Techniques and Limitations of Gore Thoracoabdominal Multibranch Endoprosthesis (TAMBE) for Type 1A Endoleak After Failed Endovascular Aortic Repairs

PURPOSE

Endovascular aortic aneurysm repair (EVAR) is the dominant treatment modality over open repair for abdominal aortic aneurysms. However, a higher rate of reinterventions remains the Achilles heel of EVAR. Although type 1A endoleak from proximal seal zone failure of EVAR remains one of the leading causes for reintervention, fenestrated branched devices suitable for proximal extension of failed EVAR are not widely available in the United States. Gore Thoracoabdominal Multibranch Endoprosthesis (TAMBE) is an off-the-shelf investigational device that provides supraceliac seal by incorporating 4 visceral and renal arteries via preloaded inner branches.

CASE REPORT

In this article, we describe 2 cases of type 1A endoleak from previous EVAR devices repaired using TAMBE. Both cases were performed under the Food and Drug Administration (FDA) compassionate use exemption. Considerations on the case planning and implantation techniques of TAMBE specific to previous EVAR devices are reviewed.

CONCLUSIONS

Gore TAMBE can be utilized to repair a type 1A endoleak of a previous infrarenal EVAR device. Greater supraceliac coverage necessary for TAMBE relative to the minimal seal zone should be considered when applying this device for a type 1A endoleak.

CLINICAL IMPACT

This report demonstrates the feasibility of applying off-the-shelf TAMBE device to treat one of the most common failure modes of EVAR, type1A endoleak.

Medical center reimbursement for vascular procedures has increased over time while professional reimbursement has declined

OBJECTIVE

The United States healthcare system uses different methods for assigning medical center reimbursement (MCR) and professional reimbursement (PR) for clinical services. We hypothesized that PR has not increased proportionately to MCR for the same vascular services.

METHODS

MCR and PR were compared for commonly performed inpatient and outpatient vascular procedures between 2012 and 2021. MCR was calculated using the Medicare inpatient prospective payment system and outpatient prospective payment system. MCR is based on the Centers for Medicare and Medicaid Services definition and criteria for comorbidities and the occurrence of complications; thus, changes in MCR were reported as a range based on the degree of comorbidities and complications using the Diagnosis Related Group. PR was calculated using the Medicare physician fee schedule, which assigns a numerical work relative value unit to each surgical service, with final compensation determined by an annually adjusted conversion factor to yield a final dollar amount. The expected reimbursement based on the observed inflation during the study period using the consumer price index was calculated and compared to the actual reimbursement.

RESULTS

From 2012 to 2021, MCR for inpatient procedures increased 20% to 26% for carotid endarterectomy, 24% to 27% for femoral endarterectomy, 24% to 27% for femoropopliteal bypass with vein, 14% to 19% for thoracic endovascular aortic repair, and 15% for aortobifemoral bypass. During the same period, PR increased 3.3% for carotid endarterectomy but decreased for femoral endarterectomy (-5.0%), femoropopliteal bypass (-4.6%), thoracic endovascular aortic repair (-4.2%), and aortobifemoral bypass (-5.0%). Comparing the expected reimbursement, adjusted for inflation, to the actual reimbursement, PR experienced a 10% to 17% reduction but MCR outpaced inflation by 3.7% to 10%. For outpatient procedures, MCR increased 117% for tibial angioplasty, 24% for superficial femoral artery (SFA) stenting, 62% for tunneled dialysis catheter (TDC) insertion, and 24% for iliac stenting but decreased 0.43% for arteriovenous fistula (AVF) creation and 7.6% for radiofrequency ablation (RFA). PR increased 0.91% for SFA stenting but decreased for tibial angioplasty (-17%), AVF creation (-6.4%), TDC insertion (-7.1%), iliac stenting (-3.8%), and RFA (-22%). Comparing the expected reimbursement, adjusted for inflation, to the actual reimbursement, PR experienced a 13% to 32% reduction. In contrast, MCR outpaced inflation 7.5% to 88% for tibial angioplasty, SFA stenting, TDC insertion, and iliac stenting but experienced a reduction for AVF (-13%) and RFA (-19%).

CONCLUSIONS

MCR for commonly performed vascular procedures has increased and outpaced inflation. In contrast, PR for these same services has decreased across all procedure types. This decrease in PR was exacerbated when adjusted for inflation. This inequity in the reimbursement methods between MCR and PR poses a threat to the viability of the physician workforce. Either changes to the reimbursement methods or a reallocation of reimbursement to physicians are imperative to sustain physician practices.

Variations in Practice Patterns for Peripheral Vascular Interventions Across Clinical Settings

BACKGROUND

Peripheral vascular interventions (PVIs) for lower extremity peripheral artery disease have been increasing, particularly in the office-based setting. Our goal was to evaluate practice patterns for PVI by site of service using a contemporary real-world dataset.

METHODS

The Vascular Quality Initiative PVI registry was queried from 2010-2021. Site of service was classified as hospital/inpatient, hospital/outpatient, and ambulatory/office-based center. Patient demographics, comorbidities, procedural details, and periprocedural outcomes were analyzed.

RESULTS

There were 54,897 hospital/inpatient (43.2%), 64,105 hospital/outpatient (50.4%), and 8,179 ambulatory/office-based center (6.4%) PVI. When comparing the 2 outpatient settings, ambulatory/office-based center patients were older than hospital/outpatient (mean age 70.7 vs. 68.7 years), more often female sex (41.4% vs. 39.1%), never smokers (27.5% vs. 18.5%), primary Medicare (61.6% vs. 55.9%), nonambulatory (6.5% vs. 4.7%), less often with coronary artery disease (30.2% vs. 34.1%), chronic obstructive pulmonary disease (18.1% vs. 26.9%), congestive heart failure (13% vs. 17.2%), obesity (30.9% vs. 33.6%), and less often on a statin (71.4% vs. 76.1%) (P < 0.001). Ambulatory/office-based center procedures were more likely for claudication (60.1% vs. 55.8%), more often involved femoro-popliteal (73.1% vs. 64.6%) and infrapopliteal (36.7% vs. 24.3%), and less often iliac interventions (24.1% vs. 33.6%) (P < 0.001).Overall, atherectomy was used in 14.2% of hospital/inpatient, 19.4% of hospital/outpatient, and 63.4% of ambulatory/office-based center procedures. Stents were used in 41.8% of hospital/inpatient, 45.1% of hospital/outpatient, and 48.8% of ambulatory/office-based center procedures. However, stent grafts were used in 12.5% of hospital/inpatient, 8.8% of hospital/outpatient, and only 1.3% of ambulatory/office-based center procedures. On multivariable analysis, compared with hospital/inpatient, atherectomy use was associated with ambulatory/office-based center setting (Odds ratio 10.9, 95% confidence interval 10.3-11.5, P < 0.001) and hospital/outpatient setting (Odds ratio 1.57, 95% confidence interval 1.51-1.62, P < 0.001). Periprocedure complications including hematoma requiring intervention (0.3%), any stenosis/occlusion (0.2%), and distal embolization (0.6%) were quite low across all settings.

CONCLUSIONS

There are substantial variations in patient populations, procedural indications, and types of interventions undertaken during PVI across different locations. Ambulatory/office-based procedures more commonly treat claudicants, use atherectomy, and less often use stent grafts. Further research is warranted to investigate long-term trends in practice patterns and long-term outcomes, for PVI in the ever-expanding ambulatory/office-based setting.

A case of Burkholderia pseudomallei mycotic aneurysm linked to exposure in the Caribbean via whole genome sequencing

Melioidosis, an infection caused by Burkholderia pseudomallei, has a very high risk of mortality when treated, with an even higher risk of fatality if undiagnosed or not treated appropriately. It is endemic to Asia, Australia, South America, and the Caribbean; however, the number of melioidosis cases reported in the United States has been increasing. Therefore, physicians should be aware of this clinical entity and its possible presentations. Mycotic aneurysms due to B. pseudomallei are extremely rare accounting for approximately 1-2% of cases. Here we describe a rare case of melioidosis presenting as a mycotic aneurysm in the United States; highlight the potential for diagnostic challenges and epidemiologic concerns; as well as provide a review of mycotic aneurysm cases due to B. pseudomallei published to date.

Malpractice Allegations Against Vascular Surgeons:Prevalence, Risk Factors, and Impact on Surgeon Wellness

OBJECTIVES

The contemporary medicolegal environment has been linked to procedure overuse, healthcare variation, and higher costs. For physicians accused of malpractice, there is also a personal toll. The objective of this study was to evaluate the prevalence of and risk factors for involvement in medical malpractice lawsuits among US vascular surgeons, and to examine the association between these allegations with surgeon wellness.

METHODS

In 2018, the Society of Vascular Surgery (SVS) Wellness Task Force conducted a confidential survey of active members using a validated burnout assessment (Maslach Burnout Index) embedded into a questionnaire. This survey included questions related to medical errors and malpractice litigation. De-identified demographic, personal, and practice-related characteristics were assessed in respondents who reported malpractice allegations in the preceding two years, then compared to those without recent medicolegal litigation. Risk factors for malpractice allegations were identified (chi-square, Kruskal-Wallis tests), and the association between malpractice allegations with wellness was examined. Multivariate logistic regression models were developed to identify independent risk factors for malpractice accusations.

RESULTS

Of 2905 active SVS members, 871 responses from practicing vascular surgeons were analyzed. 161 (18.5%) were named in a malpractice lawsuit within two years. Malpractice allegations were significantly associated with surgeon burnout [OR 1.47 (1.01, 2.15), p=0.041], but not with self-reported depression or suicidal ideation. The nature of malpractice claims included procedural errors (23.1%), failure to treat (18.8%) and error/delay in diagnosis (16.9%). 20% of claims were settled prior to trial and 19% were dismissed. Defendant vascular surgeons reported a "fair" resolution in 26.4% of closed cases. By unadjusted analysis, factors significantly associated with recent malpractice claims included mean age (51.7+/-10.0 vs. 49.3+/-11.2; p=0.0044) and mean years in practice (18.0+/-10.7 vs. 15.2+/-11.8; p=0.0007). Multivariate analysis revealed independent variables associated with malpractice allegations, including on-call frequency (p=0.0178), recent medical errors (p=0.0189), and male surgeons (p=0.045).

CONCLUSIONS

Malpractice allegations are common for vascular surgeons and are significantly associated with surgeon burnout. Nearly 20% of survey respondents reported being named in a lawsuit within the preceding two years. Our findings underscore the need for SVS initiatives to provide counseling and peer support for vascular surgeons facing litigation.

Surgical and reconstructive outcomes in primary venous leiomyosarcoma

OBJECTIVES

Primary venous leimyosarcomas (PVL) are rare and pose challenges in surgical management. This study evaluates the clinical outcomes and identifies predictors of survival in our surgical series of PVL.

METHODS

A retrospective review was performed of patients who had resection of PVL at three centers between 1990-2018. Patient demographics, comorbidities, intraoperative data, survival, and graft related outcomes were recorded. Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards regression.

RESULTS

Seventy patients with a diagnosis of PVL were identified between 1990 and 2018. Fifty-four patients (77%) had PVL of the IVC and 16 (23%) had peripheral PVL. Mean follow up for the series was 55.0 months (range 1-217 months). Fifty one patients (96%) with IVC PVL needed caval reconstruction and 3 (4%) had resection only. There were no deaths within thirty days of surgery. Five patients (9%) required early re-intervention including one (2%) IVC stent. Sixteen peripheral PVL were identified. Eight patients (50%) had venous reconstructions performed and 8 (50%) had the vein resected without reconstruction. There were no deaths within thirty days. Five year survival was 57.5% for IVC PVL and 70.0% for peripheral PVL . Kaplan-Meier survival analysis for IVC and peripheral PVL revealed no difference in overall survival (p = 0.624) at 5 years.

CONCLUSIONS

PVL is a rare and aggressive disease even with surgical resection. We found no difference in survival between IVC and peripheral lesions suggesting aggressive management is warranted for PVL of any origin. Management of PVL requires a multidisciplinary approach to provide patients with the best long term outcomes.

Proximal fixation of endovascular aortic device may not be associated with renal function decline after abdominal aortic aneurysm repair

OBJECTIVE

Significant debate exists among providers who perform endovascular abdominal aortic aneurysm repair (EVAR) regarding the renal function change between suprarenal (SuF) and infrarenal (InF) fixation devices. The purpose of this study is to review our institution's experience using these devices in terms of renal function.

METHODS

This is a retrospective review of all elective EVARs performed within a three-site health system (Florida, Minnesota, and Arizona) during the period of 2000 to 2018. The primary outcome was renal function decline on long-term follow-up depending on the anatomical fixation of the device (SuF vs InF). Secondary outcomes were length of hospitalization (LOH) and progression to hemodialysis. Multivariable regression analysis was performed to test for associations affecting LOH.

RESULTS

There were 1130 elective EVARs included in our review. Of those, 670 (59.3%) had SuF and 460 (40.7%) InF. Long-term follow-up was 4.8 ± 3.7 years, and the rate of change in creatinine and estimated glomerular filtration rate (eGFR) were not statistically significant among groups (SuF vs InF). LOH was higher in those individuals with a SuF device (3.4 ± 2.2 vs 2.3 ± 1.0 days; P < .001). Ten patients with chronic kidney disease progressed to hemodialysis at 6.7 ± 3.8 years from EVAR. On Kaplan-Meier analysis, patients with chronic kidney disease with SuF were more likely to progress to hemodialysis (P = .039). On multivariable regression, female sex (Coef, 2.4; 95% confidence interval [CI], 0.17-0.41; P = .02), SuF (Coef, 9.5; 95% CI, 0.11-1.11; P < .0001), and intraoperative blood loss of greater than 150 mL (Coef, 15.4; 95% CI, 0.11-1.76; P < .0001) were predictors of prolonged LOH.

CONCLUSION

Our three-site, single-institution data indicate that, although the starting eGFR was statistically lower in those individuals undergoing elective EVAR with InF, device fixation type did not affect the creatinine and eGFR on long-term follow-up. However, caution should be exercised at the time of abdominal aortic aneurysm repair in those individuals who already presented with renal dysfunction.

Follicular Dendritic Cell Sarcoma of the Chest

Follicular dendritic cell sarcoma is a rare, low-grade cancer derived from follicular dendritic cells, which serve as accessory cells to the lymphoid system. Here, we describe the case of a 57-year-old man who had a mediastinal mass with aortic involvement incidentally identified during evaluation for indeterminate pulmonary nodules. The mass, later diagnosed as follicular dendritic cell sarcoma, was successfully treated with surgical resection aided by placement of endovascular aortic stent graft.

Retrograde Endovascular With Intimal Re-Entry Through Endarterectomy: The REWIRE Technique

OBJECTIVE

Hybrid lower extremity revascularization has been well described, typically consisting of common femoral endarterectomy (CFE) followed by direct patch puncture and endovascular treatment of any distal disease. We describe a modified technique that obviates the need for endovascular re-entry and simplifies treatment at the proximal and distal endpoints.

METHODS

The REWIRE technique begins with retrograde arterial access via a patent tibial, pedal or femoropopliteal vessel. The diseased segment is crossed in the subintimal plane. Once the wire reaches the common femoral artery (CFA), the vessel is surgically exposed. Arteriotomy is performed and the wire is externalized during standard CFE. With through-wire access achieved, a sheath is inserted and the distal disease is treated. The proximal extent of the endovascular revascularization is incorporated into a standard CFE with patch angioplasty.

RESULTS

Seven patients with chronic limb-threatening ischemia were treated with this approach, all with long segment occlusions of the SFA and significant CFA disease. The SFA disease was stented and bovine pericardial patch was used for CFE in all. Technical success was achieved in all patients. There were no complications related to the retrograde puncture site, which was controlled with manual pressure (4) or excluded with a covered stent (3). Thirty-Day freedom from major adverse limb events was 100%.

CONCLUSIONS

The REWIRE technique is an effective approach to hybrid revascularization involving the CFA. By crossing the occluded segment in a retrograde fashion and surgically externalizing the wire during CFE, the proximal and distal endpoints can be addressed with ease, the profunda femoris is protected under direct visualization, and the need for endovascular re-entry is eliminated.

Procedure Reimbursement, Inflation, and the Declining Buying Power of the Vascular Surgeon (2011-2021)

PURPOSE

The purpose of this study was to evaluate trends in Medicare reimbursement for common vascular procedures over the last decade. To enrich the context of this analysis, vascular procedure reimbursement is directly compared to inflation-adjusted changes in other surgical specialties.

METHODS

The Centers for Medicare & Medicaid Services Physician/Supplier Procedure Summary file was utilized to identify the 20 procedures most commonly performed by vascular surgeons from 2011-2021. A similar analysis was performed for orthopedic, general, and neurological surgeons. The Centers for Medicare & Medicaid Services Physician-Fee Schedule Look-Up Tool was queried for each procedure, and reimbursement data was extracted. All monetary data was adjusted for inflation to 2021 dollars utilizing the consumer price index. Average year-over-year and total percentage change in reimbursement were calculated based on adjusted data for included procedures. Comparisons to other specialty data were made with ANOVA.

RESULTS

From 2011-2021, the average, unadjusted change in reimbursement for vascular procedures was -7.2%. Accounting for inflation, the average procedural reimbursement declined by 20.1%. The greatest decline was observed in phlebectomy of varicose veins (-50.6%). Open arteriovenous fistula revision was the only vascular procedure with an increase in inflation-adjusted reimbursement (+7.5%). Year-over-year, inflation-adjusted reimbursement for common vascular procedures decreased by 2.0% per year. Venous procedures experienced the largest decrease in average adjusted reimbursement (-42.4%), followed by endovascular (-20.1%) and open procedures (-13.9%). These changes were significantly different across procedural subgroups (P < 0.001). During the same period, the average adjusted change in reimbursement for the 20 most common procedures in orthopedic surgery, general surgery, and neurosurgery was -11.6% vs. -20.1% for vascular surgery (P = 0.004).

CONCLUSION

Medicare reimbursement for common surgical procedures has declined over the last decade. While absolute reimbursement has remained relatively stable for several procedures, accounting for a decade of inflation demonstrates the true diminution of buying power for equivalent work. The most alarming observation is that vascular surgeons have faced a disproportionate decrease in inflation-adjusted reimbursement in comparison to other surgical specialists. Awareness of these trends is a crucial first step towards improved advocacy and efforts to ensure the "value" of vascular surgery does not continue to erode.

Deep vein thrombosis and pulmonary embolism among hospitalized coronavirus disease 2019-positive patients predicted for higher mortality and prolonged intensive care unit and hospital stays in a multisite healthcare system

Objective

We assessed the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) in hospitalized patients with coronavirus disease 2019 (COVID-19) compared with that in a matched cohort with similar cardiovascular risk factors and the effects of DVT and PE on the hospital course.

Methods

We performed a retrospective review of prospectively collected data from COVID-19 patients who had been hospitalized from March 11, 2020 to September 4, 2020. The patients were randomly matched in a 1:1 ratio by age, sex, hospital of admission, smoking history, diabetes mellitus, and coronary artery disease with a cohort of patients without COVID-19. The primary end point was the incidence of DVT/PE and the odds of developing DVT/PE using a conditional logistic regression model. The secondary end point was the hospitalization outcomes for COVID-19 patients with and without DVT/PE, including mortality, intensive care unit (ICU) admission, ICU stay, and length of hospitalization (LOH). Multivariable regression analysis was performed to identify the variables associated with mortality, ICU admission, discharge disposition, ICU duration, and LOH.

Results

A total of 13,310 patients had tested positive for COVID-19, 915 of whom (6.9%) had been hospitalized across our multisite health care system. The mean age of the hospitalized patients was 60.8 ± 17.0 years, and 396 (43.3%) were women. Of the 915 patients, 82 (9.0%) had had a diagnosis of DVT/PE confirmed by ultrasound examination of the extremities and/or computed tomography angiography of the chest. The odds of presenting with DVT/PE in the setting of COVID-19 infection was greater than that without COVID-19 infection (0.6% [5 of 915] vs 9.0% [82 of 915]; odds ratio [OR], 18; 95% confidence interval [CI], 8.0-51.2; P < .001). The vascular risk factors were not different between the COVID-19 patients with and without DVT/PE. Mortality (P = .02), the need for ICU stay (P < .001), duration of ICU stay (P < .001), and LOH (P < .001) were greater in the DVT/PE cohort than in the cohort without DVT/PE. On multivariable logistic regression analysis, the hemoglobin (OR, 0.71; 95% CI, 0.46-0.95; P = .04) and D-dimer (OR, 1.0; 95% CI, 0.33-1.56; P = .03) levels were associated with higher mortality. Higher activated partial thromboplastin times (OR, 1.1; 95% CI, 1.00-1.12; P = .03) and higher interleukin-6 (IL-6) levels (OR, 1.0; 95% CI, 1.01-1.07; P = .05) were associated with a greater risk of ICU admission. IL-6 (OR, 1.0; 95% CI, 1.00-1.02; P = .05) was associated with a greater risk of rehabilitation placement after discharge. On multivariable gamma regression analysis, hemoglobin (coefficient, −3.0; 95% CI, 0.03-0.08; P = .005) was associated with a prolonged ICU stay, and the activated partial thromboplastin time (coefficient, 2.0; 95% CI, 0.003-0.006; P = .05), international normalized ratio (coefficient, −3.2; 95% CI, 0.06-0.19; P = .002) and IL-6 (coefficient, 2.4; 95% CI, 0.0011-0.0027; P = .02) were associated with a prolonged LOH.

Conclusions

A significantly greater incidence of DVT/PE occurred in hospitalized COVID-19–positive patients compared with a non–COVID-19 cohort matched for cardiovascular risk factors. Patients affected by DVT/PE were more likely to experience greater mortality, to require ICU admission, and experience prolonged ICU stays and LOH compared with COVID-19–positive patients without DVT/PE. Advancements in DVT/PE prevention are needed for patients hospitalized for COVID-19 infection.

Intraoperative posture and workload assessment in vascular surgery

Quantifying the workload and postural demand on vascular surgeons provides valuable information on the physical and cognitive factors that predispose vascular surgeons to musculoskeletal pain and disorders. The aim of this study was to quantify the postural demand, workload, and discomfort experienced by vascular surgeons and to identify procedural factors that influence surgical workload. Both objective (wearable posture sensors) and subjective (surveys) assessment tools were used to evaluate intraoperative workload during 47 vascular surgery procedures. Results demonstrate unfavorable neck and low back postures as well as high pain scores for those body segments. Additionally, workload from subjective surveys increased significantly as a function of operative duration, and mental workload was high across all procedure types. Neck postural risk exposure and physical demand were among the variables that increased with surgical duration, procedure type, and loupes used by the surgeons. Correlations among postural angles and pain scores showed consistency between the objective assessment and the subjective surveys for neck and trunk. The authors believe that the results of this study highlight the need for developing mitigating measures such as ergonomic interventions for vascular surgery.

Women have similar mortality but higher morbidity than men after elective endovascular abdominal aortic aneurysm repair

OBJECTIVE

Sex disparities regarding outcomes for women after open and endovascular abdominal aortic aneurysm repair have been well-documented. The purpose of this study was to review whether these disparities were also present at our institution for elective endovascular aneurysm repair (EVAR) and whether specific factors predispose female patients to negative outcomes.

METHODS

All elective EVARs were identified from our three sites (Florida, Minnesota, and Arizona) from 2000 to 2018. The primary outcome was in-hospital mortality and three-year mortality. Secondary outcomes included complications requiring return to the operating room, length of hospitalization (LOH), intensive care unit (ICU) days, and location of discharge after hospitalization. Multivariable logistic regression models were used to assess for the risk of complications.

RESULTS

There were 1986 EVARs; 1754 (88.3%) were performed in male and 232 (11.7%) in female patients. Female patients were older (79 years [interquartile range (IQR), 72-83 years] vs 76 years [IQR, 70-81 years]; P < .001), had a lower body mass index (median, 26.1 kg/m² [IQR, 22.1-31.0 kg/m²] vs 28.3 kg/m² [IQR, 25.3-31.6 kg/m²]; P < .001 and hematocrit (median, 37.6% [IQR, 33.4%-40.6%] vs 39.4% [IQR, 35.6%-42.6%]; P < .001) and had higher glomerular filtration rate (median, 84.4 mL/min per 1.73m² [IQR, 62.3-103 mL/min/1.73 m²] vs 51.1 mL/min/1.73 m² [IQR, 41.8-60.8 mL/min/1.73 m²]; P < .001. Female patients were also more likely to be active smokers (15.3% vs 13.1%; P < .001) and have chronic obstructive pulmonary disease (24.7% vs 15.3%; P = .001). They were less likely to have coronary artery disease (31.6% vs 45.6%; P < .001). Aneurysms in women were slightly smaller in size (median, 54 mm [IQR, 50.0-58.0 mm] vs 55 mm [IQR, 51.0-60.0 mm]; P = .004). In-hospital mortality and mortality at the 3-year follow-up was not significant between female and male patients (0.86% vs 0.17%; P = .11 and 38.4% vs 36.2%; P = .57). However, female patients returned to the operating room with a greater frequency than male patients (3.9% vs 1.4%; P = .011). LOH (mean, 3.4 ± 3.8 days vs 2.5 ± 2.4 days; P < .001) and ICU days (mean, 0.3 ± 2.0 days vs 0.1 ± 0.5 days; P < .001) were longer for female patients. After hospitalization, female patients were discharged to rehabilitation facilities in greater proportion (12.7% vs 3.1%; P < .001) than their male counterparts. On multivariable analysis, female sex was associated with a return to the operating room (odds ratio, 6.4; 95% confidence interval [CI], 1.4-3.5; P = .02), longer LOH (Coef 4.0; 95% CI, 1.0-2.5; P = .00007), more ICU days (Coef 2.8; 95% CI, 1.1-3.0; P = .005), and a greater likelihood of posthospitalization rehabilitation facility placement (odds ratio, 5.8; 95% CI, 1.5-2.4; P = .0001).

CONCLUSIONS

Our three-site, single-institution data support sex disparities to the detriment of female patients regarding return to the operating room after EVAR, LOH, ICU days, and discharge to rehabilitation facility. However, we found no differences for in-hospital or 3-year mortality.

Telemedicine in vascular surgery during the coronavirus disease-2019 pandemic: A multisite healthcare system experience

Objective

To assess the introduction of telemedicine as an alternative to the traditional face-to-face encounters with vascular surgery patients in the era of the coronavirus disease 2019 (COVID-19) pandemic.

Methods

A retrospective review of prospectively collected data on face-to-face and telemedicine interactions was conducted at a multisite health care system from January to August 2020 in vascular surgery patients during the COVID-19 pandemic. The end point is direct patient satisfaction comparison between face-to-face and telemedicine encounters/interactions prior and during the pandemic.

Results

There were 6262 patient encounters from January 1, 2020, to August 6, 2020. Of the total encounters, 790 (12.6%) were via telemedicine, which were initiated on March 11, 2020, after the World Health Organization's declaration of the COVID-19 pandemic. These telemedicine encounters were readily adopted and embraced by both the providers and patients and remain popular as an option to patients for all types of visits. Of these patients, 78.7% rated their overall health care experience during face-to-face encounters as very good and 80.6% of patients rated their health care experience during telemedicine encounters as very good (P = .78).

Conclusions

Although the COVID-19 pandemic has produced unprecedented consequences to the practice of medicine and specifically of vascular surgery, our multisite health care system has been able to swiftly adapt and adopt telemedicine technologies for the care of our complex patients. Most important, the high quality of patient-reported satisfaction and health care experience has remained unchanged.

Vascular surgeon wellness and burnout: A report from the Society for Vascular Surgery Wellness Task Force

INTRODUCTION

Physician burnout has been linked to medical errors, decreased patient satisfaction, and decreased career longevity. In light of the increasing prevalence of cardiovascular disease, vascular surgeon burnout presents a legitimate public health concern owing to the impact on the adequacy of the vascular surgery workforce. The aims of this study were to define the prevalence of burnout among practicing vascular surgeons and identify factors that contribute to burnout to facilitate future Society for Vascular Surgery (SVS) initiatives to mitigate this crisis.

METHODS

In 2018, active SVS members were surveyed electronically and confidentially using the Maslach Burnout Inventory. The survey was tailored to explore specialty-specific issues, and to capture demographic and practice-related characteristics. Emotional exhaustion (EE) and depersonalization (DP) were analyzed as dimensions of burnout. Consistent with convention, surgeons with a high score on the DP and/or EE subscales of the Maslach Burnout Inventory were considered to have at least one manifestation of professional burnout. Risk factors associated with symptoms of burnout were identified using bivariate analyses (χ², Kruskal-Wallis). Multivariate logistic regression models were developed to identify independent risk factors for burnout.

RESULTS

Of 2905 active SVS members, 960 responded to the survey (34% participation rate). After excluding retired surgeons and incomplete submissions, responses from 872 practicing vascular surgeons were analyzed. The mean age was 49.7 ± 11.0 years; the majority of respondents (81%) were male. Primary practice settings were academic (40%), community practice (41%), veteran's hospital (3.3%), active military practice (1.5%), or other. Years in practice averaged 15.7 ± 11.7. Overall, 41% of respondents had at least one symptoms of burnout (ie, high EE and/or high DP), 37% endorsed symptoms of depression in the past month, and 8% indicated they had considered suicide in the last 12 months. In unadjusted analysis, factors significantly associated with burnout (P < .05) included clinical work hours, on-call frequency, electronic medical record and documentation requirements, work-home conflict, and work-related physical pain. On multivariate analysis, age, work-related physical pain and work-home conflict were independent predictors for burnout.

CONCLUSIONS

Symptoms of burnout and depression are common among vascular surgeons. Advancing age, work-related physical pain, and work-home conflict are independent predictors for burnout among vascular surgeons. Efforts to promote vascular surgeon well-being must address specialty-specific challenges, including the high prevalence of work-home conflict and occupational factors that contribute to work-related pain.

Carotid endarterectomy surgeon volumes in contemporary practice: A comparison to randomized trial inclusion criteria

BACKGROUND

Clinical decisions regarding the utility of carotid revascularization are informed by randomized controlled trial (RCT) results. However, RCTs generally require participating surgeons to meet strict inclusion criteria with respect to procedure volume. The purpose of this study was to compare annual surgeon volume for carotid endarterectomy (CEA) in contemporary practice to RCT inclusion thresholds.

METHODS

Surgeon volume thresholds were identified in 17 RCTs evaluating the efficacy of CEA (1986-present, n = 17). Contemporary annual surgeon volumes (2012-2017) were identified by aggregating data from the Medicare Provider Utilization Database and Healthcare Cost and Utilization Project Network (HCUP), and compared to RCT inclusion thresholds. Further comparisons were performed over time, and across specialties (i.e., vascular surgeon vs. other, based on board certification associated with provider NPI).

RESULTS

Minimal surgeon volume in 17 RCTs ranged from 10 to 25 CEA annually when specific case volumes were required. From 2012 to 2017, CEA incidence in Medicare beneficiaries declined from 68,608 to 56,004 and became increasingly consolidated in fewer providers (7,331 vs. 6,626). However, in 2016 only 26.2% of surgeons performing CEA in Medicare beneficiaries would have met the least stringent volume requirement (10 CEA/year). Only 6.5% of surgeons performing CEA met the most stringent RCT volume threshold (25 cases/year) during the same time period. In 2017, 819 vascular surgeons (25.5% of those certified in the specialty) performed >10 CEA in Medicare beneficiaries.

CONCLUSIONS

The majority of surgeons performing CEA do not meet the annual volume thresholds required for participation in the RCTs that have evaluated the efficacy of carotid revascularization. Given the established volume-outcome relationship in CEA, the disparity between surgeon experience in the context of RCTs versus contemporary practice is concerning. These findings have potential implications for informed decision-making, hospital privileging, and regionalization of care.

A multi-institutional review of endovenous thermal ablation of the saphenous vein finds male sex and use of anticoagulation are predictors of long-term failure

BACKGROUND

To review long-term outcomes and saphenous vein (SV) occlusion rate after endovenous ablation (EVA) for symptomatic varicose veins.

METHODS

A review of our EVA database (1998-2018) with at least 3-years of clinical and sonographic follow-up. The primary end point was SV closure rate.

RESULTS

542 limbs were evaluated. 358 limbs had radiofrequency and 323 limbs had laser ablations; 542 great saphenous veins (GSV), 106 small saphenous veins (SSV) and 33 anterior accessory saphenous veins (AASV) were treated. Follow-up was 5.6 ± 2.3 years; 508 (74.6%) veins were occluded, 53 (7.8%) partially occluded and 120 (17.6%) were patent. On multivariable Cox regression analysis, male sex (HR 1.6, 95% CI [0.46-018], p = 0.012) and use anticoagulation (HR 2.0, 95% CI [0.69-0.34], p = 0.044) were predictors of long-term failure. On Kaplan-Meier curve, we had an 86.3% occlusion rate.

CONCLUSION

Our experience revealed a 5-year closure rate of 86.3%. Ablations have satisfactory occlusion rate.

Practice Patterns of Vascular Surgery's "1%"

BACKGROUND

Public focus on health care spending has increased attention on variation in practice patterns and overutilization of high-cost services. Mainstream news reports have revealed that a small number of providers account for a disproportionate amount of total Medicare payments. Here, we explore variation in Medicare payments among vascular surgeons and compare practice patterns of the most highly reimbursed surgeons to the rest of the workforce.

METHODS

2016 Medicare Provider Utilization Data were queried to identify procedure, charge, and payment data to vascular surgeons, identified by National Provider Identification taxonomy. Commonly performed services (>10/year) were stratified into categories (endovascular, open surgery, varicose vein, evaluation and management, etc.). Practice patterns of vascular surgeons comprising the top 1% Medicare payments (n = 31) were compared with the remainder of the workforce (n = 3,104).

RESULTS

In 2016, Medicare payments to vascular surgeons totaled $589 M. 31 vascular surgeons-1% of the workforce-received $91 million (15% of total payments). Practice patterns of the 1% differed significantly from the remainder of vascular surgeons (P < 0.05), with endovascular procedures accounting for 85% of their reimbursement. Specifically, the 1% received 49% of total Medicare payments for atherectomy ($121 M), 98% of which were performed in the office setting.

CONCLUSIONS

One percentage of vascular surgeons receive an inordinate amount of total Medicare payments to the specialty. This discrepancy is due to variations in volume, utilization, and site of service. Disproportionate use of outpatient atherectomy in a small number of providers, for example, raises concerns regarding appropriateness and overutilization. Given current scrutiny over health care spending, these findings should prompt serious discussion regarding the utility of personal and societal self-regulation.

Prevalence of Intracranial Aneurysms in Patients with Infrarenal Abdominal Aortic Aneurysms: A Multicenter Experience

Prior studies suggest high prevalence of intracranial aneurysms (IA) in patients with infrarenal abdominal aortic aneurysms (AAA). We reviewed our multicenter experience in clinical detection/treatment of IAs in AAA patients and estimated the risk of IA in patients with AAA relative to patients without AAA. We reviewed cases of vascular surgery infrarenal AAA repairs at three Mayo Clinic sites from January 1998 to December 2018. Concurrent controls were randomly matched in a 1:1 ratio by age, sex, smoking history, and head imaging characteristics. Conditional logistic regression was used to calculate odds ratios. We reviewed 2,300 infrarenal AAA repairs. Mean size of AAA at repair was 56.9 ± 11.4 mm; mean age at repair, 75.8 ± 8.0 years. 87.5% of the cases ( n  = 2014) were men. Head imaging was available in 421 patients. Thirty-seven patients were found to have 45 IAs for a prevalence of 8.8%. Mean size of IA was 4.6 ± 3.5 mm; mean age at IA detection, 72.0 ± 10.8 years. Thirty (81%) out of 37 patients were men. Six patients underwent treatment for IA: four for ruptured IAs and two for unruptured IAs. All were diagnosed before AAA repair. Treatment included five clippings and one coil-assisted stenting. Time from IA diagnosis to AAA repair was 16.4 ± 11.0 years. Two of these patients presented with ruptured AAA, one with successful repair and a second one that resulted in death. Odds of IA were higher for patients with AAA versus those without AAA (8.8% [37/421] vs. 3.1% [13/421]; OR 3.18; 95% confidence interval, 1.62-6.27, p  < 0.001). Co-prevalence of IA among patients with AAA was 8.8% and is more than three times the rate seen in patients without AAA. All IAs were diagnosed prior to AAA repair. Surveillance for AAA after IA treatment could have prevented two AAA ruptures and one death.

Intraprocedural ergonomics of vascular surgeons

OBJECTIVE

The objective of this study was to estimate the ergonomic postural risk (EPR) for musculoskeletal posture of vascular surgeons performing open and endovascular procedure types and with various adjunctive equipment using wearable inertial measurement unit (IMU) sensors. The hypothesis was that EPR will increase with increased physical and mental demand as well as with procedural complexity.

METHODS

A prospective, observational study was conducted at a large, quaternary academic hospital located at two sites. Sixteen vascular surgeons (13 male) participated in the study. Participants completed a presurgery and postsurgery survey consisting of a body part discomfort scale and a modified NASA-Task Load Index. Participants wore IMU sensors on the head and upper body to measure EPR during open and endovascular procedures.

RESULTS

Vascular surgeons have increased EPR scores of the neck as measured by the IMUs and increased lower back pain when performing open surgery compared with non-open surgery (P < .05). Open procedures were rated as more physically demanding. The use of loupes resulted in increased EPR scores for the neck and torso (P < .05), and they were significantly associated with higher levels of lower back pain during procedures (P < .05) as well as with higher levels of physical demand (P < .05). The use of headlights also resulted in increased subjectively measured levels of physical demand and lower back pain. In comparing survey responses with IMU data, surveyed physical demand was strongly and significantly correlated with the neck (r = 0.61; P < .0001) and torso (r = 0.59; P < .0001) EPR scores. The use of lead aprons did not affect EPR or most surveyed measures of workload but resulted in significantly higher levels of distraction (P < .01). The data presented highlight the potential of using wearable sensors to measure the EPR of surgeons during vascular surgical procedures.

CONCLUSIONS

Vascular surgeons should be aware of EPR during the performance of their duties. Procedure type and surgical adjuncts can alter EPR significantly.

Impact of Procedure Type, Case Duration, and Adjunctive Equipment on Surgeon Intraoperative Musculoskeletal Discomfort

BACKGROUND

Surgeons are at high risk of developing musculoskeletal disorders.

STUDY DESIGN

This study was designed to identify risk factors and assess intraoperative physical stressors using subjective and objective measures, including type of procedure and equipment used. Wearable sensors and pre- and postoperation surveys were analyzed.

RESULTS

Data from 116 cases (34 male and 19 female surgeons) were collected across surgical specialties. Surgeons reported increased pain in the neck, upper, and lower back both during and after operations. High-stress intraoperative postures were also revealed by the real-time measurement in the neck and back. Surgical duration also impacted physical pain and fatigue. Open procedures had more stressful physical postures than laparoscopic procedures. Loupe usage negatively impacted neck postures.

CONCLUSIONS

This study highlights the fact that musculoskeletal disorders are common in surgeons and characterizes surgeons' intraoperative posture as well as surgeon pain and fatigue across specialties. Defining intraoperative ergonomic risk factors is of paramount importance to protect the well-being of the surgical workforce.

Meta-analysis and systematic review of interventional therapy versus anticoagulation for isolated femoropopliteal deep venous thrombosis

OBJECTIVE

Percutaneous endovenous intervention (PEVI) is gaining acceptance for select patients with symptomatic proximal lower extremity deep venous thrombosis (DVT), but the benefits are uncertain in patients with isolated femoropopliteal DVTs. We performed a systematic review and meta-analysis of the literature to assess the safety and effectiveness of PEVI vs systemic anticoagulation for patients with isolated femoropopliteal DVT.

METHODS

We systematically searched PubMed, Embase, and the Cochrane Library from inception to March 2018. All studies comparing clinical outcomes between PEVI and systemic anticoagulation were included. The main end points were post-thrombotic syndrome and bleeding complications. Secondary outcomes included femoropopliteal patency rate, venous obstruction, and recurrent DVT.

RESULTS

No studies directly comparing PEVI with systemic anticoagulation in isolated femoropopliteal DVTs were identified by the systematic review. A traditional literature review identified one randomized controlled trial comparing the two, which found no difference in rates of post-thrombotic syndrome in PEVI vs systemic anticoagulation (risk ratio, 0.96; 95% confidence interval, 0.82-1.11; P = .56). We additionally identified five retrospective case series containing patients with isolated femoropopliteal DVTs, of which two reported on patency rates (46%-100% at 2 years).

CONCLUSIONS

More data are required to definitively state that PEVI should be the preferred intervention for patients with isolated femoropopliteal DVTs, although the initial evidence is promising.

Transradial interventions in contemporary vascular surgery practice

OBJECTIVES

Upper extremity arterial access is often required for endovascular procedures, especially for antegrade access to the visceral aortic branches. Radial arterial access has been shown previously to have low complication rates, and patients tolerate the procedure well and are able to recover quickly. However, transradial access remains relatively uncommon amongst vascular surgeons.

METHODS

The radial artery was evaluated by ultrasound to evaluate for adequate caliber, and to identify any aberrant anatomy or arterial loops. A modified Barbeau test was performed to ensure sufficient collateral circulation. A cocktail of nitroglycerin, verapamil and heparin was administered intra-arterially to combat vasospasm. Sheaths up to 6 French were utilized for interventions. On completion of the procedure, a compression band was used for hemostasis in all cases.

RESULTS

Twenty-five interventions were performed in 24 patients. The left radial artery was used in 23/25 cases (92.0%). Procedures included visceral and renal artery interventions; stent graft repair of a renal artery aneurysm; embolization of splenic, pancreaticoduodenal and internal mammary aneurysms; embolization of bilateral hypogastric arteries following blunt pelvic trauma; interventions for peripheral arterial disease; delivery of a renal snorkel graft during endovascular aortic aneurysm repair, and access for diagnostic catheters during thoracic endovascular aortic aneurysm repair. Technical success was 92.0%. There was one post-operative radial artery occlusion (4.3%) which led to paresthesias but resolved with anticoagulation. There were no instances of arterial rupture, hematoma, or hand ischemia requiring intervention.

CONCLUSIONS

Using the transradial approach, we have demonstrated a high technical success rate over a range of clinical contexts with minimal morbidity and no significant complications such as bleeding or hand ischemia. The safety profile compares favorably to historical complication rates from brachial access. Radial access is a safe and useful skill for vascular surgeons to master.

Totally Percutaneous Fenestration via the "Cheese-Wire" Technique to Facilitate Endovascular Aneurysm Repair in Chronic Aortic Dissection

Here, we describe a totally percutaneous technique for longitudinal fenestration of a chronic dissection flap in the setting of endovascular aneurysm repair (EVAR), where the septum would otherwise preclude proper endograft sealing. This technique is demonstrated in a 65-year-old man with a history of open surgical repair of a Stanford type A aortic dissection, with a type B component that was managed nonoperatively. The patient developed aneurysmal degeneration of the infrarenal aorta during follow-up, and his anatomy was well suited for EVAR with the exception of a chronic dissection flap dividing the proximal seal zone. Using bilateral percutaneous access, a wire was passed through an existing fenestration in the septum from true to false lumen and snared from the contralateral side. Downward traction on this through-wire was then used as a "cheese-wire" to divide the septum longitudinally and clear it from the proximal fixation site. Removal of the septum provided an adequate proximal seal zone for the endograft, and standard infrarenal EVAR was then performed with a good technical result. Longitudinal fenestration using this technique is a useful adjunctive maneuver to facilitate EVAR in the setting of chronic aortic dissection and is safely achievable via a totally percutaneous approach.

Prophylactic Inferior Vena Cava Filter Utilization and Risk Factors for Nonretrieval

PURPOSE

Inferior vena cava filters (IVCFs) are often placed for prophylactic indications. We sought to better define the range of practice indications for placement of prophylactic IVCFs, as well as the specific retrieval rate and risk factors for nonretrieval.

METHODS

A retrospective, single-institution review of patients undergoing IVCF placement over a 2-year period was performed. Patients undergoing prophylactic IVCF placement were selected from a prospectively collected database. Risk factors for nonretrieval were identified using a multivariate logistic regression model.

RESULTS

Of 615 IVCFs placed, 256 were retrievable filters placed for prophylactic indications and comprised the study cohort. The most common indications were a history of venous thromboembolic disease (43.7%), malignancy (35.1%), bleeding risk precluding anticoagulation (33.9%), and trauma (22.6%). One hundred sixty-three (63.6%) were placed preoperatively. Placement was performed in 70.3% by interventional radiology, 21.4% by vascular surgery, and 8.2% by cardiology. The most common requesting services were orthopedics (67%), general surgery (11%), neurosurgery (9%), and bariatric surgery (7%). Of all, 67.6% were placed in the inpatient setting and 32.4% in outpatients. Seventy-one (27.7%) of the 256 prophylactic filters were retrieved, with a mean indwelling time of 92 ± 74 days. Inpatients were significantly less likely to have their IVCF removed (32.4% vs 57.8%; P < .001), as were preoperative patients.

CONCLUSIONS

This study helps define current practice trends for the placement of prophylactic IVCFs. Importantly, the specific retrieval rate for prophylactic filters is low. This suggests that prophylactic IVCF usage is suboptimal and efforts should be taken to increase retrieval, especially among inpatients and perioperative patients.

Risk Factors for Suboptimal Utilization of Statins and Antiplatelet Therapy in Patients Undergoing Revascularization for Symptomatic Peripheral Arterial Disease

BACKGROUND

The objective of this study was to identify risk factors for suboptimal medical therapy (defined as reported antiplatelet and statin use) among patients undergoing lower extremity bypass (LEB) and peripheral vascular interventions (PVIs) for symptomatic peripheral arterial disease (PAD).

METHODS

The Vascular Study Group of Greater New York (VSGGNY) database was used to identify all patients undergoing PVI or LEB for PAD (2011-2013). Bivariate analyses were performed to identify characteristics of patients who were not prescribed statins and/or antiplatelet agents before revascularization. Multivariate relative risk regression models were developed to identify patients at risk for suboptimal therapy, with regards to antiplatelet and statin therapy.

RESULTS

About 1,030 patients underwent endovascular therapy (n = 822; 80%) or surgical bypass (n = 208; 20%) for symptomatic PAD (57.2% claudication; 15% rest pain and 27.8% tissue loss). Overall, preoperative statin use was observed in 59%. Preoperative antiplatelet therapy was observed in 79% of patients. Bivariate analysis revealed comparatively reduced statin use among patients without other cardiovascular risk factors including hypertension (63% vs. 39.3%; P < 0.0001) and coronary artery disease (CAD) with or without prior cardiac revascularization (coronary artery bypass grafting [CABG]/percutaneous coronary intervention [PCI]; 75.2% vs. 47.4%; P < 0.0001). Multivariate relative risk regression confirmed higher rates of statin use among patients with other cardiovascular risk factors including hypertension (1.14 [1.02-1.27]; P = 0.02) and CAD with prior CABG/PCI (1.22 [1.13-1.31]; P < 0.0001). Reduced statin use was observed in patients over 80 years old. (0.92 [0.84-0.1.0]; P = 0.059). By multivariate regression, antiplatelet therapy use was associated with CAD and/or prior CABG/PCI (1.11 [1.04-1.17]; P = 0.0015) and prior peripheral revascularization (1.07 [1.01-1.13]; P = 0.03).

CONCLUSIONS

Patients with symptomatic PAD, but without an antecedent cardiovascular history, are less likely to be optimally managed with statins and antiplatelet therapy preoperatively. Given the established role of these medications in the optimal medical management of patients with PAD, this presents an opportunity for improvement in the overall vascular care of patients undergoing intervention for symptomatic PAD at VSGGNY centers.

Left-Sided Varicocele as a Rare Presentation of May-Thurner Syndrome

BACKGROUND

May-Thurner syndrome (MTS), the clinical sequelae of left iliac vein compression between the right iliac artery and the spine, is an accepted cause of lower extremity edema and venous thromboembolism. It is more prevalent in younger women and typically presents with left lower extremity symptoms. Atypical presentations such as right-sided symptoms, chronic pelvic pain, and even fatal venous rupture have been reported. Here, we describe iliac vein compression presenting as a chronic left-sided testicular varicocele.

METHODS

A 22-year-old man presented with left testicular varicocele, scrotal edema, and pain after failing multiple attempts at surgical repair. MRI revealed left iliac vein compression and marked cross-pelvic collaterals. Venography and intravascular ultrasound confirmed left common iliac vein compression and typical changes of MTS. There was no gonadal vein (GV) reflux. An iliac vein stent (WALLSTENT, Boston Scientific) was placed.

RESULTS

A good technical result was achieved, with elimination of internal iliac vein reflux and marked reduction in pelvic collateral flow (see image). The patient reported resolution of his symptoms.

CONCLUSIONS

Varicocele is a leading cause of testosterone insufficiency and infertility in young males. In the majority of cases, successful treatment can be achieved by addressing reflux in the internal spermatic vein (ISV) and/or GV by a variety of surgical or endovascular approaches. In unusual cases, the culprit pathology may be reflux in the vein of the vas deferens, which unlike the ISV and GV, drains into the internal iliac vein. In such cases, iliac vein compression usually associated with MTS may result in varicocele. To our knowledge, this is the first report of refractory varicocele secondary to iliac vein compression successfully treated with endovenous stenting.

Comparison of outcomes after endovascular and open repair of abdominal aortic aneurysms in low-risk patients

Background

In randomized trials endovascular aortic aneurysm repair (EVAR) has been shown to have superior perioperative outcomes compared with open aneurysm repair (OAR). However, outcomes in patients at low risk of complications are unclear and many surgeons still prefer OAR in this cohort. The objective was to analyse perioperative and longer-term outcomes of OAR and EVAR in this low-risk group of patients.

Methods

All elective infrarenal EVARs and OARs in the Vascular Study Group of New England database were reviewed from 2003 to 2014. The Medicare scoring system was used to identity patients at low risk of perioperative complications and death. Perioperative and longer-term outcomes were analysed in this cohort. A Kaplan–Meier plot was constructed for evaluation of longer-term survival. Further propensity matching and multivariable analysis were performed to analyse additional differences between the two groups.

Results

Some 1070 patients who underwent EVAR and 476 who had OAR were identified. Mean(s.d.) age was 67·3(5·7) and 65·1(6·3) years respectively (P &lt; 0·001). EVAR was associated with a lower overall perioperative complication rate (4·2 versus 26·5 per cent; P &lt; 0·001). There was no difference in 30-day mortality (0·4 versus 0·6 per cent; P = 0·446). Overall survival at 3 years was similar after EVAR and OAR (92·5 versus 92·1 per cent respectively; P = 0·592). In multivariable analyses there was no difference in freedom from reintervention (odds ratio 1·69, 95 per cent c.i. 0·73 to 3·90; P = 0·220) or survival (hazard ratio 0·85, 0·61 to 1·20; P = 0·353).

Conclusion

In patients predicted to be at low risk of perioperative death following aneurysm repair, EVAR resulted in fewer perioperative complications than OAR. However, perioperative mortality, reinterventions and survival rates in the longer term appeared similar between endovascular and open repair.