Durability of Stroke Prevention with Carotid Endarterectomy and Carotid Stenting.

BACKGROUND: Carotid artery stenting remains an effective alternative to carotid endarterectomy for stroke prevention; however, the long-term durability of carotid artery stenting remains poorly defined. We performed a 10-year "real-world" comparative analysis of carotid endarterectomy and carotid artery stenting to help evaluate the success of these procedures in preventing late ischemic stroke events. METHODS: This was a single-center retrospective review of 996 patients (symptomatic and asymptomatic) treated with carotid endarterectomy or carotid artery stenting from January 2001 through December 2011 at a tertiary academic medical center. All-cause death, stroke, and myocardial infarction event rates were analyzed using log-rank analysis. RESULTS: Among the 996 patients treated with carotid endarterectomy (n = 787) or carotid artery stenting (n = 209), the 30-day, 1-year, 5-year, and 10-year survival rates for carotid endarterectomy patients were 99.1%, 95.3%, 77.9%, and 54.8%; carotid artery stenting rates were 99.5%, 96.2%, 67.8%, and 40.2%, respectively (P = .005, at 10 years). There was no significant difference in early stroke rates or myocardial infarction rates between the groups. Subgroup analysis comparing symptomatic status demonstrated no statistically significant differences in overall survival, stroke, or myocardial infarction rates at 10 years. In addition to reduced long-term overall survival, carotid artery stenting patients had a higher long-term restenosis rate as compared to carotid endarterectomy (6.3% vs 2.8%, P < .0001) and reduced restenosis-free survival (P = .01). CONCLUSIONS: Early death, stroke, and myocardial infarction rates are comparable after carotid endarterectomy and carotid artery stenting. Carotid artery stenting is an effective means of preventing stroke among patients with carotid artery stenosis. Symptomatic status does not seem to affect rates of stroke, myocardial infarction, or death. Carotid endarterectomy continues to be the preferred long-term solution for extracranial carotid artery occlusive disease as it is associated with better long-term survival and lower restenosis rates.

Impact of Body Mass Index on Outcomes after Mesenteric Revascularization for Chronic Mesenteric Ischemia.

BACKGROUND: Historically, patients with chronic mesenteric ischemia (CMI) are underweight with a low body mass index (BMI). However, with the recent obesity epidemic many of these patients now are overweight with a high BMI. We evaluated the impact of BMI on outcomes after mesenteric revascularization for CMI. METHODS: A retrospective chart review of patients undergoing open or endovascular mesenteric revascularization for CMI between January 2000 and June 2015 was performed. Demographics, comorbidities, BMI, Society for Vascular Surgery-combined comorbidity score, treatment modality, postoperative complications, reintervention, and all-cause mortality were analyzed. The primary end point for the study was all-cause mortality at 5 years. Patients were stratified using the World Health Organization BMI criteria. Univariate, Kaplan-Meier survival, and multivariate analyses were performed. RESULTS: In the study period, 104 unique patients underwent mesenteric revascularization for CMI, for 77 of whom BMI information was available. Of these 77, 30 patients were treated by endovascular revascularization, and 47 patients were treated by open revascularization. Overall, 27 (35.1%) were overweight or obese with a BMI ≥25. Median follow-up time was 41 months. High BMI patients were less likely to have weight loss at the time of surgery (P = 0.004). Stratified by BMI <25 versus BMI ≥25, 5-year survival for patients treated by open revascularization was 90% versus 50% (P = 0.02); survival for patients treated by endovascular revascularization was 27% vs. 53% (P = 0.37). Multivariate survival analysis identified active smoking, hypertensive chronic kidney disease, open repair with the use of venous conduit instead of prosthetic conduit (P < 0.001), and history of peripheral arterial disease (PAD) (P = 0.002), as independent predictors of increased all-cause mortality. CONCLUSIONS: BMI needs to be considered in assessing and counseling patients on outcomes of mesenteric revascularization for CMI, as a BMI over 25 is associated with poorer long-term survival after open revascularization. Smoking, hypertensive chronic kidney disease, PAD, and open repair with the use of venous conduit are independent predictors of long-term mortality after mesenteric revascularization independent of BMI.

Racial differences in functional decline in peripheral artery disease and associations with socioeconomic status and education.

OBJECTIVE: The objective of this study was to determine whether blacks with lower extremity peripheral artery disease (PAD) have faster functional decline than whites with PAD. METHODS: Participants with ankle-brachial index <0.90 were identified from Chicago medical centers and observed longitudinally. Mobility impairment and the 6-minute walk were assessed at baseline and every 6 to 12 months. Mobility loss was defined as becoming unable to walk up and down a flight of stairs or to walk » mile without assistance. RESULTS: Of 1162 PAD participants, 305 (26%) were black. Median follow-up was 46.0 months. Among 711 PAD participants who walked 6 minutes continuously at baseline, black participants were more likely to become unable to walk 6 minutes continuously during follow-up (64/171 [37.4%] vs 156/540 [28.9%]; log-rank, P = .006). Black race was associated with becoming unable to walk 6 minutes continuously, adjusting for age, sex, ankle-brachial index, comorbidities, and other confounders (hazard ratio, 1.45; 95% confidence interval, 1.05-1.99; P = .022). This association was attenuated after adjustment for income and education (P = .229). Among 844 participants without baseline mobility impairment, black participants had a higher rate of mobility loss (64/209 [30.6%] vs 164/635 [25.8%]; log-rank, P = .009). Black race was associated with increased mobility loss, adjusting for potential confounders (hazard ratio, 1.42; 95% confidence interval, 1.04-1.94; P = .028). This association was attenuated after additional adjustment for income and education (P = .392) and physical activity (P = .113). There were no racial differences in average annual declines in 6-minute walk, usual-paced 4-meter walking velocity, or fast-paced 4-meter walking velocity. CONCLUSIONS: Black PAD patients have higher rates of mobility loss and becoming unable to walk for 6 minutes continuously. These differences appear related to racial differences in socioeconomic status and physical activity.

Surveillance, anticoagulation, or filter in calf vein thrombosis.

OBJECTIVE: This study compared the efficacy and complication rates of inferior vena cava (IVC) filters for calf vein thrombosis (CVT) vs conservative treatment with or without anticoagulation. METHODS: Vascular laboratory studies of patients who had an isolated CVT (anterior and posterior tibialis, peroneal, soleal, and gastrocnemius veins) from April 2009 to January 2014 were retrospectively analyzed from a single institution. Of 647 patients with isolated CVT, 285 (44%) received an IVC filter, and 362 (56%) received medical treatment alone (38.9% surveillance, 11.6% prophylactic anticoagulation, and 49.4% therapeutic anticoagulation). Univariate, multivariate, propensity matching, and Kaplan-Meier analyses were performed on abstracted data, which included, but was not limited to, risk factors, treatment modalities, venous thromboembolism (VTE) complications (defined as propagation of deep vein thrombosis [DVT] or pulmonary embolism [PE]), bleeding complications, and IVC filter-related complications (ie, filter tilting >15°, perforation >3 mm, fracture, migration >10 mm). RESULTS: The overall incidence of PE in was 2.5% in the IVC filter group and 3.3% in the medical group (P = .27). The overall incidence of VTE complications (propagation of DVT, PE) was 35% for the surveillance group without anticoagulation, 30% in patients treated with prophylactic anticoagulation, and 10% in patients treated with therapeutic anticoagulation (P = .0003). Only a minority of patients underwent duplex ultrasound imaging after filter insertion. In the IVC filter group, the most common reasons that contraindicated anticoagulation were bleeding (35%) or recent surgery (27%). The number of IVC filter-related complications in the IVC filter group was 29 (10%). Because the IVC filter group was older (mean age, 65 vs 61 years, P = .004) and more likely to have a history of thromboembolic events (56% vs 16%, P < .0001), and malignancy (49% vs 28%, P < .0001), propensity analyses were performed yielding a homogenous cohort. The overall complication and thromboembolic rates did not differ for muscular (soleal, gastrocnemius) vs tibial DVTs (anterior, posterior, peroneal veins). CONCLUSIONS: The use of anticoagulation in patients with CVT significantly decreases the rates of VTE complications. The use of IVC filters in this study was associated with a 10% complication rate and did not significantly reduce the incidence of PE. Nevertheless, given the overall low rates of PE and the higher risk of VTE in patients who receive filters, the decision to insert a filter in patients with calf CVT should be individualized.

Implications of Intraoperative Vascular Surgery Assistance for Hospitals and Vascular Surgery Trainees.

Importance: Vascular surgeons possess a skill set that allows them to assist nonvascular surgeons in the operating room. Existing studies on this topic are limited in their scope to specific procedures or clinical settings. Objective: To describe the broad spectrum of cases that require intraoperative vascular surgery assistance. Design, Setting, and Participants: A retrospective medical record review of patients undergoing nonvascular surgery procedures that required intraoperative vascular surgery assistance between January 2010 and June 2014 at a single urban academic medical center (Northwestern Memorial Hospital, Chicago, Illinois). Trauma patients and inferior vena cava filter placements were excluded. Exposures: Intraoperative vascular surgery assistance stratified by need for vascular reconstruction, anatomic location, urgency of consultation, and timing of consultation. Main Outcomes and Measures: A composite primary end point of death, myocardial infarction, or unplanned return to the operating room within 30 days of the index operation. Results: We identified 299 patients involving 12 different surgical subspecialties that met the study criteria. The cohort included 148 men (49.5%) and had a mean (SD) age of 56.4 (15) years. Most consultations occurred preoperatively (n = 224; 74.9%; odds ratio, 0.04; 95% CI, 0.02-0.08; P < .001) and were elective (n = 212; 70.9%; odds ratio, 0.06; 95% CI, 0.03-0.12; P < .001 ). The indications for vascular surgery assistance were 156 spine exposure (52%), 43 vascular control without hemorrhage (14.4%), 43 control of hemorrhage (14.4%), and 57 vascular reconstruction (19%). Vascular repairs consisted of 13 bypasses (4.3%), 18 patch angioplasties (6.0%), and 79 primary repairs (26.4%). All procedures required open surgical exposure by the vascular surgeon. The incidence of death, myocardial infarction, or unplanned return to the operating room was 11.4% for the cohort with a mortality rate of 1.7%. Patients who required vascular repair had a higher incidence of death, myocardial infarction, or unplanned return to the operating room (17.4% vs 7.9%; P = .01). These cases resulted in an additional 1371.46 work relative value units per year. Conclusions and Relevance: Vascular surgeons provide crucial operative support across multiple specialties. Although vascular reconstruction is not needed in most patients, it may be associated with increased risk of death, myocardial infarction, or unplanned return to the operating room. The high proportion of emergent cases that require vascular repair demonstrates the importance of having vascular surgeons immediately available at the hospital. To continue providing this valuable service, vascular surgery trainees need to continue to learn the full breadth of open anatomic exposures and vascular reconstruction.

Surgical management of aortitis with early aneurysmal dilation.

BACKGROUND: Aortitis is a rare and serious condition that requires expedient surgical evaluation. Diagnosis is generally made by computed tomography (CT). Surgery is most often performed when significant aneurysmal changes have already occurred. Outcomes of early surgical management of aortitis with early aneurysmal dilation have not been reported previously. METHODS: A retrospective review of open abdominal aortic repairs performed from 1999 to 2009 at a single center was done from a prospectively collected database. Patients with a confirmed radiographic appearance of aortitis and treated surgically were selected. Demographic, clinical, and surgical data of patients with aortitis showing early aneurysmal changes (aortic diameter <4 cm) were then analyzed. All aortitis cases with >4-cm aortic diameters and with prosthetic aortic grafts were excluded. RESULTS: During the observation period, 421 open abdominal aortic repairs were performed. Of these, 10 (2.4%) were identified as having primary aortitis without significant aneurysmal changes. The mean age of the patients was 62 (range 48-77) years. There were 6 (60%) men and 4 (40%) women in the cohort. Four patients (40%) had culture-negative aortitis, whereas 6 (60%) had positive microbial cultures at the time of diagnosis. Paravisceral involvement was seen in 8 (80%) cases. All patients underwent in situ repair with aortic homografts. Mean operative time was 348 minutes and mean estimated blood loss was 2475 mL. Median follow-up time was 23.1 months with a range of 1.7-51.4 months. Operative mortality was 0%, and 1 late death occurred at 23 months postoperatively. There were 9 significant in-hospital (30-day) events occurring in 5 patients, including 3 cardiovascular events, 2 pulmonary events, 3 acute renal failures, and 1 deep surgical site infection. CONCLUSIONS: Aortitis is an uncommon indication for aortic repair. Infectious aortitis is most commonly confirmed by microbiologic studies, but a significant number of cases have no demonstrable microbial source. Outcomes after early surgical management for aortitis with small aneurysms demonstrated improved mortality when compared with series reviewing outcomes in aortitis patients with large mycotic aneurysms.

Comparative effectiveness study of self-directed walking exercise, lower extremity revascularization, and functional decline in peripheral artery disease.

OBJECTIVE: Among individuals with peripheral artery disease (PAD), we compared annual change in 6-minute walk performance between participants who neither underwent lower extremity revascularization nor walked for exercise (group 1, reference), those who walked regularly for exercise (group 2), and those who underwent lower extremity revascularization (group 3). METHODS: Participants were recruited from Chicago-area vascular laboratories and followed annually. Change in 6-minute walk was calculated beginning at the study visit preceding lower extremity revascularization or exercise behavior and continuing for 1 additional year after the therapy was reported. Results are adjusted for age, sex, race, comorbidities, and other confounders. RESULTS: Of 348 PAD participants, 43 underwent revascularization during median follow-up of 84 months. Adjusted annual declines in 6-minute walk were -96.6 feet/year for group 1, -49.9 feet/year for group 2, and -32.6 feet/year for group 3 (P < .001). Forty-one percent of revascularizations were not associated with ankle-brachial index (ABI) improvement. When group 3 was limited to participants with ABI improvement ≥0.15 after revascularization, annual adjusted changes in 6-minute walk were -97.7 feet/year for group 1, -46.5 feet/year for group 2, and +68.1 feet/year for group 3 (P < .001). When group 3 was limited to participants without ABI improvement ≥0.15 after revascularization, annual adjusted changes in 6-minute walk were -99.2 feet/year for group 1, -48.0 feet/year for group 2, and -61.7 feet/year for group 3 (P < .001). CONCLUSIONS: A large proportion of PAD participants did not have ABI improvement of at least 0.15 at follow-up study visit after revascularization. The benefits of lower extremity revascularization in patients with PAD appear closely tied to improvements in the ABI after revascularization.

The Group Oriented Arterial Leg Study (GOALS) to improve walking performance in patients with peripheral arterial disease.

People with lower extremity peripheral artery disease (PAD) have greater functional impairment and faster functional decline than those without PAD. We describe methods for the Group Oriented Arterial Leg Study (GOALS), an ongoing randomized controlled clinical trial designed to determine whether a Group-Mediated Cognitive Behavioral (GMCB) intervention improves functional performance in PAD participants, compared to a health education control condition. In GOALS, PAD participants were randomized to either an intervention or a health education control condition in a parallel design. Both conditions consist of weekly group sessions with other PAD participants. In the intervention, cognitive behavioral techniques are used to assist participants in setting and adhering to home-based walking exercise goals. Participants are encouraged to walk for exercise at home at least 5 days/week. In the control condition, participants receive lectures on health-related topics. After 6 months of on-site weekly sessions, participants are transitioned to telephone follow-up for another 6 months. Participants in the intervention are asked to continue home walking exercise. The primary outcome is change in six-minute walk performance between baseline and six-month follow-up. Secondary outcomes include change in six-minute walk performance at 12-month follow-up, and change in treadmill walking performance, the Walking Impairment Questionnaire, quality of life, and physical activity at six and 12-month follow-up. In conclusion, if our group-mediated cognitive behavioral intervention is associated with improved walking performance in individuals with PAD, results will have major public health implications for the large and growing number of people with PAD.

Early versus delayed carotid endarterectomy in symptomatic patients.

BACKGROUND: Delayed carotid endarterectomy (CEA) after a stroke or transient ischemic attack (TIA) is associated with risks of recurrent neurologic symptoms. In an effort to preserve cerebral function, urgent early CEA has been recommended in many circumstances. We analyzed outcomes of different time intervals in early CEA in comparison with delayed treatment. STUDY DESIGN: Retrospective chart review from a single university hospital tertiary care center between April 1999 and November 2010 revealed 312 patients who underwent CEA following stroke or TIA. Of these 312 patients, 69 received their CEA within 30 days of symptom onset and 243 received their CEA after 30 days from symptom onset. The early CEA cohort was further stratified according to the timing of surgery: group A (27 patients), within 7 days; group B (17), between 8 and 14 days; group C (12), between 15 and 21 days; and group D (12), between 22 and 30 days. Demographic data as well as 30-day (mortality, stroke, TIA, and myocardial infarction) and long-term (all-cause mortality and stroke) adverse outcome rates were analyzed for each group. These were also analyzed for the entire early CEA cohort and compared against the delayed CEA group. RESULTS: Demographics and comorbid conditions were similar between groups. For 30-day outcomes, there were no deaths, 1 stroke (1.4%), 0 TIAs, and 0 myocardial infarctions in the early CEA cohort; in the delayed CEA cohort, there were 4 (1.6%), 4 (1.6%), 2 (0.8%), and 2 (0.8%) patients with these outcomes, respectively (P > .05 for all comparisons). Over the long term, the early group had one ipsilateral stroke at 17 months and the delayed group had two ipsilateral strokes at 3 and 12 months. For long-term outcomes, there were 16 deaths in the early CEA cohort (21%) and 74 deaths in the delayed CEA cohort (30%, P > .05). Mean follow-up times were 4.5 years in the early CEA cohort and 5.8 years in the delayed CEA cohort. CONCLUSIONS: There were no differences in 30-day and long-term adverse outcome rates between the early and delayed CEA cohorts. In symptomatic carotid stenosis patients without evidence of intracerebral hemorrhage, carotid occlusion, or permanent neurologic deficits early carotid endarterectomy can be safely performed and is preferred over delaying operative treatment.

Clinical correlates of size and number of collateral vessels in peripheral artery disease.

We studied associations of the number and size of magnetic resonance angiography (MRA)-assessed lower extremity collateral vessels with the ankle-brachial index (ABI), severity of superficial femoral artery (SFA) plaque, and leg symptoms in participants with peripheral artery disease (PAD). A total of 303 participants with PAD underwent time-resolved MRA at the thigh station. Collaterals were categorized by number (Category 1: 0-3 collaterals; Category 2: 4-7 collaterals; Category 3: ≥ 8 collateral vessels) and size (Grade 1: ≤ 5 small collaterals; Grade 2: > 5 small vessels; Grade 3: ≤ 5 large collaterals; Grade 4: > 5 large collaterals). Adjusting for age, sex, race, comorbidities and other covariates, more numerous collateral vessels were associated with lower ABI values (Category 1: 0.79; Category 2: 0.67; Category 3: 0.60; p trend < 0.001). Similarly, larger collateral vessels were associated with lower ABI values (Grade 1: 0.75; Grade 2: 0.65; Grade 3: 0.62; Grade 4: 0.59; p trend < 0.001). More numerous (p < 0.001) and larger (p < 0.001) collateral vessels were associated with greater mean SFA plaque area (p trend < 0.001). More numerous (p trend = 0.007) and larger (p trend = 0.017) collateral vessels were associated with a lower prevalence of asymptomatic PAD. In conclusion, among participants with PAD, larger and more numerous collaterals, measured by MRA, were associated with lower ABI values, greater plaque area in the SFA, and a lower prevalence of asymptomatic PAD. Further study is needed to determine the role of collateral vessels in maintaining functional performance in PAD.

How 'preventable' are lower extremity amputations? A qualitative study of patient perceptions of precipitating factors.

PURPOSE: Clinicians commonly believe that lower extremity amputations are potentially preventable with coordinated care and motivated patient self-management. We used in-depth interviews with recent amputees to assess how patients viewed their initial amputation risk and causes. METHOD: We interviewed 22 patients at a rehabilitation hospital 2-6 weeks after an incident amputation. We focused on patients' representations of amputation cause and methods of coping with prior foot and leg symptoms. RESULTS: Patients reported unexpected onset and rapid progression of ulceration, infection, progressive vascular disease, foot trauma and complications of comorbid illness as precipitating events. Fateful delays of care were common. Many had long histories of painful prior treatments. A fatalistic approach to self-management, difficulties with access and communication with providers and poor understanding of medical conditions were common themes. Few patients seemed aware of the role of smoking as an amputation risk factor. CONCLUSIONS: Most patients felt out of control and had a poor understanding of the events leading to their initial amputations. Prevention of subsequent amputations will require rehabilitation programs to address low health literacy and psychosocial obstacles to self-management.

Scalene muscle injections for neurogenic thoracic outlet syndrome: case series.

UNLABELLED: Scalene muscle injections are used to confirm the diagnosis of neurogenic thoracic outlet syndrome and predict the response of patients to surgery. We performed a retrospective study to determine if relief of pain was related to brachial plexus blockade in these patients. METHODS: We reviewed the charts of 12 patients who had anterior and middle scalene muscle injections, for neurogenic thoracic outlet syndrome, between April 2009 and September 2010. The injections were performed under ultrasound guidance wherein 2 to 5 mL of 0.25% bupivacaine was injected into the belly of the anterior and scalene muscles. The following were noted: (1) sites of preprocedure pain; (2) volume injected into each of the anterior and middle scalene muscles; (3) presence of numbness after injection; and (4) presence and duration of pain relief. RESULTS: All 12 patients had relief of their pain. Six of the twelve patients developed numbness, which ranged from blockade of the C4-5, C6-7, and C4-T1 dermatomes. In the patients who developed numbness, there was no relationship between the duration of numbness and the duration of pain relief or the location of numbness and the location of pain relief. CONCLUSIONS: The relief from scalene muscle injections in patients with neurogenic thoracic outlet syndrome is not related to blockade of the brachial plexus.

Stepwise age-related outcomes of elective endovascular abdominal aortic aneurysm repair: 11-year institutional review.

OBJECTIVE: Endovascular repair of abdominal aortic aneurysms (EVAR) has largely supplanted open surgery over the past 2 decades. Faced with an aging population, the outcomes of EVAR among various age groups were examined. METHOD: Retrospective review of elective EVAR cases was performed at a single institution from 1998 to 2009. Patients were separated into 4 age groups for easy comparison. Perioperative data were analyzed using Fisher's exact test. RESULTS: Demographics were similar among the groups except for sex, BMI, and smoking status. The 30-day morbidity and mortality data were not statistically different among groups. From EVAR to end of the study, there was a 10.9% all-cause mortality rate (with no difference among groups) and an 8.0% reintervention rate (with the oldest age group having a lower reintervention rate; P < .03). CONCLUSIONS: EVAR remains a good treatment option for elective aneurysm repair despite advanced age, which alone does not appear to be an independent predictor of outcome.

Late abdominal aortic endograft explants: indications and outcomes.

BACKGROUND: Despite advances in endoluminal salvage for failed endografts, certain circumstances necessitate open endovascular abdominal aneurysm repair (EVAR) conversion. We review the indications for and outcomes after late EVAR explants. METHODS: Retrospective review of EVAR patients requiring delayed (>30 days) conversion from 1999 to 2009. Demographics, index endovascular procedure, conversion indication/technique, and outcomes were analyzed. RESULTS: Among 16 patients who required late conversion, the mean age was 73 years (range, 41-84 years) and 94% were men. Indications included 9 device failures, 6 endograft infections, and a single type II endoleak with sac enlargement. Explanted prostheses included the following: 7 Cook Zenith(®) endoprosthesis, 3 Gore Excluder(®) grafts, 3 Medtronic AneuRx(®) endograft devices, 2 Endologix Powerlink(®) endografts, and 1 Guidant Ancure(®) graft. Before conversion, 7 patients underwent unsuccessful secondary salvage procedures. Transperitoneal (81%) and left retroperitoneal approaches (19%) were used, with 75% requiring supraceliac control. Reconstructions depended on clinical manifestations and included 10 in situ prosthetic repairs, 4 extra-anatomic bypasses, and 2 in situ cryopreserved human allograft repairs. Two patients died during their hospitalization, resulting in a 13% mortality rate. Mean hospitalization for survivors was 18 days (range, 6-78 days), and 7 (50%) of the patients were discharged directly home. CONCLUSION: Most delayed EVAR conversions are because of device failure or infection and can be successfully converted to open surgical reconstruction. Supraceliac control is often required, and the perioperative complications are greater than primary elective open or endovascular repair. This study addresses how best to manage failed abdominal aortic endografts and what can be done to improve patient outcomes with this difficult clinical problem.

Normal preoperative white blood cell count is predictive of outcomes for endovascular procedures.

BACKGROUND: An abnormally elevated preoperative white blood cell count (WBC) has been associated with postoperative morbidity and mortality. However, it is unknown if a normal WBC is predictive of postoperative outcomes following vascular interventions. Thus, the objective of this study is to determine if a WBC within the normal range is predictive of outcomes following vascular interventions. METHODS: The medical records of patients undergoing endovascular and open repair of carotid stenosis, aortic aneurysm, and peripheral arterial disease from 1999 to 2009 were retrospectively reviewed. Major adverse events (MAE) were defined as death, stroke, and myocardial infarction. RESULTS: Of 1773 cases with normal preoperative WBC (3.5-10.5 K/µL), there were 804 [45.3%] endovascular and 969 [54.7%] open vascular surgeries. Patients with complications (55) or MAE (19) after endovascular intervention had higher preoperative WBC compared with patients without complications (WBC 7.7 ± 1.47 vs 7.1 ± 1.57, respectively, P = .002) or MAE (WBC 8.3 ± 1.26 vs 7.1 ± 0.06, respectively, P = .001). No difference was observed for patients who received open surgery. Patients undergoing endovascular intervention were 2.3, 4.8, and 22 times more likely to experience complications (P = .004), MAE (P = .003), or death (P = .036) when WBC exceeded 7.5 K/µL. Multivariate analysis showed that preoperative normal WBC was an independent predictor of complications, MAE, and death in patients after endovascular procedures but only for death in patients after open vascular procedures. CONCLUSIONS: This study demonstrates a strong linear correlation between an increasing preoperative WBC within the normal range and an increased risk for postoperative complications and death following endovascular interventions. The study also found a significant curvilinear U-shaped relation between a normal preoperative WBC and death in the open surgical cohort, with patients in the very low and very high normal WBC range at an increased risk of death.

Superficial femoral artery plaque and functional performance in peripheral arterial disease: walking and leg circulation study (WALCS III).

OBJECTIVES: We studied associations of magnetic resonance imaging measurements of plaque area and relative percent lumen reduction in the proximal superficial femoral artery with functional performance among participants with peripheral arterial disease. BACKGROUND: The clinical significance of directly imaged plaque characteristics in lower extremity arteries is not well established. METHODS: A total of 454 participants with an ankle brachial index <1.00 underwent magnetic resonance cross-sectional imaging of the proximal superficial femoral artery and completed a 6-min walk test, measurement of 4-m walking velocity at usual and fastest pace, and measurement of physical activity with a vertical accelerometer. RESULTS: Adjusting for age, sex, race, body mass index, smoking, statin use, comorbidities, and other covariates, higher mean plaque area (1st quintile [least plaque]: 394 m, 2nd quintile: 360 m, 3rd quintile: 359 m, 4th quintile: 329 m, 5th quintile [greatest plaque]: 311 m; p trend <0.001) and smaller mean percent lumen area (1st quintile [greatest plaque]: 319 m, 2nd quintile: 330 m, 3rd quintile: 364 m, 4th quintile: 350 m, 5th quintile: 390 m; p trend <0.001) were associated with shorter distance achieved in the 6-min walk test. Greater mean plaque area was also associated with slower usual-paced walking velocity (p trend = 0.006) and slower fastest-paced 4-m walking velocity (p trend = 0.003). Associations of mean plaque area and mean lumen area with 6-min walk distance remained statistically significant even after additional adjustment for the ankle brachial index and leg symptoms. CONCLUSIONS: Among participants with peripheral arterial disease, greater plaque burden and smaller lumen area in the proximal superficial femoral artery are associated independently with poorer functional performance, even after adjusting for the ankle brachial index and leg symptoms.