Excess mortality in US Veterans during the COVID-19 pandemic: an individual-level cohort study.

BACKGROUND: Most analyses of excess mortality during the COVID-19 pandemic have employed aggregate data. Individual-level data from the largest integrated healthcare system in the US may enhance understanding of excess mortality. METHODS: We performed an observational cohort study following patients receiving care from the Department of Veterans Affairs (VA) between 1 March 2018 and 28 February 2022. We estimated excess mortality on an absolute scale (i.e. excess mortality rates, number of excess deaths) and a relative scale by measuring the hazard ratio (HR) for mortality comparing pandemic and pre-pandemic periods, overall and within demographic and clinical subgroups. Comorbidity burden and frailty were measured using the Charlson Comorbidity Index and Veterans Aging Cohort Study Index, respectively. RESULTS: Of 5 905 747 patients, the median age was 65.8 years and 91% were men. Overall, the excess mortality rate was 10.0 deaths/1000 person-years (PY), with a total of 103 164 excess deaths and pandemic HR of 1.25 (95% CI 1.25-1.26). Excess mortality rates were highest among the most frail patients (52.0/1000 PY) and those with the highest comorbidity burden (16.3/1000 PY). However, the largest relative mortality increases were observed among the least frail (HR 1.31, 95% CI 1.30-1.32) and those with the lowest comorbidity burden (HR 1.44, 95% CI 1.43-1.46). CONCLUSIONS: Individual-level data offered crucial clinical and operational insights into US excess mortality patterns during the COVID-19 pandemic. Notable differences emerged among clinical risk groups, emphasizing the need for reporting excess mortality in both absolute and relative terms to inform resource allocation in future outbreaks

Procedural Safety Comparison Between Transcarotid Artery Revascularization, Carotid Endarterectomy, and Carotid Stenting: Perioperative and 1‐Year Rates of Stroke or Death

Background Transcarotid artery revascularization (TCAR) was approved by the Food and Drug Administration in 2015 for patients with carotid artery stenosis. However, no randomized trial to evaluate TCAR has been performed to date, and previous reports have important limitations. Accordingly, we measured stroke or death after TCAR compared with carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TF‐CAS). Methods and Results We used the Vascular Quality Initiative registry to study patients who underwent TCAR, CEA, or TF‐CAS from September 2016 to June 2021. Our primary outcomes were perioperative and 1‐year stroke or death. We used logistic regression for risk adjustment for perioperative outcomes and Cox regression for risk adjustment for 1‐year outcomes. We used a 2‐stage residual inclusion instrumental variable (IV) method to adjust for selection bias and other unmeasured confounding. Our instrument was a center's preference to perform TCAR versus CEA or TF‐CAS. We performed a subgroup analysis stratified by presenting neurologic symptoms. We studied 21 234 patients who underwent TCAR, 82 737 who underwent CEA, and 14 595 who underwent TF‐CAS across 662 centers. The perioperative rate of stroke or death was 2.0% for TCAR, 1.7% for CEA, and 3.7% for TF‐CAS (P<0.001). Compared with TCAR, the IV‐adjusted odds ratio of perioperative stroke or death for CEA was 0.74 (95% CI, 0.55–0.99) and for TF‐CAS was 1.66 (95% CI, 0.99–2.79). Results were similar among both symptomatic and asymptomatic patients. The 1‐year rate of stroke or death was 6.4% for TCAR, 5.2% for CEA, and 9.7% for TF‐CAS (P<0.001). Compared with TCAR, the IV‐adjusted hazard ratio of 1 year stroke or death for CEA was 0.97 (95% CI, 0.80–1.17), and for TF‐CAS was 1.45 (95% CI, 1.04–2.02). IV analysis further demonstrated that symptomatic patients with carotid stenosis had the lowest 1‐year likelihood of stroke or death with TCAR (compared with TCAR, symptomatic IV‐adjusted hazard ratio for CEA: 1.30 [95% CI, 1.04–1.64], and TF‐CAS: 1.86 [95% CI, 1.27–2.71]). Conclusions Perioperative stroke or death was greater following TCAR when compared with CEA. However, at 1 year there was no statistically significant difference in stroke or death between the 2 procedures. TCAR performed favorably compared with TF‐CAS at both time points. Although CEA remains the gold standard procedure for patients with carotid stenosis, TCAR appears to be a safe alternative to CEA and TF‐CAS when used selectively and may be useful when treating symptomatic patients

Contemporary Management of Acute Aortic Occlusion Has Evolved but Outcomes Have Not Significantly Improved

BACKGROUND: Most existing series of acute aortic occlusion (AAO) predate the changes in surgical and endovascular therapy of the last 2 decades. We examined the contemporary management and outcomes of AAO. METHODS: We reviewed consecutive patients with AAO at a tertiary referral center from 2004 to 2012. Outcomes were stratified and compared according to etiology and procedure performed. RESULTS: AAO in 29 patients was due to in situ thrombosis in 21 (72%) and embolism in 8 (28%) patients. Vascular patients with embolism were on average older (77 +/- 7 vs. 66 +/- 12 years, P = 0.02) and had higher rates of atrial fibrillation (100% vs. 20%, P = 0.0002) and congestive heart failure (75% vs. 0%, P = 0.0001) in comparison with those with in situ thrombosis. Neurologic deficit was present in 16 (55%) patients. Six patients (21%) presented with bilateral paresis/paralysis secondary to spinal cord or lumbosacral plexus ischemia, and primary neurologic etiology was investigated before vascular consultation was obtained in 4 of these 6 patients. Of the 29 patients, 28 (97%) underwent revascularization including transfemoral embolectomy (n = 6), transperitoneal aortoiliac thrombectomy (n = 2), axillobifemoral bypass (n = 10), aortobifemoral bypass (n = 6), and endovascular therapy including thrombolysis, angioplasty +/- stenting (n = 4). In-hospital mortality was 31% and did not vary significantly according to etiology (embolism 38% vs. in situ thrombosis 29%, P = 0.67). In-hospital mortality varied widely according to procedure (transfemoral embolectomy 50%, aortoiliac thrombectomy 100%, axillobifemoral bypass 30%, aortobifemoral bypass 0%, and endovascular therapy 25%, P = 0.08). Major morbidity (59%), length of stay (8.6 +/- 8.0 days), and discharge to a rehabilitation facility (50%) did not vary by etiology or procedure. At a media follow-up of 361 +/- 460 days (range 3-2014), overall survival was 42%. There were no amputations among 20 survivors of initial hospitalization. CONCLUSIONS: AAO is now more commonly caused by in situ thrombosis rather than embolism. A high index of suspicion for AAO is required for prompt diagnosis and treatment, particularly when patients present with profound lower extremity neurologic deficit. In comparison with previous reports, the contemporary management of AAO includes increased use of axillobifemoral bypass and now involves endovascular revascularization, although a variety of open surgical procedures are utilized. However, the in-hospital mortality and morbidity of AAO has not decreased significantly over the last 2 decades and mid-term survival remains limited. Further study is required to identify strategies that improve outcomes after AAO