Background Recent reports have suggested that angioplasty +/− stenting (PTA/S) may have lower perioperative mortality than open surgery for revascularization of acute and chronic mesenteric ischemia (AMI and CMI). It is unclear if there has been nationwide adoption of this methodology or whether there is in fact a mortality benefit. Methods We identified all patients undergoing mesenteric revascularization, either surgical (bypass, endarterectomy, or embolectomy) or PTA/S from the Nationwide Inpatient Sample from 1988–2006. A diagnosis by ICD-9 coding of AMI or CMI was required for inclusion. We evaluated trends in management over this time period and compared in-hospital mortality and complications between surgical bypass and PTA/S for the years 2000–2006. Results From 1988 to 2006 there were 6,342 PTA/S and 16,071 open surgical repairs overall. PTA/S increased steadily over time surpassing all surgery for CMI in 2002. PTA/S for AMI has also increased and surpassed bypass in 2002 but has not surpassed all surgical procedures for AMI even in 2006. Mortality was lower after PTA/S than bypass for both CMI (3.7% vs 13%, P<0.01) and AMI (16% vs 28%, P<0.01). Bowel resection was more common after bypass than PTA/S for CMI (7% vs 3%, P<0.01) and this subgroup showed an increased in-hospital mortality for both repair types (54% and 25%). Conclusion PTA/S in being utilized with increasing frequency for revascularization of both CMI and AMI. Based on lower in-hospital mortality for patients as they are currently being selected, PTA/S is appropriate therapy for selected patients with CMI. Longitudinal data are needed to determine the durability of this benefit. The greater proportion of patients undergoing bowel resection with bypass for AMI suggests a more advanced level of ischemia in this group making comparison with PTA/S difficult. However, PTA/S may be useful in selected patients with AMI and appropriate anatomy. Further data with greater detail regarding symptomatology and anatomy will clarify appropriate patient selection.

OBJECTIVE With the expansion of elective abdominal aortic aneurysm (AAA) repair after the introduction of endovascular aneurysm repair (EVAR), there is a concern that even with a lower operative mortality there could be increasing number of aneurysm related deaths. To evaluate this, we looked at national trends in AAA repair volume as well as mortality after intact and ruptured AAA repair encompassing the introduction of EVAR. METHODS Patients with intact or ruptured AAA undergoing open repair or EVAR and all those with a diagnosis of ruptured AAA were identified within the 1993–2005 Nationwide Inpatient Sample database using ICD-9 diagnosis and procedure codes. The number of repairs, number of rupture diagnoses without repair, number of deaths, and associated mortality rates were measured for each year of the database. Outcomes (mean annual volumes) were compared from the pre-EVAR era (1993–1998) to the post-EVAR era (2001–2005). RESULTS Since introduction, EVAR increased steadily and accounted for 56% of repairs, yet only 27% of the deaths for intact repairs in 2005. The mean annual number of intact repairs increased from 36,122 in the pre-EVAR era to 38,901 in the post-EVAR era while the mean annual number of deaths related to intact AAA repair decreased from 1,693 pre-EVAR to 1,207 post-EVAR (P < .0001). Mortality for all intact AAA repair decreased from 4.0% to 3.1% (P < .0001) pre and post-EVAR but open repair mortality was unchanged (open repair 4.7% to 4.5%, P= .31; EVAR 1.3%). During the same time periods, mean annual number of ruptured repairs decreased from 2,804 to 1,846 and deaths from ruptured AAA repairs decreased from 2,804 to 1,846 (P < .0001). Mortality for ruptured AAA repair decreased from 44.3% to 39.9% (P < .0001) pre and post-EVAR (open repair 44.3% to 39.9%, P< .001; EVAR 32.4%). The overall mean annual number of ruptured AAA diagnoses (9,979 to 7,773, P < .0001) and overall mean annual deaths from a ruptured AAA decreased post-EVAR (5,338 to 3,901, P < .0001). CONCLUSIONS Since the introduction of EVAR, there has been a significant decrease in the annual number of deaths from both intact and ruptured AAA. This coincided with an increase in intact AAA repair after the introduction of EVAR and a decrease in ruptured AAA diagnosis and repair volume.

No abstract

Infrapopliteal angioplasty is a reasonable primary treatment for CLI patients with TASC A, B, or C lesions. Restenosis, reintervention, or amputation was higher in patients who were unsuitable candidates for bypass; however, an attempt at PTA may be indicated as an alternative to primary amputation. Although restenosis, reintervention, or amputation is high after tibial angioplasty for CLI, excellent limb salvage rates may be obtained with careful follow-up and reinterventions when necessary, including bypass in 15%.

INTRODUCTION AND OBJECTIVES The impact of risk factors upon perioperative mortality might differ for patients undergoing open versus endovascular repair (EVAR) of abdominal aortic aneurysms (AAA). In order to investigate this, we developed a differential predictive model of perioperative mortality after AAA repair. METHODS A total of 45,660 propensity score matched Medicare beneficiaries undergoing elective open or endovascular AAA repair from 2001–2004 were studied. Using half the dataset we developed a multiple logistic regression model for a matched cohort of open and EVAR patients and used this to derive an easily evaluable risk prediction score. The remainder of the dataset formed a validation cohort used to confirm results. RESULTS The derivation cohort included 11,415 open and 11,415 endovascular repairs. Perioperative mortality was 5.3% and 1.8% respectively. Independent predictors of mortality (RR, 95% CI) were open repair (3.2, 2.7–3.8), age (71–75 years 1.2, 0.9–1.6; 76–80 years 1.9, 1.4–2.5; >80 years 3.1, 2.4–4.2), female sex (1.5, 1.3–1.8), dialysis (2.6, 1.5–4.6), chronic renal insufficiency (2.0, 1.6–2.6), congestive heart failure (1.7, 1.5–2.1), and vascular disease (1.3, 1.2–1.6). There were no differential predictors of mortality across the two procedures. A simple scoring system was developed from a logistic regression model fit to both endovascular and open patients (area under the ROC curve of 72.6) from which low, medium, and high risk groups were developed. The absolute predicted mortality ranged from 0.7% for an EVAR patient ≤ 70 years of age with no comorbidities to 38% for an open patient > 80 with all the comorbidities considered. Although relative risk was similar among age groups, the absolute difference was greater for older patients (with higher baseline risk). CONCLUSIONS Mortality after AAA repair is predicted by comorbidities, sex, and age and these predictors have similar effects for both methods of AAA repair. This simple scoring system can predict repair mortality for both treatment options and thus may help guide clinical decisions.

Objectives-Patients undergoing lower extremity bypass are at high risk for surgical site infections (SSI). We examine lower extremity bypasses by graft origin and body mass index (BMI) classification to analyze differences in postoperative mortality and SSI occurrence. Methods-The 2005-2007National Surgical Quality Improvement Program (NSQIP), a multiinstitutional risk-adjusted database, was queried to compare perioperative mortality (30-day), overall morbidity, and SSIs after lower extremity arterial bypass for peripheral arterial disease. Bypass was stratified by graft origin as aorto-iliac, femoral, or popliteal. Patient demographics, comorbidities, operative, and post-operative occurrences were analyzed.

Objective To examine the modern epidemiology of abdominal aortic aneurysm (AAA) rupture and short-term AAA-related mortality after the introduction of endovascular aneurysm repair (EVAR). Background Prior epidemiologic studies have demonstrated stable rates of AAA repair, repair mortality, and AAA rupture. Recently, EVAR has been introduced as a less invasive treatment method and its use has expanded to over 75% of elective AAA repairs. Methods We identified Medicare beneficiaries undergoing AAA repair and those hospitalized with a ruptured AAA during the period 1995–2008 and calculated standardized annual rates of AAA-related deaths due to either elective repair or rupture. Results 338,278 patients underwent intact AAA repair over the study period. There were 69,653 patients with AAA rupture of whom 47,524 underwent repair. Intact repair rates increased substantially in those over age 80 (57.7 to 92.3 per 100,000, P<0.001), but decreased in those aged 65–74 (81.8 to 68.9, P<0.001). A decline in ruptures with and without repair was seen in all age groups. By 2008, 77% of all intact repairs and 31% of all rupture repairs were performed with EVAR (P<0.001). Operative mortality declined over the study period for both intact (4.9% to 2.4%, P<0.001) and ruptured (44.1% to 36.3%, P<0.001) AAA repair. Short-term AAA-related deaths decreased by more than half (26.1 to 12.1 per 100,000, P<0.001) with the greatest decline occurring in those over age 80 (53.7 to 27.3, P<0.001). Conclusions A recent decline in AAA rupture and short-term AAA-related mortality is demonstrated and likely related in part to the introduction and expansion of EVAR. This is due to decreased deaths from ruptures (with and without repair) and decreased mortality with intact repairs, particularly in patients over age 80.

For patients with a diagnosis of T(B)AD who undergo repair, the endovascular approach is being used for older patients with greater comorbidities, yet has reduced morbidity and in-hospital mortality. The use of endovascular stent graft repair for type B thoracic aortic dissection merits further longitudinal analysis.