Patient Perspectives on the Implementation of Risk-Aligned Bladder Cancer Surveillance: Systematic Evaluation Using the Tailored Implementation for Chronic Diseases Framework

PURPOSE

Many patients living with bladder cancer do not undergo surveillance that is aligned with their risk for recurrence or progression, which exposes them to unnecessary risk and burden of procedures. To implement risk-aligned surveillance as recommended by multiple guidelines, we need to understand patient-, provider-, and system-level factors contributing to the delivery of risk-aligned surveillance. In this study, we sought to systematically assess patient-level factors.

PARTICIPANTS AND METHODS

Guided by the Tailored Implementation for Chronic Diseases framework, we conducted semistructured interviews with 22 patients with bladder cancer undergoing surveillance cystoscopy procedures at three facilities within the Department of Veterans Affairs. Patients were sampled using quantitative data on bladder cancer risk category (low v high) and on surveillance category (aligned v not aligned with cancer risk). Interview transcripts were analyzed using a priori codes from the Tailored Implementation for Chronic Diseases framework. Quantitative and qualitative data were integrated by cross-tabulating determinants across risk and surveillance categories.

RESULTS

Participants included seven low-risk and 15 high-risk patients; 10 underwent risk-aligned surveillance and 12 did not. In mixed-methods analyses, perception of risk appropriately differed by risk but not by surveillance category. Participants understood the recommended surveillance schedule according to their risk category. Participants emphatically expressed that adhering to providers' recommendations is prudent; intentions to adhere did not vary across risk and surveillance categories.

CONCLUSION

Participants intended to adhere to providers' recommendations and strongly endorsed the importance of adherence. These findings suggest implementation strategies to improve risk-aligned surveillance may be most effective when targeting provider- and system-level factors rather than patient-level factors.

The financial evolution of endovascular aneurysm repair delivery in contemporary practice

OBJECTIVE

The fiscal impact of endovascular repair (EVR) of aortic aneurysms and the requisite device costs have previously highlighted the tenuous long-term financial sustainability among Medicare beneficiaries. The Centers for Medicare & Medicaid Services have since reclassified EVR remuneration paradigms with new Medicare Severity Diagnosis-Related Groups (MS-DRGs) intended to better address the procedure's cost profile. The impact of this change remains unknown. The purpose of this analysis was to compare EVR-specific costs and revenue among Medicare beneficiaries both before and after this change.

METHODS

All infrarenal EVRs performed in fiscal years (FYs) 2014 and 2015, before the MS-DRG change, and those performed in FYs 2017 and 2018, after the MS-DRG change, were identified using the DRG codes 238 (n = 108) and 269 (n = 84), respectively. We then identified those who were treated according to the instructions for use guidelines with a single manufacturer's device and billed to Medicare (n = 23 in FY14-15; n = 22 in FY17-18). From these cohorts, we determined total procedure technical costs, technical revenue, and net technical margin in conjunction with the hospital finance department. Results were then compared between these two groups.

RESULTS

The two cohorts demonstrated similar demographic profiles (FY14-15 vs FY17-18 cohort: age, 78 years vs 74 years; median length of stay, 1.0 day vs 1.0 day). Mean total technical costs were slightly higher in the FY17-18 group ($24,511 in FY14-15 vs $26,445 in FY17-18). Graft implants continued to account for a significant portion of the total cost, with the device cost accounting for 56% of the total procedure costs in both cohorts. Net revenue was greater in the FY17-18 group by $5800 ($30,698 in FY14-15 vs $36,498 in FY17-18), resulting in an increased overall margin in the FY17-18 group compared with the FY14-15 group ($6188 in FY14-15 vs $10,053 in FY17-18).

CONCLUSIONS

Device costs remain the single greatest cost driver associated with EVR delivery. DRG reclassification of EVR to address total procedure and implant costs appears to better address the requisite associated procedure costs and may thereby better support long-term fiscal sustainability of this procedure for hospitals and health systems alike.

Medicare costs for endovascular abdominal aortic aneurysm treatment in the Vascular Quality Initiative

BACKGROUND

Reintervention after endovascular repair (EVR) of abdominal aortic aneurysms is common. However, the cumulative financial impact of reintervention after EVR on a national scale is poorly defined. Our objective was to describe the cost to Medicare for aneurysm treatment (EVR plus reinterventions) among a cohort of patients with known follow-up for 5 years after repair.

METHODS

We identified patients who underwent EVR within the Vascular Quality Initiative who were linked to their respective Medicare claims file (n = 13,995). We excluded patients who underwent EVR after September 30, 2010, and those who had incomplete Medicare coverage (n = 12,788). The remaining cohort (n = 1207) had complete follow-up until death or 5 years (Medicare data available through September 30, 2015). We then obtained and compiled the corresponding Medicare reimbursement data for the index EVR hospitalization and all subsequent reinterventions.

RESULTS

We studied 1207 Medicare patients who underwent EVR and had known follow-up for reinterventions for 5 years. The mean age was 76.2 years (±7.1 years), 21.6% of patients were female, and 91.1% of procedures were elective. The Kaplan-Meier reintervention rate at 5 years was 18%. Among patients who underwent reintervention, 154 (73.7%) had a single reintervention, 40 (19.1%) had two reinterventions, and 15 (7.2%) had three or more reinterventions. The median cost to Medicare for the index EVR hospitalization was $25,745 (interquartile range, $21,131-$28,774). The median cost for subsequent reinterventions was $22,165 (interquartile range, $17,152-$29,605). The cumulative cost to Medicare of aneurysm treatment (EVR plus reinterventions) increased in a stepwise fashion among patients who underwent multiple reinterventions, with each reintervention being similar in cost to the index EVR.

CONCLUSIONS

The overall cost incurred by Medicare to reimburse for each reintervention after EVR is roughly the same as for the initial procedure itself, meaning that Medicare cost projections would be greater than $100,000 for any individual who undergoes an EVR with three reinterventions. The long-term financial impact of EVR must be considered by surgeons, patients, and healthcare systems alike as these cumulative costs may hinder the fiscal viability of an EVR-first therapeutic approach and highlight the need for judicious patient selection paradigms.

Epidemiology and Risk of Amputation in Patients With Diabetes Mellitus and Peripheral Artery Disease

Peripheral artery disease (PAD) stems from atherosclerosis of lower extremity arteries with resultant arterial narrowing or occlusion. The most severe form of PAD is termed chronic limb-threatening ischemia and carries a significant risk of limb loss and cardiovascular mortality. Diabetes mellitus is known to increase the incidence of PAD, accelerate disease progression, and increase disease severity. Patients with concomitant diabetes mellitus and PAD are at high risk for major complications, such as amputation. Despite a decrease in the overall number of amputations performed annually in the United States, amputation rates among those with both diabetes mellitus and PAD have remained stable or even increased in high-risk subgroups. Within this cohort, there is significant regional, racial/ethnic, and socioeconomic variation in amputation risk. Specifically, residents of rural areas, African-American and Native American patients, and those of low socioeconomic status carry the highest risk of amputation. The burden of amputation is severe, with 5-year mortality rates exceeding those of many malignancies. Furthermore, caring for patients with PAD and diabetes mellitus imposes a significant cost to the healthcare system-estimated to range from $84 billion to $380 billion annually. Efforts to improve the quality of care for those with PAD and diabetes mellitus must focus on the subgroups at high risk for amputation and the disparities they face in the receipt of both preventive and interventional cardiovascular care. Better understanding of these social, economic, and structural barriers will prove to be crucial for cardiovascular physicians striving to better care for patients facing this challenging combination of chronic diseases.

Outcomes of Innominate Artery Revascularization Through Endovascular, Hybrid, or Open Approach

BACKGROUND

Atherosclerotic disease of the innominate artery (IA) is rare and can lead to cerebral, upper extremity, and vertebral steal symptoms. Nonocclusive lesions can be treated with endovascular interventions, often with a hybrid approach while performing a right carotid endarterectomy (RCEA). Calcified IA lesions have a high risk of embolization to bilateral cerebral hemispheres. Occlusive lesions may require treatment through a median sternotomy and bypass. The purpose of our study is to review our short-term and long-term outcomes of IA revascularization.

METHODS

Our operative database was used to identify patients who underwent IA revascularization between January 1998 and December 2018. Patients who underwent innominate artery stenting (IAS), combined with RCEA and IAS as well as aortoinnominate bypass (AIB), were identified. Our primary end points were freedom from neurologic event, all-cause mortality, and need for reintervention.

RESULTS

Thirty-three patients (18 females [55%]) who underwent IA revascularization were identified. Average age was 67 ± 8 years, and mean clinical follow-up was 51 ± 21 months. Most patients (30 [91%]) were on a statin and antiplatelet therapy. Twenty-one patients (64%) were symptomatic. Twelve patients (36%) were asymptomatic and underwent combined RCEA with retrograde IAS for critical right carotid stenosis and IA stenosis. Preoperative imaging included a carotid duplex and computed tomography angiography. Eighteen patients (55%) underwent RCEA + IAS, 11 patients (33%) underwent isolated IAS, and 4 patients (12%) underwent AIB. In our attempt to protect bilateral hemispheres during IAS for heavily calcified lesions, we used right common carotid artery (CCA) clamping although open exposure and left CCA embolic protection filter was placed through transfemoral approach. Patients who underwent AIB had chronic heavily calcified IA occlusions or occluded IA stents with failed endovascular interventions. Perioperative stroke rate was 3%, involving 1 patient who developed reperfusion syndrome after RCEA + IAS. Perioperative mortality was 0%. Long-term stroke rate was 0%, and long-term mortality was 15% (5 of 33) because of cardiac disease. Overall restenosis rate was 9%, involving 3 patients who required secondary interventions for IA in-stent restenosis.

CONCLUSIONS

IA interventions through a hybrid approach or an open approach are safe, with acceptable perioperative stroke and mortality rates. Long-term patency of these interventions is acceptable. Bilateral cerebral embolic protection can be accomplished by clamping the right CCA through an open exposure and placing a filter in the left CCA through a transfemoral approach. Patients undergoing IAS appear to have a higher rate of restenosis compared with AIB, and therefore, close follow-up with noninvasive imaging is recommended.

Online Ratings for Vascular Interventional Proceduralists Vary by Physician Specialty

BACKGROUND

Multiple specialties offer vascular interventional care, creating potential competition for referrals and procedures. At the same time, patient/consumer ratings have become more impactful for physicians who perform vascular procedures. We hypothesized that there are differences in online ratings based on specialty.

METHODS

We used official program lists from the Association for Graduate Medical Education to identify institutions with training programs in integrated vascular surgery (VS), integrated interventional radiology (IR), and interventional cardiology (IC). Faculty providers were identified in each specialty at these institutions. A standardized search was performed to collect online ratings from Vitals.com, Healthgrades.com, and Google.com as well as from online demographics. Between specialty differences were analyzed using chi-squared and analysis of variance tests as appropriate. Multivariable linear regression was used to identify factors associated with review volume and star rating.

RESULTS

A total of 1,330 providers (n = 454 VS, n = 451 IR, n = 425 IC) were identified across 47 institutions in 27 states. VS (55.5%-69.4%) and IC (63.8%-71.1%) providers were significantly more likely to have reviews than IR (28.6%-48.8%) providers across all online platforms (P < 0.001 for all websites). Across all platforms, IC providers were rated significantly higher than VS and IR providers. Multivariable regression showed that provider specialty and additional time in practice were associated with higher review volume. In addition to specialty, review volume was associated with star rating as those physicians with more reviews tended to have a higher rating.

CONCLUSIONS

On average, vascular surgeons have more reviews and are more highly rated than interventional radiologists but tend to have fewer reviews and lower ratings than interventional cardiologists. VS providers may benefit from encouraging patients to file online reviews, especially in competitive markets.

Longitudinal Spending on Endovascular and Open Abdominal Aortic Aneurysm Repair

BACKGROUND

Endovascular repair (EVR) has replaced open surgery as the procedure of choice for patients requiring elective abdominal aortic aneurysm (AAA) repair. Long-term outcomes of the 2 approaches are similar, making the relative cost of caring for these patients over time an important consideration.

METHODS AND RESULTS

We linked Medicare claims to Vascular Quality Initiative registry data for patients undergoing elective EVR or open AAA repair from 2004 to 2015. The primary outcome was Medicare's cumulative disease-related spending, adjusted to 2015 dollars. Disease-related spending included the index operation and associated hospitalization, surveillance imaging, reinterventions (AAA-related and abdominal wall procedures), and all-cause admissions within 90 days. We compared the incidence of disease-related events and cumulative spending at 90 days and annually through 7 years of follow-up. The analytic cohort comprised 6804 EVR patients (median follow-up: 1.85 years; interquartile range: 0.82-3.22 years) and 1889 open repair patients (median follow-up: 2.62 years; interquartile range: 1.13-4.80 years). Spending on index surgery was significantly lower for EVR (median [interquartile range]: $25 924 [$22 280-$32 556] EVR versus $31 442 [$24 669-$40 419] open; P<0.001), driven by a lower rate of in-hospital complications (6.6% EVR versus 38.0% open; P<0.001). EVR patients underwent more surveillance imaging (1.8 studies per person-year EVR versus 0.7 studies per person-year open; P<0.001) and AAA-related reinterventions (4.0 per 100 person-years EVR versus 2.1 per 100 person-years open; P=0.041). Open repair patients had higher rates of 90-day readmission (12.9% EVR versus 17.8% open; P<0.001) and abdominal wall procedures (0.6 per 100 person-years EVR versus 1.5 per 100 person-years open; P<0.001). Overall, EVR patients incurred more disease-related spending in follow-up ($7355 EVR versus $2706 open through 5 years). There was no cumulative difference in disease-related spending between surgical groups by 5 years of follow-up (-$33 EVR [95% CI: -$1543 to $1476]).

CONCLUSIONS

We observed no cumulative difference in disease-related spending on EVR and open repair patients 5 years after surgery. Generalized recommendations about which approach to offer elective AAA patients should not be based on relative cost.

Design of the PReferences for Open Versus Endovascular Repair of Abdominal Aortic Aneurysm (PROVE-AAA) Trial

For patients with abdominal aortic aneurysm (AAA), randomized trials have found endovascular AAA repair (EVAR) is associated with lower perioperative morbidity and mortality than open surgical repair (OSR). However, OSR has fewer long-term aneurysm-related complications, such as endoleak or late rupture. Patients treated with EVAR and OSR have similar survival rates within two years after surgery, and OSR does not require intensive surveillance. Few have examined if patient preferences are aligned with the type of treatment they receive for their AAA. Although many assume that patients may universally prefer the less-invasive nature of EVAR, our preliminary work suggests that patients who value the lower risk of late complications may prefer OSR. In this study, called The PReferences for Open Versus Endovascular Repair of Abdominal Aortic Aneurysm (PROVE-AAA) trial, we describe a cluster-randomized trial to test if a decision aid can better align patients' preferences and their treatment type for AAA. Patients enrolled in the study are candidates for either endovascular or open repair and are followed up at VA hospitals by vascular surgery teams who regularly perform both types of repair. In Aim 1, we will determine patients' preferences for endovascular or open repair and identify domains associated with each repair type. In Aim 2, we will assess alignment between patients' preferences and the repair type elected and then compare the impact of a decision aid on this alignment between the intervention and control groups. This study will help us to accomplish two goals. First, we will better understand the factors that affect patient preference when choosing between EVAR and OSR. Second, we will better understand if a decision aid can help patients be more likely to receive the treatment strategy they prefer for their AAA. Study enrollment began on June 1, 2017. Between June 1, 2017 and November 1, 2018, we have enrolled 178 of a total goal of 240 veterans from 20 VA medical centers and their vascular surgery teams across the country. We anticipate completing enrollment in PROVE-AAA in June 2019, and study analyses will be performed thereafter.

Outcomes of rotational atherectomy in complex lesions of the superficial femoral artery

BACKGROUND

The effectiveness of rotational atherectomy in the treatment of complex superficial femoral artery (SFA) lesions remains poorly defined. Outcomes of SFA lesions treated with rotational atherectomy were analyzed.

METHODS

This retrospective review assessed all patients who underwent rotational atherectomy of the SFA at a single institution between 2015 and 2018. The data of all patients were deidentified, and the study was approved by the Institutional Review Board. Informed consent was not obtained for this retrospective analysis. Main outcomes were Kaplan-Meier primary patency rate, freedom from major amputation, and 2-year survival rate. The effect of drug-coated balloon angioplasty (DCBA) on patency and time to death was investigated with univariate regression. The safety profile for atherectomy and DCBA was assessed by the 30-day incidence of major amputation and all-cause mortality.

RESULTS

Fifty-three patients (mean age, 70.2 ± 9.8 years; 73% male; 65% critical limb-threatening ischemia; 47 [90%] current or former smokers; seven [13%] with prior failed ipsilateral endovascular intervention) underwent rotational atherectomy (Jetstream; Boston Scientific, Marlborough, Mass) with mean follow-up of 543 days. Forty-six (87%) patients underwent DCBA (Lutonix; BD Bard, Covington, Ga) after atherectomy. Mean lesion length was 13.2 ± 9.0 cm. Thirty-one (58%) lesions were TransAtlantic Inter-Society Consensus C or D class. At 1-month follow-up, 39 of 45 (87%) patients experienced improvement in symptoms and Rutherford class. An improvement in ankle-brachial index was also noted in 13% of patients without improvement of symptoms, with no patients progressing to surgical bypass or major amputation. Mean ankle-brachial index increased from 0.54 ± 0.035 to 0.90 ± 0.031 at 1 month after intervention (P < .001) and remained constant out to 18 months. Mean toe pressure increased from 36 ± 3.8 mm Hg to 67 ± 4.5 mm Hg at 1 month after intervention (P < .001) and remained constant out to 18 months. Kaplan-Meier primary patency rate was 75% (95% confidence interval, 61%-85%) at 12 months and 65% (51%-77%) at 24 months. There was a trend toward improved primary patency after adjunctive DCBA compared with plain balloon angioplasty at 1 year (75% vs 43%; P = .1082). There was no significant difference in mortality between adjunctive DCBA and plain balloon angioplasty at 2 years (11% vs 0%). The 2-year incidence of major amputation in critical limb-threatening ischemia patients was 3.9% (1.2%-6.5%). One patient died and none underwent amputation within 30 days.

CONCLUSIONS

Rotational atherectomy with adjunctive DCBA of long SFA lesions has excellent long-term patency. Two-year major amputation and mortality rates are low, and the technique has an exceptional safety profile.

Failure on a Vascular Surgery Board-American Board of Surgery Examination does not predict cardiovascular outcomes in the Society for Vascular Surgery Vascular Quality Initiative

OBJECTIVE

The Vascular Surgery Board of the American Board of Surgery (VSB-ABS) Qualifying and Certifying examinations are meant to assess qualifications to independently practice vascular surgery, but it is unclear whether examination performance correlates with clinical outcomes. We assessed this relationship using clinical outcomes data for VSB-ABS diplomates from the Society for Vascular Surgery Vascular Quality Initiative (SVS-VQI).

METHODS

VSB-ABS examination performance for vascular surgeons participating in the SVS-VQI registry was characterized according to pass/fail status. Surgical experience was measured by number of years since completion of training. Examination performance and experience were compared with a composite clinical outcome (in-patient major adverse cardiac events or postoperative death [MACE+POD]) after arterial reconstructions (carotid stenting or endarterectomy, aortic aneurysm repair, open peripheral surgical bypasses) registered in the SVS-VQI. Multivariate mixed effects regression was performed adjusting for sex and surgery type, as well as clustering by surgeon and by hospital.

RESULTS

From 2003 to 2017, complete data were available for 776 vascular surgeons who performed 124,171 arterial reconstructions (carotid n = 56,650; aortic n = 34,764; peripheral n = 32,757) registered in the SVS-VQI. Patient characteristics associated with higher odds of MACE+POD were female sex (odds ratio [OR] 1.07; 95% confidence interval [CI], 1.03-1.12; P = .006) and advancing age (OR, 1.04; 95% CI, 1.03-1.04; P < .001). Of the 776 surgeons, 149 (17%) had failed at least one VSB-ABS examination (group F). The unadjusted primary composite outcome of MACE+POD was marginally higher after operations performed by surgeons who never failed an examination (group P; 7% vs 6%; P = .03). This difference seems to be driven by higher rates of postoperative congestive heart failure in the aortic and lower extremity bypass cohorts as well as more postoperative myocardial infarctions after lower extremity bypass by group P surgeons. Following multivariable analyses, examination pass status was not associated with MACE+POD (OR, 0.98; 95% CI, 0.89-1.50; P = .517). However, increasing surgical experience correlated with significantly lower odds of MACE+POD (2% lower odds/year of experience since training [OR, 0.98; 95% CI, 0.98-0.99; P < .001]).

CONCLUSIONS

VSB-ABS examination performance by SVS-VQI surgeons does not correlate with registry-reported mortality or cardiovascular complications. Increasing surgical experience is strongly associated with lower odds of cardiovascular morbidity and death.

Adverse cardiac events after vascular surgery are prevalent despite negative results of preoperative stress testing

OBJECTIVE

Cardiac risk assessment is a critical component of vascular disease management before surgical intervention. The predictive risk reduction of a negative cardiac stress test result remains poorly defined. The objective of this study was to compare the incidence of postoperative cardiac events among patients with negative stress test results vs those who did not undergo testing.

METHODS

We reviewed all patients who underwent elective open abdominal aortic aneurysm repair, suprainguinal bypass, endovascular aneurysm repair (EVAR), carotid endarterectomy (CEA), and infrainguinal bypass within the Vascular Study Group of New England from 2003 to 2017. We excluded patients with positive stress test results (n = 3312) and studied two mutually exclusive groups: elective surgery patients with a negative stress test result and elective surgery patients with no stress test (total n = 26,910). The primary outcome was a composite of in-hospital postoperative cardiac events (dysrhythmia, heart attack, heart failure) or death.

RESULTS

A preoperative stress test was obtained in 66.3% of open repairs, 42.8% of suprainguinal bypasses, 37.1% of EVARs, 36.0% of CEAs, and 31.2% of infrainguinal bypasses. The proportion of patients receiving a preoperative stress test varied widely across centers, from 37.1% to 80.0%. The crude odds ratio of in-hospital postoperative cardiac event or death was 1.37 (95% confidence interval [CI], 1.07-1.76) for open repair and 1.52 (CI, 1.13-2.03) for suprainguinal bypass, indicating that patients with negative stress test results before these procedures were 37% and 52% more likely to suffer a postoperative event or die compared with patients selected to proceed directly to surgery without testing. Conversely, the crude odds ratio was 0.92 (CI, 0.66-1.29) for EVAR, 0.92 (CI, 0.70-1.21) for CEA, and 1.13 (CI, 0.90-1.40) for infrainguinal bypass, indicating that patients undergoing these procedures had a similar likelihood of sustaining an event whether they had a negative stress test result or proceeded directly to surgery without a stress test.

CONCLUSIONS

The use of cardiac stress testing before vascular surgery varies widely throughout New England. Whereas patients are often appropriately selected to proceed directly to surgery, a negative preoperative stress test result should not assuage the concern for an adverse outcome as these patients retain a substantial likelihood of cardiac events, especially after large-magnitude procedures.

The impact of low- versus high-intensity surveillance cystoscopy on surgical care and cancer outcomes in patients with high-risk non-muscle-invasive bladder cancer (NMIBC)

Purpose

To assess the association of low- vs. guideline-recommended high-intensity cystoscopic surveillance with outcomes among patients with high-risk non-muscle invasive bladder cancer (NMIBC).

Materials & methods

A retrospective cohort study of Veterans Affairs patients diagnosed with high-risk NMIBC between 2005 and 2011 with follow-up through 2014. Patients were categorized by number of surveillance cystoscopies over two years following diagnosis: low- (1–5) vs. high-intensity (6 or more) surveillance. Propensity score adjusted regression models were used to assess the association of low-intensity cystoscopic surveillance with frequency of transurethral resections, and risk of progression to invasive disease and bladder cancer death.

Results

Among 1,542 patients, 520 (33.7%) underwent low-intensity cystoscopic surveillance. Patients undergoing low-intensity surveillance had fewer transurethral resections (37 vs. 99 per 100 person-years; p<0.001). Risk of death from bladder cancer did not differ significantly by low (cumulative incidence [CIn] 8.4% [95% CI 6.5–10.9) at 5 years) vs. high-intensity surveillance (CIn 9.1% [95% CI 7.4–11.2) at 5 years, p = 0.61). Low vs. high-intensity surveillance was not associated with increased risk of bladder cancer death among patients with Ta (CIn 5.7% vs. 8.2% at 5 years p = 0.24) or T1 disease at diagnosis (CIn 10.2% vs. 9.1% at 5 years, p = 0.58). Among patients with Ta disease, low-intensity surveillance was associated with decreased risk of progression to invasive disease (T1 or T2) or bladder cancer death (CIn 19.3% vs. 31.3% at 5 years, p = 0.002).

Conclusions

Patients with high-risk NMIBC undergoing low- vs. high-intensity cystoscopic surveillance underwent fewer transurethral resections, but did not experience an increased risk of progression or bladder cancer death. These findings provide a strong rationale for a clinical trial to determine whether low-intensity surveillance is comparable to high-intensity surveillance for cancer control in high-risk NMIBC.

Shunt intention during carotid endarterectomy in the early symptomatic period and perioperative stroke risk

OBJECTIVE

Whether recent stroke mandates planned shunting during carotid endarterectomy (CEA) is controversial. Our goal was to determine associations of various shunting practices with postoperative outcomes of CEAs performed after acute stroke.

METHODS

The Vascular Quality Initiative database (2010-2018) was queried for CEAs performed within 14 days of an ipsilateral stroke. Surgeons who prospectively planned to shunt either shunted routinely per their usual practice or shunted selectively for preoperative indications. Surgeons who prospectively planned not to shunt either shunted selectively for intraoperative indications or did not shunt. Univariable and multivariable analyses compared shunting approaches.

RESULTS

There were 5683 CEAs performed after acute ipsilateral stroke. Surgeons planned to shunt in 56.1% of cases. Patients whose surgeons planned to shunt vs planned not to shunt were more likely to have severe contralateral stenosis (8.8% vs 6.9%; P = .008), to receive general anesthesia (97.5% vs 89.1%; P < .001), and to undergo conventional CEA (94% vs 81.8%; P < .001). Unadjusted outcomes were similar between the cohorts for operative duration (124.3 ± 48.1 minutes vs 123.6 ± 47 minutes; P = .572) and 30-day stroke (3.4% vs 3%; P = .457), myocardial infarction (1.1% vs 0.8%; P = .16), and mortality (1.6% vs 1.3%; P = .28). On multivariable analysis, planning to shunt vs planning not to shunt was associated with similar risk of 30-day stroke (odds ratio [OR], 1.17; 95% confidence interval [CI], 0.82-1.67; P = .402). On subgroup analysis, in 38.4% patients, no shunt was placed, whereas the remainder received routine shunts (44.4%), preoperatively indicated shunts (11.6%), and intraoperatively indicated shunts (5.5%). Compared with no shunting, shunting by surgeons who routinely shunt was associated with a similar stroke risk (OR, 1.39; 95% CI, 0.91-2.13; P = .129), but shunting by surgeons who selectively shunt on the basis of preoperative indications (OR, 2.11; 95% CI, 1.22-3.63; P = .007) or intraoperative indications (OR, 3.34; 95% CI, 1.86-6.01; P < .001) was associated with increased stroke risk. Prior coronary revascularization independently predicted increased intraoperatively indicated shunting (OR, 1.37; 95% CI, 1.05-1.8; P = .022).

CONCLUSIONS

In CEAs performed after acute ipsilateral stroke, there is no difference in postoperative stroke risk when surgeons prospectively plan to shunt or not to shunt. Shunting is often not necessary; however, when shunting is performed, routine shunters achieve better outcomes.

Mortality After Paclitaxel Coated Balloon Angioplasty and Stenting of Superficial Femoral and Popliteal Artery in the Vascular Quality Initiative

BACKGROUND

To compare mortality after treatment of superficial femoral-popliteal artery disease with paclitaxel and nonpaclitaxel devices using a multicenter vascular registry.

METHODS

Patients (N=8376) undergoing endovascular treatment of superficial femoral-popliteal artery disease in the Society for Vascular Surgery Vascular Quality Initiative were studied from October 2016 to December 2017. One-year mortality was compared between 3 groups; plain balloon angioplasty (N=2104) versus paclitaxel-coated balloon angioplasty (N=3543), bare-metal stenting (N= 2045) versus paclitaxel-eluting stents (N=684), and combined paclitaxel versus nonpaclitaxel devices. Mortality rates with hazard ratios (HR) and 95% CI were compared in unadjusted and propensity-matched cohorts and illustrated by Kaplan-Meier analysis with subgroup analysis for intermittent claudication, chronic limb-threatening ischemia, and secondary interventions.

RESULTS

In propensity-matched analyses, mortality was similar after plain balloon angioplasty (12.6%) and paclitaxel-coated balloon angioplasty (9.6%; HR=0.84 [95% CI, 0.66-1.06], P=0.14). In propensity-matched groups, mortality was similar after bare-metal stenting (9.8%) and paclitaxel-eluting stenting (8.8%; HR=0.93 [95% CI, 0.62-1.41], P=0.75). In the combined, matched analysis mortality was significantly lower in the paclitaxel device group (8.5%) compared with the nonpaclitaxel device group (11.5%; HR=0.82 [95% CI, 0.68-0.98], P=0.03). Secondary interventions were similar after nonpaclitaxel (N=1113/4149, 26.8%) and paclitaxel device use (N=1113/4227, 26.3%). For intermittent claudication, mortality was lower after paclitaxel device use (1.6%) compared with nonpaclitaxel devices (4.4%; adjusted HR=0.59 [95% CI, 0.39-0.89], P=0.01). For chronic limb-threatening ischemia, the mortality difference was not significant; paclitaxel (12.8%) versus nonpaclitaxel devices (15.5%; adjusted HR=0.85 [95% CI, 0.72-1.00], P=0.05).

CONCLUSIONS

At 1 year, mortality was similar if not lower after treatment of femoral-popliteal occlusive disease with paclitaxel versus nonpaclitaxel devices. This work highlights the potential use of the Society for Vascular Surgery Vascular Quality Initiative for surveillance of the safety of new peripheral arterial devices.

Association of Sex With Repair Type and Long-term Mortality in Adults With Abdominal Aortic Aneurysm

IMPORTANCE

Sex-based differences exist in the prevalence and clinical presentation of abdominal aortic aneurysm (AAA). However, it is unclear if sex is associated with AAA repair type and long-term mortality.

OBJECTIVE

To investigate whether a sex-related difference exists in mortality risk after AAA repair owing to differences in repair type.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study uses data from the Vascular Quality Initiative, a national clinical registry, and Medicare claims to investigate endovascular and surgical repair procedures performed between January 1, 2003, and September 30, 2015, in patients aged 65 years or older with AAA. The data were analyzed from October 1, 2018, to November 19, 2019.

EXPOSURE

Sex of the patient.

MAIN OUTCOMES AND MEASURES

Endovascular (EVR) or open surgical AAA repair type and subsequent long-term, all-cause mortality.

RESULTS

In this cohort study of 16 386 patients, 12 757 (77.9%) were men and 3629 (22.1%) were women. Women were more likely than men to be older (mean [SD] age, 77 [6.5] years vs 75 [6.6] years; P < .001), active smokers (33% vs 28%; P < .001), and to have smaller aneurysms (mean [SD] diameter, 57 [11.7] mm vs 59 [17.7] mm; P < .001). Surgical AAA repair was performed in 27% (983 of 3629) of women compared with 18% (2328 of 12 757) of men (P < .001). After inverse probability weighting for risk adjustment, women were more likely to receive open surgical repair than EVR repair (risk ratio, 1.65; 95% CI, 1.51-1.80). The 10-year unadjusted survival rate after EVR repair was 14% lower in women than in men (23% vs 37%; log-rank P < .001), but the rates were comparable after open surgical repair (36% in men vs 32% in women; log-rank P = .22). Risk-adjusted analysis showed that women were associated with higher mortality rates after EVR repair (hazard ratio, 1.13; 95% CI, 1.03-1.24), whereas both men and women had a similar risk of death after open surgical repair (hazard ratio, 0.94; 95% CI, 0.84-1.06). After further stratification by symptom severity, higher risk of mortality among women was limited to elective EVR and open surgical repair for ruptured AAA.

CONCLUSIONS AND RELEVANCE

In this study, women were 65% more likely than men to undergo open surgical repair. After EVR repair, women were 13% more likely to die than men, although no sex-based difference in mortality was found after open surgical repair. The differential treatment benefit of EVR repair in women is concerning given the shift toward an EVR-first approach to AAA repair.