The Impact of Patient Sex on Outcomes after Endovascular Treatment of Aortoiliac Occlusive Disease

BACKGROUND

The aim of this study was to explore the effect of patient sex on short-term and long-term outcomes after endovascular treatment for aortoiliac occlusive disease (AIOD).

METHODS

A multicenter retrospective analysis was performed on all patients who underwent iliac artery stenting for AIOD across the 3 participating sites from October 1, 2018 to September 21, 2021. Preoperative clinical, operative, and postoperative data were collected on a dedicated database. Demographics and outcomes were compared between male and female patients and the probability of freedom from amputation and freedom from target lesion reintervention were estimated with the Kaplan-Meier method.

RESULTS

Of 574 patients, 346 (60%) were male and 228 (40%) were female. Mean follow-up was 12 months. Female patients were significantly older (69.2 ± 10.2 years vs. 67.8 ± 8.9 years, P = 0.025) and more likely to have Trans-Atlantic Inter-Society Consensus II D disease (P = 0.003). The female cohort had significantly less coronary artery disease (40% vs. 50%, P = 0.013), coronary stenting (14% vs. 21%, P = 0.039), and coronary artery bypass grafting (13% vs. 25%, P < 0.001) than the male cohort, as well as less statin use (69% vs. 80%, P = 0.004). There were no differences in stent type, concomitant open surgery, intraoperative events, or hospital length of stay. For 30-day postoperative complications, female patients had a significantly higher rate of thrombotic acute limb ischemia (2% vs. 0%, P = 0.01), while male patients had a higher rate of amputation (4% vs. 9%, P = 0.048). On mid-term outcomes, there was no difference in freedom from amputation or target lesion reintervention between male and female patients (P = 0.14 and P = 0.32, respectively).

CONCLUSIONS

Female patients had lower incidence of cardiovascular risk factors but presented with higher Trans-Atlantic Inter-Society Consensus II classification and had higher rates of 30-day thrombotic acute limb ischemia. Male patients were more likely to require amputation within 30 days. Despite no differences in the mid-term, these short-term findings suggest that patient sex may be a relevant consideration in postoperative management and surveillance after endovascular treatment of AIOD.

Impact of Shunting Practice Patterns During Carotid Endarterectomy for Symptomatic Carotid Stenosis

BACKGROUND

We aimed to assess the effect of surgeons' shunting practice and shunt use on the early outcomes of carotid endarterectomy (CEA) in recently symptomatic patients.

METHODS

We conducted a retrospective observational study based on a multicenter national prospective database. The Vascular Quality Initiative database (2010-2019) was queried for CEAs performed within 14 days after an ipsilateral stroke or transient ischemic attack. Surgeons were gauged as routine shunters if they shunted in >95% of CEAs, otherwise were classified as selective shunters. In-hospital stroke and death rates were compared between routine and selective shunters, stratifying by type of index event (transient ischemic attack versus stroke) and timing of CEA (≤2 versus >2 days).

RESULTS

Thirteen thousand four hundred sixty-nine CEAs were performed after a transient ischemic attack (43%) or stroke (57%), 3186 (24%) by routine shunters, and 10 283 (76%) by selective shunters. Comparing routine and selective shunters, in-hospital stroke (1.9% versus 2.4%; P=0.09) and death (0.4% versus 0.5%; P=0.73) rates were similar. A lower stroke rate (1.5% versus 4.2%; P=0.02) was achieved by routine shunters for CEA performed <2 days after an ischemic stroke. Among selective shunters, a higher stroke rate occurred in case of shunt use (2.9% versus 2.3%; P<0.01), mainly due to cases presenting with stroke (3.5% versus 2.4%; P<0.01) but not transient ischemic attack (1.8% versus 1.5%; P=0.57). Awake anesthesia was adopted in 7.8% of cases by selective shunters and in 0.8% by routine shunters, without impact on the perioperative stroke rate (1.8% versus 2.3%; P=0.349).

CONCLUSIONS

In this large national cohort, the overall outcomes of CEA were similar between routine and selective shunters. A lower postoperative stroke rate was achieved by routine shunters in CEA performed <2 days after an ischemic stroke. Among selective shunters, intraoperatively indicated shunting determined an increased stroke rate, likely due to intraoperative hypoperfusion. These data may guide the decision regarding timing of CEA and shunting intention in symptomatic patients.

Predictors of Long-Term Aortic Growth and Disease Progression in Patients with Aortic Dissection, Intramural Hematoma, and Penetrating Aortic Ulcer

BACKGROUND

We aimed to identify predictors of long-term aortic diameter change and disease progression in a population cohort of patients with newly diagnosed aortic dissection (AD), intramural hematoma (IMH), or penetrating aortic ulcer (PAU).

METHODS

We used the Rochester Epidemiology Project record linkage system to identify all Olmsted County, MN-USA, residents diagnosed with AD, IMH, and PAU (1995-2015). The endpoints were aortic diameter change, freedom from clinical disease progression (any related intervention, aortic aneurysm, new aortic syndrome, rupture or death) and disease resolution (complete spontaneous radiological disappear). Linear regression was used to assess aortic growth rate; predictors of disease progression were identified with Cox proportional hazards.

RESULTS

Of 133 incident cases, 46 ADs, 12 IMHs, and 28 PAUs with sufficient imaging data were included. Overall median follow-up was 8.1 years. Aortic diameter increase occurred in 40 ADs (87%, median 1.0 mm/year), 5 IMHs (42%, median 0.2 mm/year) and 14 PAUs (50%, median 0.4 mm/year). Symptomatic presentation (P = 0.045), connective tissue disorders (P = 0.005), and initial aortic diameter >42 mm (P = 0.013) were associated with AD growth rate. PAU depth >9 mm (P = 0.047) and female sex (P = 0.013) were associated with aortic growth rate in PAUs and IMHs. At 10 years, freedom from disease progression was 22% (95% CI 12-41) for ADs, 44% (95% CI 22-92) for IMHs, and 46% (95% CI 27-78) for PAUs. DeBakey I/IIIB AD (HR 3.09; P = 0.038), initial IMH aortic diameter (HR 1.4; P = 0.037) and PAU depth >10 mm (HR 3.92; P = 0.018) were associated with disease progression. No AD spontaneously resolved; resolution rate at 10 years was 22% (95% CI 0-45) for IMHs and 11% (95% CI 0-23) for PAUs.

CONCLUSIONS

Aortic growth and clinical disease progression are observed in most patients with aortic syndromes, while spontaneous resolution is uncommon. Predictors of aortic growth and disease progression may be used to tailor appropriate follow-up and eventual early intervention.

Long-term fate of aortic branches in patients with aortic dissection

OBJECTIVE

Late morbidity and mortality related to aortic branches in patients with aortic dissection (AD) have not been well described. We investigated the fate of aortic branches in a population cohort of patients with newly diagnosed AD.

METHODS

We used the Rochester Epidemiology Project record linkage system to identify all Olmsted County, Minnesota, residents with a diagnosis of AD from 1995 to 2015. Only patients with >30 days of available follow-up imaging studies were included in the present analysis. The primary outcome was freedom from any branch-related event (any intervention, aneurysm, malperfusion, rupture, or death occurring after the acute phase >14 days). The secondary outcome was the diameter change in the aortic branches. Univariate and multivariable Cox proportional hazards models were used to identify the predictors of branch-related events. Univariate and multivariate linear regression models were used to assess the aortic branch growth rate.

RESULTS

Of 77 total incident AD cases, 58 patients who had survived and had imaging follow-up studies available were included, 28 (48%) with type A and 30 (52%) with type B AD. The presentation was acute in 39 patients (67%), 6 (10%) of whom had had branch malperfusion. Of 177 aortic branches involved by the AD, 81 (46%) had arisen from the true lumen, 33 (19%) from the false lumen, and 63 (36%) from both. After the acute phase, freedom from any branch-related event at 15 years was 48% (95% confidence interval [CI], 32%-70%). A total of 31 branch-related events had occurred in 19 patients within 15 years, including 12 interventions (76% freedom; 95% CI, 63%-92%), 10 aneurysms (67% freedom; 95% CI, 50%-90%), 8 cases of malperfusion (76% freedom; 95% CI, 61%-94%), and 1 rupture (94% freedom; 95% CI, 84%-100%). No branch-related deaths had occurred. Type B AD (hazard ratio [HR], 3.5; 95% CI, 1.1-10.8; P = .033), patency of the aortic false lumen (HR, 6.8; 95% CI, 1.1-42.2; P = .038), and malperfusion syndrome at presentation (HR, 6.0; 95% CI, 1.3-28.6; P = .023) were predictors of late aortic branch-related events. The overall growth rate of aortic branches was 1.3 ± 3.0 mm annually. Patency of the aortic false lumen, initial branch diameter, and Marfan syndrome were significantly associated with diameter increase.

CONCLUSIONS

In patients with AD, aortic branch involvement was responsible for significant long-term morbidity, without any related mortality. Type B AD, patency of the aortic false lumen, and malperfusion syndrome at presentation resulted in a greater risk of branch events during the long-term follow-up. Dilatation of the aortic branches was observed in one third of cases during follow-up, especially in the case of a patent aortic false lumen or the presence of Marfan syndrome.

Long-term symptom improvement and health-related quality of life after operative management of median arcuate ligament syndrome

OBJECTIVE

To investigate long-term symptom improvement and health-related quality of life (HRQOL) after operative intervention for median arcuate ligament syndrome (MALS).

METHODS

Clinical data of all consecutive patients treated by operative management of MALS from 1999 to 2018 were reviewed. A cross-sectional questionnaire using the Visick score, the Gastrointestinal Quality of Life Index, and Short Form (SF)-12v2 questionnaires was performed to assess long-term outcomes. The SF-12 HRQOL domains were compared between symptom-free and symptomatic patient groups and to averages for the US general population. Treatment failure was defined as no relief after surgery and Visick category 3 to 4 symptoms. Freedom from symptoms was estimated at 5 years.

RESULTS

A total of 100 patients were treated for MALS (mean age, 38 ± 18 years; 75% female). Open surgical release was performed in 81 and laparoscopic release in 19 patients. The most common presenting symptom was abdominal pain in 99 patients with postprandial exacerbation in 85. There was no mortality. Major adverse events at 30 days had occurred in 21 patients (open 19, laparoscopic 2) including myocardial infarction (n = 1), pancreatitis (n = 2), respiratory failure (n = 4), estimated blood loss of more than 1 L (n = 8), and postoperative ileus (n = 8). One patient treated by laparoscopic release required conversion for an aortic injury, which was treated by primary repair and splenectomy. Forty-six patients responded to the questionnaire with a mean follow-up of 8 ± 4 years. Initial symptom resolution or improvement was reported by 38 patients (83%), whereas 8 patients (17%) reported treatment failure. Seven of the 38 patients (18%) with initial treatment success reported symptom recurrence. The estimated 5-year freedom from symptoms was 67 ± 7%. All SF-12 HRQOL domains were significantly lower and below the average population range in symptomatic patients compared with those who were symptom free, in which all domains were within the average population range. The Gastrointestinal Quality of Life Index scores were also significantly lower in symptomatic patients. Forty respondents (87%) reported that they would still undergo operative management if given the choice, including all respondents who reported symptom recurrence.

CONCLUSIONS

The operative management of MALS can be performed with a low rate of complications. Approximately two-thirds of respondents were free of symptoms 5 years after the procedure. Treatment success in symptom-free patients was associated with an improved HRQOL on par with the population average compared with symptomatic patients. The vast majority of respondents would opt to have the operation again if given a choice. However, patients should be well-informed about the possibility of failure to relieve symptoms and symptom recurrence.

Incidence and natural history of isolated abdominal aortic dissection: A population-based assessment from 1995 to 2015

BACKGROUND

Isolated abdominal dissection (IAD) is an uncommon clinical problem that is less well-understood than thoracic aortic dissection (AD). We performed a population-based assessment of the incidence, natural history, and treatment outcomes of IAD to better characterize this disease.

METHODS

We used the Rochester Epidemiology Project to identify all Olmsted County, MN residents with a diagnosis of AD, intramural hematoma or penetrating ulcer (1995-2015). Diagnostic imaging of all patients was reviewed to confirm the diagnosis of IAD for inclusion. Presentation, treatment, and outcomes were reviewed. Survival of IAD patients was compared to age- and sex-matched population controls 3:1.

RESULTS

Of 133 residents with aortic syndrome (AD, intramural hematoma, or penetrating ulcer), 23 were initially diagnosed with IAD. Nine were reclassified as having a penetrating aortic ulcer and were excluded, leaving 14 patients for review (10 male [71%]; mean age, 71 years). Three patients (21%) were symptomatic (abdominal pain, back pain, hypertension) and none had malperfusion or rupture. Prior aortic dilatation was present in eight patients (57%) and Marfan syndrome in one (7%). Two patients (14%) had iatrogenic IAD. Initial management was medical in 13 and endovascular aneurysm repair in one (symptomatic subacute, infrarenal dissection with small aneurysm). The median clinical and imaging follow-up was 6.7 years (range, 0-17 years). An abdominal aortic aneurysm occurred in eight (six at the time of IAD diagnosis, one at 2.9 years, and one at 5.2 years after diagnosis). The average growth in the entire cohort was 0.9 ± 0.4 cm, which translated to an average growth rate of 0.09 cm/year. Subsequent intervention was performed in two patients; for severe aortic stenosis with claudication in one (infrarenal aortic stenting) and increasing aortic size in one (open repair). One patient required reintervention (thrombolysis and stenting for endovascular aneurysm repair limb thrombosis). Survival for IAD at 1, 3, and 5 years was 93%, 85%, and 76%, respectively, compared with population controls at 98%, 85%, and 71%, respectively (long rank P = .38). Mortality was due to cardiovascular causes in three patients (21%) and no deaths were aortic related. Major adverse cardiac events occurred in five patients (36%) owing to heart failure.

CONCLUSIONS

IAD is rare. The initial management for asymptomatic patients is medical. The aortic growth rate is slow, with no aortic-related mortality and a low rate of aortic intervention. The overall mortality is similar to population controls. Heart failure and cardiac-related death are prevalent, suggesting that close cardiovascular care is needed in this patient population.

Single-center experience with Indigo aspiration thrombectomy for acute lower limb ischemia

OBJECTIVE

Acute lower limb ischemia (ALLI) is a challenging vascular emergency with notable morbidity. Aspiration mechanical thrombectomy (AMT) devices are an alternative approach to remove thrombus in the peripheral arterial system and to restore limb perfusion, but data are limited. We evaluated the outcomes of AMT for the treatment of ALLI at our institution.

METHODS

We performed a single-center retrospective review of patients with ALLI treated with Indigo (Penumbra Inc, Alameda, Calif) AMT device from 2014 to 2017. The primary outcome was technical success (restoration of blood flow with <50% residual thrombus without need for catheter-directed thrombolysis [CDT] or open surgery) as main treatment or adjunctive treatment (after failure of another modality). Indications, anatomic segments treated, outcomes, and complications were reviewed.

RESULTS

There were 41 patients (68% male, 32% female; mean age, 67 years; range, 27-90 years) who underwent 43 procedures. The cause of ALLI was embolism (18), native vessel thrombosis (13), bypass thrombosis (7), intraluminal thrombus due to pseudoaneurysm (1), stent thrombosis (1), intraprocedural embolization (1), recurrent thrombosis of native vessel (1), and chronic thrombosis (1). AMT was the main treatment in 29 cases and adjunctive in 14. Technical success was 52% (15/29) as main treatment and 50% (7/14) as adjunctive treatment. Thrombolysis was avoided in 53% of patients (23/43). There were six thrombotic recurrences, one after successful isolated AMT. The other five required multiple modalities after AMT failure. There were no 30-day deaths. Five patients required amputations, but only one after successful AMT. Complications included intraoperative distal embolization (two), access site hematoma (one), pseudoaneurysm (one), acute kidney injury (one), and spontaneous calf hematoma (one). There were no blood transfusions required or severe bleeding complications.

CONCLUSIONS

With an overall success rate of 51% in selected patients, the Indigo AMT device avoided the need for CDT or open surgery in about half of patients with ALLI. The device has a favorable safety profile, particularly in high-risk cases. Given its moderate effectiveness, the role of Indigo AMT in the management of ALLI will further be defined by the description of optimal technique, the determination of treatment indications, and a direct comparison with CDT.

Transfusion Timing and Postoperative Myocardial Infarction and Death in Patients Undergoing Common Vascular Procedures

BACKGROUND

Perioperative allogenic blood transfusions, specifically packed red bloods cells (pRBC), after vascular surgery procedures are modifiable risk factors that are associated with increased cardiovascular events and 30-day mortality. The aim of this study is to evaluate the effect of transfusion timing (intraoperative vs. postoperative) on the rate of postoperative myocardial infarction (POMI) and death.

METHODS

Six surgical and endovascular modules within the Vascular Quality Initiative (VQI) from 2013 to 2017 were reviewed at a single institution. Transfusion data on elective and urgent cases were abstracted and all patients who underwent inpatient procedures had routine postoperative troponin/ECG testing. The primary endpoint was POMI utilizing the American Heart Association's third universal definition for myocardial infarction. These criteria include the detection of a rise/and or fall of cTnT with at least one value above the 99th percentile and with at least one of the following 1) symptoms of acute myocardial ischemia, 2) new ischemic ECG changes, 3) development of pathological Q waves, 4) imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with ischemic etiology. The secondary endpoint was 30-day all-cause mortality. Multivariable logistic regression analysis was utilized to evaluate the risk of transfusions on POMI and death.

RESULTS

We identified 1,154 cases for analysis (299 abdominal aortic aneurysm [EVAR], 117 infrainguinal bypasses, 127 open abdominal aortic aneurysm [AAA], 41 suprainguinal bypasses, 168 thoracic endovascular aortic repair [TEVAR], and 402 peripheral vascular interventions). Overall, the POMI rate was 2% and mortality 1%. Rates of POMI differed by procedure type (P = 0.04), where infrainguinal bypass had the highest rate of POMI at 4%. Death rates did not vary by type of procedure (P = 0.89). Mean number of intraoperative pRBC and postoperative pRBC transfusion was higher for patients with POMI (intraop: 1.3 vs. 0.3, postop: 1.8 vs. 0.4, both P < 0.01) and death (intraop: 1.4 vs. 0.3, postop: 2.5 vs. 0.4, both P < 0.01). In addition, older age and coronary artery disease (CAD) were associated with POMI on univariate analysis. On multivariable analysis for POMI, CAD (odds ratio [OR] = 5.15, 95% confidence interval [CI] [2.00-13.24], P < 0.001), receiving both an intraoperative and postoperative transfusion (OR = 6.20, 95% CI [1.78-21.55], P < 0.01) as well as a postoperative transfusion only (OR = 5.70, 95% CI [1.81-17.94], P < 0.01) compared to no transfusion were associated with higher odds of POMI; however intraoperative transfusion only was not (OR = 3.42, 95% CI [0.88-13.31], P = 0.08). On multivariable analysis, increasing age of the patient was associated with higher odds of death (OR = 1.08, 95% CI [1.01-1.15], P = 0.02) and statin use was highly protective (OR = 0.27, 95% CI [0.10-0.74], P = 0.01), but any intraoperative or postoperative transfusion compared to no transfusion was not associated with death after adjustment.

CONCLUSIONS

In our series with routine postoperative troponin screening in the inpatient setting, the use of an isolated postoperative transfusion as well as cases requiring both an intraoperative and postoperative transfusion was associated with POMI. However, isolated intraoperative transfusion was not associated with POMI, and we did not identify an association of transfusion with 30-day mortality. These data suggest that the perioperative setting of transfusions is important in its impact on postoperative outcomes and needs to be accounted for when evaluating transfusion outcomes and indications.