multivariable logistic regression, adjusting for sex, age, race, degree of stenosis, symptomatic status, and the usage of preoperative medications. An analysis stratified by functional status was also performed., Results: Of the 7836 patients, 188 (2.4%) had experienced perioperative stroke or death, 765 (9.8%) had required a nonhome discharge, and 2584 (33.0%) had required a prolonged postoperative stay. A higher (≥0.6 vs <0.6) 5mFI score was associated with greater odds of perioperative stroke or death (adjusted odds ratio [aOR], 2.75; 95% confidence interval [CI], 1.42-5.28; P = .003), non-home discharge (aOR, 2.70; 95% CI, 1.89-3.85; P < .001), and a prolonged postoperative length of stay (aOR, 1.96; 95% CI, 1.56-2.46; P < .001). For the predictive accuracy of the perioperative outcomes, the 5mFI model had an area under the curve for in-hospital stroke or death, nonhome discharge, and prolonged postoperative length of stay of 0.714, 0.767, and 0.668, respectively. The functional status model was not inferior to the 5mFI model for any of these outcomes. In the subgroup analysis, of the asymptomatic patients, a higher 5mFI score was associated with greater odds of perioperative stroke or death (aOR, 7.08; 95% CI, 2.02-24.48; P = .002), nonhome discharge (aOR, 5.87; 95% CI, 2.45-13.90; P < .001), and a prolonged postoperative stay (aOR, 2.60; 95% CI, 1.82-3.71; P < .001)., Conclusions: Frailty, as measured using the 5mFI, and functional status were independent predictors of perioperative stroke or death, nonhome discharge, and an increased length of stay for patients undergoing CAS. These results were greatly pronounced in asymptomatic patients. The results from the present study, thus, caution against the use of CAS for asymptomatic frail patients., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Thoracic endovascular aortic repair (TEVAR) is a suitable alternative to open aortic surgery especially for older patients with poor general health and functional status. However, data on the benefit of TEVAR in elderly patients are limited. The aim of this study was to use a large national database to compare the outcomes of TEVAR in octogenarians vs nonoctogenarians in the treatment of thoracic aortic aneurysms and dissection., Methods: All patients who underwent TEVAR for nonruptured thoracic aneurysms or dissection (zones 1-5) between January 2014 and February 2019 were identified in the Vascular Quality Initiative database. The primary outcome was in-hospital mortality. Secondary outcomes included cardiac adverse events; neurologic events; respiratory complications; new-onset dialysis; leg compartment syndrome; postoperative hematoma in addition to spinal, bowel, arm, and leg emboli/ischemia; and return to the operating room. Outcomes were compared between octogenarians (age ≥80 years) and nonoctogenarians (age <80 years) using univariable and multivariable logistic regression models., Results: A total of 2042 patients were identified, including 390 octogenarians (19.1%). Compared with nonoctogenarians, octogenarians had higher percentages of females (49.5% vs 40.4%; P < .01) and White patients (75.9% vs 68.6%; P < .01) and were more likely to present with thoracic aneurysms (86.2% vs 64.3%; P < .001). They also had larger aortic diameters (maximum diameter, 60.3 ± 15.8 mm vs 53.4 ± 17.4 mm), less proximal disease zones (zone 1, 3.3% vs 5.5%; zone 2, 13.9% vs 24.1%; P < .001) and were more likely to undergo the procedure under local/regional anesthesia (5.4% vs 2.4%; P < .01) compared with patients less than 80 years of age. No association was observed between octogenarians and in-hospital mortality after TEVAR for aneurysms (5.1% vs 3.3%; odds ratio [OR], 1.38; 95% confidence interval [CI], 0.72-2.61; P = .33) or dissection (5.6% vs 4.9%; OR, 0.68; 95% CI, 0.14-3.32; P = .63). However, for thoracic aneurysm repair, octogenarians had a 44% higher adjusted odds of in-hospital complications (27.4% vs 20.7%; OR, 1.44; 95% CI, 1.04-1.98; P = .03) compared with their younger counterparts. In-hospital complications (27.8% vs 26.2%; P = .79; OR, 1.02; 95% CI, 0.50-2.11; P = .95) were similar in octogenarians undergoing endovascular repair for dissections of the thoracic aorta. Octogenarians were also associated with 1.74 times the mortality hazard compared with nonoctogenarians (adjusted hazard ratio, 1.74; 95% CI, 1.18-2.58; P = .01)., Conclusions: TEVAR is an acceptable treatment option for octogenarians who have aortic arch and descending aortic aneurysms or dissections (zones 1-5). However, in case of aneurysms, they might be at a higher risk of in-hospital complications. Octogenarians also had increased hazard of 1-year mortality; however, the exact cause of this mortality could not be deciphered. Our findings suggest that elderly patients should not be denied TEVAR based on age if they are medically and anatomically fit for this procedure., (Copyright © 2021. Published by Elsevier Inc.)

Objectives: Standard endovascular repair (EVAR) is not suitable in patients with hostile aortic anatomy. Open aneurysm repair (OAR) has been the gold-standard approach in managing these patients. EndoAnchors have been introduced as a technique to make EVAR in patients with short and angulated necks possible. The use of EndoAnchors in managing hostile aneurysms in octogenarians has not been studied before. Thus, the purpose of this study is to evaluate both short and long-term outcomes in octogenarians versus nonoctogenarians patients with hostile aortic anatomy undergoing EVAR using EndoAnchors., Methods: Only patients enrolled in the primary arm of the ANCHOR registry were included and stratified into octogenarians (80-89 years) and nonoctogenarians (<80 years). Standard univariate (chi-square, fisher's exact, student's t-tests) and multivariable (logistic, cox-regression) analysis was used to evaluate patients' characteristics and outcomes between octogenarians versus nonoctogenarians as appropriate., Results: Of 461 patients, 21% (N = 97) were octogenarians. Compared to nonoctogenarians, octogenarians were more likely to have a history of renal (32.0% vs. 18.4%) and genitourinary (30.9% vs. 21.2%) disease (both P < 0.05). They were also more likely to have an AAA diameter greater than 55 mm compared to nonoctogenarians (59% vs. 46%), had increased neck tortuosity index (mean [S.D.] 1.07 [0.08] vs. 1.05 [0.05]), greater proximal neck angulation (mean [S.D.]: 28.2 [17.3] vs. 23.7 [16] degrees) and were more likely to have localized (29.3% vs. 18.7%) and diffuse (25.6% vs. 20.7%) neck calcification (All P < 0.05). The overall procedural success was similar between both groups. However, octogenarians had higher rates of endoleaks at completion (32.0% vs. 21.2%, P = 0.03) and 30-day bleeding (12.4% vs. 5.8%) and cardiac (13.4% vs. 5.2%) complications (All P < 0.05). Additionally, compared to nonoctogenarians, octogenarians had lower freedom from all-cause mortality (87.90% vs. 96.50%) and type II endoleak (73.30% vs. 88.60%) based on Kaplan Meier estimates through one year (Both P < 0.05). In multivariable cox-regression analysis, octogenarians demonstrated a 5-fold increase in all cause mortality (HR [95% CI]: 5.19 [1.92-14], P = 0.001) and a 3-fold increase in type II endoleak (HR [95% CI]: 2.99 [1.54-5.81], P = 0.001) at 1-year. However, no significant difference was seen in aneurysm/device related mortality (HR [95% CI]: 1.42 [0.14-14.7], P = 0.77) and type I endoleak (HR [95% CI]: 1.71 [0.31-9.55], P = 0.54) at 1-year., Conclusions: Despite a worse aortic neck anatomy, octogenarians undergoing EVAR using EndoAnchors showed acceptable short and long-term outcomes. The results of our study could expand the utilization of EVAR in octogenarians with hostile neck., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Racial disparities in open thoracic aortic aneurysm repair have been well-documented, with Black patients reported to suffer from poor outcomes compared with their White counterparts. It is unclear whether these disparities extend to the less invasive thoracic endovascular aortic repair (TEVAR). This study aims to examine the clinical characteristics, perioperative outcomes, and 1-year survival of Black vs White patients undergoing TEVAR in a national vascular surgery database., Methods: The Vascular Quality Initiative database was retrospectively queried to identify all patients who underwent TEVAR between January 2011 and December 2019. The primary outcomes were 30-day mortality and 1-year survival after TEVAR. Secondary outcomes included various types of major postoperative complications. Multivariable logistic regression analyses were performed to identify predictors of 30-day mortality and perioperative complications. Multivariable Cox regression analysis was used to determine the predictors of 1-year survival., Results: A total of 2669 patients with TEVAR were identified in the Vascular Quality Initiative, of whom 648 were Black patients (24.3%). Compared with White patients, Black patients were younger and had a higher burden of comorbidities, including hypertension, diabetes, congestive heart failure, dialysis dependence, and anemia. Black patients were more likely to be symptomatic, present with aortic dissection, and undergo urgent or emergent repair. There was no statistically significant difference in 30-day mortality between Black and White patients (3.4% vs 4.9%; P = .1). After adjustment for demographics, comorbidities, and operative factors, Black patients were independently associated with a 56% decrease in 30-day mortality risk compared with their White counterparts (odds ratio, 0.44; 95% confidence interval [CI], 0.22-0.85; P = .01) and not associated with an increased risk of perioperative complications (odds ratio, 0.90; 95% CI, 0.68-1.17; P = .42). Black patients also had a significantly better 1-year overall survival (log-rank, P = .024) and were associated with a significantly decreased 1-year mortality (hazard ratio, 0.65; 95% CI, 0.47-0.91; P = .01) after adjusting for multiple clinical factors., Conclusions: Although Black patients carried a higher burden of comorbidities, the racial disparities in perioperative outcomes and 1-year survival do not persist in TEVAR., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The association between stent design and outcomes after carotid artery stenting (CAS) has remained controversial. The available data are conflicting regarding the superiority of any specific stent design. The present study investigated the association between cell design and outcomes after carotid artery stenting (CAS) in a real world setting., Methods: Patients who had undergone CAS with distal embolic protection in the Society for Vascular Surgery Vascular Quality Initiative (VQI) database from 2016 to 2018 were included in the present study. Patients undergoing CAS for trauma or dissection or more than two treated lesions were excluded. We also excluded lesions for which more than two carotid stents had been used and lesions confined to the common or external carotid artery. Univariable and multivariable logistic regression analyses were used to compare the outcomes after CAS between the open- and closed-cell stent designs., Results: Of the 2671 CAS procedures included in the present analysis, 1384 (51.8%) had used closed-cell stents and 1287 (48.2%) had used open-cell stents. On univariable analysis, no significant differences were noted between the closed- and open-cell stents in in-hospital mortality (1.8% vs 1.4%; P = .40), stroke (1.8% vs 2.4%; P = .28), and stroke/death (3.3% vs 3.5%; P = .81). After adjusting for potential confounders (ie, age, symptomatic status, previous major amputation, statin and antiplatelet use, American Society of Anesthesiologists class, elective procedures, approach, and post-stent dilatation), no difference was noted in in-hospital stroke/death between the two stent designs (odds ratio [OR], 1.08; 95% confidence interval [CI], 0.68-1.74; P = .74). However, the interaction between stent design (open vs closed) and lesion location (bifurcation vs internal carotid artery [ICA]) was statistically significant (P = .02). Closed-cell stents were associated with five times the odds of in-hospital stroke/death when used in carotid artery bifurcation (OR, 5.5; 95% CI, 1.3-22.2; P = .02). However, when the stent was limited to the ICA, no differences were noted (OR, 0.87; 95% CI, 0.51-1.45; P = .62). One-year follow-up data were available for 19% of patients. No differences in ipsilateral stroke or death at 1 year were noted between the open- and closed-cell stents, except when the lesion was located in the carotid bifurcation (hazard ratio, 6.7; 95% CI, 1.4-31.4; P = .02)., Conclusions: Closed-cell stents were associated with an increased odds of in-hospital stroke/death for carotid bifurcation lesions, which might be related to the relatively lower conformability of closed-cell stents in the tortuous and diameter-mismatched bifurcation anatomy vs the relatively linear uniform diameter of the ICA. Improved follow-up and in-depth analysis of lesion-specific characteristics that might influence the outcomes of these two designs are needed to validate these results., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Treatment of massive and submassive pulmonary embolism (PE) has been shown to be a valuable therapeutic modality. However, a paucity of data exists, regarding length and guidelines for treatment and typically these patients are treated by other than vascular surgery specialists. The aim of this study is to evaluate the effectiveness and safety of short duration treatment of massive and submassive PE, exclusively by vascular surgeons, without routine follow-up pulmonary angiography., Methods: Retrospective analysis of prospectively collected data at a single-institution treating massive and submassive PE with catheter-directed thrombolysis (CDT). Internal review board approval was obtained. Descriptive statistical analysis was performed from the data set. Continuous covariates were presented in mean (SD) or median (IQR) and categorical covariates as number (percentage). For continuous variables, a paired t test was used to measure results against the baseline. P value less than 0.05 was defined as statistically significant. STATA® statistical software was used for analysis., Results: From January of 2013 to December of 2016, 28 consecutive patients were treated for massive and submassive PE with CDT. All patients had evidence of right heart strain on echocardiogram, as evidence by a right ventricular to left ventricular (RV/LV) diameter ratio of >0.9. Of the 28 patients, 19 (68%) had hemodynamic derangement with either systolic blood pressure (SBP) less then 90 or tachycardia (HR > 100). The mean RV/LV ratio before CDT was 1.18. After therapy, RV/LV ratio was reduced to 0.86 at 48 hr (P < 0.0001). In addition, mean right ventricular systolic pressure (RVSP) before CDT treatment was 53 mm Hg, and after treatment, RVSP was reduced to 40 mm Hg at 48-hr (P value = 0.0001). There was complete resolution of hypotension in hemodynamically unstable patients (i.e., SBP <90) after CDT. Mean HR before therapy was 102. After 24 hr of CDT, mean HR reduced to 84 (P < 0.0001). From 2013 to 2016, there was a significant decrease in mean hospital length of stay from 8 days to 4 days (P = 0.05). Mean t-PA dose used decreased, as well, from 2014 (21.7 mg) to 2016 (14.9 mg), but this was not statistically significant (P = 0.13). There was no major bleeding complications or CDT-related death in any of the patients treated during the study period., Conclusions: CDT treatment of massive and submassive PE is safe and highly efficacious at reducing right heart strain acutely. Significant hemodynamic improvement was shown in our cohort throughout the study period. Improvement in tachycardia and resolution of hypotension were seen within 24 hr of CDT. Tissue plasminogen activator dosage decreased throughout the study period as a more restrictive approach to follow-up angiography was used without adverse safety or patient outcomes., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Sepsis is one the most serious and life-threatening complication in patients with chronic hemodialysis (HD) access. Arteriovenous fistula (AVF) use is associated with a lower risk of infection. However, several prior studies identified significantly higher number of patients initiating HD using a catheter (HC) or arteriovenous graft (AVG). The aim of this study was to use a large national renal database to report the incidence and risk factors of sepsis in patients with end-stage renal disease (ESRD) initiating HD access using AVF, AVG, or HC in the United States., Methods: All patients with ESRD initiating HD access (AVF, AVG, HC) between January 1, 2006, and December 31, 2014, in United States Renal Data System were included. International Classification of Diseases, 9th edition-Clinical Modification diagnosis code (038x, 790.7) was used to identify patients who developed first onset of sepsis during follow-up. Standard univariate (Students t-test, χ 2 , and Kaplan-Meier) and multivariable (logistic/Cox regression) analyses were performed as appropriate., Results: A total of 870,571 patients were identified, of whom, 29.8% (n = 259,686) developed sepsis. HC (31.2%) and AVG (30.6%) were associated with a higher number of septic cases compared with AVF (22.9%; P < .001). The incident rate of sepsis was 12.66 episodes per 100 person-years. It was the highest among HC vs AVG vs AVF (13.86 vs 11.49 vs 8.03 per 100 person-years). Patients with sepsis were slightly older (mean age 65.09 ± 14.49 years vs 63.24 ± 15.17 years) and had higher number of comorbidities including obesity (40.7% vs 37.7%), congestive heart failure (36.6% vs 30.8%), peripheral arterial disease (15.6% vs 12.4%), and diabetes (59.6% vs 53.5%) (all P < .001). After adjusting for potential confounders, compared with AVF, patients with AVG (hazard ratio [HR], 1.35 [95% confidence interval [CI], 1.31-1.40) and HC (HR, 1.80 [95% CI, 1.77-1.84) were more likely to develop sepsis at 3 years (both P < .001). Compared with patients with no sepsis, sepsis was associated with a three-fold increase the odds of mortality (odds ratio, 3.16; 95% CI, 3.11-3.21; P < .001). Additionally, in patients who developed sepsis, AVF use was associated with significantly lower mortality compared with AVG and HC (73.7% vs 78.7% vs 78.0%; P < .001). After adjusting for significant covariates, compared with AVF, mortality at 1 year after sepsis was 21% higher in AVG (HR, 1.21; 95% CI, 1.15-1.28; P < .001) and nearly doubled in HC (HR, 1.94; 95% CI, 1.88-2.00; P < .001)., Conclusions: Sepsis risk in HD patients is clearly related to access type and is associated with dramatic increase in mortality. Initiating HD access with AVF to meet the National Kidney Foundation Kidney Disease Outcomes Quality recommendations should be implemented to reduce the incidence of sepsis and improve survival in patients with ESRD., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The Relay Thoracic Stent-Graft with Plus Delivery System (RelayPlus; Terumo Aortic, Sunrise, Fla) was designed to handle the curvature and tortuosity of the thoracic aorta. It was approved by the Food and Drug Administration in 2012; the postapproval study was stopped early because of adequate safety and efficacy data, and no difference was identified in experienced vs first-time users of RelayPlus. The purpose of this study was to report real-world outcomes of patients with thoracic aortic aneurysms and penetrating atherosclerotic ulcers (PAUs) undergoing thoracic endovascular aortic repair (TEVAR) with RelayPlus., Methods: This is a prospective, multicenter, nonrandomized postapproval study that required the use of novice implanters in the United States. Primary and secondary end points included device-related adverse events (deployment failure, conversion to open repair, endoleaks, migration, rupture, and mortality) and major adverse events (stroke, paraplegia/paraparesis, renal failure, respiratory failure, and myocardial infarction), respectively. Continuous and categorical covariates were reported in means or medians and percentages, respectively. Kaplan-Meier survival estimates were used to report long-term TEVAR-related mortality, all-cause mortality, and reinterventions at 3 years., Results: A total of 45 patients with mean age (standard deviation [SD]) of 73.5 (±7.20) years were treated for descending thoracic fusiform aneurysm (56%) or saccular aneurysm/PAU (44%). The patients were predominantly white (80.0%) and male (68.9%). Mean (SD) proximal neck, distal neck, and lesion lengths were 38.2 (±37) mm, 42.1 (±28) mm, and 103.8 (±74) mm, respectively. Mean (SD) aneurysm, proximal neck, and distal neck diameters were 53.9 (±13) mm, 31.3 (±4) mm, and 31.7 (±6) mm, respectively. Technical success was 100%. TEVAR-related mortality at 30 days was 4.4%; two patients died postoperatively, one of shock and the second of bilateral hemispheric stroke. No patient in the study had any conversion to open repair or post-TEVAR rupture. Two patients experienced three major adverse events, which included stroke (2.2%), paraplegia (2.2%), and respiratory failure (2.2%) at 30 days. Three-year freedom from TEVAR-related mortality, all-cause mortality, and reinterventions was 95.6%, 84.0%, and 97.2%, respectively. There were two type I endoleaks at 3 years: one type IB associated with no migration or aneurysm sac increase and one type IA associated with caudal migration of proximal neck and expansion of the proximal aorta., Conclusions: The RelayPlus postapproval study reported low operative mortality and morbidity and supported use of the device as a safe and effective thoracic aortic aneurysm and PAU endovascular treatment. Early midterm follow-up showed sustained freedom from TEVAR-related mortality in real-world practice. Follow-up continues to evaluate the durability of this endograft., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The role of non-steroidal anti-inflammatory drugs in aortic aneurysm disease has been debated. Animal studies demonstrated that intrathecal ketorolac reduces the inflammatory response associated with aortic clamping. However, no human-subject study evaluated this association. Therefore, we sought to explore the effects of ketorolac use in open abdominal aortic aneurysm repair., Methods: The Premier Healthcare Database (June 2009-March 2015) was inquired to capture patients who underwent open abdominal aortic aneurysm repair for non-ruptured abdominal aortic aneurysm, identified via International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Intravenous ketorolac was coded as any or none. Outcomes were in-hospital mortality, cardiac, respiratory, renal, neurological, and hemorrhagic complications. Multivariable logistic regression coarsened exact matching followed by conditional fixed-effect regression modeling were performed., Results: A total of 6394 patients were identified (ketorolac: 806; 12.6%). Patients who received ketorolac were younger and less likely to have hypertension (76.1% vs. 79.3%), diabetes mellitus (12.5% vs. 17.4%), or chronic kidney disease (8.3% vs. 21.4%; all p values   ≤   .033). There was no significant difference in medication use including oral non-steroidal anti-inflammatory drugs and malignant or musculoskeletal diseases. Mortality, respiratory, and renal complications were less prevalent with ketorolac (2.5% vs. 4.9%, 25.2% vs. 34.6%, 10.0% vs. 21.1%; p  ≤   .002). Ketorolac was associated with lower adjusted odds for those events: 0.58 (0.36-0.93), 0.53 (0.42-0.68), and 0.72 (0.60-0.86), respectively (all p values   ≤   .025). There was no association with neurological, cardiac, or hemorrhagic complications. The findings were replicated by coarsened exact matching analysis., Conclusion: This study demonstrated 40% mortality reduction with intravenous ketorolac following open abdominal aortic aneurysm repair. The survival benefit could be due to its anti-inflammatory and opioid-sparing properties. This is evident by its protective effect against respiratory outcomes. The lack of association with the classical non-steroidal anti-inflammatory drugs-related cardiac and hemorrhagic complication could be attributable to the short-term use of ketorolac compared with non-steroidal anti-inflammatory drugs chronic use.

Background: Anemia has been identified as a risk factor for postoperative morbidity and mortality after major vascular procedures. Carotid revascularization carries less cardiac morbidity and physiologic stress compared with other vascular interventions. This study evaluated the association between preoperative anemia and major adverse events after carotid revascularization., Methods: Patients undergoing carotid endarterectomy (CEA) and carotid artery stenting (CAS) between January 2012 and June 2018 in the Vascular Quality Initiative database were identified. Anemia was defined as a preoperative hemoglobin level of <12 g/dL in women and <13 g/dL in men. Multivariable logistic analysis and 1:1 coarsened exact matching were used to study the association between preoperative anemia and in-hospital major adverse cardiac events (MACEs), defined as a composite of stroke, death, and myocardial infarction, and between anemia and 30-day mortality after CEA and CAS., Results: Of 102,719 patients included in the analysis, 34.8% were anemic (CEA, 34.1%; CAS, 37.8%; P < .001). Anemic patients were older and had more medical comorbidities compared with nonanemic patients. In-hospital MACEs (2.8% vs 1.9%; P < .001) and 30-day mortality (0.9% vs 0.4%; P < .001) were higher among anemic patients. On multivariable analysis, anemia was associated with 18% higher odds of in-hospital MACEs (odds ratio, 1.18; 95% confidence interval, 1.07-1.31, P = .001) and 74% higher odds of 30-day mortality (odds ratio, 1.74; 95% confidence interval, 1.40-2.17, P < .001). Coarsened exact matching showed similar results. The association between preoperative anemia and adverse outcomes was similar in both CAS and CEA and in symptomatic and asymptomatic patients (P interaction > .05)., Conclusions: Anemia is associated with increased odds of adverse events after CEA and CAS. It should be factored into the preoperative risk assessment of patients undergoing carotid revascularization. Prospective studies are needed to study the effectiveness of correcting low preoperative hemoglobin levels in these patients and the association between anemia and long-term outcomes after CEA and CAS., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The prevalence of end-stage renal disease spans the spectrum of age. Arteriovenous grafts are viable alternatives for hemodialysis access in patients whose anatomy precludes placement of an arteriovenous fistula. This report describes the age-related outcomes after arteriovenous graft placement in a population-based cohort., Methods: A retrospective cohort study was conducted of all patients who initiated hemodialysis in the U.S. Renal Data System (2007-2014). The χ 2 test, t-test, Kaplan-Meier analysis, log-rank test, and multivariable logistic and Cox regression analyses were employed to evaluate access maturation, interventions, patency, and mortality., Results: Of the 78,341 patients studied, 10,150 (13%) were younger than 50 years, 13,167 (16.8%) were 50 to 59 years, 19,975 (25.5%) were 60 to 69 years, 20,307 (25.9%) were 70 to 79 years, and 14,742 (18.8%) were 80+ years. There was no significant difference in access maturation time for patients in the older age categories compared to patients younger than 50 years. Primary patency at 5 years comparing <50 years vs 50 to 59 years vs 60 to 69 years vs 70 to 79 years vs 80+ years was 12% vs 12% vs 9% vs 9% vs 8% (P < .001). Primary assisted patency at 5 years was 20% vs 21% vs 18% vs 17% vs 14% (P < .001). Secondary patency at 5 years was 36% vs 39% vs 36% vs 30% vs 31% (P < .001). There was no significant difference in primary patency (adjusted hazard ratio [aHR], 1.00; 95% confidence interval [CI], 1.00-1.00; P < .001), primary assisted patency (aHR, 1.00; 95% CI, 1.00-1.00; P < .001), and secondary patency (aHR, 1.00; 95% CI, 1.00-1.00; P = .029) with increasing age. However, there was a decrease in severe prosthetic graft infection requiring graft excision (aHR, 0.99; 95% CI, 0.99-0.99; P < .001) and increase in mortality (aHR, 1.03; 95% CI, 1.03-1.03; P < .001) for the older age categories compared with the younger patients., Conclusions: In this population-based cohort of hemodialysis patients, there was no significant association between older age and prosthetic graft maturation or patency. However, older age was associated with a decrease in severe graft infection and the expected increase in mortality., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Few centers in the United States have the expertise to manage patients with a thoracoabdominal aortic aneurysm (TAAA). The purpose of this study is to use a nationally representative vascular database to assess the role of hospital volume on outcomes in patients undergoing endovascular repair for TAAA., Methods: All patients undergoing complex endovascular repair (cEVAR) for TAAA were identified in the Vascular Quality Initiative (VQI) database (2012-2018). The total mean number of cases per year was identified at each center and were used to group into three quantiles containing an equal number of patients (Low [LVH], Medium [MVH], High [HVH]). Standard univariate and multivariable (logistic regression) analyses were performed to evaluate the patient's characteristics and short-term outcomes., Results: A total of 2,115 patients from 118 centers (Low - 92, Medium - 19, High - 7) were identified in VQI from 2012 to 2018. The annual mean (S.D.) number of cases at HVH, MVH, LVH were 22.7 (4.7), 9.6 (3.0), 3.6 (1.4), respectively. The repair of Type III TAAA was slightly higher in HVH versus MVH versus LVH (22.5% vs. 21.0% vs. 15.1%), while Type I was more common among LVH versus MVH versus HVH (13.7% vs. 11.5% vs. 3.7%) (Both P < 0.001). Custom/modified devices were more likely to be used in HVH versus MVH versus LVH (67.9% vs. 27.6% vs. 27.2%) (P < 0.001). Additionally, HVH and MVH utilized fenestrated/branched or chimney/snorkel options more frequently, whereas surgical bypasses were common in LVH for revascularization of visceral arteries. In univariate analysis, HVH were associated with significantly lower mortality (2.2% vs. 5.1% and 6.5%), failure to rescue [FTR] (3.5% vs. 11.6% and 12.1%) and any complication (24.6% vs. 27.1% and 31.2%) compared to LVH and MVH (All P < 0.001). After adjusting for potential confounders, both LVH and MVH were associated with 2-4 fold increase in the odds of mortality [OR (95% CI): 2.30 (1.20-4.41) and 2.14 (1.16-3.93)] and FTR [OR (95% CI): 4.42 (1.86-10.54) and 4.08 (1.73-9.62)] compared to HVH., Conclusions: Our study demonstrates significantly lower morbidity and mortality in high volume hospitals performing cEVAR for TAAA, despite operating on older patients with more complex TAAA types. This is likely due to better rescue phenomenon in addition to more experienced operators. Complex endovascular repair of TAAA can be performed safely in high volume aortic centers of excellence., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The impact of race and gender on surgical outcomes has been studied in infrainguinal revascularization for peripheral arterial disease. The aim of this study is to explore how race and gender affect the outcomes of suprainguinal bypass (SIB) for aortoiliac occlusive disease., Materials and Methods: Patients who underwent SIB were identified from the procedure-targeted National Surgical Quality Improvement Program data set (2011-2016). Patients were stratified into four groups: nonblack males, black males (BM), nonblack females, and black females (BF). Primary outcomes were 30-d major adverse cardiac events, a composite of myocardial infarction, stroke, or death; postoperative bleeding requiring transfusion or intervention; major amputation and prolonged length of stay (>10 d). Predictors of outcomes were determined by multivariable logistic regression analysis., Results: About 5044 patients were identified. BM were younger, more likely to be smokers, less likely to be on antiplatelet drug or statin, and to receive elective SIB (all P ≤ 0.01). BFs were more likely to be diabetic and functionally dependent (all P ≤ 0.02). Major adverse cardiac events were not significantly different among all groups. BM had a threefold higher risk of amputation (adjusted odds ratio [OR] [95% confidence interval (95% CI)], 3.10 [1.50-6.43]; P < 0.002). Female gender was associated with bleeding in both races, that association was more drastic in BF (OR [95% CI], 2.43 [1.63-3.60]; P < 0.0001), whereas nonblack females (OR [95% CI], 1.46 [1.19-1.80]; P < 0.0001). BF had higher odds of prolonged length of stay (OR [95% CI]: 1.62 [1.08-2.42]; P < 0.019)., Conclusions: In this large retrospective study, we demonstrated the racial and gender disparity in SIB outcomes. BM had more than threefold increase in amputation risk as compared with nonblack males. Severe bleeding risk was more than doubled in BF. Race and gender consideration is warranted in risk assessment when patients are selected for aortoiliac disease revascularization, which in turn necessitate preoperative risk modification and optimization in addition to enhancing their access to primary preventive care measures., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: The few randomized trials comparing endovascular with open surgical repair of ruptured abdominal aortic aneurysm (rAAA) were poorly designed and heavily criticized. The short-term and midterm survival advantages of endovascular repair remain unclear. We sought to compare the two treatment modalities using a propensity-matched analysis in a real-world setting., Methods: All ruptured cases of open surgical repair (rOSR) and endovascular aneurysm repair (rEVAR) in the Vascular Quality Initiative were analyzed (2003-2018). Raw and propensity-matched rEVAR and rOSR cohorts were compared. Primary and secondary outcomes included postoperative major adverse events (cardiovascular, pulmonary, renal, bowel or limb ischemia, reoperation) and 30-day and 1-year mortality. Univariate, multivariate, and Kaplan-Meier analyses were performed., Results: There were 4929 rAAA repairs performed, 2749 rEVAR and 2180 rOSR. Compared with rEVAR patients, rOSR patients had higher rates of myocardial ischemic events (15% vs 10%; P < .001), major adverse events (67% vs 37%; P < .001), and 30-day death (34% vs 21%; P < .001). On adjusted analysis, rOSR was predictive of 30-day mortality (odds ratio, 1.8; 95% confidence interval, 1.5-2.2). After 1:1 matching, the study cohort consisted of 724 pairs of rOSR and rEVAR. The rOSR patients had twice the length of stay (median, 10 days [interquartile range, 5-19 days] vs 5 days [interquartile range, 3-10 days]; P < .001). Univariate analysis demonstrated persistent increased 30-day mortality after rOSR (32% vs 18%; P < .001) and higher rates of myocardial infarction (14% rOSR vs 8% rEVAR; P = .002), respiratory complications (38% vs 20%; P < .001), and acute kidney injury (42% vs 26%; P < .001). Overall major adverse event rate was higher after rOSR (68% vs 35%; P < .001). Multivariable regression analysis of the propensity-matched pairs demonstrated that rOSR was associated with double the 30-day mortality compared with rEVAR (odds ratio, 2.0; 95% confidence interval, 1.6-2.7). All-cause 1-year survival was 73% and 59% after rEVAR and rOSR in the propensity-matched cohort, respectively (P < .001)., Conclusions: This is one of the largest studies of rAAA demonstrating clear short-term and midterm survival benefits of rEVAR over rOSR that persisted after matching on all major demographic, comorbid, and anatomic variables. Furthermore, patients who survived rOSR had twice the length of stay with increased rates of complications compared with rEVAR patients. These data suggest a more aggressive endovascular approach for rAAA in patients with suitable anatomy., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The use of IV narcotic analgesics (IVNA) within the context of vascular procedures is not fully described. We sought to evaluate the burden of IVNA including narcotic analgesia-related adverse drug events (NARADE), associated mortality and hospitalization cost in open and endovascular vascular procedures, and to compare it with nonnarcotic analgesia (IVNNA)., Methods: Retrospective cross-sectional study in hospitals participating in Premier database (2009-2015). Logistic regression analysis was implemented to report the risks of NARADE and in-hospital mortality. Negative binomial regression was used to assess length of stay and generalized linear modeling was used to estimate the hospitalization cost., Results: A total of 171,473 patients were identified. NARADE occurred in 6.2% of the cohort. NARADE group was similar in gender and race but was slightly older (median age 71 vs. 70; P < 0.001). After risk-adjustment, NARADE risk was higher in patients who received IVNA-alone in carotid and lower extremity revascularization (LER) [OR (odds ratio) (95% confidence interval [CI]): 1.17 (1.02-1.34) and 1.31 (1.14-1.50)] or combined with IVNNA [OR (95% CI): 1.34 (1.13-1.59) and 1.81 (1.54-2.13)], respectively. Patients receiving aortic repair benefited from the use of IVNA + IVNNA [OR (95% CI): 0.82 (0.69-0.98)]. Occurrence of NARADE doubled the LOS, amplified mortality risk and increased cost in all domains. NARADE increased the odds of mortality by 24.3, 6.5 (4.9-8.68) and 16.6 times and added $5,368, $12,737 and $11,349 to the cost of carotid, aortic and LER interventions, respectively. In contrast, IVNNA was not associated with NARADE risk, increased LOS or cost and showed a survival benefit in patients undergoing open aortic repair [aOR (95% CI): 0.52 (0.36-0.75)]., Conclusions and Relevance: The use of opioid-based narcotics had increased the risk of NARADE, resources utilization and NARADE-related mortality. Yet the use of nonopioid-based analgesic was safe, did not increase the cost and reduced mortality in open AA repair. This entices shifting the paradigm toward exploring nonopioid-based analgesia options in order to replace or minimize opioid requirements., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Hostile infrarenal proximal neck (β) anatomy of abdominal aortic aneurysm has been associated with increased risk of aneurysm-related complications after endovascular aneurysm repair (EVAR). However, there is a paucity of literature addressing the suprarenal angle (α). The aim of this study was to evaluate short- and long-term outcomes after EVAR in patients with severe suprarenal neck angulation (α >60 degrees)., Methods: A retrospective review of the medical records of 561 patients who underwent EVAR between January 2005 and December 2017 was performed. The main exclusion criteria were preoperative aneurysm rupture and fenestrated or branched endograft placement. High-resolution computed tomography images of 452 patients were available. Patients were grouped into angulated (α >60 degrees) and nonangulated (α ≤60 degrees) groups. The primary end point was freedom from type IA endoleak. Secondary end points included 30-day mortality, long-term survival, primary clinical success, and freedom from aneurysm rupture and graft migration. Primary clinical success was defined according to Society for Vascular Surgery guidelines as clinical success without the need for an additional or secondary surgical or endovascular procedure., Results: Of 452 patients, 45 (10%) were included in the angulated group (α >60 degrees). Median follow-up time was 34 months (interquartile range, 14-56 months). Compared with patients in the nonangulated group, those in the angulated group had larger neck diameter at the level of the renal arteries (mean [standard deviation], 25.6 [3.8] mm vs 24.6 [3.4] mm; P = .06) and increased β angle (mean [standard deviation], 50.5 [22.9] degrees vs 41.6 [23.9] degrees; P = .01). The 3-year freedom from type IA endoleak estimate was 80.2% for the angulated group compared with 97.8% for the nonangulated group (P < .001). The angulated group showed significantly higher 30-day mortality (11.1% vs 0.25%; P < .001).The 3-year results showed that patients in the nonangulated group had higher rates of primary clinical success (90.2% vs 67.1%; P < .001), freedom from rupture (99% vs 97.1%; P = .02), freedom from migration (100% vs 92.4%; P < .001), and long-term survival (91.6% vs 75.8%; P = .006) compared with those in the angulated group. After adjustment for age, sex, neck diameter, and β angle, severe suprarenal neck angulation was associated with higher odds of type IA endoleak (adjusted hazard ratio, 8.9; 95% confidence interval [CI], 2.9-27), loss of primary clinical success (adjusted hazard ratio, 4.8; 95% CI, 2.6-8.9), and 30-day mortality (adjusted odds ratio, 52.5; 95% CI, 5.3-514) compared with α ≤60 degrees (all P < .001)., Conclusions: This is the first report to show a significant increase in operative mortality in patients undergoing EVAR with severely angulated suprarenal neck. Patients who survive the operation are at increased risk of secondary interventions. These findings suggest that EVAR should be used with caution in patients with severe α angulation and underpin the role of close follow-up in this particular population., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Restenosis after carotid revascularization is clinically challenging. Several studies have looked into the management of recurrent restenosis; however, studies looking into factors associated with restenosis are limited. This study evaluated the predictors of restenosis after carotid artery stenting (CAS) and carotid endarterectomy (CEA) using a large national database., Methods: Patients undergoing CEA or CAS in the Vascular Quality Initiative data set (2003-2016) were analyzed. Patients with no follow-up (33%) and those who had prior ipsilateral CEA or CAS were excluded. Significant restenosis was defined as ≥70% diameter-reducing stenosis, target artery occlusion or peak systolic velocity ≥300 cm/s, or repeated revascularization. Kaplan-Meier survival analysis and bootstrapped Cox regression models with stepwise forward and backward selection were used., Results: A total of 35,720 procedures were included (CEA, 31,329; CAS, 4391). No significant difference in restenosis rates was seen between CEA and CAS at 2 years (7.7% vs 9.4% [P = .09]; hazard ratio [HR], 0.99; 95% confidence interval [CI], 0.79-1.25; P = .97). However, after adjustment for age, sex, and symptomatic status at the time of the index operation, CAS patients who had postoperative restenosis were more likely to have a symptomatic presentation (odds ratio, 2.2; 95% CI, 1.2-4.0; P = .01) and to undergo repeated revascularization at 2 years (HR, 1.75; 95% CI, 1.3-2.4; P < .001) compared with patients who had restenosis after CEA. Predictors of restenosis after CAS included a common carotid artery lesion (HR, 1.65; 95% CI,1.06-2.57; P = .03), whereas age (HR, 0.91; 95% CI, 0.84-0.99; P = .03) and dilation after stent placement (HR, 0.53; 95% CI, 0.39-0.72; P < .001) were associated with decreased restenosis at 2 years. Predictors of restenosis after CEA included female sex (HR, 1.55; 95% CI, 1.38-1.74; P < .001), prior neck irradiation (HR, 2.35; 95% CI, 1.66-3.30; P < .001), and prior bypass surgery (HR, 1.29; 95% CI, 1.01-1.65; P = .04). On the other hand, factors associated with decreased restenosis after CEA included age (HR, 0.95; 95% CI, 0.92-0.98; P < .001), black race (HR, 0.57; 95% CI, 0.37-0.89; P = .01), patching (HR, 0.61; 95% CI, 0.47-0.79; P < .001), and completion imaging (HR, 0.70; 95% CI, 0.52-0.95; P = .02)., Conclusions: Our results show no significant difference in restenosis rates at 2 years between CEA and CAS. Restenosis after CAS is more likely to be manifested with symptoms and to undergo repeated revascularization compared with that after CEA. Poststent ballooning after CAS and completion imaging and patching after CEA are associated with decreased hazard of restenosis; however, further research is needed to assess longer term outcomes and to balance the risks vs benefits of certain practices, such as poststent ballooning., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Although the majority of vascular surgeons perform conventional carotid endarterectomy (c-CEA), others prefer eversion CEA (e-CEA). Despite several randomized controlled trials and single center studies, the advantage of one technique over the other is still not clearly defined. The purpose of this study is to compare the postoperative outcomes and durability of c-CEA versus e-CEA in a nationally representative cohort., Methods: We performed a retrospective review of the Vascular Quality Initiative database between 2003 and 2018. Patients with prior ipsilateral carotid intervention (CEA and carotid artery stenting) and those undergoing concomitant procedures were excluded. Multivariable logistic and Cox-regression analyses were used to compare risk-adjusted perioperative and 1-year outcomes (stroke, death, and high-grade restenosis [>70%]) between c-CEA (using direct closure or patch angioplasty) and e-CEA., Results: A total of 95,726 CEA cases were included, of which 12,050 (12.6%) were e-CEA and the remaining (87.4%) were c-CEA. Patch angioplasty was used in 94.9% of c-CEA compared with 49.7% of e-CEA (P < 0.001). On univariable analysis, no difference in perioperative outcomes was noted between the 2 approaches except for higher rates of in-hospital dysrhythmia (1.5% vs. 1.3%) and postprocedural hemodynamic instability (27.3% vs. 24.3%) after c-CEA compared with e-CEA (all P < 0.05). On the other hand, e-CEA patients were more likely to return to the operating room for bleeding (1.3% vs. c-CEA: 0.9%, P < 0.001). The outcomes of e-CEA did not differ if the common carotid artery was closed primarily or with a patch. After adjusting for potential confounders and stratifying with respect to patch use, there was no significant difference in outcomes between e-CEA and c-CEA when a patch is used in both procedures. However, when no patching was performed, e-CEA was associated with lower stroke/death at 30 days (odds ratio 0.72, 95% confidence interval [CI] 0.54-0.95, P = 0.02) and at 1 year (hazard ratio 0.75, 95% CI 0.58-0.97, P = 0.03)., Conclusions: Both e-CEA and c-CEA are safe and durable techniques with similar stroke/death and restenosis rates up to 1-year of follow up, as long as c-CEA is performed with patch angioplasty. However, e-CEA is superior to c-CEA without patch angioplasty and is associated with 28% and 25% reduction in 30-day and 1-year stroke/death, respectively., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Patients with end-stage renal disease (ESRD) whether on dialysis therapy (DT) or who received a kidney transplant (KT) have previously shown unfavorable surgical outcomes. Little is known about the comparative efficacy and durability of lower extremity bypass (LEB) in those patients. The Vascular Quality Initiative database was explored to identify DT or KT recipients (2003-2016) who had LEB. We included 1,714 bypass procedures; DT: 1,512 (88.2%). Primary patency (PP) at 2 year was comparable between KT and DT groups (PP [95% confidence interval {CI}]: 77.0% [69.7%-82.8%] vs. 80.5% [77.8%-82.9%]; P = 0.212), and the risk-adjusted hazard was similar (adjusted hazard ratio [aHR] [95% CI]: 0.89 [0.61-1.30]; P = 0.540). Amputation-free survival (AFS) at 2 year was more favorable in KT group (AFS [95% CI]: 73.1% [66.3%-78.8%] vs. 48.0% [45.4%-50.6%]; P < 0.001), (aHR [95% CI]: 2.29 [1.62-3.23]; P < 0.001). Patients on DT exhibited a higher risk of mortality than KT recipients (aHR [95% CI]: 2.94 [2.07-4.17]; P < 0.001). This study demonstrated superior limb outcomes in KT recipients than patients on DT after LEB. Despite the comparable PP, the risk of amputation or death was doubled in patients on DT compared with KT recipients. Because both groups were similar in several baseline characteristics, the difference in outcome is likely driven by the positive effect of KT on the physiological milieu of these patients., (Copyright © 2019. Published by Elsevier Inc.)

Background: The vast majority of patients undergoing hemodialysis (HD) are anemic. The severity of anemia in these patients may influence the postoperative outcomes and the durability of vascular access. Thus, the purpose of this study is to assess the association between anemia and adverse outcomes in patients undergoing HD access placement (arteriovenous grafts and fistula)., Methods: Patients with chronic kidney disease stages IV and V recorded in the Vascular Quality Initiative Hemodialysis database between 2011 and 2017 were included. Patients were divided into 3 study groups based on preoperative hemoglobin (Hgb) levels: normal/mild anemia (Hgb: females ≥10 g/dL, males ≥12 g/dL), moderate anemia (Hgb: females: 7-9.9 g/dL, males: 9-11.9 g/dL), and severe anemia (Hgb: females<7 g/dL, males<9 g/dL). Multivariable logistic and Cox regression analyses were implemented to evaluate the association between anemia and 30-day mortality and primary patency (PP) at 1 year., Results: A total of 28,000 patients undergoing HD access surgery were identified (normal/mild [42%], moderate [49%], and severe [9%] anemia). Postoperative bleeding (2.1% vs. 2.2% vs. 2.2%) and 30-day outcomes including swelling (0.4% vs. 0.5% vs. 0.7%) and wound infection (0.4% vs. 0.3% vs. 0.1%) were similar in mild/normal, moderate, and severe anemia groups, respectively (All P > 0.05). However, 30-day mortality was significantly higher in patients with severe anemia compared with normal/mild and moderate anemia (2.1% vs. 1.1% and 1.1%, P < 0.001). After adjusting for potential confounders, severe anemia was associated with 90% higher risk of 30-day mortality (odds ratio [95% confidence interval]: 1.90 [1.20-3.00], P = 0.006) and 17% increase in PP loss at 1 year (adjusted hazard ratio [95% confidence interval]: 1.17 [1.02-1.35], P = 0.01) compared with the normal/mild anemia group. However, no significant difference was seen between normal/mild and moderate anemia., Conclusions: In this large study of patients undergoing HD access placement, severe anemia was associated with 90% increased risk of 30-day mortality and 17% increased risk of loss of PP compared with those with normal/mild anemia. Management of severe anemia before surgery might be indicated to reduce operative mortality and improve the durability of HD access., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Although blood transfusion can be lifesaving in active hemorrhage or severe anemia, it is also associated with increased morbidity and mortality. Several trials have established this risk and therefore defined a restrictive standard for transfusion, but this threshold and the risk of transfusions have not been specifically examined in vascular surgery patients. We therefore sought to assess transfusion practices and outcomes of anemic patients undergoing elective endovascular aneurysm repair (EVAR)., Methods: The Vascular Quality Initiative database was queried for patients undergoing EVAR between the years 2008 and 2017. Anemic patients were included in the study and were further stratified into mild anemia, defined by a hemoglobin level of 10 to 13 g/dL in men or 10 to 12 g/dL in women, and moderate to severe anemia, defined by a hemoglobin level <10 g/dL. The primary study outcomes were in-hospital mortality and complications., Results: Among 27,777 EVAR patients, one-third (n = 9232) were anemic and included in the study. One-fifth (n = 1866) of anemic patients received a perioperative transfusion. Transfused patients were more likely to have a history of cardiovascular disease. In-hospital mortality was significantly higher for anemic patients who received transfusions, both in mild anemia (mortality, 3.6% vs 0.4% in no transfusion; P < .001) and in moderate to severe anemia (4.5% vs 1.3%; P < .01). Morbidity was also significantly higher, with anemic patients who received a transfusion having higher rates of myocardial infarction, congestive heart failure, dysrhythmias, renal complications, leg ischemia, respiratory complications, and reoperation compared with anemic patients who did not receive any transfusion. The 30-day mortality was also higher in transfused patients (P < .001). After adjustment for patients' demographics, comorbidities, and operative factors, transfusion in anemic patients was associated with a nearly 4.4-fold increased odds of in-hospital mortality (odds ratio [OR], 4.38; 95% confidence interval [CI], 2.72-7.05; P < .001) and 4.3-fold higher odds of any in-hospital complication (OR, 4.31; 95% CI, 3.47-5.34; P < .001). This was more pronounced among patients with mild anemia, with 5.7 times (OR, 5.7; 95% CI, 1.78-18.0) and 4.3 times (OR, 4.3; 95% CI, 3.46-5.29) the odds of in-hospital mortality and complications, respectively., Conclusions: Among anemic patients undergoing elective EVAR, transfusion is associated with an increased risk of death and in-hospital complications, even after controlling for patients' comorbidities and operative factors. These data suggest that the restrictive use of blood transfusions might be safer in vascular surgery EVAR patients. Medical management of anemia may be warranted in these patients to reduce morbidity and mortality; however, further studies are needed to evaluate effectiveness., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study is to use a large, nationally representative vascular database to assess differences in patient characteristics, aortic neck anatomy, and outcomes between men and women following open (open aneurysm repair [OAR]) and endovascular (endovascular aneurysm repair [EVAR]) abdominal aortic aneurysm (AAA) repair., Methods: Patients undergoing AAA repair from 2003 to 2018 in Vascular Quality Initiative were identified and stratified by procedure (EVAR vs OAR). Thirty-day mortality and major in-hospital complications were assessed between genders within each operative cohort. An EVAR subset analysis was performed to assess differences in aortic neck anatomy; hostile neck anatomy was defined as length <15 mm (L < 15), angle >60° (A > 60), and/or diameter >28 mm (D > 28). Standard univariate and multivariable analyses were performed., Results: A total of 50 213 patients were identified: 9263 (19%) OAR and 40 950 (82%) EVAR. In both cohorts, majority of patients were men (OAR 73% and EVAR 81%). Women were more likely to have a hostile neck (31.7% vs 24.1%, P < .001), L < 15 (19.8% vs 11.9%, P < .001), and A > 60 (11.5% vs 5.4%, P < .001). Men had larger aneurysm (mean, 57 vs 55 mm, P < .001) and were more likely to have D > 28 (14.0% vs 10.6%, P < .001). Women undergoing EVAR were more likely to undergo aortic extensions (21.9% vs 16.0%) and receive higher contrast volume. After adjusting for potential confounders, female gender was associated with 86% and 50% increased risk of 30-day mortality in OAR and EVAR, respectively. Women were more likely than men to experience renal, cardiac, and pulmonary complications only in the EVAR cohort. Women had a 2-fold increased odds of developing type 1 endoleak., Conclusion: Our study demonstrates unfavorable neck anatomy occurs more frequently in women compared to men. Women were also at an increased risk of developing major complications, particularly following EVAR. Careful patient selection is indicated in all patients to reduce complications, with special attention in women with hostile neck.

Objective: We sought to assess whether sex-related differences in timely repair of ruptured abdominal aortic aneurysm (rAAA) were associated with excess risk of early mortality in women., Summary Background Data: rAAA is a surgical emergency and timeliness of intervention affects outcomes. A door-to-intervention time of <90 minutes is recommended., Methods: All rAAA repairs in the Vascular Quality Initiative from 2003 to 2017 were reviewed. Patients were stratified by sex and time-delay cohorts. Univariate and multivariate analyses were performed., Results: There were 3719 rAAA repairs, of which 797 (21%) were performed in women. Sex did not affect repair type: open versus endovascular (21% females, each). Despite similar presentation delays [median 6 hours (inter quartile range, IQR: 3-16)], admission-to-intervention time was longer for women than men [median 1.5 hours (IQR 1-4] vs 1.2 hours (IQR 1-3), P=0.047]. Overall, 45% of patients had a >90-minute delay from admission to repair, with more women than men experiencing this delay (49% vs 44%, P=0.01). Neither were more likely to undergo transfer for treatment. After risk adjustment, female sex was associated with a 48% increase in 30-day mortality. Sex differences in mortality were no longer observed in patients with intervention delays of ≤90 minutes. In patients with >90-minute delays, a 77% increase in 30-day mortality of women over men was noted., Conclusions: Nearly half of rAAA patients have a door-to-intervention time longer than recommended societal guidelines. Sex differences in mortality after rAAA repair seem to be driven by in-hospital treatment delays.

Objective: Bowel ischemia (BI) is a serious complication after abdominal aortic aneurysm (AAA) repair. We sought to identify the incidence and risk factors associated with the development of postoperative BI and the post-BI outcomes for patients undergoing open aortic repair (OAR) and endovascular aortic repair (EVAR) of AAAs., Methods: A retrospective analysis was conducted for all patients who had undergone OAR or EVAR from 2003 to 2017 using the Vascular Quality Initiative database. Univariate (Student's t test, χ 2 , median) and multivariable (logistic regression) analyses were used to identify independent factors associated with postoperative BI and compare the post-BI in-hospital outcomes and mortality., Results: We identified 45,474 patients who had undergone infrarenal AAA repair (OAR, 21.5%; EVAR, 78.5%). The overall incidence of postoperative BI was 1.9% (OAR, 6.2% vs EVAR, 0.8%; P < .001). OAR was associated with a threefold increased odds of BI compared with EVAR (adjusted odds ratio [aOR], 3.24; 95% confidence interval [CI], 2.49-4.22; P < .001). The independent factors associated with BI after OAR included older age (aOR per year of age, 1.02; 95% CI, 1.00-1.03), congestive heart failure (aOR, 1.44; 95% CI, 1.05-1.98), and ruptured aneurysm (aOR, 4.16; 95% CI, 2.98-5.81; P < .01 for all). We also found that transfusion ≥1 U (aOR, 1.69; 95% CI, 1.30-2.20), a transperitoneal approach (aOR, 2.13; 95% CI, 1.03-1.87), supraceliac clamping (aOR, 1.58; 95% CI, 1.08-2.33), and inferior mesenteric artery reimplantation (aOR, 1.41; 95% CI, 1.06-1.89) were associated with greater odds of BI after OAR (P < .01 for all). Similarly, we found that ruptured aneurysms, a longer operative time, and transfusion of ≥1 U of blood were associated with BI after EVAR (P < .001 for all). For both OAR and EVAR, the postoperative stay (median, 13 days [interquartile range (IQR), 7-26 days] vs 7 days [IQR, 5-10 days] and 11 days [IQR, 4-23 days] vs 1 day [IQR, 1-3 days], respectively) and 30-day mortality (35.0% vs 6.4% and 40.5% vs 1.9%, respectively) were significantly higher for patients with BI (P < .001 for all). The predictors of mortality for patients with BI were surgical management (aOR, 2.05; 95% CI, 1.28-3.30), older age (aOR, 1.05; 95% CI, 1.02-1.07), symptomatic aneurysm (aOR, 1.26; 95% CI, [0.60-2.62), ruptured aneurysm (aOR, 2.23; 95% CI, 1.43-3.48), longer operative time (aOR, 1.11; 95% CI, 1.01-1.22), and postoperative renal complications (aOR, 2.98; 95% CI, 1.80-4.96; P < .05 for all)., Conclusions: Confirming the results from previous studies, we found that BI is more common after a ruptured aneurysm and OAR. Other associated intraoperative factors included a transperitoneal approach, supraceliac clamping, and a reimplanted inferior mesenteric artery. More than one third of patients who developed postoperative BI in our cohort had died within 30 days after AAA repair. The factors associated with mortality after BI included surgical management and postoperative renal failure. A high index of suspicion for the signs and symptoms of BI should be maintained postoperatively for patients presenting with the risk factors identified., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The benefit of statins in reducing perioperative cardiovascular events in patients undergoing suprainguinal bypass is still controversial. The purpose of this study was to evaluate the association between statin use and perioperative mortality in patients undergoing aortobifemoral bypass (ABFB) for aortoiliac occlusive disease., Methods: We retrospectively analyzed all patients who had ABFB in the American College of Surgeons National Surgical Quality Improvement Program data set from 2011 to 2016. Univariable (t-test, χ 2 test, or Fisher exact test) and multivariable logistic regression analyses were used to compare patients' characteristics and the primary outcome (30-day mortality) between statin users and nonstatin users. Propensity score matching between statin users and nonusers was also performed on the basis of variables that were different between the two groups., Results: A total of 4445 patients underwent ABFB. Of those, 3032 (68.2%) were taking statins. Compared with nonstatin users, statins users were older (median [interquartile range], 67 years [59-74 years] vs 63 years [56-72 years]; P < .01) and more likely to be diabetic (31% vs 16%) and hypertensive (84% vs 63%) and to have a history of chronic obstructive pulmonary disease (20% vs 17%; all P < .05). Statin users had lower rates of 30-day mortality (3.4% vs 4.7%; P = .03) and renal complications (2.5% vs 3.7%; P = .04) compared with nonstatin users. After adjustment for patients' demographics (age, sex, race), comorbidities (diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, dialysis, bleeding disorder), smoking, clinical presentation (claudication vs critical limb ischemia), and elective surgery status, statin use was associated with 32% reduction in 30-day mortality (odds ratio, 0.68; 95% confidence interval, 0.47-0.96; P = .03). Propensity score matching showed similar results (odds ratio, 0.63; 95% confidence interval, 0.41-0.95; P = .03)., Conclusions: This is the largest study to date demonstrating an association between preoperative statin use and lower 30-day mortality after ABFB for aortoiliac occlusive disease. This study highlights an area of potential quality improvement as one-third of the patients undergoing this procedure are not receiving statins., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Endovascular aneurysm repair (EVAR) offered outstanding survival benefit but at the expense of cost, periodic radiographic monitoring, and higher reinterventions rates. Perioperative complications, although rare, can occur after EVAR, contributing to longer hospitalization, higher cost, and significant comorbidity and mortality. Therefore, the aim of this study was to identify the predictors of in-hospital events (IHEs) after elective EVAR., Methods: The Vascular Quality Initiative database was explored from 2003 to 2017. Patients who had converted to open repair were excluded. IHEs were defined as any in-hospital myocardial infarction, dysrhythmia, congestive heart failure (CHF), stroke, pneumonia, respiratory failure, renal failure, lower extremity ischemia, bowel ischemia, or reoperation. Stepwise backward selection based on the Akaike information criterion statistic was implemented to select the predictors of IHE from the multivariable logistic regression models. Bootstrapping was performed with 1000 replications to internally validate the model and to obtain bias-corrected estimates. Receiver operating characteristic curves (area under the curve [AUC]) and Hosmer-Lemeshow tests were used to assess the discrimination and calibration of the models., Results: A total of 28,240 patients with full information about IHEs were included. Any IHE took place in 2365 (8.4%) patients. Patients who had an IHE were slightly older (mean age ± standard deviation, 75.6 ± 8.1 years vs 73.3 ± 8.5 years; P < .001]. A higher proportion of women had an IHE (25.6% vs 17.9%; P < .001). Comorbid conditions were more prevalent in patients who developed an IHE (chronic kidney disease, 49.1% vs 33.2%; coronary artery disease, 34.3% vs 29.0%; moderate to severe CHF, 3.9% vs 1.4%; chronic obstructive pulmonary disease, 42.5% vs 31.9%; hypertension, 87.0% vs 83.1%; and diabetes, 18.0% vs 16.1%; all P ≤ .015). An IHE was associated with high in-hospital (5.6% vs 0.03%) and 30-day mortality (6.3% vs 0.3%; both P < .001) and worse 3-year survival beyond the perioperative period (81.1% [79.3%-82.9%] vs 91.1% [90.7%-91.5%]; P < .001). Two models were constructed, one from preoperative factors and the second from preoperative and intraoperative factors. The selected predictors of IHEs were female sex, moderate or severe CHF, chronic kidney disease, coronary artery disease, chronic obstructive pulmonary disease, hypertension, and aneurysm diameter. Intraoperative factors were contrast material volume, operative time, and packed red blood cell transfusion. Nomograms were constructed from the final models. AUC significantly improved after adding intraoperative factors (AUC [95% confidence interval], 0.71 [0.70-0.73] vs 0.65 [0.64-0.66]; P < .001]., Conclusions: In-hospital adverse events can complicate the perioperative course of EVAR and increase the risk of operative and long-term mortality. Predicting IHEs and identifying their risk factors can potentially mitigate their development in patients at high risk. Predicting IHE risk can have tremendous prognostic value and help disposition planning. This study introduces an internally validated tool to enable vascular surgeons to identify patients' chance of having an IHE., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Drug abuse may affect lower extremity vessels due to ischemia following intra-arterial injections, vasospasm, arterial and venous pseudoaneurysms, arteriovenous fistulae, vasculitis, and complicated abscesses. Little is known about the outcomes of lower extremity bypass (LEB) for peripheral arterial disease (PAD) in patients with a history of drug abuse disorder. The aim of this study is to evaluate the outcomes of LEB in this patient population., Methods: A retrospective study of the Premier Healthcare Database 2009-2015 was performed. In-hospital complications, mortality, and hospitalization costs were assessed in patients with a history of drug abuse disorder (opioids, cannabis, cocaine, sedatives/hypnotics/anxiolytics, and hallucinogens/methamphetamine/psychoactive drugs) who underwent LEB for PAD. Multivariable logistic and generalized linear models were utilized to study the association between drug use/misuse and in-hospital outcomes after LEB., Results: Our cohort included 50,976 patients, of which 967 (2%) had a history of drug abuse disorder on admission. The majority of drugs were cannabis (38.5%), followed by opioids (21.5%) and cocaine (14.5%). Patients with a history of drug use/misuse were significantly at a higher risk of developing complications during their hospital stay (71.9% vs. 64.2%, P < 0.001) including acute renal failure (11.8% vs. 9.1%), stroke (1.6% vs. 0.6%), respiratory complications (pneumonia and respiratory failure) (15.0% vs. 9.6%), hemorrhage/shock (36.2% vs. 31.8%), vascular or graft-related complications (29.8% vs. 26.4%), wound complications (9.1% vs. 6.3%), cellulitis (8.5% vs. 6.8%), and sepsis (2.1% vs. 1.2%, all P < 0.001). In addition, drug users were found to have higher risk of concomitant major amputations compared to nondrug users (2.0% vs. 0.9%, P < 0.001). On multivariable analysis, no difference was noted between the 2 groups in terms of in-hospital mortality and concomitant major amputations. However, drug use/misuse was associated with 57% higher odds of overall in-hospital complications (odds ratio [OR] 1.57, 95% confidence interval [CI] 1.34-1.83, P < 0.001), a prolonged length of hospital stay (median: 7 days vs. 5 days in nonabusers, P < 0.001), and higher hospitalization costs compared to nonusers (adjusted mean difference: OR $3,075, 95% CI $2,096-$4,055, P < 0.001)., Conclusions: Drug use/misuse is significantly associated with increased odds of in-hospital complications, longer hospital stays, and higher hospitalization costs following LEB. Vascular surgeons need to pay special attention to this patient population and explore interventions to decrease the morbidity and economic burden associated with drug use., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The timing of carotid revascularization in symptomatic patients is a matter of ongoing debate. Current evidence indicates that carotid endarterectomy (CEA) within 2 weeks of symptoms is superior to delayed treatment. However, there is little evidence on the outcomes of emergent CEA (eCEA). The purpose of this study was to compare outcomes of emergency eCEA vs nonemergent CEA (non-eCEA), stratified by type of presenting symptoms., Methods: We analyzed the Vascular Targeted-National Surgical Quality Improvement Program dataset from 2011 to 2016. Symptomatic patients were divided into two groups: eCEA and non-eCEA. Univariable and multivariable methods were used to compare patient characteristics and to evaluate stroke, death, myocardial infarction (MI), stroke/death, and stroke/death/MI within 30 days of surgery adjusting for all potential confounders. A further subgroup analysis was done to compare the outcomes of eCEA vs non-eCEA stratified by the type of presenting symptoms (amaurosis, transient ischemic attack [TIA], and stroke)., Results: A total of 9271 patients were identified, of which 10.7% were eCEA vs 89.3% non-eCEA. Comparing eCEA vs non-eCEA, the two groups were similar in age (70.8 vs 70.5), female gender (36.3% vs 36.9%), diabetes (26.2% vs 28.9%), and smoking status (31.9% vs 28.7%; all P > .05). Patients undergoing eCEA were less likely to be hypertensive (76.2% vs 80.2%; P = .025), but more likely to belong to non-white race (51.5% vs 20.5%; P < .001). The eCEA patients were less likely to be on preprocedural medication vs non-eCEA (antiplatelets, 76.8% vs 89.2%; statins, 74.2% vs 79.9%; beta-blockers, 44.6% vs 50.4%; all P < .05). The 30-day outcomes comparing eCEA vs non-eCEA were: stroke, 6.2% vs 3.1%; death, 2% vs 1%; and stroke/death, 6.9% vs 3.7% (all P < .05). After risk adjustment, perioperative stroke (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.36-3.0), stroke/death (OR, 1.66; 95% CI, 1.13-2.45), and stroke/death/MI (OR, 1.58; 95% CI, 1.18-2.23) were higher after eCEA (all P < .01). When stratified by the type of presenting symptom, eCEA vs non-eCEA stroke outcomes were similar in patients who presented with stroke or amaurosis fugax. However, in the subset of patients presenting with TIA, eCEA had much worse outcomes compared with non-eCEA (stroke, 8.3% vs 2.5%; stroke/death, 8.3% vs 3.2%) and had significantly higher odds of stroke (OR, 3.12; 95% CI, 1.71-5.68) and stroke/death (OR, 2.24; 95% CI, 1.25-4.03) in the adjusted analysis (all P < .05)., Conclusions: In patients presenting with stroke, eCEA does not seem to add significant risk compared with non-eCEA. However, patients presenting with TIA might be better served with non-emergent surgery as their risk of stroke is tripled when CEA is performed emergently., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Several randomized clinical trials have shown that carotid artery endarterectomy (CEA) is safer than carotid artery stenting (CAS) in the elderly. However, those studies were limited by their strict inclusion criteria that might make their findings inapplicable to real-world practice. Therefore, the aim of this study was to evaluate the association of age with the efficacy of CEA and CAS in a population-based registry., Methods: The Vascular Quality Initiative database was inquired (2005-2017). The primary outcome was 30-day and 2-year stroke and a combined outcome of stroke/death. Logistic regression models with age-by-treatment interaction term were fitted adjusting for patients' characteristics. Restricted cubic spline modelling was also implemented. Two-year events were assessed via survival analysis methods., Results: Overall, 89,853 patients were included, 26.9% were less than 65 years of age, 39.1% were 65 to 74 years of age, and 34.1% were 75 years of age or older. The CAS-to-CEA odds of 30-day stroke became significant at age 56.5 and doubled at age 72.5 years. After CEA, the risk of stroke rose by 1.3-fold when age increased from 76 to 85 (odds ratio [OR], 1.30; 95% confidence interval [CI], 1.05-1.62). Yet after CAS, when age increased from 65 to 71 years, the OR of stroke was 1.36 (95% CI, 1.04-1.76); from 71 to 76 years, the OR was 1.47 (95% CI, 1.10-1.96), and from 76 to 85 years the OR was 1.38 (95% CI, 1.06-1.81). The superiority of CEA with increasing age extended to 2 years after the procedure. The CAS-to-CEA 2-year hazard of stroke was significant at age 53 and it doubled at 71.5 years., Conclusions: In this multicenter registry, we confirmed the effect modification role that age plays in the safety and efficacy of carotid revascularizations. The risk-adjusted effectiveness of CAS was particularly sensitive to patient age, whereas CEA performance was relatively stable across various age strata. Of note, the observed effect was more pronounced and a decade earlier than what previously reported in the ideal setting of a randomized clinical trial., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Several prior studies have shown lower risk of myocardial infarction (MI) in carotid artery stenting (CAS) compared with carotid endarterectomy. This is likely because the majority of endarterectomies are performed under general anesthesia (GA), whereas CAS is mainly performed under local anesthesia (LA). Performing CAS under GA may reverse its minimally invasive benefits. The aim of this study was to compare the safety profile of CAS-GA with that of CAS-LA., Methods: A retrospective analysis of the Vascular Quality Initiative database from 2005 to 2017 was performed. Primary outcomes included major adverse cardiac events (MACE), a composite of in-hospital death and MI, and postoperative neurologic events. Multivariable logistic models, and coarsened exact matching were used to evaluate the association between the primary outcomes and anesthesia technique., Results: Of 12,919 CAS cases performed, 2024 (15.7%) were under GA. Comparing CAS-GA with CAS-LA in the overall cohort, CAS-GA had significantly higher crude rates of in-hospital mortality (2.1% vs 0.5%), MI (1.3% vs 0.7%), composite MACE (3.1% vs 1.2%), and ipsilateral stroke (2.3% vs 1.6%). Patients undergoing CAS-GA also had higher rates of dysrhythmia (3.0% vs 2.2%), acute congestive heart failure (1.6% vs 0.7%) and perioperative hypertension (13.2% vs 9.4%), and were more likely to have a length of hospital stay of more than 4 days (prolonged length of stay) (17.6% vs 8.5%) compared with those undergoing CAS-LA. On multivariable analysis, CAS-GA had a 2.3 times higher odds of in-hospital mortality compared with CAS-LA (OR, 2.52; 95% CI, 1.26-5.03), a 1.9 times the odds of MACE (OR, 1.87; 95% CI, 1.15-3.03), and a 2.3 times the odds of acute congestive heart failure (OR, 2.29; 95% CI, 1.26-4.15; all P < .05). In addition, these patients had a 43% higher odds of developing perioperative hypertension (OR, 1.43; 95% CI, 1.09-1.87; P = .01) and almost 2 times the odds of a prolonged length of stay (OR, 1.82; 95% CI, 1.41-2.35; P < .001). The adjusted odds of stroke, dysrhythmia and reperfusion syndrome were not significantly different between the two groups. Additional analysis using coarsened exact matching showed similar results., Conclusions: In addition to the established increase risk of perioperative stroke/death with CAS compared with carotid endarterectomy, performing it under GA seems to be associated with increased cardiac complications, length of stay, and consequently hospitalization costs. Pending future data from prospective, randomized, controlled trials to validate our findings, there is evidence to suggest that it may be better to perform CAS under LA, especially in medically high-risk patients., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background:: Fenestrated endovascular repair (FEVAR) and chimney endovascular repair (ChEVAR) endovascular repair offer a less invasive alternative to open aortic repair (OAR) in managing juxtarenal, pararenal, and suprarenal abdominal aortic aneurysms (AAAs). The aim of this study is to evaluate the 30-day postoperative outcomes following endovascular and open repair of nonruptured AAA involving the renal vessels., Study Design:: All patients undergoing endovascular (FEVAR and ChEVAR) and open repair of juxtarenal, pararenal, and suprarenal AAA in National Surgical Quality Improvement Program database from 2012 to 2016 were included. Continuous and categorical covariates were analyzed using medians and χ 2 /Fisher exact test, respectively. Multivariable logistic regression analyses were performed to evaluate primary (mortality) and secondary (renal and cardiopulmonary failure) outcomes between open versus endovascular approach., Results:: A total of 1191 patients underwent AAA repair using open (72%) or endovascular (FEVAR: 14%, ChEVAR: 14%) approach. In univariate analysis, no significant difference in 30-day mortality was seen between the 3 groups (FEVAR: 2.47% vs ChEVAR: 7.32% vs OAR: 6.13%, P = .13). However, 30-day major complications including renal failure (9.36% vs 6.10% vs 1.85%, P = .003) and cardiopulmonary complications (19.77% vs 3.66% vs 4.94%, P < 001) failure were significantly higher in patients undergoing OAR versus ChEVAR versus FEVAR. After adjusting for potential confounders, OAR was associated with 2- to 5-folds increased risk of mortality (odds ratio, OR [95% confidence interval, CI]: 2.14 [1.09-4.21], P = .03), renal (OR [95% CI]: 2.87 [1.48-5.57], P = .002), and cardiopulmonary failure (OR [95% CI]: 4.63 [2.47-8.67], P < .001) compared to any endovascular repair., Conclusion:: Using a large national surgical data set, our study found 2- to 5-folds higher mortality and morbidity in patients undergoing open versus endovascular repair of AAA involving the renal vessels. Endovascular repair seems to be a safer approach, especially when managing older patients with AAA.

Background: Fenestrated endovascular aneurysm repair (FEVAR) has expanded the indications of this minimally invasive procedure to include patients with pararenal aneurysms. The actual cost of this relatively newer technology compared with standard endovascular aneurysm repair (EVAR) has not been studied before. Thus, the aim of this study was to analyze in-hospital costs and adverse outcomes in patients undergoing FEVAR vs EVAR for intact abdominal aortic aneurysms (AAAs)., Methods: Using the Premier Healthcare Database (2012-2015), we identified all patients who underwent elective EVAR and FEVAR. Univariable (χ 2 test, Student t-test, median test) and multivariable (logistic regression and generalized linear modeling) analyses were implemented to examine in-hospital cost and adverse outcomes adjusting for patients' demographics, comorbidities, and regional characteristics., Results: A total of 17,689 elective endovascular AAA repairs were performed; 1641 patients underwent FEVAR (9%), and the remaining 16,048 patients underwent standard EVAR (91%). Patients undergoing FEVAR were more likely to be white (86.3% vs 84.3%; P = .03). Both groups had similar comorbidities except for cerebrovascular disease, which was higher among patients undergoing FEVAR (8.4% vs 6.7%; P = .01). The total length of hospital stay was slightly higher in patients undergoing FEVAR compared with EVAR (mean [standard deviation], 2.40 [3.39] days vs 2.23 [3.10] days; P = .03). The rates of any complication (11.3% vs 9.6%), renal injury (5.8% vs 4.3%), and neurologic injury (0.7% vs 0.4%) were significantly higher in the FEVAR group (all P < .05). No differences were seen in mortality (0.8% vs 0.5%) or cardiac (4.9% vs 4.4%), pulmonary (2.4% vs 2.2%), and bowel (1.5% vs 1.2%) complications between the two groups (all P > .05). In multivariable logistic regression analysis, FEVAR was associated with 40% increased odds of renal failure (odds ratio, 1.40; 95% confidence interval [CI], 1.11-1.76; P = .004) and 91% increased odds of neurologic injury (odds ratio, 1.91; 95% CI, 1.02-3.57; P = .04). The median total cost of the treatment was also significantly higher among patients undergoing FEVAR ($28,227 vs $26,781; P < .001). After adjustment, generalized linear modeling analysis showed that the cost of FEVAR was on average $1612 higher than the cost of EVAR (adjusted cost, $1612; 95% CI, $1123-$2101; P < .001)., Conclusions: In this large cohort of elective endovascular AAA repairs, compared with standard EVAR, FEVAR is associated with significantly increased odds of renal and neurologic injury. In addition, despite adjusting for patients' demographics, comorbidities, and major complications, total cost of FEVAR was significantly higher compared with standard EVAR. This is likely driven by the additional cost of fenestrated endografts and by the increased rate of complications related to FEVAR., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Anemia is associated with increased cardiac adverse events during the early postoperative period because of high physiologic stress and increased cardiac demand. The aim of this study was to assess the surgical outcomes and prognostic implications of anemia in patients undergoing repair of intact abdominal aortic aneurysms (AAAs)., Methods: A retrospective analysis of all patients who underwent open aortic repair (OAR) or endovascular aneurysm repair (EVAR) in the Vascular Quality Initiative database (2008-2017) was performed. Patients with preoperative polycythemia, patients with ruptured aneurysms, and patients transfused with >4 units of packed red blood cells were excluded. Hemoglobin levels were categorized into three groups: moderate-severe anemia (<10 g/dL), mild anemia (10-12 g/dL in women and 10-13 g/dL in men), and no anemia (>12 g/dL in women and >13 g/dL in men). Multivariate logistic models and coarsened exact matching were used to analyze the association between anemia and 30-day mortality and between anemia and major in-hospital complications after OAR and EVAR., Results: A total of 34,397 patients were identified undergoing AAA repair. Of those, 28.5% had mild anemia and 4.3% had moderate-severe anemia. In both OAR (n = 6112) and EVAR (n = 28,285), patients with moderate-severe anemia had significantly higher rates of in-hospital adverse events, such as in-hospital mortality, myocardial infarction, renal and respiratory complications, and reoperation, compared with patients with mild or no anemia. They also had higher rates of 30-day mortality. After multivariate analysis and 1:1 coarsened exact matching, no association was found between anemia and 30-day mortality and other in-hospital outcomes in patients undergoing OAR. On the other hand, in EVAR, moderate-severe anemia was associated with 2.7 times the odds of 30-day mortality (odds ratio [OR], 2.65; 95% confidence interval [CI], 1.69-4.18), 2.5 times the odds of renal complications (OR, 2.47; 95% CI, 1.78-3.43; P < .05), and twice the risk of acute congestive heart failure (OR, 1.96; 95% CI, 1.18-3.25) and respiratory complications (OR, 2.01; 95% CI, 1.26-3.19). Mild anemia was also associated with increased odds of 30-day mortality and renal and respiratory complications in patients undergoing EVAR. Interestingly, preoperative blood transfusion in mildly anemic patients undergoing EVAR was associated with double the odds of in-hospital major adverse cardiac events (stroke, death, and myocardial infarction; OR, 2.1; 95% CI, 1.38-3.11; P < .001)., Conclusions: Preoperative anemia is associated with higher odds of 30-day mortality and in-hospital adverse outcomes after EVAR but not after OAR. These findings highlight the need to incorporate anemia into the preoperative risk assessment of patients undergoing EVAR. Future studies are needed to assess the efficacy of medical therapies in improving postoperative outcomes in anemic patients undergoing AAA repair., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Studies of infrainguinal bypass surgery (IBS) in patients with end-stage renal disease have focused on hemodialysis (HD) patients. Little is known of the applicability of their outcomes to patients with renal transplants (RTs). In this study, we sought to compare perioperative and long-term outcomes of IBS in a large population-based cohort of HD and RT patients., Methods: A retrospective review of all HD and RT patients who underwent IBS between January 2007 and December 2011 in the U.S. Renal Data System was performed. Univariable, Kaplan-Meier, multivariable logistic, and Cox regression analyses were employed to evaluate 30-day postoperative (graft failure, limb loss, conduit infection, death) and long-term (primary patency [PP], primary assisted patency [PAP], secondary patency [SP], limb salvage, mortality) outcomes., Results: There were 10,787 IBSs performed in 9739 (90%) HD patients and 1048 (10%) RT patients who presented predominantly with critical limb ischemia (72%). Bypass configurations were femoral-popliteal (48%), femoral-tibial (34%), and popliteal-tibial (18%). Comparing HD vs RT patients, PP, PAP, and SP were 18% vs 33%, 23% vs 38%, and 30% vs 48%, respectively, at 5 years among autogenous conduit recipients (all P < .001) and 20% vs 28% (P = .02), 23% vs 31% (P = .02), and 33% vs 53% (P < .001) among prosthetic conduit recipients. Limb salvage and patient survival were 39% vs 56% and 19% vs 48%, respectively, at 5 years (all P < .001). Risk-adjusted analyses demonstrated higher PP (adjusted hazard ratio [aHR], 1.32; 95% confidence interval [CI], 1.20-1.45; P < .001), PAP (aHR, 1.32; 95% CI, 1.19-1.45; P < .001), SP (aHR, 1.47; 95% CI, 1.31-1.65; P < .001), limb salvage (aHR, 1.48; 95% CI, 1.30-1.67; P < .001), and patient survival (aHR, 2.42; 95% CI, 2.17-2.71; P < .001) for RT compared with HD patients., Conclusions: The HD-dependent state is associated with elevated bypass and patient-level risks after IBS compared with patients with RTs. These results show that the benefits of renal transplantation likely extend to infrainguinal bypass-specific outcomes. The estimates of risk reported herein should inform the patient's and provider's expectations at the point of care., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Despite recent reports of improved patency with regional anesthesia (RA), general anesthesia (GA) remains the most common choice for anesthesia for patients undergoing arteriovenous fistula (AVF) or arteriovenous graft (AVG) creation, with nearly 85% utilization. Previous studies of the effect of anesthesia type on outcomes have been conducted through single institutions or a national database with poor granularity for vascular-specific data. Given the high variability of practice patterns and the high prevalence of end-stage renal disease requiring access creation, further study of the impact of anesthesia choice during AVF or AVG creation is warranted., Methods: The Vascular Quality Initiative hemodialysis data set was queried to identify patients undergoing AVF or AVG creation between 2011 and 2017. Patients were grouped according to access type and anesthesia method (GA vs local anesthesia/RA). The primary outcome was early access failure within 120 days. Secondary outcomes were in-hospital and 30-day complications, including steal, swelling, hemorrhage, and wound infection., Results: There were 31,028 patients undergoing AVG (6961) or AVF (24,067) identified. Compared with patients with GA, patients undergoing access creation with RA had higher early failure rates (AVG, 26.2% vs 23%; AVF, 22.3% vs 20.6%; both P = .04). However, in the GA group undergoing AVF creation, there was a 26% increase (adjusted odds ratio, 1.26 [1.06-1.55]) in bleeding complications and a 3.4-fold increase (adjusted odds ratio, 3.43 [1.38-8.51]) in wound infection rates., Conclusions: Whereas it is traditionally performed under GA, hemodialysis access with fistula or graft creation is increasingly being performed under RA. In our analysis, rates of perioperative complications, including infection and bleeding, may be lessened by using RA, especially among patients undergoing AVF creation. However, this was accompanied by a 3.2% absolute (21% relative) increased risk of early failure within the first 120 days after dialysis creation among patients undergoing AVG., (Copyright © 2018. Published by Elsevier Inc.)

Objective: Obesity is a worldwide epidemic, particularly in Western society. It predisposes surgical patients to an increased risk of adverse outcomes. The aim of our study was to use a nationally representative vascular database and to compare in-hospital outcomes in obese vs nonobese patients undergoing elective open aortic repair (OAR) and endovascular aneurysm repair (EVAR)., Methods: All patients undergoing elective abdominal aortic aneurysm repair were identified in the Vascular Quality Initiative database (2003-2017). Obesity was defined as body mass index ≥30 kg/m 2 . Univariable (Student t-test and χ 2  test) and multivariable (logistic regression) analyses were implemented to compare in-hospital mortality and any major complications (wound infection, renal failure, and cardiopulmonary failure) in obese vs nonobese patients., Results: We identified a total of 33,082 patients undergoing elective OAR (nonobese, n = 4605 [72.4%]; obese, n = 1754 [27.6%]) and EVAR (nonobese, n = 18,338 [68.6%]; obese, n = 8385 [31.4%]). Obese patients undergoing OAR and EVAR were relatively younger compared with nonobese patients (mean age [standard deviation], 67.55 [8.26] years vs 70.27 [8.30] years and 71.06 [8.22] years vs 74.55 [8.55] years), respectively; (both P < .001). Regardless of approach, obese patients had slightly longer operative time (OAR, 259.02 [109.97] minutes vs 239.37 [99.78] minutes; EVAR, 138.27 [70.64] minutes vs 134.34 [69.98] minutes) and higher blood loss (OAR, 2030 [1823] mL vs 1619 [1642] mL; EVAR, 228 [354] mL vs 207 [312] mL; both P < .001). There was no significant difference in mortality between the two groups undergoing OAR and EVAR (OAR, 2.9% vs 3.2% [P = .50]; EVAR, 0.5% vs 0.6% [P = .76]). On multivariable analysis, obese patients undergoing OAR had 33% higher odds of renal failure (adjusted odds ratio [OR], 1.33; 95% confidence interval [CI], 1.09-1.63; P = .006) and 75% higher odds of wound infections (adjusted OR, 1.75; 95% CI, 1.11-2.76; P = .02) compared with nonobese patients. However, in patients undergoing EVAR, no association was seen between obesity and any major complications. A significant interaction was found between obesity and surgical approach in the event of renal failure, in which obese patients undergoing OAR had significantly higher odds of renal failure compared with those in the EVAR group (OR interaction , 1.36; 95% CI, 1.05-1.75; P = .02)., Conclusions: Using a large nationally representative database, we demonstrated an increased risk of renal failure and wound infections in obese patients undergoing OAR compared with nonobese patients. On the other hand, obesity did not seem to increase the odds of major adverse outcomes in patients undergoing EVAR. Further long-term prospective studies are needed to verify the effects of obesity after abdominal aortic aneurysm repair and the implications of these findings in clinical decision-making., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Open aortic repair (OAR) is associated with higher risk of mortality compared with endovascular aneurysm repair (EVAR). The aim of this study was to compare failure to rescue (FTR) after major predischarge complications in patients undergoing OAR and EVAR., Methods: Patients who underwent OAR or EVAR in the American College of Surgeons National Surgical Quality Improvement Program between 2011 and 2015 were selected. Patients with ruptured aneurysm and those with type IV thoracoabdominal aneurysms were excluded. The primary outcome was FTR, defined as 30-day mortality in patients who developed at least one complication during their hospital stay. Univariable and multivariable statistics were used., Results: A total of 9097 patients underwent abdominal aortic aneurysm repair. Of those, 3291 (36.2%) had at least one major predischarge complication, 82.5% after OAR (95% confidence interval [CI], 80.9%-84.1%) vs 21.3% after EVAR (95% CI, 20.4%-22.3%; P < .001). Increased FTR was seen after aneurysm rupture, cardiac arrest, septic shock, and acute kidney injury. On multivariable analysis, FTR was not significantly different between OAR and EVAR (adjusted odds ratio, 0.87; 95% CI, 0.61-1.24; P = .44). Propensity score matching and coarsened exact matching showed similar results., Conclusions: Although EVAR has fewer complications and lower in-hospital mortality than OAR, FTR after major predischarge complications does not depend on the type of surgical approach. When an in-hospital major complication occurs after EVAR, surgeons should be alert that FTR risk resulting in mortality is similar to that of OAR. Therefore, there is no safety net with EVAR., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Many previous studies have evaluated the outcomes of open and endovascular repair of thoracoabdominal aortic aneurysms (TAAAs). However, little is known about the differences in cost of these procedures and the potential factors driving these differences. The aim of this study was to evaluate the outcomes and cost of open aortic repair (OAR) vs endovascular repair of intact TAAA., Methods: All patients undergoing repair for intact TAAA were identified in the Premier Healthcare Database (July 2009-March 2015). Categorical and continuous variables were analyzed using the χ 2 test, Student t-test, and median test as appropriate. A multivariable generalized linear model was used to examine total in-hospital cost., Results: A total of 879 TAAA repairs were identified (481 [55%) endovascular repairs vs 398 [45%] OARs). Patients undergoing endovascular repair were on average 5 years older (71.2 [±10.0] years vs 66.5 [±10.9] years; P < .001) and more likely to be female (48% vs 42%; P = .05) and hypertensive (87% vs 80%; P = .009). Otherwise, there were no significant differences in comorbidities between the two groups. Patients undergoing OAR were more likely to stay longer in the hospital (median [interquartile range], 11 [7-20] days vs 5 [2-9] days; P < .001). In-hospital mortality (15% vs 5%; P < .001) and all major complications were two to three times higher after OAR. The median total cost of OAR was significantly higher compared with endovascular repair (cost [interquartile range], $44,355 [$32,177-$54,824] vs $36,612 [$24,395-$53,554]; P = .004). The majority of the cost attributed to TAAA repair was also higher in patients undergoing open repair: room and board ($11,561 vs $4720), operating room ($9230 vs $4929), pharmacy ($2309 vs $900), blood bank ($1189 vs $195), rehabilitation/physical therapy ($378 vs $236), and respiratory therapy ($875 vs $168; all P < .001). Only the cost of central supplies, which includes endovascular grafts and stents, was the highest among patients undergoing endovascular repair ($17,472 vs $5501; P < .001). The cost of diagnostic imaging ($625 vs $595) and anesthesia ($479 vs $478) was similar in both approaches. In a multivariable analysis, the adjusted total hospitalization cost for OAR was $5974 (95% confidence interval, $1828-$10,120; P = .005) higher compared with endovascular repair. However, after adjusting for in-hospital complications, no difference was seen between the two approaches (-$460; 95% confidence interval, -$4390 to $3470; P = .82)., Conclusions: In this large cohort of intact TAAAs, we showed a significantly higher adjusted total hospitalization cost of open compared with endovascular repair despite the additional cost of endografts. This is likely driven by longer length of stay and higher morbidity after OAR., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Antiplatelet therapy (APT) is often used on anecdotal grounds to improve vascular access patency. The aim of this study was to assess the role of APT in hemodialysis (HD) patients undergoing arteriovenous fistula (AVF) or graft (AVG) placement., Methods: All patients in a large HD vascular qualitative initiative database (2011-2017) were included and divided into no antiplatelet therapy (no-APT) vs. any APT [aspirin (ASA) or P2Y12 inhibitors (PI)]. Multivariate [logistic (MLR) and Cox (MCR) regression] analyses were used as appropriate., Results: A total of 24,847 patients undergoing HD access creation were identified (78% AVF). APT was noted among 49 and 46% of AVG and AVF patients, respectively. In MLR analysis, patients on no-APT vs. APT had a 12-fold increased risk of in-hospital mortality (odds ratio (OR) 11.79, [95% confidence interval 5.30-26.26]) and the risk of developing steal syndrome was higher among patients discharged on APT (OR 1.81, [1.19-2.76]). In patients undergoing AVF, primary patency (PP) was similar between APT and no-APT. However, in patients undergoing AVG, PP rates at 12 months were significantly higher for APT: ASA (47 vs. 41%) and PI (51 vs. 41%) than for no-APT (p = 0.008). At MCR analysis, the loss of PP at 12 months was 13% lower in ASA users (hazard ratio (HR) 0.87, [0.77-0.97], p = 0.02) and 24% lower in PI users (HR 0.76, [0.57-0.99], p = 0.046) compared to no-APT., Conclusion: In a large national database, we showed that antiplatelet therapy was associated with lower in-hospital mortality. Aspirin and P2Y12-inhibitor use among AVG patients demonstrated improved PP rates compared to no antiplatelet therapy. We recommend the use of antiplatelet therapy especially in patients on AVG.

Background: Prior studies have shown that octogenarians have a higher risk of mortality than nonoctogenarians undergoing open aneurysm repair (OAR) and endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). Fenestrated endovascular aneurysm repair (F-EVAR) was approved by the Food and Drug Administration (FDA) in 2012 and has been used as a less invasive approach to treat patients with suboptimal neck anatomy with favorable outcomes compared with traditional OAR. The aim of the study is to compare 30-day outcomes of F-EVAR versus OAR in octogenarians undergoing repair of AAA involving the visceral vessels in the United States., Methods: All patients with postoperative diagnosis of nonruptured AAA repair were identified in the National Surgical Quality Improvement Program database (2006-2015). Univariate and multivariate analyses were implemented to examine 30-day morbidity and mortality adjusting for patient demographics and comorbidities., Results: A total of 548 octogenarians underwent repair of nonruptured AAA involving the visceral vessels, of which 242 (44%) were F-EVARs, and 306 (56%) were OARs. Octogenarians undergoing F-EVAR were on average 1-year older (median age [interquartile range]: 83 [82, 86] versus 82 [81, 85], P = 0.004) and more likely to be male (82% vs. 64%, P < 0.001) compared with OAR. Prevalence of diabetes (13% vs. 6%, P = 0.005) and progressive renal failure (57% vs. 47%, P = 0.03) was also higher in patients undergoing F-EVAR compared with OAR. Thirty-day postoperative mortality was higher after OAR (8.5% vs. 4.1%, P = 0.04). Secondary outcomes including cardiopulmonary (27.1% vs. 5.8%, P < 0.001) and renal injury (10.8% vs. 2.1%, P < 0.001) were also significantly higher in OAR compared with F-EVAR. After adjusting for patients' demographics and comorbidities, OAR had almost 4-fold increased risk of 30-day postoperative mortality compared with F-EVAR (odds ratio [95% confidence interval]: 3.90 [1.48-10.31], P = 0.006)., Conclusions: In this large national cohort of octogenarians undergoing repair for complex AAA's, we showed that F-EVAR is associated with significantly lower postoperative morbidity and mortality than open repair. One of the main limitations of the study is the lack of anatomical data. However, despite that, our findings support the shifting paradigm toward minimally invasive approach in this frail population for treatment of complex AAA's. Further studies are needed to evaluate the long-term benefit of any repair in octogenarians., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: To quantify and compare the incremental cost associated with in-hospital stroke, death, and myocardial infarction (MI) after carotid endarterectomy (CEA) vs carotid artery stenting (CAS)., Methods: A retrospective analysis was performed of 100,185 patients (mean age 70.7±9.5 years; 58.3% men) who underwent CEA (n=86,035) or CAS (n=14,150) between 2009 and 2015 and were entered into the Premier Healthcare Database. Multivariate logistic models and generalized linear models were used to analyze binary outcomes and hospitalization costs, respectively. Outcomes are presented as the adjusted odds ratio (aOR) and 95% confidence interval (CI)., Results: CAS was associated with 1.6 times higher adjusted odds of stroke [aOR 1.55 (95% CI 1.36 to 1.77), p<0.001] and with 2.6 times higher odds of death [aOR 2.60 (95% CI 2.14 to 3.17), p<0.001] compared with CEA. There was no significant difference in MI risk between the 2 procedures. The adjusted incremental cost of death and MI were similar between the 2 procedures. However, the adjusted incremental cost of stroke was significantly higher in CEA compared with CAS by an estimated $2000. When stratified with respect to symptomatic status, the increased adjusted incremental cost of stroke in CEA was mainly seen in asymptomatic patients ($5284 vs $2932, p<0.01)., Conclusion: The incremental cost of in-hospital stroke is relatively higher in CEA compared to CAS. However, CEA remains a more cost-effective carotid intervention due to lower complication rates and baseline costs compared with CAS. Long-term cost-effectiveness studies are needed before definite conclusions are made.

Objective: The majority of previous studies, including randomized controlled trials, have failed to provide sufficient evidence of superiority of endovascular aneurysm repair (EVAR) over open aortic repair (OAR) of ruptured abdominal aortic aneurysm (rAAA) while comparing mortality and complications. This is in part due to small study size, patient selection bias, scarce adjustment for essential variables, single insurance type, or selection of only older patients. This study aimed to provide real-world, contemporary, comprehensive, and robust evidence on mortality of EVAR vs OAR of rAAA., Methods: A retrospective observational cohort study was performed of rAAA patients registered in the Premier Healthcare Database between July 2009 and March 2015. A multivariate logistic regression model was operated to estimate the association between procedure types (OAR vs EVAR) and in-hospital mortality. The final model was adjusted for demographics (age, sex, race, marital status, and geographic region), hospital characteristics (urban or rural, teaching or not), and potential confounders (hypertension, diabetes, hypercholesterolemia, obesity, ischemic heart disease, chronic kidney disease, symptoms of critical limb ischemia, chronic obstructive pulmonary disease, smoking, and alcoholism). Furthermore, coarsened exact matching was applied to substantiate the result in the matched cohort., Results: There were a total of 3164 patients with rAAA (1550 [49.0%] OAR and 1614 [51.0%] EVAR). Mortality was 23.79% in the EVAR group compared with 36.26% in the OAR group (P < .001). The adjusted odds ratios of mortality (1.91; 95% confidence interval [CI], 1.62-2.25; P < .001), cardiac complication (1.54; 95% CI, 1.22-1.96; P < .001), pulmonary failure (1.90; 95% CI, 1.60-2.24; P < .001), renal failure (1.90; 95% CI, 1.61-2.23; P < .001), and bowel ischemia (2.40; 95% CI, 1.70-3.35; P < .001) were significantly higher after OAR compared with EVAR. We further applied coarsened exact matching, which followed the same pattern of mortality (odds ratio, 1.68; 95% CI 1.41-1.99; P < .001) and all major complications., Conclusions: Although the choice of repair of rAAA is highly dependent on the experience of the operating team and the anatomic suitability of the patient, this contemporary analysis of a large cohort of rAAA showed significantly higher adjusted risk of mortality in OAR compared with EVAR and substantially higher complications., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to compare conduit use and surgical outcomes of hemodialysis-dependent men and women after open lower extremity bypass surgery., Methods: Using the United States Renal Data System, we studied all hemodialysis patients in the United States who underwent infrainguinal bypass surgery between January 1, 2006, and December 31, 2011. Univariate methods (χ 2 , analysis of variance) were employed to compare patient and bypass characteristics between men and women. Kaplan-Meier, univariate and multivariate logistic, and Cox regression analyses were employed to evaluate outcomes that included patency, graft failure, and mortality at 30 days. In addition, we compared limb salvage and patient survival rates between men and women., Results: There were 9739 bypasses performed in 5927 (61%) men and 3812 (39%) women who presented most commonly with critical limb ischemia (men, 73%; women, 71%; P = .04). Bypass configurations were femoral-popliteal (48%), femoral-tibial (34%), and popliteal-tibial (18%). The prevalence of autogenous conduits was higher for men (61 vs 55%; P < .001), and they were associated with higher patency compared with prosthetics (adjusted hazard ratio [aHR], 1.10; 95% confidence interval [CI], 1.01-1.19; P = .03). The risk-adjusted analyses revealed higher odds of acute graft failure for women compared with men who received prosthetic conduits (adjusted odds ratio, 1.23; 95% CI, 1.03-1.46; P = .021) but not among patients who received autogenous conduits (adjusted odds ratio, 1.07; 95% CI, 0.91-1.25; P = .41). Despite the difference in choice of conduit, there was no significant difference in primary patency (aHR, 1.00; 95% CI, 0.95-1.06; P = .90), primary assisted patency (aHR, 1.03; 95% CI, 0.97-1.10; P = .28), secondary patency (aHR, 1.01; 95% CI, 0.95-1.08; P = .75), limb salvage (aHR, 0.97; 95% CI, 0.90-1.04; P = .41), and survival (aHR, 0.97; 95% CI, 0.92-1.03; P = .45) for women compared with men., Conclusions: We found lower use of autogenous conduits in women than in men. In patients who received prosthetic conduit, acute graft failure was higher for women than for men. The benefits of autogenous conduits over prosthetic grafts underscore the need to improve the selection of appropriately sized autogenous conduits for bypass irrespective of gender., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)