Long-term outcomes of carotid endarterectomy vs transfemoral carotid stenting in a Medicare-matched database.

BACKGROUND: Carotid endarterectomy (CEA) is associated with lower risk of perioperative stroke compared with transfemoral carotid artery stenting (TFCAS) in the treatment of carotid artery stenosis. However, there is discrepancy in data regarding long-term outcomes. We aimed to compare long-term outcomes of CEA vs TFCAS using the Medicare-matched Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database. METHODS: We assessed patients undergoing first-time CEA or TFCAS in Vascular Quality Initiative Vascular-Vascular Implant Surveillance and Interventional Outcomes Network from January 2003 to December 2018. Patients with prior history of carotid revascularization, nontransfemoral stenting, stenting performed without distal embolic protection, multiple or nonatherosclerotic lesions, or concomitant procedures were excluded. The primary outcome of interest was all-cause mortality, any stroke, and a combined end point of death or stroke. We additionally performed propensity score matching and stratification based on symptomatic status. RESULTS: A total of 80,146 carotid revascularizations were performed, of which 72,615 were CEA and 7531 were TFCAS. CEA was associated with significantly lower risk of death (57.8% vs 70.4%, adjusted hazard ratio [aHR], 0.46; 95% confidence interval [CI], 0.41-0.52; P < .001), stroke (21.3% vs 26.6%; aHR, 0.63; 95% CI, 0.57-0.69; P < .001) and combined end point of death and stroke (65.3% vs 76.5%; HR, 0.49; 95% CI, 0.44-0.55; P < .001) at 10 years. These findings were reflected in the propensity-matched cohort (combined end point: 34.6% vs 46.8%; HR, 0.53; 95% CI, 0.46-0.62) at 4 years, as well as stratified analyses of combined end point by symptomatic status (asymptomatic: 63.2% vs 74.9%; HR, 0.49; 95% CI, 0.43-0.58; P < .001; symptomatic: 69.9% vs 78.3%; HR, 0.51; 95% CI, 0.45-0.59; P < .001) at 10 years. CONCLUSIONS: In this analysis of North American real-world data, CEA was associated with greater long-term survival and fewer strokes compared with TFCAS. These findings support the continued use of CEA as the first-line revascularization procedure.

Association Between Conduit Type and Outcomes After Open Repair of Popliteal Artery Aneurysms.

INTRODUCTION: Prior studies have demonstrated acceptable midterm outcomes with prosthetic conduits for above-knee bypass for occlusive disease in patients with inadequate segment great saphenous vein (GSV). In this study we aimed to investigate whether this holds true for open repair of popliteal artery aneurysms (PAA). METHODS: We queried the Vascular Quality Initiative data for patients who underwent open PAA repair (OPAR). We divided the cohort into three groups based on the conduit used: GSV, other autologous veins, or prosthetic graft. Study outcomes included primary patency, freedom from major amputation, amputation-free survival, and overall survival at 1 y. Kaplan-Meier survival estimates, log-rank tests and multivariable Cox regression were used to compare outcomes between study groups. RESULTS: A total of 4016 patients underwent bypass for PAA from January 2010 to October 2021. The three cohorts were significantly different in many demographic and clinical characteristics. The adjusted odds of postoperative amputation among symptomatic patients were 3-fold higher for prosthetic conduits compared to the GSV (odds ratio, 3.20; 95% CI, 1.72-5.92; P < 0.001). For the 1-y outcomes, the adjusted risk of major amputation was almost 3-fold higher for patients with symptomatic disease undergoing bypass with prosthetic conduits (hazard ratio [HR], 2.97; 95% CI, 1.35-6.52; P = 0.007). When compared with GSV, prosthetic conduits were associated with 96% increased risk of death when used for repair in symptomatic patients (adjusted hazard ratio (aHR), 1.96; 95% CI, 1.29-2.97; P = 0.002) but no significant association with mortality in asymptomatic patients (aHR, 0.83; 95% CI, 0.37-1.87; P = 0.652). When compared with GSV, prosthetic conduits were associated with a 2-fold increased risk of 1-y major amputation or death when used for repair in symptomatic patients (aHR, 2.03; 95% CI, 1.40-2.94; P < 0.001) but no significant association with mortality in asymptomatic patients (aHR, 0.91; 95% CI, 0.42-1.98; P = 0.816). Comparing bypass with other veins to the GSV among patients with symptomatic disease, there was no statistically significant difference in major amputation risk (HR; 2.44; 95% CI, 0.55-10.82; P = 0.242) and no difference in the adjusted risk of all-cause mortality (aHR, 0.77; 95% CI, 0.26-2.44; P = 0.653). There were no differences in the adjusted risk of loss of primary patency comparing other veins to GSV (HR, 1.53; 95% CI, 0.85-2.76; P = 0.154) and prosthetic conduits to GSV (HR, 0.85; 95% CI, 0.57-1.26; P = 0.422). CONCLUSIONS: This large study shows that among patients undergoing OPAR, 1-y primary patency does not differ between conduit types. However, prosthetic conduits are associated with significantly higher risk of amputation and death compared to GSV among symptomatic patients. Though non-GSV autologous veins are less often used for OPAR, they have comparably acceptable outcomes as GSV.

Novel Risk Score Calculator for Perioperative Mortality after EVAR with Incorporation of Anatomical Factors.

BACKGROUND: Hostile proximal aortic neck anatomy has been associated with an increased risk of perioperative mortality after endovascular aneurysm repair (EVAR). However, all available mortality risk prediction models after EVAR lack neck anatomic associations. The aim of this study is to develop a preoperative prediction model for perioperative mortality after EVAR incorporating important anatomic factors. METHODS: Data were obtained from the Vascular Quality Initiative database on all patients who underwent elective EVAR between January 2015 and December 2018. A stepwise multivariable logistic regression analysis was implemented to identify independent predictors and develop a risk calculator for perioperative mortality after EVAR. Internal validation was done using bootstrap of 1,000 reps. RESULTS: A total of 25,133 patients were included, of whom 1.1% (N = 271) died within 30 days or before discharge. Significant preoperative predictors of perioperative mortality were age (odds ratio [OR], 1.053; 95% confidence interval [CI], 1.050-1.056; P < 0.001), female sex (OR, 1.46; 95% CI, 1.38-1.54; P < 0.001), chronic kidney disease (OR, 1.65; 95% CI, 1.57-1.73; P < 0.001), chronic obstructive pulmonary disease (OR, 1.86; 95% CI, 1.77-1.94; P < 0.001), congestive heart failure (OR, 2.02; 95% CI, 1.91-2.13, P < 0.001), aneurysm diameter ≥ 6.5 cm (OR, 2.35; 95% CI, 2.24-2.47, P < 0.001), proximal neck length < 10 mm (OR, 1.96; 95% CI, 1.81-2.12; P < 0.001), proximal neck diameter ≥ 30 mm (OR, 1.41; 95% CI, 1.32-1.5; P < 0.001), infrarenal neck angulation ≥ 60° (OR, 1.27; 95% CI, 1.18-1.26; P < 0.001), and suprarenal neck angulation ≥ 60° (OR, 1.26; 95% CI, 1.16-1.37; P < 0.001). Significant protective factors included aspirin use (OR, 0.89; 95% CI, 0.85-0.93; P < 0.001) and statin intake (OR, 0.77; 95% CI, 0.73-0.81; P < 0.001). These predictors were incorporated to build an interactive risk calculator of perioperative mortality after EVAR (C-statistic = 0.749). CONCLUSIONS: This study provides a prediction model for mortality following EVAR that incorporates aortic neck features. The risk calculator can be used to weigh risk/benefit ratio when counseling patients preoperatively. Prospective use of this risk calculator may show its benefit in long-term prediction of adverse outcomes.

The Impact of Endovascular Repair of Abdominal Aortic Aneurysms on Vascular Surgery Training in Open Aneurysm Repair.

BACKGROUND: Since the introduction of endovascular aneurysm repair (EVAR) in 1992, the number of open AAA repair (OAR) cases continue to decline. The consequence of reduced OAR cases raises valid concerns related to patient safety and the future training of vascular surgeons that need to be appropriately addressed. Our objective is to analyze trends in OAR and EVAR cases and to assess their implications on the quality of vascular surgery training. METHODS: We analyzed the Accreditation Council for Graduate Medical Education (ACGME) case log database for total clinical experience in OAR and EVAR for graduating vascular surgery fellows (VSFs) finishing 5 + 2 programs between 2002 and 2019 and vascular surgery integrated residents (VSRs) between 2013 and 2019. VSF case totals were calculated by combining average total cases of open and endovascular supra- and infrarenal AAA repair during fellowship years combined with total cases performed during their general surgery residency. VSR case totals included only the cases performed during the 5-year residency period. Isolated Iliac and thoracic aortic aneurysms were excluded from our analysis. RESULTS: The average number of OAR cases per trainee has decreased by 60% (from 36.9 to 14.7) with a rate of 1.4 cases per year (P < 0.001) for VSF. Meanwhile, EVAR average cases have increased by 102% (from 22 to 44.4). However, there were 2 different trends exhibited with EVAR over the study period. Between 2002 and 2007, EVAR cases tended to increase by 5.9 cases per year (P < 0.001). Whereas, between 2007 and 2019, there was a slightly decreased trend in EVAR cases by 0.3 cases per year (P = 0.01). For VSR, while no significant trend was observed in the mean number of OAR cases (Coef. -0.3, P = 0.2) due to the limited time frame, the proportion of open cases was significantly lower compared to endovascular cases. Additionally, there were 2 different trends exhibited with EVAR over the study period. Between 2013 and 2015, EVAR cases tended to increase by 1.7 cases per year (P = 0.1). Whereas, between 2015 and 2019, there was a slightly decreased trend in EVAR cases by 0.2 cases per year (P = 0.007). CONCLUSIONS: A significant reduction in average OAR cases and an increase in EVAR cases were observed over the study period. Vascular surgery training programs may need to introduce further training programs in open surgical repair to ensure vascular surgery trainees have the required technical skills and expertize to perform such a high-risk procedure safely and independently.

Impact of Flow Reversal Duration on Neurological Outcomes of Transcarotid Artery Revascularization (TCAR).

BACKGROUNDS: Flow reversal is a key component of transcarotid artery revascularization (TCAR). However, the impact of flow reversal duration on neurological outcomes and the duration of flow reversal which optimizes TCAR's outcomes is not known. We evaluated the association of flow reversal time with the intraoperative and postoperative neurological outcomes of TCAR. METHODS: We studied all patients undergoing TCAR from September 2016 to October 2021. The exposure of interest was the duration of flow reversal. Multivariable logistic and fractional polynomial models were used to study the impact of flow reversal duration on in-hospital stroke, intraoperative neurological change/intolerance and stroke/death following TCAR and to identify the flow reversal time above which significant perioperative neurological events occur. RESULTS: The study included 19,462 patients with mean age of 73.4 years who were mostly Caucasian (91%) and male (63%). The mean flow reversal time was 10.7 minutes, and the overall stroke rate was 1.4%. The odds of intraoperative neurological change increased by 3.6% per minute increase in flow reversal time (odds ratio (OR), 1.04; 95%, 1.01-1.06; P < 0.002). Flow reversal duration >10 minutes was associated with 78% increased odds of neurological changes compared to flow reversal duration <10 minutes. There was no significant association between flow reversal duration and stroke, and stroke/death in the first 5 minutes after initiation of flow reversal. The odds of stroke increased by 2.7% per minute increase in flow reversal time >5 minutes (OR, 1.03; 95%, 1.01-1.04; P < 0.001), with flow reversal duration >10 minutes associated with 38% increased odds of stroke compared to flow reversal duration ≤10 minutes (OR, 1.37, 95% confidence interval (CI), 1.09-1.73, P = 0.006). The odds of stroke/death increased by 2.5% per minute increase in flow reversal time >5 minutes (OR, 1.03; 95%, 1.01-1.04; P < 0.001). Flow reversal duration >10 minutes was associated with 25% increased odds of stroke/death compared to flow reversal duration <10 minutes (OR, 1.25, 95% CI, 1.01-1.53, P = 0.038). Symptomatic status did not modify outcomes. CONCLUSIONS: Our findings suggest that outcomes following TCAR are optimal if the duration of flow reversal is minimized. A clinical cutoff time of 10 minutes is suggested by this study and recommended as a guide. Further studies targeted at the flow reversal component of TCAR are needed to solidify the evidence regarding the clinical effects of temporarily induced retrograde cerebral blood flow during TCAR.

Association of Renin-Angiotensin-Aldosterone System Inhibitor Usage Patterns with Midterm Amputation-Free Survival after Lower Extremity Bypass for Peripheral Arterial Disease.

BACKGROUND: Different renin-angiotensin-aldosterone system inhibitor (RAASI) usage patterns exist among patients undergoing lower extremity bypass (LEB) for peripheral arterial disease. We studied the association of RAASI usage patterns with LEB outcomes to determine which pattern is associated with improved survival after LEB. METHODS: We evaluated peripheral arterial disease patients who underwent LEB between January 2014 and December 2018 in the Vascular Quality Initiative-Medicare matched database. Study cohorts included no RAASI use, preoperative RAASI use only, postoperative RAASI use only, and continuous RAASI use both preoperatively and postoperatively. Logistic and Cox regression was used to adjust for potential confounders. Primary outcome was 2-year amputation-free survival (AFS). RESULTS: Of 19,012 patients included, 1,574 (8.3%) were on RAASIs preoperatively only, 1,051 (5.5%) postoperatively only, and 8,484 (45.2%) continuously. Compared to no RAASI use, isolated preoperative RAASI use was associated with 2.8-fold increased odds of 30-day mortality (adjusted Odds Ratio, 2.75; 95% confidence interval [CI], 2.15-3.51; P < 0.001) whereas continuous RAASI use had 56% lower odds of 30-day mortality (adjusted Odds Ratio, 0.44; 95% CI, 0.34-0.58; P < 0.001). Two-year AFS was 63.2% for no RAASI use and 60.4%, 66.2%, and 73.4% for preoperative, postoperative, and continuous RAASI use, respectively (P < 0.001). While no RAASI use and postoperative RAASI use had comparable adjusted risks of 2-year major amputation or death (adjusted Hazard Ratio [aHR], 0.94; 95% CI, 0.83-1.06; P = 0.312), this risk was 14% higher for preoperative RAASI use only (aHR, 1.14; 95% CI, 1.04-1.26; P = 0.006) and 23% lower for continuous RAASI use (aHR, 0.77; 95% CI, 0.72-0.82; P < 0.001). CONCLUSIONS: Isolated preoperative RAASI use was associated with worse 30-day mortality and 2-year AFS, while continuous RAASI use was associated with improved 30-day mortality and 2-year AFS. Optimum survival benefit may be derived from continuous RAAS inhibition in the preoperative and postoperative periods.

Anemia is associated with higher mortality and morbidity after thoracic endovascular aortic repair.

BACKGROUND: It is uncertain whether preoperative anemia is independently associated with thoracic endovascular aortic repair (TEVAR) outcomes. Using a national vascular surgery database, we evaluated the associations between preoperative anemia and 30-day mortality, postoperative complications, and 1-year survival for patients undergoing TEVAR. METHODS: We retrospectively analyzed all patients in the Vascular Quality Initiative who had undergone TEVAR for aortic dissection, aortic aneurysm, penetrating aortic ulcer, hematoma, or thrombus between January 2011 and December 2019. We excluded patients with a ruptured aneurysm, traumatic dissection, emergent repair, treated aorta distal to zone 5, polycythemia, transfusion of >4 U of packed red blood cells intraoperatively or postoperatively, and missing data on hemoglobin level or surgical indications. The final study cohort was dichotomized into two groups: normal/mild anemia (women, ≥10 g/dL; men, ≥12 g/dL) and moderate/severe anemia (women, <10 g/dL; male, <12 g/dL). Propensity scores by stratification were used to control for confounding in the analysis of the association between the outcomes of 30-day mortality, postoperative complications, and 1-year survival and a binary indicator variable of moderate/severe anemia vs normal/mild anemia. Kaplan-Meier analysis and log-rank tests were used to compare the 1-year survival between the two groups. A Cox regression model was fitted to assess the associations between anemia and survival outcomes. RESULTS: A total of 3391 patients were analyzed, 958 (28.3%) of whom had had moderate/severe anemia. After adjustment for multiple clinical factors using propensity score stratification, moderate/severe anemia was associated with a 141% increased odds of 30-day mortality (adjusted odds ratio [aOR], 2.41; 95% confidence interval [CI], 1.15-5.05; P = .019), 58% increased odds of any in-hospital complication (aOR, 1.58; 95% CI, 1.17-2.13; P = .003), 281% increased odds of intraoperative transfusion (aOR, 3.81; 95% CI, 2.68-5.53; P < .001). In addition, moderate/severe anemia was associated with significantly worse survival within the first year after TEVAR (log-rank P < .001; 1-year survival rate using Kaplan-Meier estimates, 86.4% ± 1.3% standard error vs 92.5% ± 0.6% standard error) and with an increased risk of mortality in the first postoperative year (adjusted hazard ratio, 1.81; 95% CI, 1.16-2.82; P = .009). CONCLUSIONS: We found that moderate or severe anemia is associated with significantly increased odds of mortality, postoperative complications, and worse 1-year survival after TEVAR. Future studies are needed to evaluate the effect of anemia correction on the outcomes of TEVAR.

Loss of follow-up after carotid revascularization is associated with worse long-term stroke and death.

OBJECTIVES: Society for Vascular Surgery practice guidelines recommend surveillance with duplex ultrasound scanning at baseline (within 3 months from discharge), every 6 months for 2 years, and annually afterward following carotid endarterectomy or carotid artery stenting. There is a growing concern regarding the significance of postoperative follow-up after several vascular procedures. We sought to determine whether 1-year loss to follow-up (LTF) after carotid revascularization was associated with worse outcomes in the Vascular Quality Initiative (VQI) linked to Vascular Implant Surveillance and Interventional Outcomes Network (VISION) database. METHODS: All patients who underwent carotid revascularization in the VQI VISION database between 2003 and 2016 were included. LTF was defined as failure to complete 1-year follow-up in the VQI long-term follow-up dataset. Data about stroke and mortality were captured in the VISION dataset using a list of Current Procedural Terminology, International Classification of Diseases (Ninth Revision), and International Classification of Diseases (Tenth Revision) codes linked to index procedures in VQI. Kaplan-Meier life-table methods and Cox proportional hazard modeling were used to compare 5- and 10-year outcomes between patients with no LTF and those who were LTF. RESULTS: A total of 58,840 patients were available for analysis. The 1-year LTF rate was 43.8%. Patients who were LTF were older and more frequently symptomatic, with chronic obstructive pulmonary diseases, chronic kidney diseases, and congestive heart failure. Also, patients who underwent carotid artery stenting were more likely to be LTF compared with carotid endarterectomy patients (54.5% vs 42.3%; P < .001). The incidence of postoperative (30 days) stroke was higher in the LTF group (2.9% vs 1.7%; P < .001). Cox regression analysis revealed that LTF was associated with an increased risk of long-term stroke at 5 years (hazard ratio [HR]: 1.4, 95% confidence interval [CI]: 1.2-1.6; P < .001) and 10 years (HR: 1.3, 95% CI: 1.2-1.5; P < .001). It was also associated with significantly higher mortality at 5 years (HR: 2.5, 95% CI: 2.3-2.8; P < .001) and 10 years (HR: 2.2, 95% CI: 1.9-2.5; P < .001). Stroke or death was significantly worse in the LTF group at 5 years (HR: 2.3, 95% CI: 2.1-2.5; P < .001) and up to 10 years (HR: 2.02, 95% CI: 1.8-2.3; P < .001). CONCLUSIONS: One-year follow-up after carotid revascularization procedures was found to be associated with better stroke- and mortality-free survival. Surgeons should emphasize the importance of follow-up to all patients who undergo carotid revascularization, especially those with multiple comorbidities and postoperative neurological complications.

Revision of Aneurysmal Arteriovenous Access with Immediate Use Graft Is Safe and Avoids Prolonged Use of Tunneled Hemodialysis Catheters.

BACKGROUND: Aneurysmal arteriovenous fistulas (AVF) can pose a difficult treatment dilemma for the vascular surgeons. Prolonged tunneled dialysis catheters (TDCs) in patients requiring long-term dialysis are associated with significantly increased mortality compared to AVF. We aimed to elucidate the outcomes of aneurysmal arteriovenous (AV) access revision with aneurysm resection and Artegraft® (LeMaitre, New Brunswick, NJ) Collage Vascular Graft placement to avoid prolonged use of TDCs. METHODS: We reviewed all patients with aneurysmal AV access in whom the access was revised with aneurysm resection and jump graft placement at a single institution from 2018 to 2021. Outcomes were time to cannulation, reintervention rates, time to reintervention, and patency (primary, primary assisted, and secondary). Patency rates were estimated with Kaplan-Meier Survival analysis. RESULTS: A total of 51 revised aneurysmal AV accesses in 51 patients were studied, of which 23.5% (n = 12) had perioperative TDC placement. Three patients were done for emergent bleeding. The cohort was 62.8% male (n = 32) with a median age of 58 years (interquartile range: 49-67). Most patients had brachiocephalic AVF (n = 37 [72.6%]). The median follow-up time was 280 days. The median time to cannulation was 2 days. Time to cannulation was significantly longer in patients with perioperative TDC as compared with those without TDC (24 days vs. 2 days, P < 0.001). Reintervention was required in 41.2% of patients (n = 21), at median time of 47 days. At 30, 90, 180, and 365 days, primary patency rates were 84.3%, 78.3%, 66.6%, and 54.9%; primary assisted patency rates were 94.1%, 88.1%, 79.4%, and 79.4%; and secondary patency rates were 100%, 97.8%, 91.6%, and 91.6%, respectively. CONCLUSIONS: The revision of aneurysmal AV access (urgent or elective) with Artegraft as jump graft is safe, with acceptable short- and mid-term patency results. This allows dialysis patients to continue to have a functional access, decreasing the need for a tunneled catheter and reducing the associated risk of sepsis and increased mortality. This should be considered for all patients with aneurysmal, dysfunctional fistulas to maintain AV access and avoid TDC placement.

Role of Renin-Angiotensin-Aldosterone System Inhibition in Patients Undergoing Carotid Revascularization.

Background Previous data suggest that using renin-angiotensin-aldosterone system inhibitors (RAASIs) improves survival in patients with cardiovascular diseases. We sought to investigate the association of different patterns of use of RAASIs on perioperative and 1-year outcomes following carotid revascularization. Methods and Results We investigated patients undergoing carotid revascularization, either with carotid endarterectomy or transfemoral carotid artery stenting, in the VQI (Vascular Quality Initiative) VISION (Vascular Implant Surveillance and Interventional Outcomes Network) data set between 2003 and 2018. We divided our cohort into 3 groups: (1) no history of RAASI intake, (2) preoperative intake only, and (3) continuous pre- and postoperative intake. The final cohort included 73 174 patients; 44.4% had no intake, 50% had continuous intake, and 5.6% had only preoperative intake. Compared with continuous intake, preoperative and no intake were associated with higher odds of postoperative stroke (odds ratio [OR], 1.7 [95% CI, 1.5-1.9]; P<0.001; OR, 1.1 [95% CI, 1.03-1.2]; P=0.010); death (OR, 4.8 [95% CI, 3.8-6.1]; P<0.001; OR, 1.9 [95% CI, 1.6-2.2]; P<0.001); and stroke/death (OR, 2.05 [95% CI, 1.8-2.3]; P<0.001; OR, 1.2 [95% CI, 1.1-1.3]; P<0.001), respectively. At 1 year, preoperative and no intake were associated with higher odds of stroke (hazard ratio [HR], 1.4 [95% CI, 1.3-1.6]; P<0.001; HR, 1.15, [95% CI, 1.08-1.2]; P<0.001); death (HR, 1.7 [95% CI, 1.5-1.9]; P<0.001; HR, 1.3 [95% CI, 1.2-1.4]; P<0.001); and stroke/death (HR, 1.5 [95% CI, 1.4-1.7]; P<0.001; HR, 1.2 [95% CI, 1.17-1.3]; P<0.001), respectively. Conclusions Compared with subjects discontinuing or never starting RAASIs, use of RAASIs before and after carotid revascularization was associated with a short-term stroke and mortality benefit. Future clinical trials examining prescribing patterns of RAASIs should aim to clarify the timing and potential to maximize the protective effects of RAASIs in high-risk vascular patients.

Outcomes of thoracic endovascular aortic repair for uncomplicated type B dissections based on chronicity.

OBJECTIVE: The long-term results of thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection (uTBAD) have been associated with improved aorta-specific survival and delayed disease progression compared with medical therapy alone. In 2020, the Society for Vascular Surgery (SVS) and Society for Thoracic Surgeons (STS) reported new reporting standards and classification for TBAD. We assessed the effectiveness of TEVAR in the treatment of uTBAD stratified by the updated classification using the Vascular Quality Initiative database. METHODS: The Vascular Quality Initiative registry was queried for patients who had undergone TEVAR for uTBAD from August 2014 to November 2020. We analyzed the outcomes stratified by the SVS/STS reporting standards. The cohort was then grouped and compared using the updated chronicity classification (hyperacute, <24 hours; acute, 1-14 days; subacute, 15-90 days; and chronic, >90 days) and univariable methods (χ2, analysis of variance), multivariable logistic regression, and survival analysis (Kaplan-Meier, Cox regression). RESULTS: Of 1476 TEVARs, 121 (8.2%) were for hyperacute, 833 (56.4%) for acute, 316 (21.4%) for subacute, and 206 (14.0%) for chronic uTBAD. The rates of in-hospital stroke for hyperacute and acute uTBAD were significantly higher than was the rate for chronic uTBAD. The rate of spinal cord ischemia (SCI) was significantly higher for hyperacute and subacute uTBAD than for chronic uTBAD but not for acute vs chronic uTBAD. After multivariable adjustment, no significant difference was found in the 30-day mortality between the four groups. However, the adjusted stroke risk was more than sixfold higher for hyperacute uTBAD than for chronic uTBAD (odds ratio [OR], 6.78; 95% confidence interval [CI], 1.83-25.17; P = .004) and more than threefold higher for acute than for chronic uTBAD (OR, 3.42; 95% CI, 1.04-11.24; P = .043). The adjusted risk of SCI was also significantly higher for hyperacute and subacute than for chronic uTBAD (OR, 19.17; 95% CI, 2.42-151.90; P = .005; and OR, 8.64; 95% CI, 1.11-67.21; P = .039, respectively) but not for acute vs chronic uTBAD (OR, 6.95; 95% CI, 0.93-51.88; P = .059). The risk of postoperative reintervention was threefold higher for hyperacute vs chronic uTBAD (OR, 3.02; 95% CI, 1.19-7.69; P = .02). The Kaplan-Meier survival estimates revealed that the 1-year survival rate for hyperacute, acute, subacute, and chronic uTBAD was 83.2%, 87.2%, 92.3%, and 92.9%, respectively (P = .010). However, no significant differences were found in the hazard of 1-year mortality after adjustment for potential confounders. CONCLUSIONS: Using the updated SVS/STS chronicity classification, we found an increased risk of perioperative stroke, SCI, and the need for reintervention after TEVAR for uTBAD in the hyperacute periods compared with the chronic period. The updated classification should be incorporated into all future study designs for TEVAR trials. We would recommend avoiding TEVAR for uTBAD in the hyperacute phase.

Open Repair Versus Endovascular Repair in the Treatment of Symptomatic Popliteal Artery Aneurysms.

BACKGROUND: Endovascular and open surgical modalities are currently used to treat popliteal artery aneurysms (PAA). However, there is limited data on the comparative durability of both repairs to guide physicians especially in the treatment of patients presenting symptomatic. We aimed to study the comparative effectiveness of endovascular PAA repair (EPAR) versus open PAA repair (OPAR). METHODS: The vascular quality initiative (VQI)-Medicare linked database was queried for patients with symptomatic PAA who underwent OPAR or EPAR from January 2010 to December 2018. Kaplan-Meier estimates, log-rank tests and multivariable Cox proportional hazard regression were employed to study the outcomes of amputation free survival (AFS), freedom from first reintervention, freedom from major amputation, and overall survival in 2 years following the index procedure. RESULTS: A total of 1,375 patients were studied, of which 23.7% (n = 326) were treated with EPAR. Patients treated with OPAR were younger, less likely to have coronary artery disease (CAD) and chronic kidney disease (CKD), but more likely to be smokers and to present with acute lower extremity ischemia. OPAR treated patients had better 2-year AFS (84.5% vs. 72.5%, P < 0.001) and overall survival (86.2% vs. 74.7%, P < 0.001). Freedom from major amputation at 2 years were comparable between EPAR and OPAR (95.5% vs. 97.7%, P = 0.164) in the overall cohort. Within the sub cohort of patients with acute limb ischemia, freedom from major amputation was significantly higher for OPAR compared to EPAR (97.4% vs. 90.6%, P = 0.021). After adjustment for confounders, OPAR was associated with decreased risk of amputation or death (aHR, 0.62; 95% CI, 0.48-0.80; P < 0.001) and mortality (aHR, 0.63; 95% CI, 0.48-0.81; P < 0.001) at 2 years. OPAR and EPAR had comparable adjusted risk of 2-year major amputation in the overall cohort. However, for patients presenting with acute limb ischemia OPAR was associated with 72% lower risk of 2-year major amputation compared to EPAR (aHR, 0.28; 95% CI, 0.10-0.83; P = 0.021). CONCLUSIONS: In this multi-institutional observational study of symptomatic popliteal aneurysms, OPAR was associated with significantly better amputation free and overall survival compared to EPAR. For patients with acute limb ischemia, OPAR was associated with reduced risk of amputation. These findings suggest that OPAR may be superior to EPAR in the treatment of symptomatic PAA. A consideration of OPAR as first line definitive treatment for symptomatic PAA patients who are good surgical candidates is suggested.

Female sex portends increased risk of major amputation following surgical repair of symptomatic popliteal artery aneurysms.

OBJECTIVE: Popliteal artery aneurysms (PAAs) are rare in women, with only ∼5% of all PAAs occurring in women. The aim of the present study was to investigate whether sex disparities exist for patients treated with open PAA repair. METHODS: We reviewed all patients with PAAs who had undergone open PAA repair in the Vascular Quality Initiative from January 2010 to July 2021. Univariate analyses and multivariable logistic or Cox regression analyses controlling for potential confounders were performed. The study outcomes included primary patency, major amputation, overall survival, and amputation-free survival at 1 year. RESULTS: The study included 3807 adult patients, of whom 160 were women (4.2%). The female patients were younger (age, 66.1 years vs 68.3 years; P = .012) and less likely to have coronary artery disease (14.5% vs 23.4%; P = .009). However, the women were more likely to be taking aspirin (69.2% vs 60.4%; P = .019) and statins (67.8% vs 60.4%; P < .001) and to undergo repair for symptomatic disease (77.5% vs 64.1%; P = .001). No difference was found between the women and men in primary patency (95.2% vs 90.8%; P = .230) and overall survival (94.3% vs 96.1%; P = .270). Amputation-free survival was lower for women than for men (91.4% vs 95.3%; P = .033). This finding resulted from by lower freedom from major amputation for women (96.1% vs 98.9%; P = .010). After adjustment for confounders, no differences were found between the women and men regarding the loss of primary patency and all-cause mortality. For symptomatic PAAs, the risk of major amputation was threefold greater for women (adjusted hazard ratio, 3.09; 95% confidence interval, 1.05-9.06; P = .040), and the risk of the composite end point of major amputation or death was twofold higher for women than for men (adjusted hazard ratio, 1.97; 95% confidence interval, 1.02-3.79; P = .043). CONCLUSIONS: In our large national study of patients with PAAs, women were more likely to be treated for symptomatic PAAs. The risk of 1-year major amputation was threefold greater for women with symptomatic PAAs than for men with a similar presentation. Early recognition and treatment of PAAs in women before the PAAs have become symptomatic could optimize limb salvage outcomes in women.

Long-term Outcomes Associated With Open vs Endovascular Abdominal Aortic Aneurysm Repair in a Medicare-Matched Database.

Importance: Endovascular aneurysm repair is associated with a significant reduction in perioperative mortality and morbidity compared with open aneurysm repair in the treatment of abdominal aortic aneurysm. However, this benefit decreases over time owing to increased reinterventions and late aneurysm rupture after endovascular repair. Objective: To compare long-term outcomes of endovascular vs open repair of abdominal aortic aneurysm. Design, Setting, and Participants: This multicenter retrospective cohort study used deidentified data with 6-year follow-up from the Medicare-matched Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database. Patients undergoing first-time elective endovascular or open abdominal aortic aneurysm repair from 2003 to 2018 were propensity score matched. Patients with ruptured abdominal aortic aneurysm, concomitant procedures, or prior history of abdominal aortic aneurysm repair, were excluded. Data were analyzed from January 1, 2003, to December 31, 2018. Exposures: First-time elective endovascular or open repair for abdominal aortic aneurysm. Main Outcomes and Measures: The primary long-term outcome of interest was 6-year all-cause mortality, rupture, and reintervention. Secondary outcomes included 30-day mortality and perioperative complications. Results: Among a total of 32 760 patients (median [IQR] age, 75 [70-80] years; 25 706 [78.5%] men) who underwent surgical abdominal aortic aneurysm repair, 28 281 patients underwent endovascular repair and 4479 patients underwent open repair. After propensity score matching, there were 2852 patients in each group. Open repair was associated with significantly lower 6-year mortality compared with endovascular repair (548 deaths [35.6%] vs 608 deaths [41.2%]; hazard ratio [HR], 0.83; 95% CI, 0.74-0.94; P = .002), with increases in mortality starting from 1 to 2 years (84 deaths [4.3%] vs 126 deaths [6.7%]; HR, 0.63; 95% CI, 0.48-0.83; P = .001) and 2 to 6 years (211 deaths [25.8%] vs 241 deaths [30.6%]; HR, 0.73; 95% CI, 0.61-0.88; P = .001). Open repair, compared with endovascular repair, also was associated with significantly lower rates of 6-year rupture (117 participants [5.8%] vs 149 participants [8.3%]; HR, 0.76; 95% CI, 0.60-0.97; P < .001) and reintervention (190 participants [11.6%] vs 267 participants [16.0%]; HR, 0.67; 95% CI, 0.55-0.80; P < .001). Open repair was associated with significantly higher odds of 30-day mortality (OR, 3.56; 95% CI, 2.41-5.26; P < .001) and complications. Conclusions and Relevance: These findings suggest that overall mortality after elective abdominal aortic aneurysm repair was higher with endovascular repair than open repair despite reduced 30-day mortality and perioperative morbidity after endovascular repair. Endovascular repair additionally was associated with significantly higher rates of long-term rupture and reintervention. These findings emphasize the importance of careful patient selection and long-term follow-up surveillance for patients who undergo endovascular repair.

Impact of Frailty on Postoperative Outcomes in Patients Undergoing TransCarotid Artery Revascularization (TCAR).

BACKGROUND: Frailty is a clinical syndrome characterized by a reduction in metabolic reserves leading to increased susceptibility to adverse outcomes following invasive surgical interventions. The 5-item modified frailty index (mFI-5) validated in prior studies has shown high predictive accuracy for all surgical specialties, including vascular procedures. In this study, we aim to utilize the mFI-5 to predict outcomes in Transcarotid Revascularization (TCAR). METHODS: All patients who underwent TCAR from November 2016 to April 2021 in the Vascular Quality Initiative (VQI) Database were included. The mFI-5 was calculated as a cumulative score divided by 5 with 1 point each for poor functional status, presence of diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and hypertension. Patients were stratified into two groups based on prior studies: low mFI-5 (0.6) and high (≥0.6). Primary outcomes included in-hospital death, extended length of postoperative stay (>1 day), and nonhome discharge. Secondary outcomes included in-hospital stroke, transient ischemic attack (TIA), myocardial infarction (MI), a composite endpoint of stroke/death, stroke/TIA, and stroke/death/MI. Univariate and multivariable logistic regression were used to assess the association between mFI-5 and postoperative outcomes. Secondary analysis stratified by symptomatic status was performed. RESULTS: Out of the 17,983 patients who underwent TCAR, 4526(25.2%) had mFI-5 score of ≥0.6 and considered clinically frail. Compared to the nonfrail group, frail patients were more likely to be female (38.7% vs. 35.6%, P < 0.001), have poor functional status (43.6 vs. 8.3%, P < 0.001), and present with significant comorbidities, including diabetes (75.3% vs. 26.1%, P < 0.001), hypertension (98.9% vs. 88.5%, P < 0.001), CHF (52.2% vs. 5.6, P < 0.001), and COPD (60.3% vs. 14.2%, P < 0.001). They were also more likely to be active smokers (25.4% vs. 20.4%, P < 0.001) and symptomatic prior to intervention (28.7% vs. 25.3%, P < 0.001). On univariate analysis, frail patients were at significantly higher risk to experience adverse outcomes, including in-hospital mortality, TIA, MI, stroke/death, stroke/TIA, stroke/death/MI, discharge to nonhome facility, and extended LOS. After adjusting for potential confounders, frail patients remained at significantly higher risk of in-hospital mortality [aOR 2.26(1.41,3.61), P = 0.001], TIA [aOR 1.65(1.08, 2.54), P = 0.040], nonhome discharge [aOR 1.99(1.71,2.32) P < 0.001], and extended LOS [aOR 1.41(1.27, 1.55) P < 0.001]. On further stratified analysis based on symptomatic status, the increased risk of stroke/death, TIA, and death was observed only in symptomatic patients. CONCLUSIONS: Modified Frailty Index is a reliable tool that can be used to identify high-risk patients for TCAR prior to intervention. This could help vascular surgeons, patients, and families in informed decision making to further optimize perioperative care and medical management in frail patients.

The impact of carotid lesion calcification on outcomes of carotid artery stenting.

OBJECTIVE: The impact of carotid artery lesion calcification on adverse events following carotid artery stenting is not well-studied. Few reports associated heavily calcified lesions with high risk of perioperative stroke following transfemoral carotid artery stenting (TFCAS). With the advent of transcarotid artery revascularization (TCAR), we aimed to compare the outcomes of these two procedures stratified by the degree of lesion calcification. METHODS: Our cohort was derived from the Vascular Quality Initiative database for carotid artery stenting. Patients with missing information on the degree of carotid artery calcification were excluded. Patients were stratified into two groups: >50% (heavy) calcification and ≤50% (no/mild) calcification. The Student t test and the χ2 test were used to compare patients' baseline characteristics and crude outcomes, as appropriate. Clinically relevant and statistically significantly variables on univariable analysis were added to a logistic regression model clustered by center identifier. RESULTS: A total of 11,342 patients were included. Patients with >50% calcification were older, had more comorbidities, and more contralateral occlusion. There were more patients with prior ipsilateral carotid endarterectomy in the ≤50% calcification group. In patients who underwent TCAR, there were no significant differences between those who had >50% vs ≤50% carotid calcification in the odds of in-hospital adverse outcomes. However, in patients with heavy calcification who underwent TFCAS, there was a 50% to 60% increase in the odds of stroke (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.04-2.5; P = .03), stroke/transient ischemic attack (TIA) (OR, 1.6; 95% CI, 1.1-2.3; P = .013), and stroke/death (OR, 1.5; 95% CI, 1.02-2.08; P = .039). Compared with TFCAS in patients with heavy calcification, TCAR was associated with a 40% to 90% reduction in the odds of contralateral stroke (OR, 0.13; 95% CI, 0.04-0.4; P = .001), contralateral stroke/TIA (OR, 0.3; 95% CI, 0.1-0.87; P = .024), any stroke/TIA (OR, 0.6; 95% CI, 0.38-0.91; P = .02), death (OR, 0.3; 95% CI, 0.13-0.72; P = .006), stroke/death (OR, 0.5; 95% CI, 0.32-0.8; P = .004), and stroke/death/myocardial infarction (OR, 0.58; 95% CI, 0.39-0.87; P = .008). There were no significant differences in the odds of stroke and myocardial infarction. CONCLUSIONS: In this retrospective analysis of patients undergoing TFCAS vs TCAR in the Vascular Quality Initiative database, TCAR demonstrated favorable outcomes compared with TFCAS among patients with calcification greater than 50% of the carotid circumference. Advance burden of carotid artery calcification was associated with worse outcomes in patients undergoing TFCAS but not TCAR. These results are consistent with previously demonstrated superiority of flow reversal compared with distal embolic protection devices. Further research is needed to assess long-term outcomes and confirm the durability of TCAR in heavily calcified lesions.

The Effect of Intravenous and Oral Beta-Blocker Use in Patients with Type B Thoracic Aortic Dissection.

BACKGROUND: Beta-blockers have become the cornerstone for medical management in patients with chronic type B aortic dissection (TBAD). However, the effect of being on and/or receiving intravenous beta-blockers during hospitalization on outcomes of surgical repair of TBAD is not fully described. We sought to investigate this association during open surgical repair (OSR) and endovascular (Endo) intervention for nontraumatic TBAD. METHODS: The Premier Healthcare Database was inquired (June/2009-March/2015). Patients with nontraumatic isolated TBAD were identified via ICD-9-CM diagnosis and procedural codes. Patients with codes that indicated TAAD were excluded. In-hospital mortality, cardiac complications (CHF, MI, arrythmia) and stroke were evaluated. Log binomial regression analyses with bootstrapping were performed to assess the relative risk of adverse outcomes. RESULTS: A total of 1,752 were admitted for OSR (54.3%) and Endo (45.7%) TBAD repair. Use of oral beta blocker (BB) was 16.0% in OSR and 56.4% in Endo groups. In each arm, patients on BB were more likely to be diabetic, on aspirin or statin and more likely to receive additional IV BB than nonBB patients. There was no significant difference in age, sex, race, or prior history of CHF between BB and nonBB groups. Mortality was proportionally lower in patients on BB in OSR group (7.9% vs. 16.7%; P = 0.006) and Endo (3.3% vs. 9.2%; P < 0.001). The adjusted relative risk for mortality and stroke were significantly lower in oral BB recipients compared with none [aRR (95% CI): 0.53 (0.32-0.90) and 0.46 (0.25-0.87); both P ≤ 0.02]. IV metoprolol was the only IV BB that reduced mortality [aRR (95% CI): 0.62 (0.46-0.85); P = 0.003]. A dose of ≤10 mg was associated with significant mortality reduction: 6.3% (3.0-9.5%) compared with 8.1% (4.6-11.6%) in no IV BB group. Cardiac complications were not affected by BB use. CONCLUSIONS: For patients with nontraumatic TBAD, use of oral BB was associated with significant protection against in-hospital mortality and stroke following repair. Metoprolol was the only Intravenous BB type associated with improved survival. Further research is warranted to elucidate the effect of beta-blockers on the long-term surgical outcomes of TBAD.

Propensity score-matched analysis of 1-year outcomes of transcarotid revascularization with dynamic flow reversal, carotid endarterectomy, and transfemoral carotid artery stenting.

OBJECTIVE: Initial studies showed no significant differences in perioperative stroke or death between transcarotid artery revascularization (TCAR) and carotid endarterectomy (CEA) and lower stroke/death rates after TCAR compared with transfemoral carotid artery stenting (TFCAS). This study focuses on the 1-year outcomes of ipsilateral stroke or death after TCAR, CEA, and TFCAS. METHODS: All patients undergoing TCAR, TFCAS, and CEA between September 2016 and December 2019 were identified in the Vascular Quality Initiative (VQI) database. The latest follow-up was September 3, 2020. One-to-one propensity score-matched analysis was performed for patients with available 1-year follow-up data for TCAR vs CEA and for TCAR vs TFCAS. Kaplan-Meier survival and Cox proportional hazard regression analyses were used to evaluate 1-year ipsilateral stroke or death after the three procedures. RESULTS: A total of 41,548 patients underwent CEA, 5725 patients underwent TCAR, and 6064 patients underwent TFCAS during the study period and had recorded 1-year outcomes. The cohorts were well-matched in terms of baseline demographics and comorbidities. Among 4180 TCAR vs CEA matched pairs of patients, there were no significant differences in 30-day stroke, death, and stroke/death. However, TCAR was associated with a lower risk of 30-day stroke/death/myocardial infarction (2.30% vs 3.25%; relative risk, 0.71; 95% confidence interval [CI], 0.55-0.91; P = .008), driven by a lower risk of myocardial infarction (0.55% vs 1.12%; hazard ratio [HR], 0.49; 95% CI, 0.30-0.81; P = .004). At 1 year, no significant difference was observed in the risk of ipsilateral stroke or death (6.49% vs 5.68%; HR, 1.14; 95% CI, 0.95-1.37; P = .157). Among 4036 matched pairs in the TCAR vs TFCAS group, TCAR was also associated with lower risk of perioperative stroke or death compared with TFCAS (1.83% vs 2.55%; HR, 0.72; 95% CI, 0.54-0.96; P = .027). At 1 year, the risks of ipsilateral stroke or death of TCAR and TFCAS were comparable (6.07% vs 7.07%; HR, 0.85; 95% CI, 0.71-1.01; P = .07). Symptomatic status did not modify the association in TCAR vs CEA. However, asymptomatic patients had favorable outcomes with TCAR vs TFCAS at 1 year (HR, 0.78; 95% CI, 0.62-0.98; P = .033). CONCLUSIONS: In this propensity score-matched analysis, no significant differences in ipsilateral stroke/death-free survival were observed between TCAR and CEA or between TCAR and TFCAS. The advantages of TCAR compared with TFCAS seem to be mainly in the perioperative period, which makes it a suitable minimally invasive option for surgically high-risk patients with carotid artery stenosis. Larger studies, with longer follow-up and data on restenosis, are warranted to confirm the mid- and long-term benefits and durability of TCAR.

Association of body mass index with outcomes after thoracic endovascular aortic repair in the vascular quality initiative.

OBJECTIVE: Although several studies have evaluated the impact of obesity on outcomes after abdominal aortic aneurysm repair, literature examining this association in thoracic endovascular aortic repair (TEVAR) is sparse. Here, we use a multi-institutional, international database to assess the role of body mass index (BMI) on adverse outcomes in patients who underwent TEVAR for descending thoracic aortic aneurysms (DTAA) and type B dissections (TBD). METHODS: A retrospective review of all patients who underwent TEVAR for DTAA or TBD from August 2014 to August 2020 was performed. Patients who were underweight (BMI <18.5 kg/m2) or obese (BMI ≥30 kg/m2) were compared with those of normal weight (≥18.5 to <30 kg/m2). Adjustment for confounding was done with multivariable logistic regression or Cox proportional hazards regression as appropriate for studying postoperative or 1-year outcomes. Primary outcomes were 30-day and 1-year mortality. Other outcomes included any postoperative complication, stroke, and spinal cord ischemia. RESULTS: A total of 3423 participants were included in the study, of whom 3.3% (n = 113) were underweight, 65.9% (n = 2253) had normal weight, and 30.8% (n = 1053) were obese. Compared with normal weight, there was no significant difference in 30-day mortality in underweight patients (odds ratio [OR], 1.81; 95% confidence interval [CI], 0.80-4.14; P = .156). Obese patients who underwent TEVAR for TBD had a 2.7-fold increase in the odds of 30-day mortality compared with normal weight (OR, 2.67; 95% CI, 1.52-4.68; P = .001). Obese and normal weight patients with DTAA had equivalent odds of 30-day mortality (OR, 1.32; 95% CI, 0.79-2.23; P = .292). The adjusted hazard of 1-year mortality was 2-fold higher in underweight patients compared with normal weight (hazard ratio, 2.15; 95% CI, 1.41-3.29; P < .001), driven by a higher risk of mortality among patients with thoracic aortic aneurysm (OR, 2.62; 95% CI, 1.63-4.21; P < .001). There was no significant difference in 1-year mortality risk between normal weight and obesity in both DTAA (OR, 0.77; 95% CI, 0.54-1.09; P = .146) and TBD (OR, 1.26; 95% CI, 0.85-1.86; P = .248). CONCLUSIONS: In this study, obese patients who underwent TEVAR for DTAA had comparable 30-day and 1-year mortality risk as normal weight individuals. Obese patients who underwent TEVAR for TBD demonstrated a 2.7-fold increase in the odds of 30-day mortality, but equivalent mortality risk as normal weight patients at 1 year. TEVAR represents a safe minimally invasive option for treatment of DTAA in obese patients. Future work should be directed toward minimizing perioperative mortality among patients with TBD to optimize TEVAR outcomes.

Risk calculator predicts 30-day mortality after thoracic endovascular aortic repair for intact descending thoracic aortic aneurysms in the Vascular Quality Initiative.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysm (DTAA) is associated with high perioperative survival, although mortality is a possible outcome. However, no risk score has been developed to predict mortality after TEVAR for intact DTAA to aid in risk discussion and preoperative patient selection. Our objective was to use a multi-institutional database to develop a 30-day mortality risk calculator for TEVAR after DTAA repair. METHODS: The Vascular Quality Initiative database was queried for patients treated with TEVAR for intact DTAA between August 2014 and August 2020. Univariable and multivariable analyses aided in developing a 30-day mortality risk score. Internal validation was done with K-fold cross-validation and calibration curve analysis. RESULTS: Of 2141 patients included in the analysis, 90 (4.2%) died within 30 days after the procedure. Clinically relevant variables identified to be independently associated with 30-day mortality and therefore used to derive the predictive model included age 75 years or greater (odds ratio [OR], 2.27; 95% confidence interval [CI], 1.50-3.44; P < .001), coronary artery disease (OR, 1.60; 95% CI, 1.03-2.47; P = .036), American Society of Anesthesiologists class IV/V (OR, 2.39; 95% CI, 1.39-4.10; P = .002), urgent vs elective procedure (OR, 3.47; 95% CI, 1.90-6.33; P < .001), emergent vs elective procedure (OR, 5.27; 95% CI, 2.36-11.75; P < .001), prior carotid revascularization (OR, 3.24; 95% CI, 1.64-6.39; P = .001), and proximal landing zone <3 (OR, 2.51; 95% CI, 1.65-3.81; P < .001). The model showed an area under the receiver operating characteristic curve of 0.75. Internal validation demonstrated a bias-corrected area under the receiver operating characteristic curve of 0.73 (95% CI, 0.66-0.79) and a calibration slope of 1.00 with a corresponding intercept of 0.00. CONCLUSIONS: This study provides a novel clinically relevant risk prediction model to estimate 30-day mortality risk after TEVAR for DTAA. The TEVAR Mortality Risk Calculator provides useful prognostic information to guide patient selection and facilitate preoperative discussions and shared decision making. An easily accessible online version of the TEVAR Mortality Risk Score is available to facilitate ease of use.