The Burden of Stroke in Neonates Undergoing Congenital Heart Surgery: A Large Multicenter Analysis.

BACKGROUND: Stroke affects surgical decision making and outcomes of neonatal cardiac surgery(CHS). We sought to assess the burden of stroke in this population from a large multi-center database. METHODS: We analyzed neonates undergoing CHS with cardiopulmonary bypass from the Pediatric Health Information System database(2004-2022). The cohort was divided into stroke-group which included pre/post-op ischemic, hemorrhagic-subtypes and grade III-IV intraventricular hemorrhages and compared in-hospital and follow-up outcomes to non-stroke group. RESULTS: Of 14,228 neonates, 800(5.6%) had a peri-operative stroke. Stroke-group was more likely to have hypoplastic left-heart syndrome (HLHS)(30.5% vs 20.7%), born pre-term(19.4% vs 11.7%), low-birthweight(17.8% vs 11.9%) and require ECMO(48.8% vs 13.8%)(all, p<0.001). Outcomes comparing stroke vs no-stroke were, mortality:33.1% vs 8.9%, non-home discharge:12.5% vs 6.9%, length of stay:41 vs 24 days, hospitalization-costs:$354,521 vs $180,489(all, p<0.05). Stroke increased odds of mortality by two-fold[OR 2.20(1.75-2.77), p<0.001] after adjusting for ECMO, prematurity among other significant factors. On follow-up, stroke-group had higher incidence of hydrocephalus(9.5% vs 1.3%), cerebral palsy (6.2% vs 1.3%), autism spectrum disorder(7.1% vs 3.5%) and had higher one- and five- year mortality among survivors of index admission(5.3% and 11.3% vs 3.3% and 5.9%, respectively) (all p<0.05). CONCLUSIONS: Neonatal CHS patients born prematurely, diagnosed with HLHS or those requiring ECMO are disproportionately affected by stroke. The occurrence of stroke is marked by significantly higher mortality. Future research should seek to identify factors leading to stroke, in order to increase rescue after stroke and for improvement of long-term outcomes.

Association of abdominal aortic aneurysm diameter indexed to patient height with symptomatic presentation and mortality.

BACKGROUND: The current guidelines have recommended repair of abdominal aortic aneurysms (AAAs) according to the maximal AAA diameter and/or its growth rate. However, many studies have suggested that the AAA diameter alone is not sufficient to predict the risk of rupture or symptomatic presentation. Several investigators have attempted to relate the AAA diameter to the body surface area in predicting for rupture. However, these calculations have not resulted in conclusive evidence. We sought in the present analysis to introduce a novel diameter-to-height index (DHI) and test its utility in predicting for symptomatic presentations, including rupture and 30-day and 5-year mortality. METHODS: The Vascular Quality Initiative database (2003-2020) was used to identify patients who had undergone open or endovascular AAA repair. The DHI was defined as the AAA diameter in centimeters divided by the height in centimeters, yielding a score of 1 to 10. Multivariable logistic regression analysis was performed to assess the risk of symptomatic presentation, including rupture and 30-day mortality. Receiver operating characteristic curves were plotted, and survival analysis techniques were used to determine the hazard of 5-year mortality. RESULTS: A total of 64,595 patients were identified, of whom, 16.3% had presented with symptomatic AAAs, including rupture. Endovascular AAA repair was performed for 69.8% of the symptomatic AAAs and 84.3% of asymptomatic AAAs (P < .001). The symptomatic group were more likely to be women (24.6% vs 19.8%; P < .001) and Black (7.81% vs 4.44%; P < .001). The mean DHI was higher in the symptomatic group than in the asymptomatic group (mean DHI, 3.92 ± 1.1 vs 3.24 ± 0.7; P < .001). The adjusted odds of a symptomatic presentation increased with an increasing DHI (adjusted odds ratio [aOR], 1.70; 95% confidence interval [CI], 1.59-1.83; P < .001). Active smoking increased the risk of a symptomatic presentation (aOR, 1.38; 95% CI, 1.28-1.51; P < .001). However, the use of preoperative statins and beta-blockers significantly reduced the odds of a symptomatic presentation (aOR, 0.58; 95% CI, 0.53-0.64; P < .001; and aOR, 0.76; 95% CI, 0.69-0.84; P < .001), respectively. Compared with the AAA diameter, the receiver operating characteristic curve for the DHI to predict for symptomatic status was slightly, but significantly, higher (aOR, 0.702; 95% CI, 0.695-0.708; vs aOR, 0.695; 95% CI, 0.688-0.701; P < .001). The DHI increment was associated with a 1.08 greater odds of 30-day mortality (aOR, 1.08; 95% CI, 1.01-1.15; P < .001) for those with symptomatic AAAs. Similarly, the hazard of 5-year mortality was increased with an increasing DHI (adjusted hazard ratio, 1.20; 95% CI, 1.13-1.29; P < .001) only for those with asymptomatic AAAs. CONCLUSIONS: The DHI is a simple tool that could be more effective than the AAA diameter in predicting for symptomatic presentations. The DHI varied by sex and race, which could collectively help to provide an individualized prognosis. The DHI can additionally predict the 5-year mortality after AAA repair for those with asymptomatic AAAs only. However, the odds of 30-day mortality remained similar in both groups.

Frailty as a predictor of outcomes for patients undergoing carotid artery stenting.

OBJECTIVE: The concept of frailty has been proposed to capture the vulnerability resulting from aging and has been implemented for the prediction of perioperative outcomes. Carotid artery stenting (CAS) is considered an appropriate minimally invasive procedure for patients considered to high risk to undergo carotid endarterectomy. Recently, the predictive accuracy for perioperative outcomes using the five-item modified frailty index (5mFI) has been reported to be relatively poor for cardiovascular surgery compared with other surgeries. The effects of functional status and the 5mFI on the outcomes after CAS remain unknown. Thus, in the present study, we investigated the relationship between 5mFI, functional status, and perioperative outcomes. METHODS: All the patients who had undergone CAS in the Vascular Quality Initiative from November 15, 2016 to December 31, 2018 were included. Good functional status was defined as the ability to perform all predisease activities without restriction using a new variable added to the Vascular Quality Initiative from November 15, 2016 onward. The 5mFI was calculated using functional status and a history of diabetes, chronic obstructive pulmonary disease, congestive heart failure, and hypertension. The perioperative outcomes included in-hospital stroke or death within 30 days after CAS, a prolonged postoperative stay (≥2 days), and nonhome discharge. The associations between functional status, 5mFI, and perioperative outcomes were examined using univariate and multivariable logistic regression, adjusting for sex, age, race, degree of stenosis, symptomatic status, and the usage of preoperative medications. An analysis stratified by functional status was also performed. RESULTS: Of the 7836 patients, 188 (2.4%) had experienced perioperative stroke or death, 765 (9.8%) had required a nonhome discharge, and 2584 (33.0%) had required a prolonged postoperative stay. A higher (≥0.6 vs <0.6) 5mFI score was associated with greater odds of perioperative stroke or death (adjusted odds ratio [aOR], 2.75; 95% confidence interval [CI], 1.42-5.28; P = .003), non-home discharge (aOR, 2.70; 95% CI, 1.89-3.85; P < .001), and a prolonged postoperative length of stay (aOR, 1.96; 95% CI, 1.56-2.46; P < .001). For the predictive accuracy of the perioperative outcomes, the 5mFI model had an area under the curve for in-hospital stroke or death, nonhome discharge, and prolonged postoperative length of stay of 0.714, 0.767, and 0.668, respectively. The functional status model was not inferior to the 5mFI model for any of these outcomes. In the subgroup analysis, of the asymptomatic patients, a higher 5mFI score was associated with greater odds of perioperative stroke or death (aOR, 7.08; 95% CI, 2.02-24.48; P = .002), nonhome discharge (aOR, 5.87; 95% CI, 2.45-13.90; P < .001), and a prolonged postoperative stay (aOR, 2.60; 95% CI, 1.82-3.71; P < .001). CONCLUSIONS: Frailty, as measured using the 5mFI, and functional status were independent predictors of perioperative stroke or death, nonhome discharge, and an increased length of stay for patients undergoing CAS. These results were greatly pronounced in asymptomatic patients. The results from the present study, thus, caution against the use of CAS for asymptomatic frail patients.

Comparison of open- and closed-cell stent design outcomes after carotid artery stenting in the Vascular Quality Initiative.

BACKGROUND: The association between stent design and outcomes after carotid artery stenting (CAS) has remained controversial. The available data are conflicting regarding the superiority of any specific stent design. The present study investigated the association between cell design and outcomes after carotid artery stenting (CAS) in a real world setting. METHODS: Patients who had undergone CAS with distal embolic protection in the Society for Vascular Surgery Vascular Quality Initiative (VQI) database from 2016 to 2018 were included in the present study. Patients undergoing CAS for trauma or dissection or more than two treated lesions were excluded. We also excluded lesions for which more than two carotid stents had been used and lesions confined to the common or external carotid artery. Univariable and multivariable logistic regression analyses were used to compare the outcomes after CAS between the open- and closed-cell stent designs. RESULTS: Of the 2671 CAS procedures included in the present analysis, 1384 (51.8%) had used closed-cell stents and 1287 (48.2%) had used open-cell stents. On univariable analysis, no significant differences were noted between the closed- and open-cell stents in in-hospital mortality (1.8% vs 1.4%; P = .40), stroke (1.8% vs 2.4%; P = .28), and stroke/death (3.3% vs 3.5%; P = .81). After adjusting for potential confounders (ie, age, symptomatic status, previous major amputation, statin and antiplatelet use, American Society of Anesthesiologists class, elective procedures, approach, and post-stent dilatation), no difference was noted in in-hospital stroke/death between the two stent designs (odds ratio [OR], 1.08; 95% confidence interval [CI], 0.68-1.74; P = .74). However, the interaction between stent design (open vs closed) and lesion location (bifurcation vs internal carotid artery [ICA]) was statistically significant (P = .02). Closed-cell stents were associated with five times the odds of in-hospital stroke/death when used in carotid artery bifurcation (OR, 5.5; 95% CI, 1.3-22.2; P = .02). However, when the stent was limited to the ICA, no differences were noted (OR, 0.87; 95% CI, 0.51-1.45; P = .62). One-year follow-up data were available for 19% of patients. No differences in ipsilateral stroke or death at 1 year were noted between the open- and closed-cell stents, except when the lesion was located in the carotid bifurcation (hazard ratio, 6.7; 95% CI, 1.4-31.4; P = .02). CONCLUSIONS: Closed-cell stents were associated with an increased odds of in-hospital stroke/death for carotid bifurcation lesions, which might be related to the relatively lower conformability of closed-cell stents in the tortuous and diameter-mismatched bifurcation anatomy vs the relatively linear uniform diameter of the ICA. Improved follow-up and in-depth analysis of lesion-specific characteristics that might influence the outcomes of these two designs are needed to validate these results.

Safety of carotid artery revascularization procedures in patients with atrial fibrillation.

BACKGROUND: Atrial fibrillation (Afib) is a major contributor to cerebrovascular events. Coexisting carotid artery disease is not uncommon in Afib patients, yet they have been excluded from major randomized clinical trials. Therefore, the aim of this study was to evaluate the safety of carotid endarterectomy (CEA) and carotid artery stenting (CAS) in Afib patients. METHODS: The Premier Healthcare Database was queried (2009-2015). Patients who underwent CEA or CAS were captured by International Classification of Diseases, Ninth Revision, Clinical Modification codes. Multivariable logistic modeling was implemented to examine the outcomes: in-hospital stroke, intracerebral hemorrhage (ICH), mortality, and stroke/death. RESULTS: There were 86,778 patients included. The majority were asymptomatic (n = 82,128 [94.6%]). Afib was reported in 6743 patients (7.8%). In terms of absolute outcomes in both asymptomatic and symptomatic patients, Afib patients (vs non-Afib patients) had higher mortality and stroke/death (asymptomatic: mortality, 0.4% vs 0.2%; stroke/death, 1.7% vs 1.2%; symptomatic: mortality, 6.9% vs 2.1%; stroke/death, 10.6% vs 4.5%; all P < .05). Adjusted analysis yielded higher odds of ICH (adjusted odds ratio [aOR], 1.29; 95% confidence interval [CI], 1.00-1.67), mortality (aOR, 1.59; 95% CI, 1.11-2.26), and stroke/death (aOR, 1.30; 95% CI, 1.08-1.58) in Afib patients. Although univariable analysis found Afib to be a statistically significant predictor of ischemic stroke, similar results could not be elucidated in the multivariable analysis (aOR, 1.17; 95% CI, 0.93-1.47). In Afib patients, important predictors of stroke/death included CAS (aOR, 1.80; 95% CI, 1.21-2.68) and symptomatic presentation (aOR, 5.00; 95% CI, 3.20-7.83). Other important predictors were type of preoperative medication use, age, and hospital size. CONCLUSIONS: Afib was associated with worse postoperative outcomes in patients with carotid artery disease. Symptomatic status in Afib patients is associated with a stroke/death risk that is higher than in recommended guidelines for CEA and particularly for CAS. Overall, CEA was associated with lower periprocedural ICH, mortality, and stroke/death in Afib patients compared with CAS.

Pediatric Frontal Bone and Sinus Fractures: Cause, Characteristics, and a Treatment Algorithm.

BACKGROUND: The purpose of this study was to assess the incidence, cause, characteristics, presentation, and management of pediatric frontal bone fractures. METHODS: A retrospective cohort review was performed on all patients younger than 15 years with frontal fractures that presented to a single institution from 1998 to 2010. Charts and computed tomographic images were reviewed, and frontal bone fractures were classified into three types based on anatomical fracture characteristics. Fracture cause, patient demographics, management, concomitant injuries, and complications were recorded. Primary outcomes were defined by fracture type and predictors of operative management and length of stay. RESULTS: A total of 174 patients with frontal bone fractures met the authors' inclusion criteria. The mean age of the patient sample was 7.19 ± 4.27 years. Among these patients, 52, 47, and 75 patients were classified as having type I, II, and III fractures, respectively. A total of 14, 9, and 24 patients with type I, II, and III fractures underwent operative management, respectively. All children with evidence of nasofrontal outflow tract involvement and obstruction underwent cranialization (n = 11). CONCLUSIONS: The authors recommend that type I fractures be managed according to the usual neurosurgical guidelines. Type II fractures can be managed operatively according to the usual pediatric orbital roof and frontal sinus fracture indications (e.g., significantly displaced posterior table fractures with associated neurologic indications). Lastly, type III fractures can be managed operatively as for type I and II indications and for evidence of nasofrontal outflow tract involvement. The authors recommend cranialization in children with nasofrontal outflow tract involvement. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

The Vascular Quality Initiative 30-day stroke/death risk score calculator after transfemoral carotid artery stenting.

OBJECTIVE: Carotid artery stenting (CAS) was introduced as an alternative carotid revascularization procedure in patients deemed to be at high risk for carotid endarterectomy. Although techniques and selection criteria for patients have dramatically improved, CAS continues to have higher risk of stroke and death in comparison to carotid endarterectomy. Several risk factors are known to be associated with worse outcomes. Whereas knowledge of these independent factors is helpful, clinical decision-making is further refined when these are considered in aggregate. This study aimed to develop a score to predict the risk of stroke/death after transfemoral CAS (TFCAS). METHODS: We analyzed the Vascular Quality Initiative CAS data set from 2010 to 2018. Lesions due to trauma, dissection, or transcarotid artery stenting and cases performed without an embolic protection device were excluded. Univariable and multivariable logistic regression methods with bootstrapping (1000 repetitions) were used to identify predictors associated with 30-day stroke/death. Stepwise backward selection for variables was used to achieve model parsimony. A risk score was made by converting regression coefficients for each predictor to integers from which probability was calculated. Scores were grouped into simplified categories. RESULTS: We identified 10,753 patients undergoing TFCAS during the study period with a combined 30-day stroke/death rate of 4.1%. On multivariable adjustment, independent predictors of 30-day stroke/death included age (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.03-1.06; P < .001), nonwhite race (OR, 1.42; 95% CI, 1.16-1.74; P = .001), diabetes (OR,1.34; 95% CI, 1.08-1.67; P = .01), coronary artery disease (OR, 1.40; 95% CI, 1.13-1.73; P = .001), congestive heart failure (OR, 1.41; 95% CI, 1.07-1.85; P = .02), symptomatic status (OR, 2.11; 95% CI, 1.64-2.72; P < .001), and contralateral occlusion (OR, 1.64; 95% CI, 1.22-2.19; P = .001). On the other hand, preoperative use of statins (OR, 0.074; 95% CI, 0.59-0.93; P = .02) and dual antiplatelet therapy (P2Y12 inhibitors and aspirin; OR, 0.46; 95% CI, 0.32-0.66; P < .001) were associated with a significant reduction in stroke/death after TFCAS. The model had a C statistic of 69.0%. The coefficients of these predictors were used to develop a risk score calculator that estimates the probability of 30-day stroke/death after TFCAS. CONCLUSIONS: In an analysis of 10,753 patients undergoing TFCAS between 2010 and 2018, significant predictors of perioperative stroke or death included old age, nonwhite race, symptomatic status, diabetes, coronary artery disease, congestive heart failure, and contralateral occlusion in addition to perioperative dual antiplatelet therapy and statin use. These variables were used to develop a risk score calculator that estimates the probability of 30-day stroke/death after TFCAS. External validation of this tool in different populations of patients and data sets is warranted to evaluate its predictive performance.

Gender-Based Utilization and Outcomes of Autogenous Fistulas and Prosthetic Grafts for Hemodialysis Access.

BACKGROUND: To evaluate gender-based patterns of utilization and outcomes of arteriovenous fistulas (AVFs) and grafts (AVGs) in a population-based cohort of hemodialysis (HD) patients. METHODS: A retrospective analysis of all patients in the United States Renal Data System who had an AVF or AVG placed for HD access (January 2007 to December 2014). Outcomes were access maturation, conduit patency, infection, and mortality. Chi-square, Student's t, Kaplan-Meier, and multivariable Cox regression analyses were employed accordingly. RESULTS: There were 456,693 (57%) males and 341,571 (43%) females who initiated HD via AVF (16%), AVG (4%) and HD catheter (80%). There was a 30% decrease in odds of initiating HD with AVF in females compared with males (adjusted odds ratio [aOR]: 0.70; 95% confidence interval [CI]: 0.69-0.71, P < 0.001). The use of HD catheter as a bridge to AVF was 36% higher in females compared with males (aOR: 1.36; 95% CI: 1.33-1.39, P < 0.001). Preemptive AVF maturation was 78% for males and 76% for females (P < 0.001). The risk-adjusted analyses showed a 7% decrease in AVF maturation comparing females with males (adjusted hazard ratio [aHR]: 0.93; 95% CI: 0.92-0.95, P < 0.001) but no difference in AVG maturation (aHR: 0.99; 95% CI: 0.97-1.01, P = 0.46) After risk adjustment, primary (AVF: aHR-0.87; AVG: aHR-0.96), primary-assisted (AVF: aHR-0.84; AVG: aHR-0.97), and secondary (AVF: aHR-0.85; AVG: aHR-0.98) patency were lower for females compared with males (all P < 0.05). Initiation of HD with a catheter and conversion to AVF was associated with lower patency in males (aHR: 0.29; 95% CI: 0.28-0.29; P < 0.001) and females (aHR: 0.31; 95% CI: 0.30-0.31; P < 0.001) compared with AVF initiates. Patient survival was higher for females compared with males who received AVF (aHR: 1.08; 95% CI: 1.07-1.09; P < 0.001) and AVG (aHR: 1.13; 95% CI: 1.11-1.15; P < 0.001). Initiation with HD catheter and subsequent conversion to AVF was associated with an increase in mortality for males (aHR: 1.45; 95% CI: 1.43-1.47; P < 0.001) and females (aHR: 1.44; 95% CI: 1.44-1.52; P < 0.001) compared with initiation via AVF. There was no significant difference in severe AVG infection comparing females with males (aHR: 1.05; 95% CI: 0.98-1.13; P = 0.16). CONCLUSIONS: Female gender is associated with a lower prevalence of preemptive AVF's, higher utilization of catheters as a bridge to AVF, and lower patency compared with males. There was no difference in access maturation but patient survival was higher for females compared with males.

Hemodialysis and peritoneal dialysis access related outcomes in the pediatric and adolescent population.

BACKGROUND: There is paucity of comparative data on the objective performance of arteriovenous fistulas (AVF), grafts (AVG), hemodialysis (HD) catheter and peritoneal dialysis (PD) catheter in the pediatric population. METHODS: A retrospective analysis of all patients <21 years in the United States Renal Database System who had an AVF, AVG, HD catheter or PD catheter placed for dialysis access between 1/2007 and 12/2014 was performed. Multivariable cox regression was used to evaluate mortality, patency (primary, primary-assisted and secondary), maturation and catheter survival. RESULTS: The 11,575 patients studied comprised of 9445 (82%) HD, 1435 (12%) PD, 528 (4.6%) HD to PD and 167 (1.4%) PD to HD patients. The HD subcohort comprised of 1296 (13.7%) AVF initiates, 199 (2.1%) AVG initiates, 1347 (14.3%) AVF converts after initial HD catheter use, 292 (3.1%) AVG converts and 6311 (67%) patients who persistently utilized HD catheters. There was no difference between PD and HD in patients 0-5 (aHR: 1.36; 95% CI: 0.89-2.07; P = 0.15) and 6-12 years (aHR: 1.05; 95% CI: 0.72-1.52; P = 0.8). However, PD was associated with 73% and 76% increase in mortality relative to HD among patients in the 13-17 (aHR: 1.73; 95% CI: 1.35-2.21; P < 0.001) and 18-20 (aHR: 1.76; 95% CI: 1.38-2.24; P < 0.001) age categories. AVG was associated with 78% increase in mortality compared to AVF (aHR: 1.78; 95% CI: 1.41-2.25; P < 0.001). Persistent use of HD catheters was associated with 29% increase in mortality (aHR: 1.29; 95% CI: 1.07-1.57; P = 0.009) compared to initiation and persistent use of AVF. Conversion from HD catheter to AVF was associated with 66% decrease in mortality compared to persistent HD catheter use (aHR: 0.34; 95% CI: 0.28-0.40; P < 0.001). Primary, primary assisted and secondary patency were higher for AVF compared to AVG. CONCLUSION: There was no difference in risk adjusted mortality between HD and PD in children less than 13 years. PD is associated with higher mortality compared to HD in adolescents. Initiation of HD with AVF is associated with better patency and patient survival relative to AVG and persistent use of HD catheters in pediatric patients irrespective of transplant potential. Conversion from HD catheter to AVF or AVG in patients who inevitably initiate HD with a catheter is associated with better survival compared to persistent HD catheter use. TYPE OF STUDY: Retrospective cohort study. LEVEL OF EVIDENCE: Level II.

Trend and Economic Burden of Intravenous Narcotic Analgesic Utilization in Major Vascular Interventions in the United States.

BACKGROUND: The use of IV narcotic analgesics (IVNA) within the context of vascular procedures is not fully described. We sought to evaluate the burden of IVNA including narcotic analgesia-related adverse drug events (NARADE), associated mortality and hospitalization cost in open and endovascular vascular procedures, and to compare it with nonnarcotic analgesia (IVNNA). METHODS: Retrospective cross-sectional study in hospitals participating in Premier database (2009-2015). Logistic regression analysis was implemented to report the risks of NARADE and in-hospital mortality. Negative binomial regression was used to assess length of stay and generalized linear modeling was used to estimate the hospitalization cost. RESULTS: A total of 171,473 patients were identified. NARADE occurred in 6.2% of the cohort. NARADE group was similar in gender and race but was slightly older (median age 71 vs. 70; P < 0.001). After risk-adjustment, NARADE risk was higher in patients who received IVNA-alone in carotid and lower extremity revascularization (LER) [OR (odds ratio) (95% confidence interval [CI]): 1.17 (1.02-1.34) and 1.31 (1.14-1.50)] or combined with IVNNA [OR (95% CI): 1.34 (1.13-1.59) and 1.81 (1.54-2.13)], respectively. Patients receiving aortic repair benefited from the use of IVNA + IVNNA [OR (95% CI): 0.82 (0.69-0.98)]. Occurrence of NARADE doubled the LOS, amplified mortality risk and increased cost in all domains. NARADE increased the odds of mortality by 24.3, 6.5 (4.9-8.68) and 16.6 times and added $5,368, $12,737 and $11,349 to the cost of carotid, aortic and LER interventions, respectively. In contrast, IVNNA was not associated with NARADE risk, increased LOS or cost and showed a survival benefit in patients undergoing open aortic repair [aOR (95% CI): 0.52 (0.36-0.75)]. CONCLUSIONS AND RELEVANCE: The use of opioid-based narcotics had increased the risk of NARADE, resources utilization and NARADE-related mortality. Yet the use of nonopioid-based analgesic was safe, did not increase the cost and reduced mortality in open AA repair. This entices shifting the paradigm toward exploring nonopioid-based analgesia options in order to replace or minimize opioid requirements.

Absorbable Fixation Devices for Pediatric Craniomaxillofacial Trauma: A Systematic Review of the Literature.

BACKGROUND: The purpose of this study was to investigate surgical outcomes with the use of resorbable plating systems for the repair of craniomaxillofacial trauma in the pediatric population. METHODS: A systematic review of the literature was performed. A descriptive analysis, operative technical data, outcomes, and postoperative complications with the use of absorbable plating systems for craniomaxillofacial trauma were included. RESULTS: The systematic literature review identified 1264 abstracts, of which only 19 met inclusion criteria. From these 19 studies, 312 clinical cases with 443 facial fractures that were treated with absorbable fixation systems were extracted for analysis. The review identified only level III/IV (n = 17) and level V (n = 2) studies. Minor and major complications were rare, occurring in 5.45 percent (n = 17) and 3.21 percent (n = 10) of cases, respectively. The most common complications were surgical-site infections (n = 4) and plate extrusion (n = 4). CONCLUSIONS: This report is, to the authors' knowledge, one of the first comprehensive reports on the use of absorbable plating systems for pediatric craniomaxillofacial trauma. Their analysis suggests that the use of absorbable fixation devices for pediatric craniomaxillofacial trauma is relatively safe, with a low-risk profile. Outcome studies with longer follow-up periods specifically investigating facial growth, reoperation rates, standardized surgical outcome metrics, and cost are necessary to effectively compare these fixation devices to titanium alternatives for craniomaxillofacial trauma.

Platelet Depletion/Transfusion as a Lethal Factor in a Colitis-associated Cancer Mouse Model.

BACKGROUND/AIM: TLR-4 Knock-out (KO) mice are protected from colitis-associated cancer in the established AOM/DSS mouse model. The aim of this study was to assess whether the TLR4 KO mice would still be protected from carcinogenesis after platelet depletion and transfusion with TLR4 wild-type platelets. MATERIALS AND METHODS: Thirty-two female C57BL6 mice were divided into 6 groups. Among the three groups that received Azoxymethane/Dextran Sulfate Sodium (AOM/DSS), one group included TLR4KO mice, which were depleted of their platelets and were then transfused with platelets from TLR4 wild-type mice. The other two groups included wild-type and TLR-4KO mice that only received AOM/DSS. RESULTS: All 6 animals in the KO group that underwent platelet depletion/transfusion succumbed. Three of them died before the administration of DSS and three in the week following DSS administration. In contrast, mice in the other two groups experienced less weight loss and only 1 mouse died in each of them. CONCLUSION: Platelet depletion/transfusion was detrimental in TLR-4 transgenic mice that received AOM/DSS.

Risk of emergent carotid endarterectomy varies by type of presenting symptoms.

BACKGROUND: The timing of carotid revascularization in symptomatic patients is a matter of ongoing debate. Current evidence indicates that carotid endarterectomy (CEA) within 2 weeks of symptoms is superior to delayed treatment. However, there is little evidence on the outcomes of emergent CEA (eCEA). The purpose of this study was to compare outcomes of emergency eCEA vs nonemergent CEA (non-eCEA), stratified by type of presenting symptoms. METHODS: We analyzed the Vascular Targeted-National Surgical Quality Improvement Program dataset from 2011 to 2016. Symptomatic patients were divided into two groups: eCEA and non-eCEA. Univariable and multivariable methods were used to compare patient characteristics and to evaluate stroke, death, myocardial infarction (MI), stroke/death, and stroke/death/MI within 30 days of surgery adjusting for all potential confounders. A further subgroup analysis was done to compare the outcomes of eCEA vs non-eCEA stratified by the type of presenting symptoms (amaurosis, transient ischemic attack [TIA], and stroke). RESULTS: A total of 9271 patients were identified, of which 10.7% were eCEA vs 89.3% non-eCEA. Comparing eCEA vs non-eCEA, the two groups were similar in age (70.8 vs 70.5), female gender (36.3% vs 36.9%), diabetes (26.2% vs 28.9%), and smoking status (31.9% vs 28.7%; all P > .05). Patients undergoing eCEA were less likely to be hypertensive (76.2% vs 80.2%; P = .025), but more likely to belong to non-white race (51.5% vs 20.5%; P < .001). The eCEA patients were less likely to be on preprocedural medication vs non-eCEA (antiplatelets, 76.8% vs 89.2%; statins, 74.2% vs 79.9%; beta-blockers, 44.6% vs 50.4%; all P < .05). The 30-day outcomes comparing eCEA vs non-eCEA were: stroke, 6.2% vs 3.1%; death, 2% vs 1%; and stroke/death, 6.9% vs 3.7% (all P < .05). After risk adjustment, perioperative stroke (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.36-3.0), stroke/death (OR, 1.66; 95% CI, 1.13-2.45), and stroke/death/MI (OR, 1.58; 95% CI, 1.18-2.23) were higher after eCEA (all P < .01). When stratified by the type of presenting symptom, eCEA vs non-eCEA stroke outcomes were similar in patients who presented with stroke or amaurosis fugax. However, in the subset of patients presenting with TIA, eCEA had much worse outcomes compared with non-eCEA (stroke, 8.3% vs 2.5%; stroke/death, 8.3% vs 3.2%) and had significantly higher odds of stroke (OR, 3.12; 95% CI, 1.71-5.68) and stroke/death (OR, 2.24; 95% CI, 1.25-4.03) in the adjusted analysis (all P < .05). CONCLUSIONS: In patients presenting with stroke, eCEA does not seem to add significant risk compared with non-eCEA. However, patients presenting with TIA might be better served with non-emergent surgery as their risk of stroke is tripled when CEA is performed emergently.

Statins reduce mortality and failure to rescue after carotid artery stenting.

OBJECTIVE: The benefit of statins has been well established in reducing morbidities and mortality after carotid endarterectomy. However, the potential advantage of statin use in patients undergoing carotid artery stenting (CAS) remains largely unknown. The purpose of this study was to evaluate the effect of statins on postoperative outcomes after CAS. METHODS: The Premier Healthcare Database was retrospectively analyzed to identify all patients who underwent CAS from 2009 to 2015. Univariate (χ2 test, t-test) and multivariate models (logistic regression) were used to evaluate the effect of statins on postoperative outcomes. RESULTS: A total of 17,800 patients underwent CAS during the study period; 12,416 (70%) patients were taking statins. The statin group had more symptomatic patients (41% vs 31%; P < .001) and had significantly higher comorbidities including hypertension, diabetes, coronary artery disease, dyslipidemia, history of congestive heart failure, history of stroke, history of myocardial infarction (MI), and peripheral artery disease (all P < .05). Postoperative mortality was 1.0% vs 1.8% in the statin and nonstatin groups, respectively (P < .001). Statin use had no effect on odds of postoperative stroke (odds ratio [OR], 1.09; 95% confidence interval [CI], 0.88-1.34; P = .44) and higher odds of MI (OR, 2.08; 95% CI, 1.26-3.45; P = .004). After adjustment for potential confounders, statins were associated with 64% reduction in the odds of death (OR, 0.36; 95% CI, 0.27-0.47; P < .001) and 18% reduction in stroke/death (OR, 0.82; 95% CI, 0.68-0.99; P = .03). In patients who had a stroke or MI, statin users had significantly lower failure to rescue (lower mortality) compared with nonstatin users (11.4% vs 30.8%; P < .001). CONCLUSIONS: Statin use is associated with significant reduction in mortality and failure to rescue in patients who develop major complications (stroke/MI) after CAS. Therefore, statin use should be strongly encouraged in all patients undergoing CAS.

Outcomes and cost of fenestrated versus standard endovascular repair of intact abdominal aortic aneurysm in the United States.

BACKGROUND: Fenestrated endovascular aneurysm repair (FEVAR) has expanded the indications of this minimally invasive procedure to include patients with pararenal aneurysms. The actual cost of this relatively newer technology compared with standard endovascular aneurysm repair (EVAR) has not been studied before. Thus, the aim of this study was to analyze in-hospital costs and adverse outcomes in patients undergoing FEVAR vs EVAR for intact abdominal aortic aneurysms (AAAs). METHODS: Using the Premier Healthcare Database (2012-2015), we identified all patients who underwent elective EVAR and FEVAR. Univariable (χ2 test, Student t-test, median test) and multivariable (logistic regression and generalized linear modeling) analyses were implemented to examine in-hospital cost and adverse outcomes adjusting for patients' demographics, comorbidities, and regional characteristics. RESULTS: A total of 17,689 elective endovascular AAA repairs were performed; 1641 patients underwent FEVAR (9%), and the remaining 16,048 patients underwent standard EVAR (91%). Patients undergoing FEVAR were more likely to be white (86.3% vs 84.3%; P = .03). Both groups had similar comorbidities except for cerebrovascular disease, which was higher among patients undergoing FEVAR (8.4% vs 6.7%; P = .01). The total length of hospital stay was slightly higher in patients undergoing FEVAR compared with EVAR (mean [standard deviation], 2.40 [3.39] days vs 2.23 [3.10] days; P = .03). The rates of any complication (11.3% vs 9.6%), renal injury (5.8% vs 4.3%), and neurologic injury (0.7% vs 0.4%) were significantly higher in the FEVAR group (all P < .05). No differences were seen in mortality (0.8% vs 0.5%) or cardiac (4.9% vs 4.4%), pulmonary (2.4% vs 2.2%), and bowel (1.5% vs 1.2%) complications between the two groups (all P > .05). In multivariable logistic regression analysis, FEVAR was associated with 40% increased odds of renal failure (odds ratio, 1.40; 95% confidence interval [CI], 1.11-1.76; P = .004) and 91% increased odds of neurologic injury (odds ratio, 1.91; 95% CI, 1.02-3.57; P = .04). The median total cost of the treatment was also significantly higher among patients undergoing FEVAR ($28,227 vs $26,781; P < .001). After adjustment, generalized linear modeling analysis showed that the cost of FEVAR was on average $1612 higher than the cost of EVAR (adjusted cost, $1612; 95% CI, $1123-$2101; P < .001). CONCLUSIONS: In this large cohort of elective endovascular AAA repairs, compared with standard EVAR, FEVAR is associated with significantly increased odds of renal and neurologic injury. In addition, despite adjusting for patients' demographics, comorbidities, and major complications, total cost of FEVAR was significantly higher compared with standard EVAR. This is likely driven by the additional cost of fenestrated endografts and by the increased rate of complications related to FEVAR.

Pediatric Nasoorbitoethmoid Fractures: Cause, Classification, and Management.

BACKGROUND: Currently, there is a paucity of information on the presentation and proper management of pediatric nasoorbitoethmoid fractures. The purpose of this study was to examine the incidence, cause, associated injuries, and management of these fractures. Furthermore, the authors sought to assess outcomes after transnasal wiring or suture canthopexy for type III nasoorbitoethmoid fractures. METHODS: A retrospective cohort review was performed of all patients with nasoorbitoethmoid fractures who presented to a Level I trauma center from 1990 to 2010. Charts and computed tomographic imaging were reviewed, and nasoorbitoethmoid fractures were labeled based on the Markowitz-Manson classification system. Patient fracture patterns, demographics, characteristics, and outcomes were recorded. Univariate and multivariate methods were used to compare groups. RESULTS: A total of 63 pediatric patients were identified in the study period. The sample's mean age was 8.78 ± 4.08 years, and 28.6 percent were girls. The sample included 18 type I injuries, 28 type II injuries, and 17 type III injuries. No significant demographic differences were found between patients with type I, II, and III fractures (p > 0.05). Operative intervention was pursued in 16.7, 46.4, and 82.4 percent of type I, II, and III nasoorbitoethmoid fractures, respectively. In patients with type III nasoorbitoethmoid fractures, no patients with transnasal wiring developed telecanthus. CONCLUSIONS: Pediatric nasoorbitoethmoid fractures are uncommon injuries. Type I fracture can often be treated with close observation. However, type II and III injury patterns should be evaluated for operative intervention. Transnasal wiring is an effective method to prevent traumatic telecanthus deformity in type III fracture patterns.

Outcomes after elective abdominal aortic aneurysm repair in obese versus nonobese patients.

OBJECTIVE: Obesity is a worldwide epidemic, particularly in Western society. It predisposes surgical patients to an increased risk of adverse outcomes. The aim of our study was to use a nationally representative vascular database and to compare in-hospital outcomes in obese vs nonobese patients undergoing elective open aortic repair (OAR) and endovascular aneurysm repair (EVAR). METHODS: All patients undergoing elective abdominal aortic aneurysm repair were identified in the Vascular Quality Initiative database (2003-2017). Obesity was defined as body mass index ≥30 kg/m2. Univariable (Student t-test and χ2 test) and multivariable (logistic regression) analyses were implemented to compare in-hospital mortality and any major complications (wound infection, renal failure, and cardiopulmonary failure) in obese vs nonobese patients. RESULTS: We identified a total of 33,082 patients undergoing elective OAR (nonobese, n = 4605 [72.4%]; obese, n = 1754 [27.6%]) and EVAR (nonobese, n = 18,338 [68.6%]; obese, n = 8385 [31.4%]). Obese patients undergoing OAR and EVAR were relatively younger compared with nonobese patients (mean age [standard deviation], 67.55 [8.26] years vs 70.27 [8.30] years and 71.06 [8.22] years vs 74.55 [8.55] years), respectively; (both P < .001). Regardless of approach, obese patients had slightly longer operative time (OAR, 259.02 [109.97] minutes vs 239.37 [99.78] minutes; EVAR, 138.27 [70.64] minutes vs 134.34 [69.98] minutes) and higher blood loss (OAR, 2030 [1823] mL vs 1619 [1642] mL; EVAR, 228 [354] mL vs 207 [312] mL; both P < .001). There was no significant difference in mortality between the two groups undergoing OAR and EVAR (OAR, 2.9% vs 3.2% [P = .50]; EVAR, 0.5% vs 0.6% [P = .76]). On multivariable analysis, obese patients undergoing OAR had 33% higher odds of renal failure (adjusted odds ratio [OR], 1.33; 95% confidence interval [CI], 1.09-1.63; P = .006) and 75% higher odds of wound infections (adjusted OR, 1.75; 95% CI, 1.11-2.76; P = .02) compared with nonobese patients. However, in patients undergoing EVAR, no association was seen between obesity and any major complications. A significant interaction was found between obesity and surgical approach in the event of renal failure, in which obese patients undergoing OAR had significantly higher odds of renal failure compared with those in the EVAR group (ORinteraction, 1.36; 95% CI, 1.05-1.75; P = .02). CONCLUSIONS: Using a large nationally representative database, we demonstrated an increased risk of renal failure and wound infections in obese patients undergoing OAR compared with nonobese patients. On the other hand, obesity did not seem to increase the odds of major adverse outcomes in patients undergoing EVAR. Further long-term prospective studies are needed to verify the effects of obesity after abdominal aortic aneurysm repair and the implications of these findings in clinical decision-making.

Octogenarians Undergoing Open Repair Have Higher Mortality Compared with Fenestrated Endovascular Repair of Intact Abdominal Aortic Aneurysms Involving the Visceral Vessels.

BACKGROUND: Prior studies have shown that octogenarians have a higher risk of mortality than nonoctogenarians undergoing open aneurysm repair (OAR) and endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). Fenestrated endovascular aneurysm repair (F-EVAR) was approved by the Food and Drug Administration (FDA) in 2012 and has been used as a less invasive approach to treat patients with suboptimal neck anatomy with favorable outcomes compared with traditional OAR. The aim of the study is to compare 30-day outcomes of F-EVAR versus OAR in octogenarians undergoing repair of AAA involving the visceral vessels in the United States. METHODS: All patients with postoperative diagnosis of nonruptured AAA repair were identified in the National Surgical Quality Improvement Program database (2006-2015). Univariate and multivariate analyses were implemented to examine 30-day morbidity and mortality adjusting for patient demographics and comorbidities. RESULTS: A total of 548 octogenarians underwent repair of nonruptured AAA involving the visceral vessels, of which 242 (44%) were F-EVARs, and 306 (56%) were OARs. Octogenarians undergoing F-EVAR were on average 1-year older (median age [interquartile range]: 83 [82, 86] versus 82 [81, 85], P = 0.004) and more likely to be male (82% vs. 64%, P < 0.001) compared with OAR. Prevalence of diabetes (13% vs. 6%, P = 0.005) and progressive renal failure (57% vs. 47%, P = 0.03) was also higher in patients undergoing F-EVAR compared with OAR. Thirty-day postoperative mortality was higher after OAR (8.5% vs. 4.1%, P = 0.04). Secondary outcomes including cardiopulmonary (27.1% vs. 5.8%, P < 0.001) and renal injury (10.8% vs. 2.1%, P < 0.001) were also significantly higher in OAR compared with F-EVAR. After adjusting for patients' demographics and comorbidities, OAR had almost 4-fold increased risk of 30-day postoperative mortality compared with F-EVAR (odds ratio [95% confidence interval]: 3.90 [1.48-10.31], P = 0.006). CONCLUSIONS: In this large national cohort of octogenarians undergoing repair for complex AAA's, we showed that F-EVAR is associated with significantly lower postoperative morbidity and mortality than open repair. One of the main limitations of the study is the lack of anatomical data. However, despite that, our findings support the shifting paradigm toward minimally invasive approach in this frail population for treatment of complex AAA's. Further studies are needed to evaluate the long-term benefit of any repair in octogenarians.

Pediatric Zygomaticomaxillary Complex Fracture Repair: Location and Number of Fixation Sites in Growing Children.

BACKGROUND: Relatively few reports have been published investigating the operative management of pediatric zygomaticomaxillary complex fractures. The purpose of this study was to assess pediatric zygomaticomaxillary complex fracture management and associated complications, and potentially describe a standard treatment paradigm for these cases. METHODS: A retrospective cohort review was performed of all patients younger than 15 years presenting to a single institution with zygomaticomaxillary complex fractures from 1990 to 2010. Patient demographics, concomitant injuries, management details, and complications were recorded. Complications were compared among patients by dentition stage, number of fixation points, and identity of fixation sites. RESULTS: A total of 36 patients with 44 unique zygomaticomaxillary complex fractures met the authors' inclusion criteria. Thirty-two fractures exhibited at least 2.0 mm of diastasis along at least one buttress (73 percent), and all but one of these were managed operatively. Among operatively managed patients with deciduous dentition, two-point fixation was associated with a lower overall complication rate compared with one- and three-point fixation (0 percent versus 75 percent and 75 percent; p = 0.01). Furthermore, rigid plate-and-screw fixation at the zygomaticomaxillary buttress was not associated with an increased complication rate in operatively managed patients with deciduous dentition (40 percent versus 50 percent; p = 0.76). CONCLUSIONS: The authors' results suggest that two-point fixation is an effective management strategy for repair of displaced zygomaticomaxillary complex fractures in children. In addition, rigid plate-and-screw fixation at the zygomaticomaxillary buttress in children with deciduous dentition appears to be safe and effective when performed. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Pain Management for Nonsyndromic Craniosynostosis: Adequate Analgesia in a Pediatric Cohort?

BACKGROUND: Postoperative pain following open craniosynostosis repair has not been studied extensively and is sometimes thought to be inconsequential. The purpose of this study was to assess postoperative pain in this pediatric population. METHODS: We performed a retrospective chart review of patients (n = 54) undergoing primary open craniosynostosis repair from 2010 to 2016. Demographics, length of stay (LOS), pain scores, emesis events, and perioperative analgesics were reviewed. Multivariable regression models were designed to assess for independent predictors of LOS and emesis. RESULTS: A high proportion had moderate to severe pain on postoperative day 0 (56.5%) and day 1 (60.9%). Opioid administered in postoperative period was 1.40 mg/kg/d in morphine milligram equivalent (MME) (±1.07 mg/kg/d MME). Majority of patients transitioned to enteral opioids on postoperative day 1 (24.5%) or day 2 (49.1%). Ketorolac was administered to 11.1% (n = 6). Emesis was documented in 50% of patients. LOS revealed a positive association with age (P = 0.006), weight (P = 0.009), and day of transition to enteral opioids (P < 0.001); association with emesis was trending toward significance (P = 0.054). There was no association between overall LOS and amount of opioids administered postoperatively (P = 0.68). Postoperative emesis did not have any significant association with age, sex, weight, total amount of postoperative opioid administered, use of ketorolac, or intraoperative steroid use. CONCLUSION: Open craniosynostosis repair is associated with high levels of pain and low utilization of nonopioid analgesics. Strategies to improve pain, decrease emesis and LOS include implementation of multimodal analgesia period and avoidance of enteral medications in the first 24 hours after surgery.