Objective Medicare studies have shown increased perioperative mortality in women compared to men following endovascular and open AAA repair. However, a recent regional study of high-volume centers, adjusting for anatomy but limited in sample size, did not show sex to be predictive of worse outcomes. This study aims to evaluate sex differences after intact AAA repair in a national clinical registry. Methods The Targeted Vascular module of NSQIP was queried to identify patients undergoing EVAR or open repair for intact, infrarenal AAA from 2011–2014. Univariate analysis was performed using the Fisher Exact test and Mann-Whitney test. Multivariable logistic regression was utilized to account for differences in comorbidities, aneurysm details, and operative characteristics. Results We identified 6,661 patients (19% women) who underwent intact AAA repair (87% EVAR; women 83% vs. men 88%, P < .001). Women were older (median age 76 vs. 73, P < .001), had smaller aneurysms (median 5.4 cm vs. 5.5 cm, P < .001), and more COPD (22% vs. 17%, P < .001). Amongst patients undergoing EVAR, women had longer operative times (median 138 [IQR 103–170] vs. 131 [106–181] minutes, P < .01) and more often underwent renal (6.3% vs. 4.1%, P < .01) and lower extremity revascularization (6.6% vs. 3.8%, P < .01). After open repair, women had shorter operative time (215 [177–304] vs. 226 [165–264] minutes, P = .02), but women less frequently underwent lower extremity revascularization (3.1% vs. 8.2%, P = .03). Thirty-day mortality was higher in women after EVAR (3.2% vs. 1.2%, P < .001) and open repair (8.0% vs. 4.0%, P = .04). After adjusting for repair type, age, aneurysm diameter, and comorbidities, female sex was independently associated with mortality (odds ratio [OR] 1.7, 95% confidence interval [CI]: 1.1 – 2.6; P = .02) and major complications (OR 1.4, CI: 1.1 – 1.7; P < .01) after intact AAA repair. However, after adjusting for aortic size index rather than aortic diameter, the association between female sex and mortality (OR 1.5, CI: 0.98 – 2.4; P = .06) and major complications (OR 1.1, CI: 0.9 – 1.4; P = .24) was reduced. Conclusions Women were at higher risk for 30-day death and major complications after intact AAA repair. Some of this disparity may be explained by differences in aortic size index, which should be further evaluated to determine the ideal threshold for repair.

Objective Unplanned hospital readmissions following surgical interventions are associated with adverse events and contribute to increasing healthcare costs. Despite numerous studies defining risk factors following lower extremity bypass surgery, evidence regarding readmission after endovascular interventions is limited. This study aims to identify predictors of 30-day unplanned readmission following infrainguinal endovascular interventions. Methods We identified all patients undergoing an infrainguinal endovascular intervention in the Targeted Vascular module of the American College of Surgeons National Surgical Quality Improvement Program between 2012 and 2014. Perioperative outcomes were stratified by symptom status (chronic limb-threatening ischemia [CLI] vs. claudication). Patients who died during index admission, and those who remained in the hospital after 30 days, were excluded. Indications for unplanned readmission related to the index procedure were evaluated. Multivariable logistic regression was used to identify preoperative and in-hospital (during index admission) risk factors of 30-day unplanned readmission. Results 4449 patients underwent infrainguinal endovascular intervention, of which 2802 (63%) had CLI (66% tissue loss) and 1647 (37%) had claudication. The unplanned readmission rates for CLI and claudication patients were 16% (N=447) and 6.5% (N=107), respectively. Mortality after index admission was higher for readmitted patients compared to those not readmitted (CLI: 3.4% vs. 0.7%, P < .001; claudication: 2.8% vs. 0.1%, P < .01). Approximately 50% of all unplanned readmissions were related to the index procedure. Among CLI patients, the most common indication for readmission related to the index procedure was wound- or infection-related (42%), while patients with claudication were mainly readmitted for recurrent symptoms of peripheral vascular disease (28%). In patients with CLI, predictors of unplanned readmission included diabetes (OR: 1.3, 95% CI: 1.01–1.6), congestive heart failure (1.6, 1.1–2.5), renal insufficiency (1.7, 1.3–2.2), preoperative dialysis (1.4, 1.02–1.9), tibial angioplasty/stenting (1.3, 1.04–1.6), in-hospital bleeding (1.9, 1.04–3.5), in-hospital unplanned return to the operating room (1.9, 1.1–3.5), and discharge other than home (1.5, 1.1–2.0). Risk factors for those with claudication were dependent functional status (3.5, 1.4–8.7), smoking (1.6, 1.02–2.5), diabetes (1.5, 1.01–2.3), preoperative dialysis (3.6, 1.6–8.3), procedure time exceeding 120 minutes (1.8, 1.1–2.7), in-hospital bleeding (2.9, 1.2–7.4), and in-hospital unplanned return to the operating room (3.4, 1.2–9.4). Conclusions Unplanned readmission after endovascular treatment is relatively common, especially in patients with CLI, and is associated with substantially increased mortality. Awareness of these risk factors will help providers identify patients at high-risk who may benefit from early surveillance and prophylactic measures focused on decreasing postoperative complications may reduce the ra...

Objective Although an increasing number of patients with peripheral arterial disease undergo multiple revascularization procedures, the effect of prior interventions on outcomes remains unclear. The purpose of this study was to evaluate perioperative outcomes of bypass surgery in patients with and those without prior ipsilateral treatment. Methods Patients undergoing non-emergent infrainguinal bypass between 2011 and 2014 were identified in the NSQIP-Targeted Vascular module. After stratification by symptom status (chronic limb-threatening ischemia [CLTI] and claudication), patients undergoing primary bypass were compared to those undergoing secondary bypass. Within the secondary bypass group, further analysis compared prior bypass to prior endovascular intervention. Multivariable logistic regression analysis was used to establish the independent association between prior ipsilateral procedure and perioperative outcomes. Results A total of 7302 patients were identified, of which 4540 (62%) underwent primary bypass (68% for CLTI), 1536 (21%) underwent secondary bypass after a previous bypass (75% for CLTI), and 1226 (17%) underwent secondary bypass after a previous endovascular intervention (72% for CLTI). Prior revascularization on the same ipsilateral arteries was associated with increased 30-day major adverse limb event in patients with CLTI (9.8% vs. 7.4%; OR: 1.4, 95% CI: 1.1–1.7) and claudication (5.2% vs. 2.5%; 2.1, 1.3–3.5). Similarly, secondary bypass was an independent risk factor for 30-day major reintervention (CLTI: 1.4, 1.1–1.8; claudication: 2.1, 1.3–3.5), bleeding (CLTI: 1.4, 1.2–1.6; claudication: 1.7, 1.3–2.4), and unplanned reoperation (CLTI: 1.2, 1.0–1.4; claudication: 1.6, 1.1–2.1), whereas major amputation was increased in CLTI patients only (1.3, 1.0–1.8). Perioperative mortality was not significantly different in patients undergoing secondary compared to primary bypass (CLTI: 1.7% vs. 2.2%, P = .22; claudication: 0.4% vs. 0.6%, P = .76). Among secondary bypass patients with CLTI, those with prior bypass had higher 30-day reintervention rates (7.8% vs. 4.9%; OR: 1.5, 95% CI: 1.0–2.2), but fewer wound infections (7.3% vs. 12%; 0.6, 0.4–0.8) compared to patients with prior endovascular intervention. Conclusions Prior revascularization, in both patients with CLTI and claudication, is associated with worse perioperative outcomes compared to primary bypass. Furthermore, prior endovascular intervention is associated with increased wound infections, whereas those with prior bypass had higher reintervention rates. The increasing prevalence of patients undergoing multiple interventions stresses the importance of patient selection for initial treatment and should be factored into subsequent revascularization options in an effort to decrease adverse events.

Compared with NDM, IDDM is associated with similar perioperative and long-term mortality but a higher risk of incomplete wound healing, major amputation, and future RAS events, especially after a PTA/S-first approach. NIDDM, on the other hand, is associated with lower long-term mortality and few adverse limb events. Overall, these data demonstrate both the importance of distinguishing between diabetes types and the potential long-term benefit of a BPG-first strategy in appropriately selected IDDM patients with CLTI.

Compared with EVAR, patients undergoing open infrarenal AAA repair were significantly more likely to undergo 30-day reintervention, which could be related to higher open anatomic complexity and lower experience of the surgeon with open repair. Reintervention after both EVAR and OSR was associated with a >10-fold increase in postoperative mortality, emphasizing the need to minimize the complications associated with reintervention.

The Endurant stent graft system provides a safe, durable approach to treating infrarenal AAA. No patients experienced late rupture or aneurysm-related mortality, and only 1 in 16 patients underwent reintervention by 3 years. The rate of reintervention with the Endurant graft appears to be lower than other contemporary grafts, despite more liberal "Instructions For Use" parameters, but further research including direct graft comparisons will be necessary to guide appropriate graft selection.

Objectives Patients with contralateral carotid occlusion (CCO) have been excluded from randomized clinical trials because of a deemed ‘high-risk’ for adverse neurological outcomes with carotid endarterectomy (CEA). Evidence for this rationale is limited and conflicting. Therefore, we aimed to compare outcomes following CEA between patients with and without CCO, and varying degrees of contralateral carotid stenosis (CCS). Methods We identified patients undergoing CEA from 2003–2015 in the Vascular Study Group of New England (VSGNE) registry. Patients were stratified by preoperative symptom status and presence of CCO. Multivariable analysis was utilized to account for differences in demographics and comorbidities. Our primary outcome was 30-day stroke/death risk. Results We identified 15,487 patients undergoing CEA, of whom 10,377 (67%) were asymptomatic. In total 914 patients had CCO, of whom 681 (75%) were asymptomatic. Overall, 30-day stroke/death was 2.0% for symptomatic (CCO: 2.6%), and 1.1% for asymptomatic patients (CCO: 2.3%). After adjustment, including symptom status, CCO was associated with higher 30-day stroke/death (OR 2.1, 95% CI 1.4–3.3, P = .001), any in-hospital stroke (OR 2.8, 95% CI 1.7–4.6, P < .001), in-hospital ipsilateral stroke (OR 2.2, 95% CI 1.2–4.0, P = .02), in-hospital contralateral stroke (OR 5.1, 95% CI 2.2–11.4, P < .001), and prolonged length of stay (OR 1.6, 95% CI 1.3–1.9, P < .001). CCS of 80–99% was only associated with a prolonged length of stay (OR 1.3, 95% CI 1.1–1.6, P = .01), not with in-hospital stroke. Neither CCO nor CCS were associated with 30-day mortality. Conclusions Although CCO increases the risk of 30-day stroke/death, in-hospital strokes, and prolonged length of stay after CEA. Thirty-day stroke/death rates in symptomatic and asymptomatic patients with CCO remain within the recommended thresholds set by the 14 societies guideline. Thus, CCO should not qualify as a ‘high-risk’ criterion for CEA. Moreover, there is no evidence that patients with CCO have lower stroke/death rates after CAS than after CEA. We believe that CEA remains a valid and safe option for patients with CCO, and CCO should not be applied as criterion to promote carotid stenting per se.

In an effort to inhibit the response to vascular injury that leads to intimal hyperplasia, this study investigated the in vivo efficacy of intraluminal delivery of thrombospondin-2 (TSP-2) small interfering RNA (siRNA). Common carotid artery (CCA) balloon angioplasty injury was performed in rats. Immediately after denudation, CCA was transfected intraluminally (15 min) with one of the following: polyethylenimine (PEI)+TSP-2 siRNA, saline, PEI only, or PEI+control siRNA. CCA was analyzed at 24 h or 21 d by using quantitative real-time PCR and immunohistochemistry. TSP-2 gene and protein expression were significantly up-regulated after endothelial denudation at 24 h and 21 d compared with contralateral untreated, nondenuded CCA. Treatment with PEI+TSP-2 siRNA significantly suppressed TSP-2 gene expression (3.1-fold) at 24 h and TSP-2 protein expression, cell proliferation, and collagen deposition up to 21 d. These changes could be attributed to changes in TGF-β and matrix metalloproteinase-9, the downstream effectors of TSP-2. TSP-2 knockdown induced anti-inflammatory M2 macrophage polarization at 21 d; however, it did not significantly affect intima/media ratios. In summary, these data demonstrate effective siRNA transfection of the injured arterial wall and provide a clinically effective and translationally applicable therapeutic strategy that involves nonviral siRNA delivery to ameliorate the response to vascular injury.-Bodewes, T. C. F., Johnson, J. M., Auster, M., Huynh, C., Muralidharan, S., Contreras, M., LoGerfo, F. W., Pradhan-Nabzdyk, L. Intraluminal delivery of thrombospondin-2 small interfering RNA inhibits the vascular response to injury in a rat carotid balloon angioplasty model.