Outcomes for symptomatic abdominal aortic aneurysms in the American College of Surgeons National Surgical Quality Improvement Program.

BACKGROUND: Historically, symptomatic abdominal aortic aneurysms (AAAs) were found to have intermediate mortality compared with asymptomatic and ruptured AAAs; but with wider use of endovascular aneurysm repair (EVAR), a more recent study suggested that mortality of symptomatic aneurysms was similar to that of asymptomatic AAAs. These prior studies were limited by small numbers. The purpose of this study was to evaluate the mortality and morbidity associated with symptomatic AAA repair in a large contemporary population. METHODS: All patients undergoing infrarenal AAA repair were identified in the 2011 to 2013 American College of Surgeons National Surgical Quality Improvement Program, vascular surgery targeted module. We excluded acute conversions to open repair and those for whom the surgical indication was embolization, dissection, thrombosis, or not documented. We compared 30-day mortality and major adverse events for asymptomatic, symptomatic, and ruptured AAA repair, stratified by EVAR and open repair, with univariate analysis and multivariable logistic regression. RESULTS: There were 5502 infrarenal AAAs identified, 4495 asymptomatic aneurysms (830 open repair, 3665 [82%] EVAR), 455 symptomatic aneurysms (143 open repair, 312 [69%] EVAR), and 552 ruptured aneurysms (263 open repair, 289 [52%] EVAR). Aneurysm diameter was similar between asymptomatic and symptomatic AAAs when stratified by procedure type, but it was larger for ruptured aneurysms (EVAR: symptomatic 5.8 ± 1.6 cm vs ruptured 7.5 ± 2.0 cm [P < .001]; open repair: symptomatic 6.4 ± 1.9 cm vs ruptured 8.0 ± 1.9 cm [P < .001]). The proportion of women was similar in symptomatic and ruptured AAAs (27% vs 23%, respectively; P = .14) but lower in asymptomatic AAAs (20%; P < .001). Symptomatic AAAs had intermediate 30-day mortality compared with asymptomatic and ruptured aneurysms after both EVAR (1.4% asymptomatic vs 3.8% symptomatic [P = .001]; symptomatic vs 22% ruptured [P < .001]) and open repair (4.3% asymptomatic vs 7.7% symptomatic [P = .08]; symptomatic vs 34% ruptured [P < .001]). After adjustment for age, gender, repair type, dialysis dependence, and history of severe chronic obstructive pulmonary disease, patients undergoing repair of symptomatic AAAs were twice as likely to die within 30 days compared with those with asymptomatic aneurysms (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.3-3.5). When stratified by repair type, the effect size and direction of the ORs were similar (EVAR: OR, 2.4 [95% CI, 1.2-4.7]; open repair: OR, 1.8 [95% CI, 0.86-3.9]) although not significant for open repair. Patients with ruptured aneurysms had a sevenfold increased risk of 30-day mortality compared with symptomatic patients (OR, 6.5; 95% CI, 4.1-10.6). CONCLUSIONS: Patients with symptomatic AAAs had a twofold increased risk of perioperative mortality compared with patients with asymptomatic aneurysms undergoing repair. Furthermore, patients with ruptured aneurysms have a sevenfold increased risk of mortality compared with patients with symptomatic aneurysms.

Bovine pericardial patch repair in infected fields.

OBJECTIVE: Bovine pericardial patches (BPP) are frequently used for arterial reconstruction, but little data exist regarding their ability to resist infection. We hypothesize that BPP would provide a reasonable alternative to autologous vein patches in infected fields. METHODS: We used BPP to repair 51 arteriotomies (25 brachial, 23 femoral, three popliteal) in 48 consecutive patients (mean age, 68 years; 65% men, 75% diabetic, 67% dialysis dependent) undergoing removal of infected (33 gram-positive, three gram-negative, eight mixed flora, and four culture-negative) polytetrafluoroethylene grafts (35 arteriovenous grafts, nine femoral-distal bypasses, and four femoral patch angioplasties) between January 2007 and January 2011. Patient records were retrospectively reviewed and outcomes, including death, rupture, secondary reconstruction, and infection, were recorded. RESULTS: Over a mean follow-up of 2.1 years (range, 3-48 months), 50 of 51 patches remained in place without evidence of recurrent infection, rupture, or revision. One patient had acute rupture of a popliteal arteriotomy 1 week postrepair and had subsequent ligation and above-knee amputation. Eight of the 48 patients died from unrelated causes during follow-up (three withdrew from dialysis, three myocardial infarction, and two unknown). CONCLUSIONS: BPP provide a durable alternative to saphenous vein for arterial reconstruction following removal of infected arterial grafts.

Popliteal artery aneurysms: a comparison of outcomes in elective versus emergent repair.

OBJECTIVE: The purpose of this study was to assess and compare outcomes of elective versus emergent operative repair of popliteal artery aneurysms. DESIGN: A retrospective analysis of a prospectively recorded vascular surgery database from June 1992 to December 2002 was performed with chart review. Main outcome measures Patient survival, limb salvage, and graft patency were evaluated. RESULTS: Fifty-one popliteal artery aneurysms were repaired in 39 patients, all male and ranging in age from 18 to 87 years (mean 67.1). Mean follow-up was 47.8 months. Repair was elective in 37 (72.5%) and emergent in 14 (27.5%) limbs, 13 with acute ischemia and one with aneurysm rupture. Thrombolytic therapy was utilized in four ischemic limbs with no suitable bypass target vessel identified on initial arteriogram. Outflow vessels included the popliteal artery in 22 (43.1%) and infrapopliteal vessels in 29 (56.9%) limbs. Cardiac morbidity and 30-day mortality rates were 0%. Overall primary patency, secondary patency, limb salvage, and actuarial survival were 95.6%, 100%, 98.0%, and 98.0% at 1 year and 85.1%, 96.9%, 98.0%, and 83.8% at 5 years, respectively. Bypass graft redo or revision was performed for stenosis in one and occlusion in four limbs. Two amputations were performed at 6 days and 63.6 months after initial aneurysm repair. No difference was noted between elective and emergent groups with regard to patency, limb salvage, or survival (P >.26), and no association between the number of identified target vessels and limb salvage or patency was demonstrated (P =.12). CONCLUSION: In our experience, the outcome of the popliteal artery aneurysm repair was comparable in the emergent and elective settings. Aggressive tibial reconstruction plays a crucial role in the treatment of popliteal artery aneurysms, especially in those presenting with acute limb ischemia. Thrombolytic therapy is infrequently required in the acute setting, although it may be useful in patients with no identifiable outflow target vessel on initial arteriogram.

Major lower extremity amputation: outcome of a modern series.

HYPOTHESIS: Major lower extremity amputation results in significant morbidity and mortality. DESIGN: Retrospective database query and medical record review for January 1, 1990, to December 31, 2001. Mean follow-up was 33.6 months. SETTING: Academic tertiary care center. PATIENTS: Nine hundred fifty-nine consecutive major lower extremity amputations in 788 patients, including 704 below-knee amputations (BKAs) (73.4%) and 255 above-knee amputations (AKAs) (26.6%). MAIN OUTCOME MEASURES: Patient survival, cardiac morbidity, infectious complications, and subsequent operation. RESULTS: Overall 30-day mortality was 8.6%, worse for AKA (16.5%) than BKA (5.7%) patients (P<.001). Thirty-day mortality for guillotine amputation for sepsis control was 14.3% compared with 7.8% for closed amputation (P =.03). Complications included cardiac (10.2%), wound infection (5.5%), and pneumonia (4.5%). Twelve AKA (4.7%) and 129 BKA (18.4%) limbs required subsequent operation. Only 66 BKAs (9.4%) required conversion to AKA (average, 77.1 days postoperatively). Overall survival was 69.7% and 34.7% at 1 and 5 years, respectively. Survival was significantly worse for AKAs (50.6% and 22.5%) than BKAs (74.5% and 37.8%) (P<.001). Survival in patients with diabetes mellitus (DM) was 69.4% and 30.9% vs 70.8% and 51.0% in patients without DM at 1 and 5 years, respectively (P =.002). Survival in end-stage renal disease patients was 51.9% and 14.4% vs 75.4% and 42.2% in patients without renal failure at 1 and 5 years, respectively (P<.001). CONCLUSIONS: Major amputation continues to result in significant morbidity and mortality. Survivors with BKA require revision or conversion to AKA infrequently. Long-term survival is dismal for patients with DM and end-stage renal disease and those undergoing AKA.