Abdominal aortic aneurysm repair in nonagenarians.

BACKGROUND: The feasibility of abdominal aortic aneurysm (AAA) repair in nonagenarians on a national level is largely unknown. We undertook this study to determine the outcomes of open and endovascular AAA repair in this population on a national level. METHODS: A retrospective review of the Nationwide Inpatient Sample Database was conducted to determine all patients 90 years and older who underwent either an open or endovascular repair of a nonruptured AAA from 1997 to 2008. Preoperative comorbidities and postoperative complications in the inpatient setting were recorded. The primary end point was mortality. Secondary end points were postoperative neurologic, cardiac, and respiratory complications. This group was then compared with all adult patients less than 90 years old (age, 18-89) who had undergone repair of a nonruptured AAA during this same period. RESULTS: Four hundred twenty-three patients 90 years and older underwent repair of a nonruptured AAA (compared with 52,370 < 90). Of these, 132 patients underwent open repair (31%) and 291 (69%) underwent endovascular repair. Inpatient mortality was 18.3% for the ≥90 open, 4.6% for the <90 open, 3.1% for the ≥90 endovascular, and 1.2% for <90 endovascular group. CONCLUSIONS: Open repair of AAA's in nonagenarians is associated with significantly high perioperative mortality, whereas endovascular repair is feasible with acceptable perioperative mortality. This mortality, although significantly higher than that obtained for endovascular repair in patients <90, is nonetheless not significantly different for the mortality noted for patients <90 undergoing open AAA repair.

Hemodialysis access.

The number of patients requiring dialysis is increasing, in particular those patients over the age of 75. The arteriovenous fistula is the preferred access for hemodialysis due to fewer complications and decreased mortality. Access complications are common and require early recognition and treatment. Postoperative access surveillance is important to ensure timely diagnosis and treatment of access-related complications. There is a continued need for high-quality data to assist in determining the best access for each patient.

Diabetes mellitus is not associated with major morbidity following open abdominal aortic aneurysm repair.

BACKGROUND: It has been suggested that there is an increased morbidity and mortality risk for diabetics undergoing elective aortic surgery. This, however, is not universally accepted. In this study, we utilize a national database to determine if diabetes is associated with adverse outcomes following open, elective, infrarenal abdominal aortic aneurysm (AAA) repair. METHODS: The American College of Surgeons' National Surgical Quality Improvement Program database was queried to identify all patients who underwent an open, elective, nonruptured AAA repair from January 1, 2005 to December 31, 2007. Patient demographics, comorbidities, and outcomes were compared by diabetes status. Multivariate analysis was performed adjusting for demographics and comorbidities. RESULTS: There were 2110 American College of Surgeons' National Surgical Quality Improvement Program patients who underwent an open, elective, nonruptured AAA repair during this time period. Of these patients, 245 (11.6%) had diabetes mellitus. The overall mortality rate was 3.7% (5.3% for diabetics and 3.5% for nondiabetics, P = 0.171). On bivariate analysis, diabetics were more likely to present preoperatively with cardiovascular and renal comorbidities. Postoperatively, there was no significant difference in mortality or in cardiac, pulmonary, or renal complications. Diabetics were more likely to develop superficial surgical site infections (SSIs) (4.5% versus 1.6%, P = 0.002). On multivariate regression, there was no difference in mortality or major complications between diabetics and nondiabetics (OR 1.4, 95% CI 0.68-2.71). Diabetics, however, were almost three times more likely to develop superficial SSIs (OR 2.8, 95% CI 1.29-6.00). CONCLUSIONS: Diabetes mellitus is not associated with significantly worse major outcomes following open, elective, infrarenal AAA repair. Diabetics, however, are more likely to develop superficial SSIs.

Upper extremity bypass for chronic ischemia--a national surgical quality improvement program study database study.

OBJECTIVE: We undertook this study to determine the outcomes of upper extremity arterial reconstruction for chronic ischemia. METHODS: The National Surgical Quality Improvement Program Database was queried to identify all patients who had undergone an upper extremity bypass for chronic ischemia between 2005 and 2007. RESULTS: A total of 55 patients were identified in a primarily female population (71% women). Mean age was 57. The most common preoperative diagnoses included ischemia resulting from prior arterial thromboembolism in 16 (29%) patients and atherosclerotic upper extremity arterial disease in 11 (20%) patients. The most common procedures performed included axillo-brachial bypass in 17 (31%) patients, brachial-brachial bypass in 11 (20%) patients, and carotid-brachial bypass in 11 (20%) patients. There were no perioperative deaths and no acute graft failures. CONCLUSION: Although upper extremity bypass remains rare, the procedures appear to be safe with excellent 30-day results. Indications differ from those for lower extremity bypass.