Background: The effects of socioeconomic factors other than insurance status and race on outcomes following cardiac surgery are not well understood. We hypothesized that the Distressed Communities Index (DCI), a comprehensive socioeconomic ranking by zip code, would predict operative mortality following coronary artery bypass grafting (CABG). Methods: All patients who underwent isolated CABG (2010-2017) in the Virginia Cardiac Services Quality Initiative database were analyzed. The DCI accounts for unemployment, education level, poverty rate, median income, business growth, and housing vacancies, with scores ranging from 0 (no distress) to 100 (severe distress). Patients were stratified by DCI quartiles (I: 0-24.9, II: 25-49.9, III: 50-74.9, IV: 75-100) and compared. Hierarchical linear regression modeled the association between DCI and mortality. Results: A total of 19,756 CABG patients were analyzed, with mean PROM of 2.0±3.5%. Higher DCI scores were associated with increasing PROM. Overall operative mortality was 2.1% [n=424] and increased with increasing DCI quartile (I: 1.6% [95], II: 2.1% [77], III: 2.4% [114],

Staged hybrid TAAA repair, using a combination of proximal TEVAR with open distal repair, can be performed using established endovascular skills and technology coupled with traditional open aortic surgical techniques, with low surgical morbidity and mortality. In the midterm, staged hybrid TAAA repair was associated favorable survival, aortic remodeling, and freedom from reintervention.

Objective Repair of patients with extent I and II thoracoabdominal aortic aneurysms (TAAAs) is associated with significant morbidity and mortality, while repair of more distal extent III and IV TAAAs has a lower risk of mortality and paraplegia. Therefore, we describe an approach using thoracic endovascular repair (TEVAR) as the index operation to convert extent I and II TAAAs to extent III and IV TAAAs amenable to subsequent open aortic repair to minimize patient risk. Methods Between July 2007 and March 2012, 10 staged hybrid operations were performed to treat 1 extent I and 9 extent II TAAAs. Aortic aneurysm pathology included 5 chronic type B dissections, 3 acute type B dissections, and 2 penetrating aortic ulcers. Initially, the proximal descending thoracic aorta was repaired with TEVAR for coverage of the most proximal fenestration or penetrating ulcer, with 7 elective and 3 emergent repairs. Interval open distal aortic replacement was performed either in a short-term planned setting or for progressive dilation of the distal aortic segment. In the open repair, the proximal end of the graft was sewn directly to the distal end of the TEVAR and outer wall of the aorta. Results Average patient age was 48 years with the majority of patients male (60%). Risk factors included hypertension (80%), current tobacco use (50%), and Marfan syndrome (30%). Postoperative complications following TEVAR included endoleaks [type IA (n=1); type II (n=3)], pleural effusions (n=3), and acute kidney injury (n=1). Endovascular re-interventions were required in 3 cases. In dissection cases, persistent filling of the false lumen was common and associated with distal thoracic aortic dilation. Complications of open repair included acute kidney injury (n=2) but no cardiac, pulmonary, or neurologic morbidity. Median time between TEVAR and open repair was 14 weeks. Most importantly, there was no mortality or neurologic deficit after either procedure with a median follow up of 35 weeks. Conclusions A staged hybrid approach to extensive TAAAs combining proximal TEVAR followed by interval open distal TAAA repair is safe and appears to be an effective alternative to traditional open repair. This approach may decrease the significant morbidity associated with single stage open extent I and II TAAA repairs and may be applicable to many TAAA etiologies.

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Background While it is anticipated that decubitus ulcers (DU) are detrimental to outcomes following vascular operations, the contemporary influence of perioperative DU in vascular surgery remains unknown. Methods Using the National Impatient Survey (NIS), all adult patients who underwent vascular surgery were selected. Patients were stratified by the presence or absence (non-DU) of decubitus ulcer. Case-mix adjusted hierarchical mixed-models examined in-hospital mortality, the occurrence of any complication, and discharge disposition. Results A total of 538,808 cases were analyzed. DU was most prevalent among Caucasian, male, Medicare beneficiaries (p<0.001). DU patients also underwent more non-elective vascular surgery (p<0.001). Wound, infectious, and procedural complications were more common in patients with DU (p<0.001). Failure to rescue, defined as mortality following any complication, was more than doubled in DU (non-DU: 1.5%, DU: 3.2%, p<0.001). Similarly, unadjusted mortality was also doubled in patients undergoing vascular surgery with DU (non-DU: 3%, DU: 6%, p<0.001). Following risk adjustment among all patients, neither the presence of a DU nor specific ulcer staging increased the adjusted odds of death. Having a DU increased the adjusted odds of discharge to an intermediate care facility (OR 2.9, p<0.001). These patients also had 1.6 times the total charges compared to their non-DU cohort (non-DU: $49,460±281 vs. DU: $81,149±5855, p<0.001). Conclusions Contrary to common perception, perioperative decubitus ulcer does not adversely affect mortality following vascular surgery in patients proceeding to surgical intervention. Patients with decubitus ulcers are, however, at higher risk for complications and incur sizeable additional charges.