Left subclavian artery coverage during thoracic endovascular aortic repair and risk of perioperative stroke or death

IntroductionLeft subclavian artery (LSA) coverage during thoracic endovascular aortic repair (TEVAR) is often necessary due to anatomic factors and is performed in to up to 40% of procedures. Despite the frequency of LSA coverage during TEVAR, reported associations with risk of periprocedural stroke or death are inconsistent in reported literature. We examined the 2005-2008 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data file to determine associations between LSA coverage during TEVAR and risk of perioperative stroke or death.MethodsCurrent procedural terminology (CPT) codes were used to identify patients undergoing TEVAR, LSA coverage, and subclavian revascularization. Patients undergoing coronary bypass, ascending aortic repair, abdominal aortic aneurysm repair, or nonvascular intra-abdominal procedures during the same operation were excluded. Perioperative stroke and mortality associations with LSA coverage were examined using logistic regression models for each outcome. Significance was assessed at α = 0.05, with univariable P < .05 required for multivariable model entry.ResultsEight hundred forty-five TEVAR procedures were identified, of which 52 patients were excluded due to additional major procedures performed with TEVAR. Seven hundred thirty-three of the remaining 793 procedures included CPT codes indicating primary placement of an initial thoracic endograft and form the basis of this analysis. LSA coverage occurred in 279 procedures (38%). Thirty-day stroke and mortality rates were 5.7% and 7.0%, respectively. LSA coverage was associated with increased 30-day risk of stroke in multivariable modeling (odds ratio [OR], 2.17 95% confidence interval [CI], 1.13-4.14; P = .019). Other significant multivariable risk factors for stroke included proximal aortic cuff placement during TEVAR (OR, 2.58; 95% CI, 1.30-5.16; P = .007) and emergency procedure status (OR, 3.60; 95% CI, 1.87-6.94; P < .001). No significant association between LSA coverage and perioperative mortality was identified (univariable OR, 1.70; 95% CI, 0.98-2.93; P = .0578).ConclusionLSA coverage during thoracic endovascular repair is associated with increased risk of perioperative stroke following TEVAR. Further evidence is needed to determine whether procedural modifications, including LSA revascularization, reduce the incidence of stroke associated with TEVAR

Characterization of resident surgeon participation during carotid endarterectomy and impact on perioperative outcomes

IntroductionThe impact of resident surgeon participation during vascular procedures on postoperative outcomes is incompletely understood. We characterized resident physician participation during carotid endarterectomy (CEA) procedures within the 2005-2009 American College of Surgeons National Surgical Quality Improvement Participant Use Datafile and evaluated associations with procedural characteristics and perioperative adverse events.MethodsCEAs were identified using primary current procedural terminology codes; those performed simultaneously with other major procedures or unknown resident participation status were excluded. Group-wise comparisons based on resident participation status were performed using χ2 or Fisher's exact test for categorical variables and t tests or nonparametric methods for continuous variables. Associations with perioperative adverse events (major = stroke, death, myocardial infarction, or cardiac arrest; minor = peripheral nerve injury, bleeding requiring transfusion, surgical site infection, or wound disruption) were assessed using multivariable logistic regression models adjusting for other known risk factors.ResultsA total of 25,280 CEA procedures were analyzed, of which residents participated in 13,705 (54.2%), while residents were absent in 11,575 (45.8%). Among CEAs with resident physician participation, resident level was categorized as junior (postgraduate year [PGY] 1-2) in 21.9%, senior (PGY 3-5) in 52.7%, and fellow (PGY ≥6) in 25.3%. Major adverse event rates with and without resident participation were 1.9% versus 2.1%, and minor adverse event rates with and without resident participation were 0.9% versus 1.0%, respectively. In multivariable models, resident physician participation was not associated with perioperative risk for major adverse events (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.75-1.08) or minor adverse events (OR, 0.93; 95% CI, 0.72-1.21).ConclusionsResident surgeon participation during CEA is not associated with risk of adverse perioperative events

A national survey of disease-specific knowledge in patients with an abdominal aortic aneurysm

OBJECTIVE: Patient education is a fundamental responsibility of medical providers caring for patients with abdominal aortic aneurysms (AAA). We sought to evaluate and quantify AAA-specific knowledge in patients under AAA surveillance and in patients who have undergone AAA repair. METHODS: In 2013, 1373 patients from 6 U.S. institutions were mailed an AAA-specific quality of life and knowledge survey. Of these patients, 1008 (73%) returned completed surveys for analysis. The knowledge domain of the survey consisted of nine questions. An AAA knowledge score was calculated for each patient based on the proportion of questions answered correctly. The score was then compared according to sex, race, and education level. Surveillance and repaired patients were also compared. RESULTS: Among 1008 survey respondents, 351 were under AAA surveillance and 657 had AAA repair (endovascular repair, 414; open, 179; unknown, 64). The majority of patients (85%) reported that their doctor\u27s office was their most important source of AAA information. The Internet and other written materials were each reported as the most important source of information 5% of the time with other patients reported 2% of the time. The mean AAA knowledge score was 47% (range 0%-100%; standard deviation, 23%) with a broad variation in percentage correct between questions. Thirty-two percent of respondents did not know that larger AAA size increases rupture risk, and 64% did not know that AAA runs in families. Only 15% of patients answered six or more of the nine questions correctly, and 23% of patients answered two or fewer questions correctly. AAA knowledge was significantly greater in men compared with women, whites compared with nonwhites, high school graduates compared with nongraduates, and surveillance compared with repaired patients. CONCLUSIONS: In a national survey of AAA-specific knowledge, patients demonstrated poor understanding of their condition. This may contribute to anxiety and uninformed decision making. The need for increased focus on education by vascular providers is a substantial unmet need