Accelerated Chest Pain Treatment With Artificial Intelligence-Informed, Risk-Driven Triage.

This quality improvement study evaluates the use of artificial intelligence to accelerate triage of patients presenting to the emergency department with chest pain.

Assessing Time to Removal of Tunneled Dialysis Catheters after Arteriovenous Access Creation.

BACKGROUND: Tunneled dialysis catheters (TDCs) are a temporary bridge until definitive arteriovenous (AV) access is established. Our objective was to evaluate the time to TDC removal in patients who underwent AV access creations with TDCs already in place. METHODS: A single-center analysis of all AV access creations in patients with TDCs was performed (2014-2020). Primary outcome was time to TDC removal after access creation. RESULTS: There were 364 AV access creations with TDCs in place. The average age was 58 years, 44% of patients were female, and 64% were Black. The median time to TDC removal was 113 days (range, 22-931 days) with 71.4% having a TDC >90 days after access creation. Patients with TDC >90 days were often older (60 vs. 54.7), had hypertension (98.1% vs. 93.3%), were diabetic (65.4% vs. 47.1%), and had longer average time to maturation (107.1 vs. 55.4 days, P < 0.001) and first access (114 vs. 59.4 days, P < 0.001). Multivariable analysis showed that older age was associated with prolonged TDC placement (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.05, P = 0.005) and prosthetic graft use was associated with shorter TDC indwelling time (OR 0.09, 95% CI 0.04-0.23, P ≤ 0.001). Kaplan-Meier analysis showed that 87% of TDCs were removed at 1 year. CONCLUSIONS: The majority of patients with TDCs who underwent AV access creation had prolonged TDC placement. Prosthetic graft use was associated with shorter catheter times. Close follow-up after access placement, improving maturation times, and access type selection should be considered to shortened TDC times.

Recent evaluation by nephrologists is associated with decreased incidence of tunneled dialysis catheter being used at the time of first arteriovenous access creation.

OBJECTIVE: Late primary care provider (PCP) or nephrologist evaluation of patients with progressive kidney disease may be associated with increased morbidity and mortality. Among patients undergoing initial arteriovenous (AV) access creation, we aimed to study the relationship of recent PCP and nephrologist evaluations with perioperative morbidity and mortality. METHODS: We performed a retrospective review of patients from 2014 to 2022 who underwent initial AV access creation at an urban, safety-net hospital. Univariable and multivariable analyses identified associations of PCP and nephrologist evaluations <1 year and <3 months before surgery, respectively, with hemodialysis initiation via tunneled dialysis catheters (TDCs), 90-day readmission, and 90-day mortality. RESULTS: Among 558 patients receiving initial AV access, mean age was 59.7 ± 14 years, 59% were female gender, and 60.6% were Black race. Recent PCP and nephrology evaluations occurred in 386 (69%) and 362 (65%) patients, respectively. On multivariable analysis, unemployed and uninsured statuses were associated with decreased likelihood of PCP evaluation (unemployment: odds ratio [OR], 0.51; 95% confidence interval [CI], 0.34-0.77; uninsured status: OR, 0.05; 95% CI, 0.01-0.45) and nephrologist evaluation (unemployment: OR, 0.63; 95% CI, 0.43-0.91; uninsured status: OR, 0.22; 95% CI, 0.06-0.83) (all P < .05). Social support was associated with increased likelihood of PCP evaluation (OR, 1.81; 95% CI, 1.07-3.08) (all P < .05). Hemodialysis was initiated with TDCs in 304 patients (55%). Older age (OR, 0.98; 95% CI, 0.96-0.99), obesity (OR, 0.38; 95% CI, 0.25-0.58), and nephrologist evaluation (OR, 0.12; 95% CI, 0.08-0.19) were independently associated with decreased hemodialysis initiation with TDCs in patients receiving an initial AV access (all P < .05). Ninety-day readmission occurred in 270 cases (48%). Cirrhosis (OR, 2.5; 95% CI, 1.03-6.03; P = .04), coronary artery disease (OR, 2.31; 95% CI, 1.5-3.57), prosthetic AV access (OR, 1.84; 95% CI, 1.04-3.26), and impaired ambulation (OR, 1.75; 95% CI, 1.15-2.66) were independently associated with increased readmission (all P < .05). Older age (OR, 0.98; 95% CI, 0.97-0.99), prior TDC (OR, 0.65; 95% CI, 0.45-0.94), and unemployment (OR, 0.58; 95% CI, 0.39-0.86) were associated with decreased readmission (all P < .05). Ninety-day mortality occurred in 1.6% of patients. Neither PCP nor nephrologist evaluation was associated with readmission or mortality. CONCLUSIONS: Recent nephrology evaluation was associated with reduced hemodialysis initiation with TDCs among patients undergoing initial AV access creation. Unemployed and uninsured statuses posed barriers to accessing nephrology care.

Five Year Survival in Medicare Patients Undergoing Interventions for Peripheral Arterial Disease: a Retrospective Cohort Analysis of Linked Registry Claims Data.

OBJECTIVE: To justify the up front risks of offering elective interventions for intermittent claudication (IC), patients should have reasonable life expectancy to derive durable clinical benefits. Open surgery for chronic limb threatening ischaemia (CLTI) is maximally beneficial in patients surviving ≥ 2 years. The aim was to assess long term survival after IC and CLTI interventions. METHODS: In a retrospective cohort analysis, the Vascular Quality Initiative (VQI) registry from 1 January 2010 to 31 May 2021 was queried for peripheral vascular intervention (PVI), infra-inguinal bypasses (IIB), and supra-inguinal bypasses (SIB) for IC and CLTI across 286 US centres. VQI linkage to Medicare insurance claims provided five year survival data. Multivariable analysis identified factors associated with five year mortality. RESULTS: There were 31 457 PVIs (44.7% IC, 55.3% CLTI), 7 978 IIBs (26.9% IC, 73.1% CLTI), and 2 149 SIBs (50.1% IC, 49.9% CLTI) recorded in the VQI. Among the PVI, IIB, and SIB cohorts, average ages were 75, 73, and 72 years, respectively. Respective five year mortality after PVI for IC and CLTI was 37.2% and 71.1%; after IIB for IC and CLTI it was 37.8% and 60%; and after SIB for IC and CLTI it was 33.8% and 53.8%. On multivariable analysis, across all procedures, end stage renal disease, CLTI, congestive heart failure, anaemia, chronic obstructive pulmonary disease, and prior amputation were independently associated with increased mortality. Pre-admission home living and pre-operative aspirin use were independently associated with decreased mortality. CONCLUSION: Long term survival in Medicare patients undergoing interventions in VQI centres for peripheral arterial disease is poor. Two thirds of CLTI patients and over one third of IC patients were not alive at five years. Intervening for IC in patients with high mortality risk should be avoided. For CLTI patients identified with decreased survival likelihood, intervention durability may be less important than invasiveness. Pre-operative medical optimisation should always be undertaken.

Functional Impairment is Associated with Poor Long-Term Outcomes after Arteriovenous Access Creation.

BACKGROUND: Functional impairment affects outcomes after a variety of procedures. However, the impact of functional impairment on outcomes of arteriovenous (AV) access creation is unclear. We aimed to evaluate the association of patients' ability to ambulate and perform activities of daily living (ADL) with AV access outcomes. METHODS: We retrospectively reviewed patients undergoing AV access creation at an urban, safety-net hospital from 2014 to 2022. We evaluated associations of impaired ambulatory and assisted ADL status with 90-day readmission, 1-year primary patency, and 5-year mortality. RESULTS: Among the 689 patients receiving AV access, mean age was 59.6 ± 13.9 years, 59% were male, and 60% were Black. Access types included brachiocephalic (42%), brachiobasilic (26%), radiocephalic (14%), other autogenous (5%) fistulas, and prosthetic grafts (13%). Impaired ambulatory status was identified in 35% and assisted ADL status, when assessed, was identified in 21% of patients. Ninety-day readmission was more likely in patients with impaired ambulatory (58% vs. 39%, P < 0.001) and assisted ADL (56% vs. 41%, P = 0.004) status. On Kaplan-Meier analysis, 1-year primary patency was lower for patients with impaired ambulatory status (44% ± 3% vs. 29% ± 3%, P = 0.001), but was not significantly different for patients with assisted ADL status (41% ± 3% vs. 32% ± 5%, P = 0.12). Five-year survival was lower for patients with impaired ambulatory status (53% ± 5% vs. 74% ± 4%, P < 0.001), but was not significantly different for patients with assisted ADL status (45% ± 9% vs. 71% ± 4%, P = 0.1). On multivariable analysis, increased likelihood of 90-day readmission was significantly associated with impaired ambulatory status (odds ratio (OR) 2.03, 95% confidence interval (CI) 1.4-2.94, P < 0.001) and assisted ADL status (OR 1.66, 95% CI 1.07-2.57, P = 0.02). One-year primary patency was not significantly associated with impaired ambulatory (hazard ratio (HR) 1.25, 95% CI 0.98-1.6, P = 0.07) or assisted ADL status (HR 1.13, 95% CI 0.87-1.48, P = 0.36). Increased likelihood of 5-year mortality was associated with impaired ambulatory (HR 1.65, 95% CI 1.04-2.62, P = 0.04) and assisted ADL status (HR 2.63, 95% CI 1.35-5.11, P = 0.004). CONCLUSIONS: Impaired ambulatory and assisted ADL statuses were associated with increased readmissions and long-term mortality after AV access creation. Approximately half of patients with functional impairment were not alive at 5 years. Setting outcome expectations as well as prospectively examining the impact of physical therapy and visiting nursing services for functionally impaired patients undergoing AV access creation are warranted.

Assessment of Risk Factors Correlated with Outcomes of Traumatic Lower Extremity Soft Tissue Reconstruction.

Identifying risk factors for traumatic lower extremity reconstruction outcomes has been limited by sample size. We evaluated patient and procedural characteristics associated with reconstruction outcomes using data from almost four million patients. Methods: The National Trauma Data Bank (2015-2018) was queried for lower extremity reconstructions. Univariable and multivariable analyses determined associations with inpatient outcomes. Results: There were 4675 patients with lower extremity reconstructions: local flaps (77%), free flaps (19.2%), or both (3.8%). Flaps were most commonly local fasciocutaneous (55.1%). Major injuries in reconstructed extremities were fractures (56.2%), vascular injuries (11.8%), and mangled limbs (2.9%). Ipsilateral procedures prereconstruction included vascular interventions (6%), amputations (5.6%), and fasciotomies (4.3%). Postoperative surgical site infection and amputation occurred in 2% and 2.6%, respectively. Among survivors (99%), mean total length of stay (LOS) was 23.2 ± 21.1 days and 46.8% were discharged to rehab. On multivariable analysis, vascular interventions prereconstruction were associated with increased infection [odds ratio (OR) 1.99, 95% confidence interval (CI) 1.05-3.79, P = 0.04], amputation (OR 4.38, 95% CI 2.56-7.47, P < 0.001), prolonged LOS (OR 1.59, 95% CI 1.14-2.22, P = 0.01), and discharge to rehab (OR 1.49, 95% CI 1.07-2.07, P = 0.02). Free flaps were associated with prolonged LOS (OR 2.08, 95% CI 1.74-2.49, P < 0.001). Conclusions: Prereconstruction vascular interventions were associated with higher incidences of adverse outcomes. Free flaps correlated with longer LOS, but otherwise similar outcomes. Investigating reasons for increased complication and healthcare utilization likelihood among these subgroups is warranted.

Brachiocephalic and Radiocephalic Arteriovenous Fistulas in Patients with Tunneled Dialysis Catheters Have Similar Outcomes.

BACKGROUND: Patients with tunneled dialysis catheters (TDCs) have a time-sensitive need for a functional permanent access due to high risk of catheter-associated morbidity. Brachiocephalic arteriovenous fistulas (BCF) have been reported to have higher maturation and patency compared to radiocephalic arteriovenous fistulas (RCF), although more distal creation is encouraged when possible. However, this may lead to a delay in establishing permanent vascular access and, ultimately, TDC removal. Our goal was to assess short-term outcomes after BCF and RCF creation for patients with concurrent TDCs to see if these patients would potentially benefit more from an initial brachiocephalic access to minimize TDC dependence. METHODS: The Vascular Quality Initiative hemodialysis registry was analyzed from 2011 to 2018. Patient demographics, comorbidities, access type, and short-term outcomes including occlusion, reinterventions, and access being used for dialysis, were assessed. RESULTS: There were 2,359 patients with TDC, of whom 1,389 (58.9%) underwent BCF creation and 970 (41.1%) underwent RCF creation. Average patient age was 59 years, and 62.8% were male. Compared with RCF, those with BCF were more often older, of female sex, obese, nonindependently ambulatory, have commercial insurance, diabetes, coronary artery disease, chronic obstructive pulmonary disease, be on anticoagulation, and have a cephalic vein diameter of ≥3 mm (all P < 0.05). Kaplan-Meier analysis for 1-year outcomes for BCF and RCF, respectively, showed that primary patency was 45% vs. 41.3% (P = 0.88), primary assisted patency was 86.7% vs. 86.9% (P = 0.64), freedom from reintervention was 51.1% vs. 46.3% (P = 0.44), and survival was 81.3% vs. 84.9% (P = 0.02). Multivariable analysis showed that BCF was comparable to RCF with respect to primary patency loss (hazard ratio [HR] 1.11, 95% confidence interval [CI] 0.91-1.36, P = 0.316), primary assisted patency loss (HR 1.11, 95% CI 0.72-1.29, P = 0.66), and reintervention (HR 1.01, 95% CI 0.81-1.27, P = 0.92). Access being used at 3 months was similar but trending towards RCF being used more often (odds ratio 0.7, 95% CI 0.49-1, P = 0.05). CONCLUSIONS: BCFs do not have superior fistula maturation and patency compared to RCFs in patients with concurrent TDCs. Creation of radial access, when possible, does not prolong TDC dependence.

Analysis of Early Death after Elective Open Abdominal Aortic Aneurysm Repair.

BACKGROUND: Mortality after open abdominal aortic aneurysm repair is a quality measure and early death may represent a technical complication or poor patient selection. Our objective was to analyze patients who died in the hospital within postoperative day (POD) 0-2 after elective abdominal aortic aneurysm repair. METHODS: The Vascular Quality Initiative was queried from 2003-2019 for elective open abdominal aortic aneurysm repairs. Operations were categorized as in-hospital death on POD 0-2 (POD 0-2 Death), in-hospital death beyond POD 2 (POD ≥3 Death), and those alive at discharge. Univariable and multivariable analyses were performed. RESULTS: There were 7,592 elective open abdominal aortic aneurysm repairs with 61 (0.8%) POD 0-2 Death, 156 (2.1%) POD ≥3 Death, and 7,375 (97.1%) alive at discharge. Overall, median age was 70 years and 73.6% were male. Iliac aneurysm repair and surgical approach (anterior/retroperitoneal) were similar among groups. POD 0-2 Death, compared to POD ≥3 Death and those alive at discharge, had the longest renal/visceral ischemia time, more commonly had proximal clamp placement above both renal arteries, an aortic distal anastomosis, longest operative time, and largest estimated blood loss (all P < 0.05). Postoperative vasopressor usage, myocardial infarction, stroke, and return to the operating room were most frequent in POD 0-2 Death and extubation in the operating room was least frequent (all P < 0.001). Postoperative bowel ischemia and renal failure occurred most commonly among POD ≥3 Death (all P < 0.001).On multivariable analysis, POD 0-2 Death was associated with congestive heart failure, prior peripheral vascular intervention, female sex, preoperative aspirin use, lower center volume quartile, renal/visceral ischemia time, estimated blood loss, and older age (all P < 0.05). CONCLUSIONS: POD 0-2 Death was associated with comorbidities, center volume, renal/visceral ischemia time, and estimated blood loss. Referral to high-volume aortic centers could improve outcomes.

Postoperative disability and one-year outcomes for patients suffering a stroke after carotid endarterectomy.

OBJECTIVE: Although post-carotid endarterectomy (CEA) strokes are rare, they can be devastating. The degree of disability that patients develop after such events and its effects on long-term outcomes are unclear. Our goal was to assess the extent of postoperative disability in patients suffering strokes after CEA and evaluate its association with long-term outcomes. METHODS: The Vascular Quality Initiative CEA registry (2016-2020) was queried for CEAs performed for asymptomatic or symptomatic indications in patients with preoperative modified Rankin Scale (mRS) scores of 0 to 1. The mRS grades stroke-related disability as 0 (none), 1 (not significant), 2 to 3 (moderate), 4 to 5 (severe), and 6 (dead). Patients suffering postoperative strokes with recorded mRS scores were included. Postoperative stroke-related disability based on mRS and its association with long-term outcomes were analyzed. RESULTS: Among 149,285 patients undergoing CEA, there were 1178 patients without preoperative disability who had postoperative strokes and reported mRS scores. Mean age was 71 ± 9.2 years, and 59.6% of patients were male. Regarding ipsilateral cortical symptoms within 6 months preoperatively, 83.5% of patients were asymptomatic, 7.3% had transient ischemic attacks, and 9.2% had strokes. Postoperative stroke-related disability was classified as mRS 0 (11.6%), 1 (19.5%), 2 to 3 (29.4%), 4 to 5 (31.5%), and 6 (8%). One-year survival stratified by postoperative stroke-related disability was 91.4% for mRS 0, 95.6% for mRS 1, 92.1% for mRS 2 to 3, and 81.5% for mRS 4 to 5 (P < .001). Multivariable analysis demonstrated that while severe postoperative disability was associated with increased death at 1 year (hazard ratio [HR], 2.97; 95% confidence interval [CI], 1.5-5.89; P = .002), moderate postoperative disability had no such association (HR, 0.95; 95% CI, 0.45-2; P = .88). One-year freedom from subsequent ipsilateral neurological events or death stratified by postoperative stroke-related disability was 87.8% for mRS 0, 93.3% for mRS 1, 88.5% for mRS 2 to 3, and 77.9% for mRS 4 to 5 (P < .001). Severe postoperative disability was independently associated with increased ipsilateral neurological events or death at 1 year (HR, 2.34; 95% CI, 1.25-4.38; P = .01). However, moderate postoperative disability exhibited no such association (HR, 0.92; 95% CI, 0.46-1.82; P = .8). CONCLUSIONS: The majority of patients without preoperative disability who suffered strokes after CEA developed significant disability. Severe stroke-related disability was associated with higher 1-year mortality and subsequent neurological events. These data can improve informed consent for CEA and guide prognostication after postoperative strokes.

Qualitative Analysis of Length of Stay and Readmission after Carotid Endarterectomy.

BACKGROUND: Length of stay (LOS) and readmissions are common measures to evaluate quality of health care. The objective of this study was to evaluate factors related to hospital LOS and readmission within 90 days following carotid endarterectomy (CEA) in patients who have not had a stroke. METHODS: Using a single institution database, patients who underwent CEA for carotid stenosis between 2014 and 2019 were identified. Asymptomatic carotid stenosis (no history of any stroke or transient ischemic attack (TIA) within 6 months prior to CEA), and patients who had a TIA without stroke were included. Demographic and perioperative factors were collected. Primary outcomes analyzed were increased LOS (>1 day) and readmission within 90 days after surgery. RESULTS: There were 125 patients identified who underwent CEA for 133 carotid stenosis, and 8 patients had bilateral CEA; of which 36.8% were asymptomatic carotid stenosis with the remaining being operated on for TIA without any stroke. The mean age was 68 years old and 36.1% of cases were female. The median postoperative LOS was 2 days. Increased LOS occurred in 81 cases (60.9%). Increased LOS, compared to no increased LOS, occurred more often in patients with diabetes (48.1% vs. 30.8%, P = 0.047), in those with operations starting after 12:00 pm (45.7% vs. 21.2%, P = 0.004) and those with any minor complications such as neck swelling, neck pain, and urinary retention (30.9% vs. 15.4%, P = 0.044). Readmission within 90 days after CEA occurred in 24 (18%) of cases. Readmission within 90 days, compared to no readmission within 90 days, occurred more often in patients with a history of coronary artery disease (58.3% vs. 27.5%, P = 0.004), congestive heart failure (37.5% vs. 11%, P = 0.001), and atrial fibrillation (29.2% vs. 8.3%, P = 0.004). CONCLUSIONS: More than half of patients undergoing CEA for carotid stenosis were discharged after postoperative day 1. Interventions on modifiable clinical risk factors, such as morning CEA scheduling and management of comorbidities, may decrease LOS and 90-day readmission rates.

Hemodialysis Access Outcomes for Patients with Unstable Housing.

BACKGROUND: End-stage renal disease has traditionally been noted to disproportionately affect patients with fewer resources. Our goal was to assess practice patterns and outcomes in patients with unstable housing undergoing permanent hemodialysis access creation. STUDY DESIGN: A retrospective, single-center review of patients with unstable housing was conducted. Perioperative and long-term outcomes were assessed. Univariable and multivariable analysis as well as Kaplan-Meier analysis were performed. RESULTS: There were 144 patients (63% male) identified with a mean age of 57 years. Thirty-three percent of patients had no current permanent residence, and 81% had at least 3 addresses the year before operation. Access type included brachiocephalic (48%), brachiobasilic (19%), radiocephalic fistulas (11%), and prosthetic grafts (19%). Thirty-day readmission was seen in 27.8% of patients. Kaplan-Meier analysis showed that 1-year and 4-year patient survival were 94.4% and 80.6%, respectively. Multivariable analysis demonstrated that newly formed access (odds ratio [OR] 3.66, 95% CI 1.02 to 13.16, p = 0.05), absence of a permanent residence (OR 2.92, 95% CI 1.15 to 7.44, p = 0.03), and female gender (OR 2.86, 95% CI, 1.18 to 7.14, p = 0.02) were associated with 90-day readmission. Multivariable analysis of mortality revealed that previous stroke (hazard ratio [HR] 7.15, 95% CI 1.93 to 26.5, p = 0.003), history of alcohol use disorder (HR 4.55, 95% CI 1.22 to 16.99, p = 0.024), and age (HR 1.10, 95% CI, 1.02 to 1.18, p = 0.017) were associated with 4-year mortality; housing instability was not associated with decreased survival. Preoperative tunneled dialysis catheter (HR 1.63, 95% CI 1.02 to 2.61, p = 0.04) was associated with 4-year reintervention and frequent address change (HR 0.47, 95% CI 0.27 to 0.81, p = 0.01) was found to be a protective factor against long-term reintervention. CONCLUSION: Poor outcomes in patients with unstable housing were primarily driven by comorbidities. Lack of permanent residence was significantly associated with readmission.

Unplanned Shunting Is Associated with Higher Stroke Risk after Eversion Carotid Endarterectomy.

BACKGROUND: Shunting during eversion carotid endarterectomy (eCEA) may be technically challenging. Whether shunting practice patterns modify perioperative stroke risk after eCEA is unclear. We aimed to compare eCEA outcomes based on shunting practice. METHODS: The Vascular Quality Initiative (2011-2019) was queried for eCEAs performed for symptomatic and asymptomatic carotid stenosis. Univariable and multivariable analyses compared outcomes based on whether shunting was routine practice, preoperatively-indicated, intraoperatively-indicated, or not performed. RESULTS: There were 13,207 eCEAs identified. Average age was 71.4 years and 59.4% of patients were male sex. Ipsilateral carotid stenosis was >80% in 45.6% and there was severe contralateral carotid stenosis in 8.6%. Early ipsilateral symptoms within 14 days of eCEA were transient ischemic attack in 5.6% and stroke in 7%. The majority of cases were performed under general anesthesia (82.7%). Electroencephalogram monitoring and stump pressures were utilized in 30.9% and 14.7%, respectively. Shunting was routine (25.4%), preoperatively-indicated (1.9%), intraoperatively-indicated (4.7%), or not implemented (68%). Preoperatively-indicated shunting was more often performed in patients with early symptomatic carotid stenosis or severe contralateral carotid stenosis. After routine shunting, preoperatively-indicated shunting, intraoperatively-indicated shunting, and no shunting, median operative duration was 110, 101, 112, and 97 min, respectively (P < 0.001), and ipsilateral perioperative stroke prevalence was 0.6%, 1.2%, 1.9%, and 0.7%, respectively (P = 0.004). On multivariable analysis, longer operative time was associated with routine shunting (MR 1.17, 95% CI 1.15-1.19, P < 0.001), preoperatively-indicated shunting (MR 1.09, 95% CI 1.04-1.15, P < 0.001), and intraoperatively-indicated shunting (MR 1.12, 95% CI 1.09-1.16, P < 0.001) compared with no shunting. Compared with no shunting, routine shunting (OR 0.91, 95% CI 0.54-1.54, P = 0.74) and preoperatively-indicated shunting (OR 1.53, 95% CI 0.47-4.99, P = 0.48) were not associated with stroke; however, intraoperatively-indicated shunting was associated with increased stroke (OR 2.74, 95% CI 1.41-5.3, P = 0.003). Shunting type was not associated with perioperative mortality. CONCLUSIONS: Intraoperatively-indicated shunting during eCEA was associated with longest operative duration and increased perioperative stroke risk. Surgeon familiarity with shunting and planning to shunt in advance may permit more expeditious shunting and prevent stroke.

Female Sex is Associated with More Reinterventions after Endovascular and Open Interventions for Intermittent Claudication.

BACKGROUND: Intermittent claudication (IC) is a commonly treated vascular condition. Patient sex has been shown to influence outcomes of interventions for other vascular disorders; however, whether outcomes of interventions for IC vary by sex is unclear. We sought to assess the association of patient sex with outcomes after IC interventions. METHODS: The Vascular Quality Initiative was queried from 2010-2020 for all peripheral endovascular interventions (PVI), infra-inguinal bypasses (IIB), and supra-inguinal bypasses (SIB) for any degree IC. Univariable and multivariable analyses compared peri-operative and long-term outcomes by patient sex. RESULTS: There were 24,701 female and 40,051 male patients undergoing PVI, 2,789 female and 6,525 male patients undergoing IIB, and 1,695 female and 2,370 male patients undergoing SIB for IC. Guideline-recommended pre-operative medical therapy differed with female patients less often prescribed aspirin for PVI (73.4% vs. 77.3%), IIB (71.5% vs. 74.8%), and SIB (70.9% vs. 74.3%) or statins for PVI (71.8% vs. 76.7%) and IIB (73.1% vs. 76.0%) (all P < 0.05). Female compared with male patients had lower 1-year reintervention-free survival after PVI (84.4% ± 0.3% vs. 86.3% ± 0.2%, P < 0.001), IIB (79.0% ± 0.9% vs. 81.2% ± 0.6%, P = 0.04), and SIB (89.4% ± 0.9% vs. 92.6% ± 0.7%, P = 0.005), but similar amputation-free survival and survival across all procedures. Multivariable analysis confirmed that female sex was associated with increased 1-year reintervention for PVI (HR 1.16, 95% CI 1.09-1.24, P < 0.001), IIB, (HR 1.16, 95% CI 1.03-1.31, P = 0.02), and SIB (HR 1.60, 95% CI 1.20-2.13, P = 0.001). CONCLUSIONS: Female patients undergoing interventions for IC were less often pre-operatively medically optimized than male patients, though the difference was small. Furthermore, female sex was associated with more reinterventions after interventions. Interventionists treating female patients should increase their efforts to maximize medical therapy. Future research should clarify reasons for poorer intervention durability in female patients.

Access site complications are uncommon with vascular closure devices or manual compression after lower extremity revascularization.

OBJECTIVE: Vascular closure devices (VCDs) and manual compression (MC) are used to achieve hemostasis after peripheral vascular interventions (PVIs). We sought to compare perioperative outcomes between MC and four VCDs after PVI in a multicenter setting. METHODS: The Vascular Quality Initiative was queried for all lower extremity PVIs with common femoral artery access performed from 2010 to 2020. The VCDs included were MynxGrip (Cordis, Santa Clara, CA), StarClose SE (Abbott Vascular, Redwood City, CA), Angio-Seal (Terumo, Somerset, NJ), and Perclose ProGlide (Abbott Vascular). In a blinded fashion, these four VCDs (labeled A, B, C, and D) were compared to MC for baseline characteristics, procedural details, and outcomes (access site hematoma and stenosis/occlusion). Those with a sheath size >8F were excluded. Propensity score matching (1:1) was performed. Univariable and multivariable analyses were completed for unmatched and matched data. RESULTS: A total of 84,172 lower extremity PVIs were identified. Of these, 32,013 (38%) had used MC and 52,159 (62%) had used VCDs (A, 12,675; B, 6224; C, 19,872; D, 13,388). The average age was 68.7 years, and 60.4% of the patients were men. The most common indications for intervention were claudication (43.8%) and tissue loss (40.1%). Compared with MC, VCDs were used more often for patients with obesity, diabetes, and end-stage renal disease (P < .001 for all). VCDs were used less often for patients with hypertension, chronic obstructive pulmonary disease, coronary artery disease, prior percutaneous coronary and extremity interventions, and major amputation (P < .001 for all). VCD use was more common than MC during femoropopliteal (73% vs 63.8%) and tibial (33.8% vs 22.3%) interventions but less common with iliac interventions (20.6% vs 34.7%; P < .001 for all). Protamine was used less often with VCDs (19.1% vs 25.6%; P < .001). Overall, 2003 hematomas had developed (2.4%), of which 278 (13.9%) had required thrombin or surgical intervention. Compared with MC, the use of any VCD had resulted in fewer hematomas (1.7% vs 3.6%; P < .001) and fewer hematomas requiring intervention (0.2% vs 0.5%; P < .001). When divided by hemostatic technique, the rate of the development of any hematoma was as follows: MC, 3.6%; VCD A, 1.4%; VCD B, 1.2%; VCD C, 2.3%; and VCD D, 1.1% (P < .001). The rate of hematomas requiring intervention was as follows: MC, 0.5%; VCD A, 0.2%; VCD B, 0.2%; VCD C, 0.3%; and VCD D, 0.1% (P < .001). Access site stenosis/occlusion was similar between the MC and any VCD groups (0.2% vs 0.2%; P = .12). Multivariable analysis demonstrated that any VCD use and the use of the individual VCDs compared with MC were independently associated with the development of fewer hematomas. The incidence of access site stenosis/occlusion was similar between the use of any VCD and MC. The matched analysis revealed similar findings. CONCLUSIONS: Although the overall rates of hematomas requiring intervention were low regardless of hemostatic technique, VCD use, irrespective of type, compared favorably with MC, with significantly fewer access site complications after PVI.

The U.S. Preventive Services Task Force Abdominal Aortic Aneurysm Screening Guidelines Negligibly Impacted Repair Rates in Male Never-Smokers and Female Smokers.

OBJECTIVE: In 2014, in addition to male smokers aged 65-75 years, the U.S. Preventive Services Task Force (USPSTF) recommended abdominal aortic aneurysm (AAA) screening for male never-smokers aged 65-75 years with cardiovascular risk factors (Grade C). The USPSTF evolved from a negative to neutral position on screening for female smokers aged 65-75 years (Grade I). We sought to determine whether 2014 guidelines resulted in more AAA repairs in these populations. METHODS: We queried the Vascular Quality Initiative national database (2013-2018) for elective endovascular aortic repairs and open aortic repairs. We implemented difference-in-differences (DID) analysis, a causal inference technique that adjusts for secular time trends, to isolate changes in repair numbers due to the 2014 USPSTF guidelines. Our DID models compared changes in repair numbers in patient groups targeted by the USPSTF updates (intervention group) to those in unaffected, older patient groups (control), before and after 2014. The first model compared changes in repair numbers between male never-smokers aged 65-75 years (intervention group) and 76-85 years (control). The second model compared repair numbers between female smokers aged 65-75 years (intervention group) and 76-85 years (control). RESULTS: There was no significant change in male never-smokers (n = 1,295) aged 65-75 (42%) vs. 76-85 (58%) undergoing AAA repairs after guideline updates, averaged over 4.5 years (+2.4 percentage points; 95% Confidence Interval [CI] -.56-5.26). However, when their primary insurer was Medicare, male never-smokers aged 65-75 years compared with 76-85 years underwent significantly more repairs over 4.5 years (+3.69 percentage points; 95% CI.16-7.22; representing a 10.4% relative increase from baseline in the proportion of male never-smokers on Medicare undergoing AAA repair). Comparing female smokers (n = 2,312) aged 65-75 (54%) vs. 76-85 (46%), there was no significant change in repairs over 4.5 years (-.66 percentage points; 95% CI -4.57-3.26). CONCLUSIONS: The USPSTF 2014 AAA guidelines were associated with modestly increased repairs in male never-smokers aged 65-75 years only on Medicare. There was no impact among female smokers. Higher-grade recommendations and improved guideline adherence may be requisites for change.

Outcomes of axillofemoral bypass for intermittent claudication.

OBJECTIVE: Although endovascular therapy is often the first-line option for medically refractory intermittent claudication (IC) caused by aortofemoral disease, suprainguinal bypass is often performed. Although this will often be aortofemoral bypass (AoFB), axillofemoral bypass (AxFB) is still sometimes performed despite limited data evaluating its utility in the management of IC. Our goal was to assess the safety and durability of AxFB performed for IC. METHODS: The Vascular Quality Initiative (2009-2019) was queried for suprainguinal bypass performed for IC. Univariable and multivariable analyses were used to compare the perioperative and 1-year outcomes between AxFB and a comparison cohort of AoFB. RESULTS: We identified 3261 suprainguinal bypasses performed for IC: 436 AxFBs and 2825 AoFBs. The mean age was 61.4 ± 9.1 years, 58.8% of the patients were men, and 59.7% currently smoked. Patients undergoing AxFB, compared with AoFB, were more often older, male, never smokers and ambulated with assistance (P < .001 for all). They had more often had hypertension, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, and end-stage renal disease and had more often undergone previous outflow peripheral endovascular interventions and previous inflow or outflow bypass. The AxFBs, compared with the AoFBs, were more often unifemoral (P < .05). Patients who had undergone AxFB, compared with AoFB, had had a shorter postoperative length of stay (median, 4 vs 6 days) and fewer perioperative pulmonary (3% vs 7.9%) and renal (5.5% vs 9.9%) complications but had required more perioperative ipsilateral major amputations (0.9% vs 0.04%; P < .05 for all). No significant differences were found in the incidence of perioperative myocardial infarction (2.8% vs 2.7%), stroke (0.7% vs 1.1%), or death (1.8% vs 1.7%). At 1 year, the Kaplan-Meier analysis demonstrated that the AxFB cohort, compared with the AoFB cohort, had had higher rates of death (7.3% vs 3.6%; P = .002), graft occlusion or death (14.3% vs 7.2%; P = .001), ipsilateral major amputation or death (12.5% vs 5.6%; P < .001), and reintervention, amputation, or death (19% vs 8.6%; P < .001). On multivariable analysis, AxFB was independently associated with an increased risk of 1-year reintervention, amputation, or death (hazard ratio, 1.6; 95% confidence interval, 1.03-2.4; P = .04). CONCLUSIONS: The results from the present retrospective analysis suggest that long-term complications were more frequent in patients who had undergone AxFB compared with AoFB, although patients treated with AxFB had had a greater risk with more comorbidities. Because AxFB was associated with significant perioperative morbidity, mortality, and long-term complications, serious consideration should be given before its use to treat IC.

Percutaneous radial artery access for peripheral vascular interventions is a safe alternative for upper extremity access.

OBJECTIVE: Percutaneous radial artery access has been increasingly used for peripheral vascular interventions (PVIs). Our goal was to characterize the practice patterns and perioperative outcomes among patients treated using PVI performed via radial artery access. METHODS: The Vascular Quality Initiative was queried from 2016 to 2020 for PVI performed via upper extremity access. Univariable and multivariable analyses were used to evaluate the periprocedure outcomes of radial artery access cases. A separate sample of brachial artery access cases was used as a comparator. RESULTS: A total of 520 radial artery access cases were identified. The mean age was 69 ± 10 years, and 41.3% were women. Most procedures were performed in the hospital outpatient setting (71.7%). The sheath size was ≤5F for 10%, 6F for 78%, and 7F for 12%. Ultrasound-guided access and protamine were used in 68.3% and 17.3% of cases, respectively. The interventions were aortoiliac (55%), femoropopliteal (55%), and infrapopliteal (9%). Stenting and atherectomy were performed in 55% and 19% of cases, respectively, and more often with 7F sheaths. Access site complications were any hematoma (4.8%), including hematomas resulting in intervention (0.8%), pseudoaneurysms (1%), and access stenosis or occlusion (0.8%). On multivariable analysis, sheath size was not associated with access site complications. Percutaneous brachial artery access (n = 1135) compared with radial access was independently associated with more overall hematomas (odds ratio, 1.73; 95% confidence interval, 1.06-2.81; P = .03). However, access type was not associated with hematomas resulting in intervention (odds ratio, 2.15; 95% confidence interval, 0.69-6.72; P = .19). CONCLUSIONS: PVIs via radial artery access exhibited a low prevalence of postprocedural access site complications and were associated with fewer minor hematoma complications compared with interventions performed using brachial artery access. Radial artery access compared with brachial artery access should be the preferred technique for PVIs.

The Association of Body Mass Index with Outcomes after Carotid Endarterectomy.

BACKGROUND: Patients who are obese or underweight are traditionally at higher risk for perioperative morbidity and mortality. The effect of body mass index (BMI) on outcomes after carotid endarterectomy (CEA) is unclear. Our goal was to analyze the association of BMI with perioperative and long-term outcomes after elective CEA. METHODS: The Vascular Quality Initiative (VQI) database was queried from 2003-2018 for patients undergoing elective CEAs. Patients were categorized into 5 BMI cohorts - underweight (UW, BMI < 18.5 kg/m2), normal weight (NW, BMI 18.5-24.9 kg/m2), overweight (OW, BMI 25-29.9 kg/m2), obese (OB, BMI 30-39.9 kg/m2), and morbidly obese (MO, BMI ≥ 40 kg/m2). Perioperative and long-term outcomes were assessed with univariable and multivariable analyses. RESULTS: There were 89,079 patients included: 2% UW, 26% NW, 38.4% OW, 29.9% OB, and 3.6% MO. Overall, the mean age was 70.6 years, 60% were male, and 91.8% were of white race. There were significant differences among the BMI cohorts in regards to age, sex, smoking status, and comorbidities (all P < 0.05). For perioperative outcomes, the BMI cohorts differed significantly in reoperation for bleeding and 30-day mortality. On multivariable analysis, BMI was not associated with stroke or perioperative mortality. MO was associated with perioperative cardiac complications (Odds Ratios [OR] 1.26, 95% CI 1-1.57, P = 0.05). UW status was associated with increased return to the operating room (OR 1.89, 95% confidence interval [95% CI] 1.28-2.78, P = 0.001), 30-day mortality (OR 1.68, 95% CI 1-2.86, P =0.05), 1-year mortality (Hazard ratio [HR] 1.37, 95% CI 1.08-1.74, P = 0.01), and 5-year mortality (HR 1.22, 95% CI 1.06-1.41, P =0.005). CONCLUSIONS: BMI status was not associated with perioperative stroke, cranial nerve injury, or surgical site infections. Patients with MO had higher perioperative cardiac complications. UW patients have lower short and long-term survival and should be a focus for long-term targeted risk factor stratification and modification.

High Mortality and Venous Thromboembolism Risk Following Major Penetrating Abdominal Venous Injuries.

BACKGROUND: Penetrating injuries to the inferior vena cava and/or iliac veins are a source of hemorrhage but may also predispose patients to venous thromboembolism (VTE). We sought to determine the relationship between iliocaval injury, VTE and mortality. METHODS: The National Trauma Data Bank was queried for penetrating abdominal trauma from 2015-2017. Univariate analyses compared baseline characteristics and outcomes based on presence of iliocaval injury. Multivariable analyses determined the effect of iliocaval injury on VTE and mortality. RESULTS: Of 9,974 patients with penetrating abdominal trauma, 329 had iliocaval injury (3.3%). Iliocaval injury patients were more likely to have a firearm mechanism (83% vs. 43%, P < 0.001), concurrent head (P = 0.036), spinal cord (P < 0.001), and pelvic injuries (P < 0.001), and higher total injury severity score (median 20 vs. 8.0, P < 0.001). They were more likely to undergo 24-hr hemorrhage control surgery (69% vs. 17%, P < 0.001), but less likely to receive VTE chemoprophylaxis during admission (64% vs. 68%, P = 0.04). Of patients undergoing iliocaval surgery, 64% underwent repair, 26% ligation, and 10% unknown. Iliocaval injury patients had higher rates of VTE (12% vs. 2%), 24-hr mortality (23% vs. 2.0%) and in-hospital mortality (33% vs. 3.4%) (P < 0.001 for all). VTE rates were similar following repair (14%) and ligation (17%). Iliocaval injury patients also had higher rates of cardiac complications (10.3% vs. 1.4%), acute kidney injury (8.2% vs. 1.3%), extremity compartment syndrome (4.0 vs. 0.2%), and unplanned return to OR (7.9% vs. 2.5%) (P < 0.001 for all). In multivariable analyses, iliocaval injury was independently associated with risk of VTE (OR 2.12; 95% CI, 1.29-3.48; P = 0.003), and in-hospital mortality (OR = 9.61; 95% CI, 4.96-18.64; P < 0.001). CONCLUSION: Iliocaval injuries occur in <5% of penetrating abdominal trauma but are associated with more severe injury patterns and high mortality rates. Regardless of repair type, survivors should be considered high risk for developing VTE.

Perioperative Outcomes for Centers Routinely Admitting Postoperative Endovascular Aortic Aneurysm Repair to the ICU.

BACKGROUND: Intensive care unit (ICU) admission after endovascular aortic aneurysm repair (EVAR) varies across medical centers. We evaluated the association of postoperative ICU use with perioperative and long-term outcomes after EVAR. STUDY DESIGN: The Vascular Quality Initiative (2003-2019) was queried for index elective EVARs. Included centers were categorized by percentage of patients with EVARs postoperatively admitted to the ICU; routine ICU (rICU) centers as ≥80% ICU admissions and nonroutine ICU (nrICU) centers as ≤20% ICU admissions. Patients admitted preoperatively or with same day discharge were excluded. Perioperative outcomes and survival were compared between rICU and nrICU centers. RESULTS: Of 45,310 EVARs in the database, 35,617 were performed at rICU or nrICU centers - 5,443 (15.3%) at 71 rICU centers and 30,174 (84.7%) at 200 nrICU centers. Overall, mean age was 73.4 years and 81.6% were male. Postoperative myocardial infarction, pulmonary complications, stroke, leg ischemia, and in-hospital mortality were similar between rICU and nrICU centers (all p > 0.05). Postoperative length of stay (LOS) was prolonged at rICU centers (mean) (2.2 ± 3.6 vs 2 ± 4.2 days, p < 0.001). One-year survival was similar between rICU and nrICU centers, respectively, (94.9% vs 95.4%, p = 0.085). When compared with nrICU centers, rICU centers had similar 1-year mortality risk (hazard ratio [HR] 1.15, 95% CI 0.99-1.34, p = 0.076), but were associated with longer postoperative LOS (means ratio 1.1, 95% CI 1.08-1.13, p < 0.001). CONCLUSIONS: Routine ICU use after EVAR was associated with prolonged postoperative LOS, without improved perioperative/long-term morbidity or mortality. Updated care pathways to include postoperative admission to lower acuity care units may reduce costs without compromising care.