Fenestrated/Branched Endovascular Aortic Aneurysm Repair Using a Supraceliac Aortic Proximal Seal Zone Versus an Infraceliac Aortic Proximal Seal Zone.

BACKGROUND: Fenestrated/branched endovascular aneurysm repair (F/B-EVAR) achieves more extensive proximal seal than conventional infrarenal devices, thereby increasing aneurysm exclusion durability. Optimal seal zone length remains undefined. We assessed relative risks and benefits of extending the proximal seal above the celiac artery. METHODS: The prospective database of all complex endovascular aortic aneurysm repairs at a single institution (institutional review board-approved, physician-sponsored investigational device exemption trial, 10/2010-6/2017) was used to classify repairs according to the number of target visceral-renal arteries incorporated: 4-vessel versus <4-vessel. Comparisons of aneurysm characteristics, perioperative details, and postoperative complications were performed, stratified by repair type. One-year survival, target artery patency, freedom from type 1 or 3 endoleak, and freedom from reintervention were estimated with Kaplan-Meier analysis. RESULTS: Among 175 F/B-EVARs, 38% (n = 67) were 4-vessel and 62% (n = 108) were <4-vessel. Intraoperatively, there was no difference in mean contrast use (76 mL vs. 74 mL, P = non significant [NS]) or dose area product (63,428 mGy cm2 vs. 96,015 mGy cm2), but there was increased median procedure time (4.8 hr, interquartile range [IQR] = 4.1-5.8 versus 3.6 hr, IQR = 2.9-4.1, P < 0.0001) and mean operating room direct costs ($52,532, standard deviation [SD] = 18,640 versus $40,128, SD = 15,135, P < 0.0001) in 4-vessel repairs. There were no differences in mortality (1.9% vs. 4.5%), paraparesis (0% vs. 3.0%), or paralysis (0.9% vs. 0%), all P = NS. There were no differences in one-year survival, target artery patency, or freedom from reintervention. There was a lower 1-year freedom from type 1 or 3 endoleak with 4-vessel repairs (82% vs. 94%, log-rank P = 0.02), driven by an increased rate of type 3 endoleaks. Endoleak resolution after treatment was equivalent in both groups (4-vessel, 10 of 12, 83% resolved; <4-vessel, 7 of 7, 100% resolved, P = NS). CONCLUSIONS: With F/B-EVAR, utilization of a supraceliac seal zone, compared with an infraceliac seal zone, is associated with statistical differences in operative characteristics/resource utilization, but with negligible clinical significance. Further innovation to eliminate type 3 endoleaks at fenestrations/branches remains an unmet need. To achieve adequate F/B-EVAR proximal seal zone length, one should have a low threshold to incorporate the celiac artery.

Carotid Duplex Velocity Criteria Recommended by the Society of Radiologists in Ultrasound and Endorsed by the Intersocietal Accreditation Commission Lack Predictive Ability for Identifying High-Grade Carotid Artery Stenosis.

BACKGROUND: Carotid duplex is the first-line imaging modality for characterizing degree of carotid stenosis. The Intersocietal Accreditation Commission (IAC), in published guideline documents, has endorsed use of the Society of Radiologists in Ultrasound (SRU) criteria to characterize ≥70% stenosis: peak systolic velocity (PSV) ≥230 cm/s. We sought to perform a validation of the SRU criteria using computed tomography (CT) angiography as a gold standard imaging modality and to perform a sensitivity analysis to determine optimal velocity criteria for identifying ≥80% stenosis. METHODS: We queried all carotid duplex examinations performed at our institution between 2008 and 2017. Patients with ≥70% carotid stenosis, based on previous criteria, were identified. Of these patients, those who also had a CT angiogram of the neck within one year formed the study cohort. Patients who underwent carotid revascularization between the 2 imaging dates were excluded. Degree of stenosis, as reported from the CT angiogram, was considered the true degree of stenosis. Receiver operating characteristic (ROC) curves were generated to evaluate the SRU criteria and to identify the optimal discrimination threshold for high-grade carotid stenosis. RESULTS: Of 37,204 carotid duplex examinations, 3,478 arteries met criteria for ≥70% stenosis. Of these, 344 patients had a CT angiogram within 1 year of the carotid duplex (mean time between studies, 55 days, SD 6.5) and 240 (69.8%) were consistent with ≥80% carotid stenosis. The predictive ability of the SRU criteria to identify ≥70% stenosis was poor, with an area under the ROC curve (AUC) of 0.51. A sensitivity analysis to identify ≥80% stenosis demonstrated the optimal discrimination threshold to be PSV ≥450 cm/s or end diastolic velocity (EDV) ≥120 cm/s, with an AUC of 0.66. CONCLUSIONS: In this validation study, the SRU criteria, endorsed by the IAC, to identify ≥70% carotid stenosis had no predictive value. For detection of ≥80% stenosis, the optimal criteria are a PSV ≥450 cm/s or EDV ≥120 cm/s. This study demonstrates the critical importance of carotid duplex examination validation.

Outpatient beta-blockers and survival from sepsis: Results from a national cohort of Medicare beneficiaries.

BACKGROUND: Elderly Americans suffer increased mortality from sepsis. Given that beta-blockers have been shown to be cardioprotective in critical care, we investigated outpatient beta-blocker prescriptions and mortality among Medicare beneficiaries admitted for sepsis. METHODS: We queried a 5% random sample of Medicare beneficiaries for patients admitted with sepsis. We used in-hospital and outpatient prescription drug claims to compare in-hospital and 30-day mortality based on pre-admission beta-blocker prescription and class of beta-blocker prescribed using univariate tests of comparison and multivariable logistic regression models and another class of medications for control. RESULTS: Outpatient beta-blocker prescription was associated with a statistically significant decrease in in-hospital and 30-day mortality. In multivariable modeling, beta-blocker prescription was associated with 31% decrease in in-hospital mortality and 41% decrease in 30-day mortality. Both cardioselective and non-selective beta-blockers conferred mortality benefit. CONCLUSIONS: Our data suggests that there may be a role for preadmission beta-blockers in reducing sepsis-related mortality.