Elevated Serum Phosphate Levels are Associated with Decreased Amputation-Free Survival After Interventions for Critical Limb Ischemia.

OBJECTIVES: Elevated serum phosphate levels have been associated with increased risks of cardiovascular events and death in several patient populations. The effects of serum phosphate on outcomes in patients with critical limb ischemia (CLI) have not been evaluated. In this study, we assessed the effect of abnormal phosphate levels on mortality and major limb events following surgical intervention for critical limb ischemia (CLI). METHODS: A retrospective review was undertaken to identify all patients at a single institution who underwent a first-time open or endovascular intervention for CLI between 2005 and 2014. Patients without recorded post-operative phosphate levels were excluded. Post-operative phosphate levels within 30-days of the initial operation were recorded and the mean was calculated. Patients were stratified according to mean phosphate levels (low <2.5, normal 2.5–4.5, high >4.5). Patient demographics, comorbidities, and operative details were compared in univariate analysis. Multivariable regression and cox-proportional hazard modeling were utilized to account for patient demographics and comorbid conditions. RESULTS: 941 patients were identified including 42(5%) with low phosphate, 768(82%) with normal phosphate, and 131(14%) with high phosphate. Patients with elevated phosphate were younger and had higher rates of congestive heart failure, diabetes, and dialysis dependence. Bypass was more common among patients with normal phosphate as compared to high or low phosphate levels. There was no difference in WiFi or TASC classification between cohorts. There were significant differences in 1-year mortality (low: 19%, normal: 17%, high: 33%, p < .01) and 3-year mortality (low 38%, normal: 34%, high: 56%, p <.01) between phosphate cohorts. Major amputation (low: 12%, normal: 12%, high: 15%) and restenosis (low: 21%, normal: 24%, high: 28%) tended toward worse outcomes among patients with elevated phosphate levels, but did not reach statistical significance. After adjustment for baseline characteristics, mortality was higher (HR: 1.7, 95% CI: 1.3–2.2) and amputation free survival was lower (HR: 1.5, 95% CI: 1.2–1.9) among patients with elevated as compared with normal phosphate levels. A subgroup analysis was then performed to assess dialysis and non-dialysis patients separately. Patients with elevated serum phosphate levels maintained a significantly higher risk of mortality in each group (Dialysis HR: 1.8 95% CI 1.2–2.6, Non-dialysis: HR 1.5, 95% CI 1.04–2.10). CONCLUSION: Elevated phosphate levels are associated with increased mortality and decreased amputation free survival following interventions for critical limb ischemia. Future studies evaluating the effects of phosphate reduction in patients with CLI are warranted

Early Extubation Reduces Respiratory Complications and Hospital Length of Stay Following Repair of Abdominal Aortic Aneurysms.

INTRODUCTION: Early extubation following cardiac surgery is associated with decreased hospital stay and resource savings with similar mortality and has led to the widespread use of early extubation protocols. In the Vascular Quality Initiative, there is significant regional variation in the frequency of extubation in the operating room (Endovascular (EVAR): 77–97%, Open: 30–70%) following repair of intact abdominal aortic aneurysms (AAA). However, the effects extubation practices on patient outcomes after repair of AAAs are unclear. METHODS: All patients undergoing repair of an intact AAA in the Vascular Study Group of New England from 2003–2015 were evaluated. Patients undergoing concomitant procedures or conversions were excluded. Timing of extubation was stratified for EVAR (Operating Room, <12 hours, >12 hours) and open repair (Operating Room, <12 hours, 12–24 hours, >24 hours). Prolonged hospital stay was defined as >2 days following EVAR and >7 days following open repair. Univariate and multivariable analyses were completed, and independent predictors of extubation outside of the operating room were identified. RESULTS: 5774 patients were evaluated (EVAR: 4453, Open: 1321). Following both EVAR and open repair, respiratory complications, prolonged hospital stay, and discharge to a skilled nursing facility (SNF) increased with intubation time. After adjustment, the odds of complications increased with each 12-hour delay in extubation: respiratory (EVAR-OR: 4.3, 95% CI: 3.0–6.1; Open-OR: 1.8, 95% CI: 1.5–2.2), prolonged hospital stay (EVAR-OR: 2.7, 95% CI: 2.0–3.8; Open–OR: 1.3, 95% CI:1.1–1.4), and discharge to SNF (EVAR-OR: 2.0, 95% CI: 1.5–2.8; Open-1.4, 95% CI 1.1–1.6). Predictors of extubation outside of the operating room following EVAR included: increasing age (OR:1.5, 95% CI:1.2–1.8), congestive heart failure (CHF) (OR:1.9, 95% CI:1.2–3.0), chronic obstructive pulmonary disease (OR: 2.0, 95% CI: 1.4–2.9), symptomatic aneurysm (OR: 3.8, 95% CI 2.3–5.7), and increasing diameter (OR: 1.01, 95% CI: 1.01–1.01). Following open repair increasing age (OR: 1.4, 95% CI: 1.1–1.6), CHF (OR: 1.8, 95% CI: 1.01–3.3), dialysis (OR: 2.8, 95% CI: 1.7–70), symptomatic aneurysm (OR 2.8, 95% CI: 1.9–4.3), and hospital practice patterns (OR: 1.01, 95% CI: 1.01–1.01) were predictive of extubation outside of the operating room. CONCLUSIONS: The benefits of early extubation in cardiac patients are also seen following AAA repair. Suitable patients should be extubated in the operating room to decrease respiratory complications, length of stay, and discharge to SNF. Early extubation protocols should be considered to reduce regional variation in extubation practices and improve patient outcomes

Percutaneous versus femoral cutdown access for endovascular aneurysm repair

Objective: Prior studies suggest that percutaneous access for endovascular abdominal aortic aneurysm repair (pEVAR) offers significant operative and postoperative benefits compared with femoral cutdown (cEVAR). National data on this topic, however, are limited. We compared patient selection and outcomes for elective pEVAR and cEVAR. Methods: We identified all patients undergoing either pEVAR (bilateral percutaneous access, whether successful or not) or cEVAR (at least one planned groin cutdown) for abdominal aortic aneurysms from January 2011 to December 2013 in the Targeted Vascular data set from the American College of Surgeons National Surgical Quality Improvement Program database. Emergent cases, ruptures, cases with an iliac conduit, and cases with a preoperative wound infection were excluded. Groups were compared by c2 test or t-test or the Mann-Whitney test where appropriate. Results: We identified 4112 patients undergoing elective EVAR, 3004 cEVAR patients (73%) and 1108 pEVAR patients (27%). Of all EVAR patients, 26% had bilateral percutaneous access; 1.0% had attempted percutaneous access converted to cutdown (4% of pEVARs); and the remainder had a planned cutdown, 63.9% bilateral and 9.1% unilateral. There were no significant differences in age, gender, aneurysm diameter, or prior open abdominal surgery. Patients undergoing cEVAR were less likely to have congestive heart failure (1.5% vs 2.4%; P [ .04) but more likely to undergo any concomitant procedure during surgery (32% vs 26%; P < .01) than patients undergoing pEVAR. Postoperatively, pEVAR patients had shorter operative time (mean, 135 vs 152 minutes; P < .01), shorter length of stay (median, 1 day vs 2 days; P < .01), and fewer wound complications (2.1% vs 1.0%; P [ .02). On multivariable analysis, the only predictor of percutaneous access failure was performance of any concomitant procedure (odds ratio, 2.0; 95% confidence interval, 1.0-4.0; P [ .04). Conclusions: Currently, one in four patients treated at Targeted Vascular National Surgical Quality Improvement Program centers are getting pEVAR, which is associated with a high success rate, shorter operation time, shorter length of stay, and fewer wound complications compared with cEVAR

Percutaneous versus femoral cutdown access for endovascular aneurysm repair

Objective: Prior studies suggest that percutaneous access for endovascular abdominal aortic aneurysm repair (pEVAR) offers significant operative and postoperative benefits compared with femoral cutdown (cEVAR). National data on this topic, however, are limited. We compared patient selection and outcomes for elective pEVAR and cEVAR. Methods: We identified all patients undergoing either pEVAR (bilateral percutaneous access, whether successful or not) or cEVAR (at least one planned groin cutdown) for abdominal aortic aneurysms from January 2011 to December 2013 in the Targeted Vascular data set from the American College of Surgeons National Surgical Quality Improvement Program database. Emergent cases, ruptures, cases with an iliac conduit, and cases with a preoperative wound infection were excluded. Groups were compared by c2 test or t-test or the Mann-Whitney test where appropriate. Results: We identified 4112 patients undergoing elective EVAR, 3004 cEVAR patients (73%) and 1108 pEVAR patients (27%). Of all EVAR patients, 26% had bilateral percutaneous access; 1.0% had attempted percutaneous access converted to cutdown (4% of pEVARs); and the remainder had a planned cutdown, 63.9% bilateral and 9.1% unilateral. There were no significant differences in age, gender, aneurysm diameter, or prior open abdominal surgery. Patients undergoing cEVAR were less likely to have congestive heart failure (1.5% vs 2.4%; P [ .04) but more likely to undergo any concomitant procedure during surgery (32% vs 26%; P < .01) than patients undergoing pEVAR. Postoperatively, pEVAR patients had shorter operative time (mean, 135 vs 152 minutes; P < .01), shorter length of stay (median, 1 day vs 2 days; P < .01), and fewer wound complications (2.1% vs 1.0%; P [ .02). On multivariable analysis, the only predictor of percutaneous access failure was performance of any concomitant procedure (odds ratio, 2.0; 95% confidence interval, 1.0-4.0; P [ .04). Conclusions: Currently, one in four patients treated at Targeted Vascular National Surgical Quality Improvement Program centers are getting pEVAR, which is associated with a high success rate, shorter operation time, shorter length of stay, and fewer wound complications compared with cEVAR

Transperitoneal versus retroperitoneal approach for open abdominal aortic aneurysm repair in the targeted vascular National Surgical Quality Improvement Program

Objective: We sought to compare current practices in patient selection and 30-day outcomes for transperitoneal and retroperitoneal abdominal aortic aneurysm (AAA) repairs. Methods: All patients undergoing elective transperitoneal or retroperitoneal surgical repair for AAA between January 2011 and December 2013 were identified in the Targeted Vascular National Surgical Quality Improvement Program database. Emergency cases were excluded. Baseline characteristics, anatomic details, and intraoperative and postoperative outcomes were evaluated among those with infrarenal or juxtarenal AAA only. Results: We identified 1135 patients: 788 transperitoneal (69%) and 347 retroperitoneal (31%). When only infrarenal and juxtarenal AAAs were evaluated, the retroperitoneal patients were less likely to have an infrarenal clamp location (43% vs 68%) and had more renal revascularizations (15% vs 6%; P <.001), more visceral revascularizations (5.6% vs 2.4%; P = .014), and more lower extremity revascularizations (11% vs 7%; P = .021) compared with the transperitoneal approach. Postoperative mortality and return to the operating room were similar. Transperitoneal patients had a higher rate of wound dehiscence (2.4% vs 0.4%; P = .045), and retroperitoneal patients had higher incidence of pneumonia (9% vs 5%; P = .034), transfusion (77% vs 71%; P = .037), and reintubation (11% vs 7%; P = .034), and a longer median length of stay (8 vs 7 days; P = .048). After exclusion of all concomitant procedures, only transfusions remained more common in the retroperitoneal approach (78% vs 70%; P = .036). Multivariable analyses showed only higher rates of reintubation in the retroperitoneal group (odds ratio, 1.7; 95% confidence interval, 1.0-3.0; P = .047). Conclusions: The retroperitoneal approach is more commonly used for more proximal aneurysms and was associated with higher rates of pneumonia, reintubation, and transfusion, and a longer length of stay on univariate analyses. However, multivariable analysis demonstrated similar results between groups. The long-term benefits and frequency of reinterventions remain to be proven

Transperitoneal versus retroperitoneal approach for open abdominal aortic aneurysm repair in the targeted vascular National Surgical Quality Improvement Program

Objective: We sought to compare current practices in patient selection and 30-day outcomes for transperitoneal and retroperitoneal abdominal aortic aneurysm (AAA) repairs. Methods: All patients undergoing elective transperitoneal or retroperitoneal surgical repair for AAA between January 2011 and December 2013 were identified in the Targeted Vascular National Surgical Quality Improvement Program database. Emergency cases were excluded. Baseline characteristics, anatomic details, and intraoperative and postoperative outcomes were evaluated among those with infrarenal or juxtarenal AAA only. Results: We identified 1135 patients: 788 transperitoneal (69%) and 347 retroperitoneal (31%). When only infrarenal and juxtarenal AAAs were evaluated, the retroperitoneal patients were less likely to have an infrarenal clamp location (43% vs 68%) and had more renal revascularizations (15% vs 6%; P <.001), more visceral revascularizations (5.6% vs 2.4%; P = .014), and more lower extremity revascularizations (11% vs 7%; P = .021) compared with the transperitoneal approach. Postoperative mortality and return to the operating room were similar. Transperitoneal patients had a higher rate of wound dehiscence (2.4% vs 0.4%; P = .045), and retroperitoneal patients had higher incidence of pneumonia (9% vs 5%; P = .034), transfusion (77% vs 71%; P = .037), and reintubation (11% vs 7%; P = .034), and a longer median length of stay (8 vs 7 days; P = .048). After exclusion of all concomitant procedures, only transfusions remained more common in the retroperitoneal approach (78% vs 70%; P = .036). Multivariable analyses showed only higher rates of reintubation in the retroperitoneal group (odds ratio, 1.7; 95% confidence interval, 1.0-3.0; P = .047). Conclusions: The retroperitoneal approach is more commonly used for more proximal aneurysms and was associated with higher rates of pneumonia, reintubation, and transfusion, and a longer length of stay on univariate analyses. However, multivariable analysis demonstrated similar results between groups. The long-term benefits and frequency of reinterventions remain to be proven

Outcomes for symptomatic abdominal aortic aneurysms in the American College of Surgeons National Surgical Quality Improvement Program.

INTRODUCTION: Historically symptomatic AAAs were found to have intermediate mortality compared to asymptomatic and ruptured AAAs but, with wider EVAR use, a more recent study suggested mortality of symptomatic aneurysms were similar to asymptomatic AAAs. These prior studies were limited by small numbers. The purpose of this study is to evaluate the mortality and morbidity associated with symptomatic AAA repair in a large contemporary population. METHODS: All patients undergoing infrarenal AAA repair were identified in the 2011–2013 ACS-NSQIP, Vascular Surgery targeted module. We excluded acute conversions to open repair and those for whom the surgical indication was embolization, dissection, thrombosis, or not documented. We compared 30-day mortality and major adverse events (MAE) for asymptomatic, symptomatic, and ruptured AAA repair, stratified by EVAR and open repair, with univariate analysis and multivariable logistic regression. RESULTS: 5502 infrarenal AAAs were identified, 4495 asymptomatic (830 open repair, 3665 [82%] EVAR), 455 symptomatic (143 open, 312 [69%] EVAR), and 552 ruptured aneurysms (263 open, 289 [52%] EVAR). Aneurysm diameter was similar between asymptomatic and symptomatic AAAs, when stratified by procedure type, but larger for ruptured aneurysms (EVAR symptomatic 5.8cm ±1.6 vs. ruptured 7.5cm ±2.0, P<.001; open repair symptomatic 6.4cm ±1.9 vs. ruptured 8.0cm ±1.9, P<.001). The proportion of females was similar in symptomatic and ruptured AAA (27% vs. 23%, P=.14, respectively), but lower in asymptomatic AAA (20%, P<.001). Symptomatic AAAs had intermediate 30-day mortality compared to asymptomatic and ruptured aneurysms after both EVAR (asymptomatic 1.4% vs. symptomatic 3.8%, P=.001; symptomatic vs. 22% ruptured, P<.001) and open repair (asymptomatic 4.3% vs. symptomatic 7.7% , P=.08; symptomatic vs. 57% ruptured, P<.001). After adjustment for age, gender, repair type, dialysis dependence, and history of severe COPD, patients undergoing repair of symptomatic AAAs were twice as likely to die within 30-days compared to those with asymptomatic aneurysms (OR 2.1, 95%CI 1.3–3.5). When stratified by repair type the effect size and direction of the odds ratios were similar (EVAR OR 2.4, CI 1.2–4.7; open repair OR 1.8, CI 0.86–3.9), although not significant for open repair. Patients with ruptured aneurysms had a sevenfold increased risk of 30-day mortality compared to symptomatic patients (OR 6.5, CI 4.1–10.6). CONCLUSION: Patients with symptomatic AAAs had a two-fold increased risk of perioperative mortality, compared to asymptomatic aneurysms undergoing repair. Furthermore, patients with ruptured aneurysms have a seven-fold increased risk of mortality compared to symptomatic aneurysms