22 research outputs found
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Transcarotid Artery Revascularization Can Be Safely Performed in Patients Undergoing Dialysis
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ReninâAngiotensinâAldosterone System Inhibitors Are Associated With Favorable Outcomes Compared to Beta Blockers in Reducing Mortality Following Abdominal Aneurysm Repair
Background The best medical therapy to control hypertension following abdominal aortic aneurysm repair is yet to be determined. We therefore examined whether treatment with renin-angiotensin-aldosterone system inhibitors (RAASIs) versus beta blockers influenced postoperative and 1-year clinical end points following abdominal aortic aneurysm repair in a Medicare-linked database. Methods and Results All patients with hypertension undergoing endovascular aneurysm repair and open aneurysm repair in the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database between 2003 and 2018 were included. Patients were divided into 2 groups based on their preoperative and discharge medications, either RAASIs or beta blockers. Our cohort included 8789 patients, of whom 3523 (40.1%) were on RAASIs, and 5266 (59.9%) were on beta blockers. After propensity score matching, there were 3053 matched pairs of patients in each group. After matching, RAASI use was associated with lower risk of postoperative mortality (odds ratio [OR], 0.3 [95% CI, 0.1-0.6]), myocardial infarction (OR, 0.1 [95% CI, 0.03-0.6]), and nonhome discharge (OR, 0.6 [95% CI, 0.5-0.7]). Before propensity score matching, RAASI use was associated with lower 1-year mortality (hazard ratio [HR], 0.4 [95% CI, 0.4-0.5]) and lower risk of aneurysmal rupture (HR, 0.7 [95% CI, 0.5-0.9]). These results persisted after propensity score matching for mortality (HR, 0.4 [95% CI, 0.4-0.5]) and aneurysmal rupture (HR, 0.7 [95% CI, 0.5-0.9]). Conclusions In this large contemporary retrospective cohort study, RAASI use was associated with favorable postoperative outcomes compared with beta blockers. It was also associated with lower mortality and aneurysmal rupture at 1âyear of follow-up
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Loss of follow-up after carotid revascularization is associated with worse long-term stroke and death.
OBJECTIVES: Society for Vascular Surgery practice guidelines recommend surveillance with duplex ultrasound scanning at baseline (within 3 months from discharge), every 6 months for 2 years, and annually afterward following carotid endarterectomy or carotid artery stenting. There is a growing concern regarding the significance of postoperative follow-up after several vascular procedures. We sought to determine whether 1-year loss to follow-up (LTF) after carotid revascularization was associated with worse outcomes in the Vascular Quality Initiative (VQI) linked to Vascular Implant Surveillance and Interventional Outcomes Network (VISION) database. METHODS: All patients who underwent carotid revascularization in the VQI VISION database between 2003 and 2016 were included. LTF was defined as failure to complete 1-year follow-up in the VQI long-term follow-up dataset. Data about stroke and mortality were captured in the VISION dataset using a list of Current Procedural Terminology, International Classification of Diseases (Ninth Revision), and International Classification of Diseases (Tenth Revision) codes linked to index procedures in VQI. Kaplan-Meier life-table methods and Cox proportional hazard modeling were used to compare 5- and 10-year outcomes between patients with no LTF and those who were LTF. RESULTS: A total of 58,840 patients were available for analysis. The 1-year LTF rate was 43.8%. Patients who were LTF were older and more frequently symptomatic, with chronic obstructive pulmonary diseases, chronic kidney diseases, and congestive heart failure. Also, patients who underwent carotid artery stenting were more likely to be LTF compared with carotid endarterectomy patients (54.5% vs 42.3%; P < .001). The incidence of postoperative (30 days) stroke was higher in the LTF group (2.9% vs 1.7%; P < .001). Cox regression analysis revealed that LTF was associated with an increased risk of long-term stroke at 5 years (hazard ratio [HR]: 1.4, 95% confidence interval [CI]: 1.2-1.6; P < .001) and 10 years (HR: 1.3, 95% CI: 1.2-1.5; P < .001). It was also associated with significantly higher mortality at 5 years (HR: 2.5, 95% CI: 2.3-2.8; P < .001) and 10 years (HR: 2.2, 95% CI: 1.9-2.5; P < .001). Stroke or death was significantly worse in the LTF group at 5 years (HR: 2.3, 95% CI: 2.1-2.5; P < .001) and up to 10 years (HR: 2.02, 95% CI: 1.8-2.3; P < .001). CONCLUSIONS: One-year follow-up after carotid revascularization procedures was found to be associated with better stroke- and mortality-free survival. Surgeons should emphasize the importance of follow-up to all patients who undergo carotid revascularization, especially those with multiple comorbidities and postoperative neurological complications
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Dual Antiplatelet Therapy Is Associated with Increased Risk of Bleeding and Decreased Risk of Stroke Following Carotid Endarterectomy.
BACKGROUND: Despite many patients undergoing carotid endarterectomy (CEA) being on dual antiplatelet therapy (DAPT) for cardiac or neurologic indications, the impact of such therapy on perioperative outcomes remains unclear. We aim to compare rates of postoperative bleeding, stroke and major adverse events (stroke, death or MI) among patients on Aspirin alone (ASAA) versus DAPT (Clopidogrel and Aspirin). METHODS: Patients undergoing CEA for carotid artery stenosis between 2010 and 2021 in the Vascular Quality Initiative (VQI) were included. We excluded patients undergoing concomitant or re-do operations or patients with missing antiplatelet information. Propensity score matching was performed between the 2 groups ASAA and DAPT based on age, sex, race, presenting symptoms, major comorbidities [hypertension, diabetes and coronary artery disease (CAD)], degree of ipsilateral stenosis, presence of contralateral occlusion, as well as preoperative medications. Intergroup differences between the treatment groups and differences in perioperative outcomes were tested with the McNemars test for categorical variables and paired t-test or Wilcoxon matched-pairs signed-rank test for continuous variables where appropriate. Relative risks with 95% confidence intervals were estimated as the ratio of the probability of the outcome event in the patients treated within each treatment group. RESULTS: A total of 125,469 patients were included [ASAA n = 82,920 (66%) and DAPT n = 42,549 (34%)]. Patients on DAPT were more likely to be symptomatic, had higher rates of CAD, prior percutaneous coronary intervention or coronary artery bypass grafting, and higher rates of diabetes. After propensity score matching, the DAPT group had an increased rate of bleeding complications (RR: 1.6: 1.4-1.8, P < 0.001) as compared with those on ASAA despite being more likely to receive both drains and protamine. In addition, patients on DAPT had a slight decrease in the risk of in-hospital stroke as compared with patients on ASAA (RR: 0.80: 0.7-0.9, P = 0.001). CONCLUSIONS: This large multi-institutional study demonstrates a modest decrease in the risk of in-hospital stroke for patients on DAPT undergoing CEA as compared with those on ASAA. This small benefit is at the expense of a significant increase in the risk of perioperative bleeding events incurred by those on DAPT at the time of CEA. This analysis suggests avoiding DAPT when possible, during CEA