In-hospital versus postdischarge adverse events following carotid endarterectomy

ObjectiveMost studies based on state and nationwide registries evaluating perioperative outcome after carotid endarterectomy (CEA) rely on hospital discharge data only. Therefore, the true 30-day complication risk after carotid revascularization may be underestimated.MethodsWe used the National Surgical Quality Improvement Program database 2005-2010 to assess the in-hospital and postdischarge rate of any stroke, death, cardiac event (new Q-wave myocardial infarction or cardiac arrest), and combined stroke/death and combined adverse outcome (S/D/CE) at 30 days following CEA. Multivariable analyses were used to identify predictors for in-hospital and postdischarge events separately, and in particular, those that predict postdischarge events distinctly.ResultsA total of 35,916 patients who underwent CEA during 2005-2010 were identified in the National Surgical Quality Improvement Program database; 59% were male, median age was 72 years, and 44% had a previous neurologic event. Thirty-day stroke rate was 1.6% (n = 591), death rate was 0.8% (n = 272), cardiac event rate was 1.0% (n = 350), stroke or death rate was 2.2% (n = 794), and combined S/D/CE rate was 2.9% (n = 1043); 33% of strokes, 53% of deaths, 32% of cardiac events, 40% of combined stroke/death, and 38% of combined S/D/CE took place after hospital discharge. Patients with a prior stroke or transient ischemic attack had similar proportions of postdischarge events compared with patients without prior symptoms. Independent predictors for postdischarge events, but not for in-hospital events were female sex (stroke [odds ratio (OR), 1.6; 95% confidence interval (CI), 1.2-2.1] and stroke/death [OR, 1.4; 95% CI, 1.1-1.7]), renal failure (stroke [OR, 3.0; 95% CI, 1.4-6.2]) and chronic obstructive pulmonary disease (death [OR, 2.5; 95% CI, 1.6-3.7], stroke/death [OR, 1.8; 95% CI, 1.4-2.4], and S/D/CE [OR 1.8, 95% CI 1.4-2.3]).ConclusionsWith 38% of perioperative adverse events after CEA happening posthospitalization, regardless of symptoms status, we need to be alert to the ongoing risks after discharge particularly in women, patients with renal failure, or chronic obstructive pulmonary disease. This emphasizes the need for reporting and comparing 30-day adverse event rates when evaluating outcomes for CEA, or comparing carotid stenting to CEA

Prosthetic graft infections involving the femoral artery

BackgroundProsthetic graft infection is a major complication of peripheral vascular surgery. We investigated the experience of a single institution over 10 years with bypass grafts involving the femoral artery to determine the incidence and risk factors for prosthetic graft infection.MethodsA retrospective cohort single-institution review of prosthetic bypass grafts involving the femoral artery from 2001 to 2010 evaluated patient demographics, body mass index, comorbidities, indications, location of bypass, type of prosthetic material, case urgency, and previous ipsilateral bypass or percutaneous interventions and evaluated the incidence of graft infections, amputations, and mortality.ResultsThere were 496 prosthetic grafts identified with a graft infection rate of 3.8% (n = 19) at a mean follow-up of 27 months. Multivariable analysis showed that redo bypass (hazard ratio [HR], 5.8; 95% confidence interval [CI], 2.2-15.0), active infection at the time of bypass (HR, 5.2; 95% CI, 1.9-14.2), female gender (HR, 4.5; 95% CI, 1.6-12.7), and diabetes mellitus (HR, 4.6; 95% CI, 1.5-14.3) were significant predictors of graft infection. Graft infection was predictive of major lower extremity amputation (HR, 9.8; 95% CI, 3.5-27.1), as was preoperative tissue loss (HR, 4.7; 95% CI, 1.8-11.9). Graft infection did not predict long-term mortality; however, chronic renal insufficiency (HR, 2.3; 95% CI, 1.6-3.4), tissue loss (HR, 1.4; 95% CI, 1.0-1.9), and active infection (HR, 2.3; 95% CI, 1.6-3.4) did. Infected grafts were removed 79% of the time. Staphylococcus epidermidis (37%) and methicillin-sensitive Staphylococcus aureus (26%) were the most common pathogens isolated.ConclusionsRedo bypass, female gender, diabetes, and active infection at the time of bypass are associated with a higher risk for prosthetic graft infection and major extremity amputation but do not confer an increased risk of mortality. Autologous vein for lower extremity bypass and endovascular interventions should be considered when feasible in high-risk patient

The value of 3D-CT angiographic assessment prior to carotid stenting

ObjectiveAnatomic suitability for carotid artery stenting (CAS) is determined by arteriography, but this has a discrete stroke risk. We evaluated the use of multidetector CT angiography with three-dimensional reconstruction (3D-CTA) as a noninvasive screening tool for prospective CAS patients.MethodsBetween 2003 and 2006, 90 CAS procedures were performed by vascular surgeons at our institution. At the discretion of the operating surgeon, 59 of the potential candidates for CAS underwent screening 3D-CTA of the aortic arch and carotid arteries. Results were used in patient selection and then analyzed retrospectively to determine clinical utility.ResultsAnalysis of 3D-CTA data by the operating surgeon allowed stratification of patients into four groups: (1) appropriate for CAS via femoral approach (n = 37, 63%); (2) appropriate for CAS with transcervical access due to adverse arch anatomy (n = 2, 3%); (3) borderline anatomy for CAS (n = 5, 9%); or (4) not appropriate anatomy for CAS (n = 15, 25%). Group 1 had 100% technical success with one minor stroke. Group 2 had successful transcervical CAS without stroke. Group 3 patients underwent arteriography but CAS was aborted in four out of five cases for the same reason that had been identified by 3D-CTA (internal carotid artery [ICA] tortuosity n = 2, ICA string sign with distal disease n = 2). The one failure in group 3 was the result of a previously placed common carotid stent extending into an already unfavorable aortic arch. Group 4 patients underwent endarterectomy (n = 7) or continued medical management (n = 8) instead of CAS (without arteriography) because of the following reasons, cited alone or in combination: common carotid tandem stenosis n = 5, difficult arch anatomy n = 2, ICA tortuosity n = 2, extreme lesion calcification or length n = 4, ICA string sign or occlusion n = 3, concomitant intracranial disease n = 2, and stenosis overestimated by duplex n = 3. The overall 30-day stroke rate, on an intention to treat basis, for patients that underwent preprocedural 3D-CTA was 2.3% (one major [NIH stroke scale >3] and one minor stroke).ConclusionsIn our initial experience, 3D-CTA reconstruction of the aortic arch and carotid arteries significantly influenced the plan for CAS in 37% of patients. Patients with clear anatomic contraindications to CAS can be excluded without the risks of arteriography. 3D-CTA further facilitates the CAS procedure by anticipating potential procedural. The cost-effectiveness and potential impact of this imaging modality on CAS outcomes deserve further study

Comparison of Open and Endovascular Repair of Ruptured Abdominal Aortic Aneurysms From the ACS-NSQIP 2005–07

Purpose: To compare endovascular (EVAR) and open surgical repair (OSR) for ruptured abdominal aortic aneurysms (RAAA) in terms of preoperative hemodynamic status and comorbidities