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Background: The Vascular Study Group of New England (VSGNE) requires documentation of follow-up for >80% of patients at least 9 months postprocedure. However, many participating groups fall short of this goal. We sought to identify factors independently associated with loss to long-term follow-up (LTF)., Methods: The VSGNE was queried from 2008 to 2012, for all carotid endarterectomy (CEA), endovascular aneurysm repair (EVAR), open abdominal aortic aneurysm repair (OPEN), infrainguinal bypass (INFRA), and suprainguinal bypass (SUPRA) procedures in patients who survived greater than 9 months postprocedure. Our primary endpoint was loss to LTF, with LTF defined as documentation of a phone call or office visit ≥9 months postprocedure. Multivariable logistic regression was used to identify independent predictors of loss to LTF. Covariates included patient and procedural characteristics, and treatment center/physician. Relative contributions of covariates to the model were assessed by evaluation of the relative model Wald chi-squared values., Results: We identified 14,452 procedures (6567 CEA, 2391 EVAR, 3356 INFRA, 979 OPEN, and 1159 SUPRA). Of those, 4669 (32%) were lost to LTF. Rates of loss to LTF varied by center, and ranged from 9.8% to 100%. Independent predictors of loss to LTF were history of coronary artery disease or percutaneous coronary artery intervention (odds ratio [OR] 1.4, 95% confidence interval [CI] 1.1-1.7), procedure type (OPEN, OR 1.4, 95% CI: 1.2-1.7; CEA, OR 1.2, 95% CI: 1.1-1.4; referent, EVAR), and discharge to rehab (OR 1.2, 95% CI: 1.1-1.4; referent, home). Center variation was the strongest determinant of loss to LTF with a model χ 2 over 40 times as large as the second strongest determinant., Conclusions: LTF is central to outcome reporting and is vital to the success of any registry effort. In the VSGNE experience, center variation is the strongest predictor of loss to LTF, outweighing patient and procedural factors. Other predictors of loss to LTF included history of coronary revascularization, procedure type, no prior history of congestive heart failure, and discharge location. High performing centers likely have specific process measures that decrease loss to LTF. As the Society for Vascular Surgery Vascular Quality Initiative continues to roll out nationally, high performing centers in VSGNE should be studied to document and propagate best practices for minimizing loss to LTF., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: The impact of a postoperative troponin elevation on long-term survival after vascular surgery is not well-defined. We hypothesize that a postoperative troponin elevation is associated with significantly reduced long-term survival., Methods: The Vascular Study Group of New England registry identified all patients who underwent carotid revascularization, open abdominal aortic aneurysm repair (AAA), endovascular AAA repair, or infrainguinal lower extremity bypass (2003-2011). The association of postoperative troponin elevation and myocardial infarction (MI) with 5-year survival was evaluated. Multivariable models identified predictors of survival and of postoperative myocardial ischemia., Results: In the entire cohort (n = 16,363), the incidence of postoperative troponin elevation was 1.3% (n = 211) and for MI was 1.6% (n = 264). Incidences differed across procedures (P < .0001) with the highest incidences after open AAA: troponin elevation, 3.9% (n = 74); MI, 5.1% (n = 96). On Kaplan-Meier analysis, any postoperative myocardial ischemia predicted reduced survival over 5 years postoperatively: no ischemia, 73% (standard error [SE], 0.5%); troponin elevation, 54% (SE, 4%); MI, 33% (SE, 4%) (P < .0001). This pattern was observed for each procedure subgroup analysis (P < .0001). Troponin elevation (hazard ratio, 1.45; 95% confidence interval, 1.1-2.0; P = .02) and MI (hazard ratio, 2.9; 95% confidence interval, 2.3-3.8; P < .0001) were independent predictors of reduced survival at 5 years., Conclusions: Postoperative troponin elevation and MI predict a 26% or a 55% relatively lower survival in the 5 years following a vascular surgical procedure, respectively, compared with patients who do not experience myocardial ischemia. This highlights the need to better characterize factors leading to postoperative myocardial ischemia. Postoperative troponin elevation, either alone, or in combination with an MI, may be a useful marker for identifying high-risk patients who might benefit from more aggressive optimization in hopes of reducing adverse long-term outcomes., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: The appropriate application of endovascular intervention vs bypass for both critical limb ischemia (CLI) and intermittent claudication (IC) remains controversial, and outcomes from large, contemporary series are critical to help inform treatment decisions. Therefore, we sought to define the early and 1-year outcomes of lower extremity bypass (LEB) in a large, multicenter regional cohort, and analyze trends in the use of LEB with or without prior endovascular interventions., Methods: The Vascular Study Group of New England database was used to identify all infrainguinal LEB procedures performed between 2003 and 2009. The primary study endpoint was 1-year amputation-free survival (AFS). Secondary endpoints included in-hospital mortality and morbidity, including major adverse cardiac events. Trend analyses were conducted to identify annual trends in the proportion of LEBs performed for an indication of IC, in-hospital outcomes, including mortality and morbidity, and 1-year outcomes, including AFS. Analyses were performed on the entire cohort and then stratified by indication., Results: Between 2003 and 2009, 2907 patients were identified who underwent LEBs (72% for CLI; 28% for IC). The proportion that underwent LEB for IC increased significantly over the study period (from 19% to 31%; P < .0001). There was a significant increase over time in the proportion of LEBs performed after a previous endovascular intervention among both CLIs (from 11% to 24%; P < .0001) and ICs (from 13% to 23%; P = .02). Neither in-hospital mortality nor cardiac event rates changed significantly among either group. There was no significant change in 1-year AFS in patients with IC (97% in 2003 and 98% in 2008; P for trend .63) or in patients with CLI (73% in 2003 and 81% in 2008; P = .10)., Conclusions: Over the last 7 years, significant changes in patient selection for LEBs have occurred in New England. The proportion of LEBs performed for ICs as opposed to CLIs has increased. Patients are much more likely to have undergone prior endovascular interventions before undergoing a bypass. In-hospital and 1-year outcomes after LEB for both IC and CLI have remained excellent with no significant changes in AFS., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Studies of infrainguinal lower extremity bypass for critical limb ischemia (CLI) have traditionally emphasized outcomes of patency, limb salvage, and death. Because functional outcomes are equally important, our objectives were to describe the proportion of CLI patients who did not achieve symptomatic improvement 1 year after bypass, despite having patent grafts, and identify preoperative factors associated with this outcome., Methods: The prospectively collected Vascular Study Group of Northern New England database was used to identify all patients with elective infrainguinal lower extremity bypass for CLI (2003 to 2007) for whom long-term follow-up data were available. The primary composite study end point was clinical failure at 1 year after bypass, defined as amputation or persistent or worsened ischemic symptoms (rest pain or tissue loss), despite a patent graft. Variables identified on univariate screening (inclusion threshold, P < .20) were included in a multivariable logistic regression model to identify independent predictors., Results: Long-term follow-up data were available for 1012 patients who underwent infrainguinal bypasses for CLI, of which 788 (78%) remained patent at 1 year. Of these, 79 (10%) met criteria for the composite end point of clinical failure: 21 (2.7%) for major amputations and 58 (7.4%) for persistent rest pain or tissue loss. In multivariable analysis, significant predictors of clinical failure included dialysis dependence (odds ratio [OR], 3.74; 95% confidence interval [CI], 1.84-7.62; P < .001) and preoperative inability to ambulate independently (OR, 2.17; 95% CI, 1.26-3.73; P = .005). A history of coronary artery bypass graft or percutaneous coronary intervention was protective (OR, 0.52; 95% CI, 0.29-0.93; P = .03)., Conclusions: After infrainguinal lower extremity bypass for CLI, 10% of patients with a patent graft did not achieve clinical improvement at 1 year. Preoperative identification of this specific patient subgroup remains challenging. To improve surgical decision making and the overall care of CLI patients, further emphasis needs to be placed on functional outcomes in addition to traditional surgical end points., Competing Interests: Competition of interest: none. The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a competition of interest., (Copyright (c) 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)