Short-Term Concerns Primarily Determine Patient Preference for Abdominal Aortic Aneurysm Repair

INTRODUCTION

Abdominal aortic aneurysm (AAA) repair may be performed through open or endovascular approaches, but the factors influencing a patient's repair-type preference are not well characterized. Here we performed a qualitative analysis to better understand factors influencing patient preference within the Preference for Open Versus Endovascular Repair of AAA Trial.

METHODS

Open-ended responses regarding primary (n = 21) and secondary (n = 47) factors influencing patient preference underwent qualitative analysis using the constant comparative method with iterative reviews. Codes were used to generate themes and themes grouped into categories, with each step conducted via consensus agreement between three researchers. Relative prevalence of themes were compared to ascertain trends in patient preference.

RESULTS

Patient responses regarding both primary and secondary factors fell into four categories: Short-term concerns, long-term concerns, advice & experience, and other. Patients most frequently described short-term concerns (23) as their primary influence, with themes including post-op complications, hospitalization & recovery, and intraoperative concerns. Long-term concerns were more prevalent (20) as secondary factors, which included themes such as survival, and chronic management. The average age of patients voicing only long-term concerns as a primary factor was 11 years younger than those listing only short-term concerns.

CONCLUSION

Short-term concerns relating to the procedure and recovery are more often the primary factor influencing patient preference, while long term concerns play a more secondary role. Long-term concerns are more often a primary factor in younger patients. Vascular surgeons should consider this information in shared decision making to reach an optimal outcome.

Exploring the rapid expansion of office-based laboratories and peripheral vascular interventions across the United States

OBJECTIVE

To characterize the relationship between office-based laboratory (OBL) use and Medicare payments for peripheral vascular interventions (PVI).

METHODS

Using the Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Public Use Files from 2014 to 2017, we identified providers who performed percutaneous transluminal angioplasty, stent placement, and atherectomy. Procedures were aggregated at the provider and hospital referral region (HRR) level.

RESULTS

Between 2014 and 2017, 2641 providers performed 308,247 procedures. The mean payment for OBL stent placement in 2017 was $4383.39, and mean payment for OBL atherectomy was $13,079.63. The change in the mean payment amount varied significantly, from a decrease of $16.97 in HRR 146 to an increase of $43.77 per beneficiary over the study period in HRR 11. The change in the rate of PVI also varied substantially, and moderately correlated with change in payment across HRRs (R2 = 0.40; P < .001). The majority of HRRs experienced an increase in rate of PVI within OBLs, which strongly correlated with changes in payments (R2 = 0.85; P < .001). Furthermore, 85% of the variance in change in payment was explained by increases in OBL atherectomy (P < .001).

CONCLUSIONS

A rapid shift into the office setting for PVIs occurred within some HRRs, which was highly geographically variable and was strongly correlated with payments. Policymakers should revisit the current payment structure for OBL use and, in particular atherectomy, to better align the policy with its intended goals.

Aortic Neck IFU Violations During EVAR for Ruptured Infrarenal Aortic Aneurysms are Associated with Increased In-Hospital Mortality

OBJECTIVE

Vascular surgeons treating patients with ruptured abdominal aortic aneurysm must make rapid treatment decisions and sometimes lack immediate access to endovascular devices meeting the anatomic specifications of the patient at hand. We hypothesized that endovascular treatment of ruptured abdominal aortic aneurysm (rEVAR) outside manufacturer instructions-for-use (IFU) guidelines would have similar in-hospital mortality compared to patients treated on-IFU or with an infrarenal clamp during open repair (ruptured open aortic aneurysm repair [rOAR]).

METHODS

Vascular Quality Initiative datasets for endovascular and open aortic repair were queried for patients presenting with ruptured infrarenal AAA between 2013-2018. Graft-specific IFU criteria were correlated with case-specific proximal neck dimension data to classify rEVAR cases as on- or off-IFU. Univariate comparisons between the on- and off-IFU groups were performed for demographic, operative and in-hospital outcome variables. To investigate mortality differences between rEVAR and rOAR approaches, coarsened exact matching was used to match patients receiving off-IFU rEVAR with those receiving complex rEVAR (requiring at least one visceral stent or scallop) or rOAR with infrarenal, suprarenal or supraceliac clamps. A multivariable logistic regression was used to identify factors independently associated with in-hospital mortality.

RESULTS

621 patients were treated with rEVAR, with 65% classified as on-IFU and 35% off-IFU. The off-IFU group was more frequently female (25% vs. 18%, P = 0.05) and had larger aneurysms (76 vs. 72 mm, P= 0.01) but otherwise was not statistically different from the on-IFU cohort. In-hospital mortality was significantly higher in patients treated off-IFU vs. on-IFU (22% vs. 14%, P= 0.02). Off-IFU rEVAR was associated with longer operative times (135 min vs. 120 min, P= 0.004) and increased intraoperative blood product utilization (2 units vs. 1 unit, P= 0.002). When off-IFU patients were matched to complex rEVAR and rOAR patients, no baseline differences were found between the groups. Overall in-hospital complications associated with off-IFU were reduced compared to more complex strategies (43% vs. 60-81%, P< 0.001) and in-hospital mortality was significantly lower for off-IFU rEVAR patients compared to the supraceliac clamp group (18% vs. 38%, P= 0.006). However, there was no significantly increased mortality associated with complex rEVAR, infrarenal rOAR or suprarenal rOAR compared to off-IFU rEVAR (all P> 0.05). This finding persisted in a multivariate logistic regression.

CONCLUSIONS

Off-IFU rEVAR yields inferior in-hospital survival compared to on-IFU rEVAR but remains associated with reduced in-hospital complications when compared with more complex repair strategies. When compared with matched patients undergoing rOAR with an infrarenal or suprarenal clamp, survival was no different from off-IFU rEVAR. Taken together with the growing available evidence suggesting reduced long-term durability of off-IFU EVAR, these data suggest that a patient's comorbidity burden should be key in making the decision to pursue off-IFU rEVAR over a more complex repair when proximal neck violations are anticipated preoperatively.

Long-term Reintervention After Endovascular Abdominal Aortic Aneurysm Repair

OBJECTIVE

To describe the long-term reintervention rate after endovascular abdominal aortic aneurysm repair (EVR), and identify factors predicting reintervention.

SUMMARY OF BACKGROUND DATA

EVR is the most common method of aneurysm repair in America, and reintervention after EVR is common. Clinical factors predicting reintervention have not been described in large datasets with long-term follow-up.

METHODS

We studied patients who underwent EVR using the Vascular Quality Initiative registry linked to Medicare claims. Our primary outcome was reintervention, defined as any procedure related to the EVR after discharge from the index hospitalization. We used classification and regression tree modeling to inform a multivariable Cox-regression model predicting reintervention after EVR.

RESULTS

We studied 12,911 patients treated from 2003 to 2015. Mean age was 75.5 ± 7.3 years, 79.9% were male, and 89.1% of operations were elective. The 3-year reintervention rate was 15%, and the 10-year rate was 33%. Five factors predicted reintervention: operative time ≥3.0 hours, aneurysm diameter ≥6.0 cm, an iliac artery aneurysm ≥2.0 cm, emergency surgery, and a history of prior aortic surgery. Patients with no risk factors had a 3-year reintervention rate of 12%, and 10-year rate of 26% (n = 7310). Patients with multiple risk factors, such as prior aortic surgery and emergent surgery, had a 3-year reintervention rate 72%, (n = 32). Modifiable factors including EVR graft manufacturer or supra-renal fixation were not associated with reintervention (P = 0.76 and 0.79 respectively).

CONCLUSIONS

All patients retain a high likelihood of reintervention after EVR, but clinical factors at the time of repair can predict those at highest risk.

Effectiveness of Blood Lipid Management in Patients With Peripheral Artery Disease

BACKGROUND

Low-density lipoprotein cholesterol (LDL-C) is associated with heightened risk of major adverse cardiovascular events (MACE) and major adverse limb events (MALE) in peripheral artery disease (PAD). Lipid-lowering therapies (LLT) that reduce LDL-C decrease this risk.

OBJECTIVES

The authors examined LLT use and actual achieved LDL-C in PAD.

METHODS

PAD patients in MarketScan from 2014 to 2018 were identified. Outcomes included LLT use, defined as high-intensity (HI) (high-intensity statin, statin plus ezetimibe, or PCSK9 inhibitor), low-intensity (any other lipid regimen), or no therapy, and follow-up LDL-C. Factors associated with LDL-C <70 mg/dl were identified with multivariable logistic regression.

RESULTS

Among 250,103 PAD patients, 20.5% and 39.5% were treated at baseline with HI and low-intensity LLT, respectively; 40.0% were on no LLT. Over a 15-month median follow-up period, HI LLT use increased by 1.5%. Among 18,747 patients with LDL-C data, at baseline, 25.1% were on HI LLT, median LDL-C was 91 mg/dl, and 24.5% had LDL-C <70 mg/dl. Within the HI LLT subgroup, median LDL-C was 81 mg/dl, and 64% had LDL-C ≥70 mg/dl. At follow-up, HI LLT use increased by 3.7%, median LDL-C decreased by 4.0 mg/dl, and an additional 4.1% of patients had LDL-C <70 mg/dl. HI LLT use was greater after follow-up MACE (55.0%) or MALE (41.0%) versus no ischemic event (26.1%). After MACE or MALE, LDL-C was <70 mg/dl in 41.5% and 36.1% of patients, respectively, versus 27.1% in those without an event. Factors associated with follow-up LDL-C <70 mg/dl included smoking, hypertension, diabetes, prior lower extremity revascularization, and prior myocardial infarction but not prior acute or critical limb ischemia.

CONCLUSIONS

In PAD, LLT use is suboptimal, LDL-C remains elevated, and LLT intensity is a poor surrogate for achieved LDL-C. Less aggressive lipid management was observed in PAD versus cardiovascular disease, highlighting missed opportunities for implementation of proven therapies in PAD.

Surgeon experience versus volume differentially affects lower extremity bypass outcomes in contemporary practice

BACKGROUND

Calls for minimum case thresholds to guide surgeon credentialing paradigms are increasing in contemporary practice. To date, the volume-outcome relationship and the role of surgeon experience as a proxy for quality have remained primarily focused on nonvascular extirpative surgery and aneurysm repair. However, it is unclear whether these data can be rightly extrapolated to predict lower extremity bypass (LEB) outcomes. Thus, the purpose of the present study was to examine whether the annualized case volume vs surgeon experience is more consequential in predicting for successful LEB reconstruction.

METHODS

A total of 25,852 procedures with sufficient 1-year follow-up data from the Society for Vascular Surgery Vascular Quality Initiative infrainguinal bypass registry (2003-2019) were reviewed for chronic limb threatening ischemia among patients undergoing infrageniculate reconstruction. The procedures were categorized according to surgeon years of practice experience at surgery (ie, 0-5, 6-10, 11-15, >15 years) and the number of LEB procedures performed by the surgeon during the year of surgery (volume quartiles: 1-8, 9-14, 15-21, and >21). Mixed effects logistic and Cox regression models were used to assess the effects of experience, volume, and their interaction on outcomes.

RESULTS

Increasing practice experience was more significantly associated with a reduction of in-hospital complications (odds ratio, 0.97; 95% confidence interval [CI], 0.96-0.99; P = .002) and the risk of major adverse limb events (odds ratio, 0.94; 95% CI, 0.92-0.97; P < .0001) compared with the volume. Increasing experience and volume were both associated with increased freedom from thrombosis (hazard ratio, 0.95; 95% CI, 0.93-0.98; P = .001). In contrast, neither experience nor volume had any significant association with early mortality. However, a higher volume was associated with diminished long-term survival (hazard ratio, 1.04; 95% CI, 1.0-1.1; P = .01). The most experienced surgeons (>15 years' experience) were significantly more likely to perform LEB for rest pain (P < .0001). No significant differences were found in the bypass rates among patients with tissue loss. The most experienced and highest volume surgeons were more likely to use an autogenous and/or composite conduit, in situ reconstruction, and/or pedal targets (P < .05). Similarly, more experienced and higher volume surgeons had less blood loss and shorter procedure times (P < .0001). Overall, the most experienced surgeons (>15 years' experience) were significantly more likely to have a higher volume with a diminished risk for all LEB outcomes.

CONCLUSIONS

Surgeon experience appears to have the most important role in predicting for overall LEB performance with improved in-hospital outcomes and major adverse limb events. The more experienced surgeons performed more complex reconstructions with fewer complications. These findings have significant clinical and educational implications as our most experienced surgeons approach retirement. Mentorship strategies to facilitate ongoing technical development among less experienced surgeons are imperative to sustain optimal limb salvage outcomes and have significant ramifications regarding expectations for regulatory and credentialing paradigms.

Geographic and Demographic Variability in Transcatheter Aortic Valve Replacement Dispersion in the United States

Background

Transcatheter aortic valve replacement (TAVR) has transformed the management of aortic valve stenosis. However, little national data are available characterizing the geographic and demographic dispersion of this disruptive technology relative to surgical aortic valve replacement (SAVR).

Methods and Results

In this US claims‐based study, we analyzed a 100% sample of fee‐for‐service Medicare beneficiaries from 2012 to 2017 and examined national rates of TAVR versus SAVR. Procedure rates were compared across years as a function of age, sex, race, and geography for TAVR and SAVR beneficiaries. There was significant growth in TAVR from 15.4 beneficiaries/100 000 enrollees in 2012 to 90.6 in 2017 (P<0.001). SAVR rates declined from 92.8 beneficiaries/100 000 enrollees in 2012 to 63.5 in 2017 (P<0.001). The growth of TAVR varied as a function of age (P<0.0001). While TAVR was the dominant strategy among beneficiaries ≥85 and 75 to 84 years old, SAVR was more common among beneficiaries 65 to 74 years old. TAVR was also used more frequently than SAVR among women (P<0.001). While TAVR increased among all races, it was less commonly used among non‐White beneficiaries (P<0.001). Contemporary use of TAVR relative to SAVR varied significantly by geographic location, with a TAVR:SAVR ratio in 2017 of 1.24 in the Midwest and 1.68 in the Northeast (P<0.001).

Conclusions

In 2017, the number of Medicare beneficiaries receiving TAVR exceeded SAVR for the first time in the United States. There is significant variation, however, in the geographic expansion of TAVR and in patient demographics relative to SAVR.

Reducing Nontraumatic Lower-Extremity Amputations by 20% by 2030: Time to Get to Our Feet: A Policy Statement From the American Heart Association

Nontraumatic lower-extremity amputation is a devastating complication of peripheral artery disease (PAD) with a high mortality and medical expenditure. There are ≈150 000 nontraumatic leg amputations every year in the United States, and most cases occur in patients with diabetes. Among patients with diabetes, after an ≈40% decline between 2000 and 2009, the amputation rate increased by 50% from 2009 to 2015. A number of evidence-based diagnostic and therapeutic approaches for PAD can reduce amputation risk. However, their implementation and adherence are suboptimal. Some racial/ethnic groups have an elevated risk of PAD but less access to high-quality vascular care, leading to increased rates of amputation. To stop, and indeed reverse, the increasing trends of amputation, actionable policies that will reduce the incidence of critical limb ischemia and enhance delivery of optimal care are needed. This statement describes the impact of amputation on patients and society, summarizes medical approaches to identify PAD and prevent its progression, and proposes policy solutions to prevent limb amputation. Among the actions recommended are improving public awareness of PAD and greater use of effective PAD management strategies (eg, smoking cessation, use of statins, and foot monitoring/care in patients with diabetes). To facilitate the implementation of these recommendations, we propose several regulatory/legislative and organizational/institutional policies such as adoption of quality measures for PAD care; affordable prevention, diagnosis, and management; regulation of tobacco products; clinical decision support for PAD care; professional education; and dedicated funding opportunities to support PAD research. If these recommendations and proposed policies are implemented, we should be able to achieve the goal of reducing the rate of nontraumatic lower-extremity amputations by 20% by 2030.

Late outcomes after endovascular and open repair of large abdominal aortic aneurysms

OBJECTIVE

The risk of aortic abdominal aneurysm (AAA) rupture increases with an increasing aneurysm diameter. However, the effect of the AAA diameter on late outcomes after aneurysm repair is unclear. Therefore, we assessed the association of a large AAA diameter with late outcomes for patients undergoing open and endovascular AAA repair.

METHODS

We identified all patients who had undergone elective open or endovascular infrarenal aneurysm repair from 2003 to 2016 in the Vascular Quality Initiative linked to Medicare claims for long-term outcomes. A large AAA diameter was defined as a diameter >65 mm. We assessed the 5-year reintervention, rupture, mortality, and follow-up rates. We constructed propensity scores and used inverse probability-weighted Kaplan-Meier estimations and Cox proportional hazard models to identify independent associations between large AAA repair and our outcomes.

RESULTS

Of the 21,119 aneurysm repairs identified, 15.2% were for large AAAs. Of the 21,119 repairs, 19,017 were endovascular and 2102 were open. The large AAA cohort was less likely to have undergone endovascular aneurysm repair (EVAR; 84.9% vs 91%; P < .001), more likely to be older (median age, 76 vs 75 years; P < .001), and were less likely to be women (16.2% vs 21.7%; P < .001). After EVAR, patients with large AAAs had had lower adjusted 5-year freedom from reintervention (73.9% vs 84.6%; P < .001), freedom from rupture (88.5% vs 93.6%; P < .001), survival (58.0% vs 66.4%; P < .001), and freedom from loss to follow-up (77.7% vs 83.3%; P < .001) compared with patients with smaller AAAs. However, after open repair, the adjusted 5-year freedom from reintervention (95.8% vs 93.3%; P = .11), freedom from rupture (97.4% vs 97.8%; P = .32), survival (70.4% vs 74.0%; P = .13), and loss to follow-up (60.5% vs 62.8%; P = .86) were similar to the results for patients with smaller AAAs. For patients with large AAAs, the adjusted 5-year survival was lower after EVAR than that after open repair (55.3% vs 63.7%) but not after smaller AAA repair (67.3% vs 70.6%).

CONCLUSION

The 5-year adjusted reintervention, ruptures, mortality, and loss to follow-up rates for patients who had undergone large AAA EVAR were higher than those for patients who had undergone small AAA EVAR and large AAA open repair. Therefore, for patients with large AAAs who are medically fit, open repair should be strongly considered. Furthermore, these findings highlight the necessity for rigorous long-term follow-up after EVAR.

Stress testing before abdominal aortic aneurysm repair does not lead to a reduction in perioperative cardiac events

OBJECTIVE

Stress testing is often used before abdominal aortic aneurysm (AAA) repair. Whether stress testing leads to a reduction in cardiac events after AAA repair has remained unclear. Our objective was to study the national stress test usage rates and compare the perioperative outcomes between centers with high and low usage of stress testing.

METHODS

We used the Vascular Quality Initiative to study patients who had undergone elective endovascular AAA repair (EVAR) or open AAA repair (OAR). We measured the usage rates of stress testing across centers and compared the Vascular Study Group of New England cardiac risk index (VSG-CRI) among patients who had and had not undergone preoperative stress testing. We determined the rate of major adverse cardiac events (MACE), a composite of perioperative myocardial infarction, stroke, heart failure exacerbation, and death across the centers. We compared the MACE and 1-year mortality between the centers in the highest quintile of stress test usage and the lowest quintile.

RESULTS

We studied 43,396 EVAR patients and 8935 OAR patients across 324 centers. The median proportion of stress test usage across centers before EVAR was 35.9% and varied from 10.2% (5th percentile) to 73.7% (95th percentile), with similar variability for OAR (median, 57.9%; 5th percentile, 13.0%; 95th percentile, 86.0%). The mean VSG-CRI for the EVAR group with preoperative stress testing was 5.6 ± 2.1 compared with 5.4 ± 2.1 (P < .001) for the EVAR group without preoperative stress testing. The findings were similar for OAR, with a VSG-CRI of 5.1 ± 2.0 vs 4.8 ± 2.1 (P < .001) for those with and without preoperative stress testing, respectively. The rate of MACE was 1.8% after EVAR and 11.6% after OAR. The 1-year mortality was 4.6% for EVAR and 6.6% for OAR. The centers in the highest quintile of stress testing had a higher adjusted likelihood of MACE after both EVAR (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.37-2.30) and OAR (OR, 1.99; 95% CI, 1.53-2.59) but similar 1-year mortality (EVAR: OR, 1.18; 95% CI, 1.02-1.37; OAR: OR, 0.87; 95% CI, 0.65-1.17) compared with the centers in the lowest quintile. The VSG-CRI was not different between the high stress test centers (EVAR, 5.5 ± 2.1; OAR: 5.0 ± 2.0), and low stress test centers (EVAR, 5.5 ± 2.1; P = .403; OAR, 4.9 ± 2.0; P = .563).

CONCLUSIONS

Stress test usage before AAA repair varied widely across Vascular Quality Initiative centers despite similar patient risk profiles. No reduction was observed in MACE or 1-year mortality among centers with high stress test usage. The value of routine stress testing before AAA repair should be reconsidered, and stress testing should be used more selectively, given these findings and the associated costs of widespread testing.

Burden and causes of readmissions following initial discharge after aortic syndromes

BACKGROUND

Aortic syndromes, including aortic dissection (AD), intramural hematoma (IMH), and penetrating aortic ulcer (PAU), carry significant morbidity and mortality; few data exist regarding burden and causes of related rehospitalizations following initial discharge.

METHODS

The study was conducted using the Rochester Epidemiology Project. All adult residents (age ≥18 years) with an incident diagnosis of AD, IMH, and PAU (1995-2015) were identified from the Rochester Epidemiology Project using the International Classification of Diseases, Ninth Revision and Tenth Revision codes and Hospital Adaptation of the International Classification of Diseases, second edition, codes. Assessment of any-cause (aortic and cardiovascular), aorta-related, or cardiovascular-related readmissions was determined following date of hospital discharge or diagnosis date (ie, the index event).

RESULTS

A total of 117 patients of 130 cases of AD, IMH, and PAU included in the initial study population survived the index event and were evaluated. The median age of diagnosis was 74 years, and 70 (60%) were male. A total of 79 patients (68%) experienced at least one readmission. The median time to first any-cause, cardiovascular, and aortic readmission was 143, 861, and 171 days, respectively. The cumulative incidence of any-cause readmissions at 2, 4, and 10 years was 45%, 55%, and 69%, respectively. The cumulative incidence of cardiovascular readmissions at 2, 4, and 10 years was 15%, 20%, and 28%, respectively. The cumulative incidence of aortic readmissions at 2, 4, and 10 years was 38%, 46%, and 59%, respectively. Overall survival for the entire cohort at 2, 4, and 10 years was 84%, 75%, and 50%, respectively.

CONCLUSIONS

Readmissions following initial discharge after diagnosis of aortic syndrome are common and not different across specific disease types. Whereas aorta-related rehospitalizations occur in more than half of patients but tend to be earlier, cardiovascular-related rehospitalizations tend to happen later in about one-third of patients. This may suggest the need for early follow-up focused on aortic complications, whereas later follow-up should address cardiovascular events.

Epidemiology of peripheral artery disease

Peripheral artery disease (PAD) is the clinical manifestation of atherosclerosis that primarily affects peripheral arteries within the lower extremities. In this brief review, we describe the epidemiology and burden of disease of PAD within the United States, particularly among high-risk populations. Although the prevalence of PAD continues to increase and is typically higher among the elderly as well as men, women in lower socioeconomic strata are affected at rates two times that of men. Among racial/ethnic groups, Black and African-American patients both experience higher rates of disease as well as lower rates of access to preventative care. Moreover, despite an overall decrease in amputation rates among all patients with PAD, high-risk populations remain disproportionally affected. Specifically, patients in rural areas, African-American and Native-American patients, and those of low socioeconomic status carry the highest risk of amputation. Efforts to improve care among PAD patients should target these high-risk populations and offer comprehensive, evidence-based preventative care. Wide adoption and integration of these practices into comprehensive care models may help to mitigate amputation in the highest-risk populations. As our treatment pathways continue to evolve, we must place further emphasis on patient input and quality of life as we work toward continual improvement in the care of patients with PAD.

Association of Adoption of Transcarotid Artery Revascularization With Center-Level Perioperative Outcomes

IMPORTANCE

Transcarotid artery revascularization (TCAR) may serve as a safer alternative to carotid endarterectomy (CEA) for certain patients with carotid artery stenosis.

OBJECTIVE

To determine the center-level association of TCAR adoption with overall perioperative outcomes for TCAR and CEA combined at centers performing both procedures.

DESIGN, SETTING, AND PARTICIPANTS

This comparative-effectiveness research was conducted with a difference-in-difference analysis using retrospective data from 2015 to 2019 from the Vascular Quality Initiative registry, a consortium of more than 400 centers in North America. Included patients underwent TCAR or CEA for carotid artery stenosis. Patients who underwent transfemoral carotid stenting were excluded. Data were analyzed from December 2019 through August 2020.

EXPOSURES

Center-level adoption of TCAR vs not.

MAIN OUTCOMES AND MEASURES

The rate of major adverse cardiovascular events (MACE), a composite of in-hospital stroke, myocardial infarction, or death at 30 days, was measured.

RESULTS

Among 86 027 patients who underwent revascularization for carotid artery stenosis, 7664 patients (8.9%) underwent TCAR (mean [SD] age, 73.1 [9.6] years; 2788 [36.4%] women; 6938 White patients [90.6%]; and 3741 patients with symptoms [48.8%]) and 78 363 patients (91.1%) underwent CEA (mean [SD] age, 70.6 [9.2] years; 30 928 [39.5%] women; 70 663 White patients [90.2%]; and 37 883 patients with symptoms [48.3%]). The number of centers performing both TCAR and CEA increased from 15 centers in 2015 to 247 centers in 2019, a more than 16-fold increase. The proportion of all carotid procedures that were TCARs increased from 90 of 12 276 (0.7%) in 2015 to 2718 of 15 956 (17.0%) in 2019, a 24-fold increase. Overall, the crude rate of MACE was similar for TCAR and CEA (178 patients [2.3%] after TCAR vs 1842 patients [2.4%] after CEA; P = .91). However, the rate of MACE over time decreased for CEA (406 of 16 404 patients [2.5%] in 2015 vs 189 of 10 097 patients [1.9%] in 2019; P for trend < .001). The rate of MACE over time decreased for TCAR as well, but the change was not statistically significant (4 of 128 patients [3.1%] in 2016 vs 59 of 2718 patients [2.2%] in 2019; P for trend = .07). Difference-in-difference analysis demonstrated that centers that adopted TCAR had a 10% decrease in the likelihood of MACE at 12 months after TCAR adoption vs if those centers had continued to perform CEA alone (odds ratio, 0.90; 95% CI, 0.81-0.99; P = .04).

CONCLUSIONS AND RELEVANCE

This comparative-effectiveness study of a cohort of patients who underwent TCAR or CEA found that availability of TCAR at a hospital was associated with a decrease in the likelihood of perioperative MACE after carotid revascularization.

Medicare reimbursement of lower extremity bypass does not cover cost of care for most patients with critical limb ischemia

OBJECTIVE

Lower extremity bypass surgery remains an important treatment option for patients with critical limb ischemia (CLI), but is resource intensive. We sought to evaluate the cost and Medicare reimbursement for lower extremity bypass surgery in patients with CLI.

METHODS

Hospital cost accounting systems were queried for total technical and professional costs incurred and reimbursement received for patients with CLI undergoing lower extremity bypass at our center between 2011 and 2017. Patients were identified by assignment to Diagnosis-Related Group (DRG) 252, 253, or 254 (other vascular procedure with major complication/comorbidity, with complication/comorbidity, and without complication/comorbidity, respectively). Additional clinical data were incorporated from the Vascular Quality Initiative clinical registry. For non-Medicare patients, reimbursement was indexed to Medicare rates. Contribution margins (reimbursement minus cost) from technical and professional services were analyzed for each patient and summarized by DRG. We compared technical, professional, and total costs; reimbursement; and contribution margins across DRGs using univariate statistics and evaluated factors associated with total contribution margin using median quantile regression.

RESULTS

We analyzed 68 patients with hemodynamically confirmed CLI (46% rest pain, 54% tissue loss), of whom 25% received a prosthetic graft. Mean age was 66.1 ± 11.6 years, 69% were male, 49% diabetic, 44% current smokers, and 4% on dialysis. In general, total infrainguinal bypass cost was adequately compensated for patients assigned only the most complex DRG 252 (median, $2490; interquartile range [IQR], -$1,621 to $10,080). In the majority of patients with less complex DRG 253 (median, -$3,100; IQR, -$8499 to $109) and DRG 254 (median, -$4902; IQR, -$9259 to $1059), reimbursement did not cover the cost of care. Both technical costs and professional costs varied significantly with the complexity of DRG. Although reimbursement from technical services increased alongside increasing complexity of DRG, there was insignificant variation in professional reimbursement as DRG complexity increased. On multivariable modeling, longer length of stay (-$2547 per additional day) and preoperative dialysis (-$5555) were significantly associated with negative margins.

CONCLUSIONS

For the majority of patients with CLI, current Medicare reimbursement does not adequately cover the cost of providing care after open bypass surgery. As commercial insurers move toward Medicare reimbursement rates, more granular risk stratification profiles are needed to ensure open surgical care for patients with CLI remains financially sustainable.

Population-Based Assessment of Aortic-Related Outcomes in Aortic Dissection, Intramural Hematoma, and Penetrating Aortic Ulcer

BACKGROUND

The aim of the study was to analyze aortic-related outcomes after diagnosis of aortic dissection (AD), intramural hematoma (IMH), and penetrating aortic ulcer (PAU) from a population-based approach.

METHODS

Retrospective review of an incident cohort of AD, IMH, and PAU patients in Olmsted County, Minnesota from 1995 to 2015. Primary end point was aortic death. Secondary end points were subsequent aortic events (aortic intervention, new dissection, or rupture not present at presentation) and first-time diagnosis of an aortic aneurysm. Outcomes were compared with randomly selected population referents matched for age and sex in a 3:1 ratio using Cox proportional hazards regression adjusting for comorbidities.

RESULTS

Among 133 patients (77 AD, 21 IMH, and 35 PAU), 57% were males, and mean age was 71.8 years (standard deviation, 14). Median follow-up was 10 years. Of 73 deaths among AD/IMH/PAU patients, 23 (32%) were aortic-related. Estimated freedom from aortic death was 84%, 80%, and 77% at 5, 10, and 15 years. There were no aortic deaths among population referents (adjusted hazard ratio [HR] for aortic death in AD/IMH/PAU, 184.7; 95% confidence interval [95% CI], 10.3-3,299.2; P < 0.001). Fifty (38%) AD/IMH/PAU patients had a subsequent aortic event (aortic intervention, new dissection, or rupture), whereas there were 8 (2%) aortic events among population referents (all elective aneurysm repairs; adjusted HR for any aortic event and aortic intervention in AD/IMH/PAU patients, 33.3; 95% CI, 15.3-72.0; P < 0.001 and 31.5; 95% CI, 14.5-68.4; P < 0.001, respectively). After excluding aortic events/interventions ≤14 days of diagnosis, AD/IMH/PAU patients remained at increased risk of any aortic event (adjusted HR, 10.8; 95% CI, 3.9-29.8; P < 0.001) and aortic intervention (adjusted HR, 9.6; 95% CI, 3.4-26.8; P < 0.001). Among those subjects with available follow-up imaging, the risk of first-time diagnosis of aortic aneurysm was significantly increased for AD/IMH/PAU patients when compared with population referents (adjusted HR, 10.9; 95% CI, 5.4-21.7; P < 0.001 and 8.3; 95% CI, 4.1-16.7; P < 0.001 for thoracic and abdominal aneurysms, respectively) and remained increased when excluding aneurysms that formed within 14 days of AD/IMH/PAU (adjusted HR, 6.2; 95% CI, 1.8-21.1; P = 0.004 and 2.8; 95% CI, 1.0-7.6; P = 0.040 for thoracic and abdominal aneurysms, respectively).

CONCLUSIONS

AD/IMH/PAU patients have a substantial risk of aortic death, any aortic event, aortic intervention, and first-time diagnosis of aortic aneurysm that persists even when the acute phase (≤14 days after diagnosis) is uncomplicated. Advances in postdiagnosis treatment are necessary to improve the prognosis in these patients.

Registry Assessment of Peripheral Interventional Devices objective performance goals for superficial femoral and popliteal artery peripheral vascular interventions

BACKGROUND

The Superficial Femoral Artery-Popliteal EvidencE Development Study Group developed contemporary objective performance goals (OPGs) for peripheral vascular interventions (PVI) for superficial femoral artery (SFA)-popliteal artery disease using the Registry Assessment of Peripheral Interventional Devices.

METHODS

The Society for Vascular Surgery Vascular Quality Initiative PVI registry from January 2010 to October 2016 was used to develop OPGs based on SFA-popliteal procedures (n = 21,377) for intermittent claudication and critical limb ischemia (CLI). OPGs included 1-year rates for target lesion revascularization (TLR), major amputation, and 1 and 4-year survival rates. OPGs were calculated for the SFA and popliteal arteries and stratified by four treatments: angioplasty alone (percutaneous transluminal angioplasty [PTA]), self-expanding stenting, atherectomy, and any treatment type. Outcomes were illustrated by unadjusted Kaplan-Meier analyses.

RESULTS

Cohorts included PTA (n = 7505), stenting (n = 9217), atherectomy (n = 2510) and any treatment (n = 21,377). The mean age was 69 years, 58% were male, 79% were White, and 52% had CLI. The freedom from TLR OPGs at 1 year in the SFA were 80.3% (PTA), 83.2% (stenting), 83.9% (atherectomy), and 81.9% (any treatments). The freedom from TLR OPGs at 1 year in the popliteal were 81.3% (PTA), 81.3% (stenting), 80.2% (atherectomy), and 81.1% (any treatments). The freedom from major amputation OPGs at 1 year after SFA PVI were 93.4% (PTA), 95.7% (stenting), 95.1% (atherectomy), and 94.8% (any treatments). The freedom from major amputation OPG at 1 year after popliteal PVI were 90.5% (PTA), 93.7% (stenting), 91.8% (atherectomy), and 91.8%, (any treatments). The 4-year survival OPGs after SFA PVI were 76% (PTA), 80% (stenting), 82% (atherectomy), and 79% (any treatments), and for the popliteal artery were 72% (PTA), 77% (stenting), 82% (atherectomy), and 75% (any treatment). On a multivariable analysis, which included patient-level, leg-level, and lesion-level covariates, CLI was the single independent factor associated with increased TLR, amputation, and mortality.

CONCLUSIONS

The Superficial Femoral Artery-Popliteal EvidencE Development OPGs define a new, contemporary benchmark for SFA-popliteal interventions using a large subset of real-world evidence to inform more efficient peripheral device clinical trial designs to support regulatory and clinical decision-making. It is appropriate to discuss proposals intended for regulatory approval with the US Food and Drug Administration to refine the OPG to match the specific trial population. The OPGs may be updated using coordinated registry networks to assess long-term real-world device performance.

Deep Learning and Multivariable Models Select EVAR Patients for Short-Stay Discharge

OBJECTIVES

We sought to develop a prediction score with data from the Vascular Quality Initiative (VQI) EVAR in efforts to assist endovascular specialists in deciding whether or not a patient is appropriate for short-stay discharge.

BACKGROUND

Small series describe short-stay discharge following elective EVAR. Our study aims to quantify characteristics associated with this decision.

METHODS

The VQI EVAR and NSQIP datasets were queried. Patients who underwent elective EVAR recorded in VQI, between 1/2010-5/2017 were split 2:1 into test and analytic cohorts via random number assignment. Cross-reference with the Medicare claims database confirmed all-cause mortality data. Bootstrap sampling was employed in model. Deep learning algorithms independently evaluated each dataset as a sensitivity test.

RESULTS

Univariate outcomes, including 30-day survival, were statistically worse in the DD group when compared to the SD group (all P < 0.05). A prediction score, SD-EVAR, derived from the VQI EVAR dataset including pre- and intra-op variables that discriminate between SD and DD was externally validated in NSQIP (Pearson correlation coefficient = 0.79, P < 0.001); deep learning analysis concurred. This score suggests 66% of EVAR patients may be appropriate for short-stay discharge. A free smart phone app calculating short-stay discharge potential is available through QxMD Calculate https://qxcalc.app.link/vqidis.

CONCLUSIONS

Selecting patients for short-stay discharge after EVAR is possible without increasing harm. The majority of infrarenal AAA patients treated with EVAR in the United States fit a risk profile consistent with short-stay discharge, representing a significant cost-savings potential to the healthcare system.