Lessons learned from the analysis of gender effect on risk factors and procedural outcomes of lower extremity arterial disease.

INTRODUCTION: Despite overall improvement, there is still a gender-related disparity in the outcomes of lower extremities peripheral arterial disease (PAD). We analyzed sex-related variability among factors that are known to influence outcomes. METHODS: Data on PAD inpatient hospitalizations from New York, New Jersey, and Florida state hospital discharge databases (1998-2007) were analyzed using univariate and multivariate logistic regression analyses. RESULTS: Of the 372,692 surgical hospitalizations identified, 162,730 (43.66%) involved women. Men and women undergoing vascular procedures differed in that more men smoked (18% vs 14%; P<.0001), and more men had coronary artery disease (40% vs 33%; P<.0001). Women were more likely to be obese (11.86% vs 4.89%; P<.0001), black (18.81% vs 12.66%; P<.0001), older, and have critical limb ischemia (CLI) (39.41% vs 37.67%; P<.0001). They had higher mortality (5.26% vs 4.21%; P<.0001) and complication rates, especially bleeding (10.62 % vs 8.19%; P<.0001) and infection (3.23% vs 2.88%; P<.0001). Mortality rates after endovascular procedures were lower and showed marginal difference between genders (2.87% vs 2.11%; P<.0001). The difference was more pronounced after open revascularizations (5.05% for women vs 4.00% for men; P<.0001) and amputations (9.82% for women vs 8.82% for men; P<.0001). Bleeding differences between men and women were greatest when both open and endovascular procedures were done during the same hospitalizations and lowest after major amputations. Similar to bleeding, transgender differences in postoperative infections were more pronounced after combination of open and endovascular procedures. Using a multivariable model, female gender remained a predictor of perioperative mortality, infection, and bleeding after vascular intervention (odds ratios 1.15, 1.21, and 1.32, respectively). Female gender negatively influenced the mortality of patients with cerebrovascular and coronary disease and those of black race even after adjusting for relevant clinical and demographic risk factors. Gender effect on mortality dissipated in octogenarians and patients with claudication. CONCLUSION: Female gender continues to be an important risk factor that negatively influences the outcomes of vascular interventions; however, these effects vary between different high-risk groups and procedures. Gender effect on mortality dissipates in elderly patients. Prompt recognition of the associations between gender and various risk factors of cardiovascular disease and aggressive modification of these risk factors in female patients may improve gender-related disparity in the outcomes of vascular disease.

Outcome of elective endovascular abdominal aortic aneurysm repair in octogenarians and nonagenarians.

OBJECTIVE: Compared to open repair of abdominal aortic aneurysms (AAA), endovascular aneurysm repair (EVAR) is associated with decreased perioperative morbidity and mortality. This study sought to examine the outcomes of EVAR in patients >or=80 years of age. METHODS: This was a retrospective review from a prospectively maintained computerized database. A total of 322 patients aged >or=80 underwent elective EVAR from January 1997 to November 2007. Mean age was 84 years +/- 3.4 years (range, 80-95 years), and 78.5% were male. Mean aneurysm size was 62 mm +/- 12 mm (range, 39-110 mm). RESULTS: Mean procedural blood loss was 350 mL (range, 50-2700 mL), and 13.9% required intraoperative transfusion. Mean length of postoperative stay was 2.46 days (median, 1 day; range, 1-42 days), with 54.3% of patients discharged on the first postoperative day. There were 25 (7.8%) perioperative major adverse events. The most common were categorized as device-related (6), cardiac (4), gastrointestinal (4), and bleeding/hematoma (3). The perioperative 30-day mortality rate was 3.1% (10 of 322). Mean follow-up was 25.7 months (range, 1-110 months). Overall, 47 patients (14.6%) required secondary intervention, 7 patients (2.2%) underwent conversion to open repair, and 4 patients (1.2%) died from AAA rupture. Endoleaks occurred in 95 patients (29.4%), with 20 type I, 48 type II, and 27 of indeterminate type; of these, 10 patients with type I endoleaks underwent secondary intervention. Freedom from all-cause mortality at 1 year was 84.3% and at 5 years was 27.4%. Freedom from aneurysm-related mortality at 5 years was 92.9%. CONCLUSION: EVAR in octogenarians is associated with high procedural success and low perioperative morbidity and mortality. The midterm results of this study support the use of EVAR in this patient population. Further studies are needed to predict short-term and long-term mortality risk, and treatment for other causes of death.

Tips and techniques in carotid artery stenting.

Significant technical advances have made carotid artery stenting an option for high-risk patients. These advances bring forth new challenges that must be overcome. Preprocedural planning is essential for optimal outcome for every patient given the high risk for significant neurologic complications. In this article we describe a standard approach for performing carotid artery stenting and techniques used to circumvent challenges that may be encountered. In addition, implementation of modifications and advanced techniques in challenging cases may allow successful treatment of carotid stenosis. Maintenance of proficiency in carotid artery stenting requires significant and ongoing experience.