Technical Predictors of Perioperative Clinical Outcomes after Carotid Artery Stenting

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Journal of Vascular Surgery

Abstracts

January 2017 Author Disclosures: S. Hui: None; R. Folsom: None; L. Killewich: None; M. Vu: None; C. Li: None; J. Michalek: None; A. Trevino: None; M. Davies: None; L. Pounds: None.

Author Disclosures: R. B. Hawkins: None; J. Mehaffey: None; A. K. Narahari: None; A. Jain: None; R. Ghanta: None; I. L. Kron: None; J. A. Kern: None; G. R. Upchurch: None.

Improving Outcomes and Value with Staged Hybrid Extent II Thoracoabdominal Aortic Aneurysm Repair

Anatomic/Technical Predictors of Perioperative Clinical Outcomes after Carotid Artery Stenting

Robert B. Hawkins,1 J. Hunter Mehaffey,1 Adishesh K. Narahari,1 Amit Jain,2 Ravi Ghanta,1 Irving L. Kron,1 John A. Kern,1 Gilbert R. Upchurch1. 1University of Virginia, Charlottesville, Va; 2University of Cincinnati, Cincinnati, Ohio Objective: Complex Crawford extent II thoracoabdominal aortic aneurysms (TAAA) can be treated in a hybrid manner with proximal thoracic endovascular aneurysm repair, followed by staged distal open thoracoabdominal repair. The purpose of this study was to evaluate the outcomes and healthcare associated value of this new method compared with traditional open repair over 10 years. Methods: A prospectively collected database was used to identify all patients with extent II TAAA undergoing repair at a single institution between 2005 and 2015. Patient characteristics, postoperative outcomes, and incidence of major adverse events (MAEs, renal failure, spinal cord ischemia, death) were compared. Value was analyzed looking at quality (1/MAE) divided by inflation adjusted total health system cost. Results: A total of 113 consecutive patients underwent extent II TAAA repairs, of which 25 (22.1%) had a staged hybrid approach with a median of 129 days between procedures. No baseline differences in demographic or comorbidity variables existed between groups (P > .05). The hybrid group had shorter operative time (255 vs 306 minutes; P ¼ .01), shorter postoperative length of stay (10.1 vs 13.3 days; P ¼ .02), and reduced blood loss (1300 vs 2600 mL; P ¼ .01) at the time of open operation. Despite higher rates of acute kidney injury in the hybrid group (76.0% vs 51.1%; P ¼ .03), there was no difference in renal failure (8.0% vs 4.5%; P ¼ .84). The incidence of MAE was significantly lower in the staged hybrid group (20.0% vs 48.9%; P ¼ .01), while in-hospital mortality (4.0% vs 3.4% P ¼ .89) and long-term survival were not different (Kaplan-Meier P ¼ .51; Fig). Median total cost was higher in the hybrid group ($112,920 vs $$72,037; P ¼ .01). The hybrid approach resulted in over 50% increased value (156 vs 100; Table). Conclusions: Staged hybrid repair of complex extent II TAAA results in lower length of stay, blood loss, operative time, and MAE. The increased costs of hybrid repair are offset by improved outcomes resulting in improved value over open repair. Table. Healthcare-associated value Variables

Staged hybrid

MAE

5 (20.0%)

Total cost (median) Value

Standard open

P value

43 (48.9%)

.017

$112,920

$72,037

.003

156

100

MAE, Major adverse event. Total cost was adjusted for inflation and represents 2015 dollars.

Ali F. AbuRahma, John E. Campbell, Aravinda Nanjundappa, Trevor DerDerian, Nizar Hariri, Elliott Adams, L. Scott Dean, Joseph AbuRahma, Robert C. Byrd. Health Sciences Center of West Virginia University, Charleston, WV Objective: Only a few studies have reported on the impact of anatomic/ technical factors on clinical outcomes of carotid artery stenting (CAS). This study will analyze the effect of these factors on perioperative stroke/death after CAS. Methods: This is a retrospective analysis of prospectively collected data on 456 patients with CAS. A logistic regression analysis was used to determine the impact of anatomic factors (lesion length, location, severity, calcification, and arch type) and technical factors (stent type, number, diameter, and length; filter type, filter insertion to recovery time, and pre- and poststent percutaneous transluminal angioplasty [PTA]) on perioperative stroke, death, and myocardial infarction (major adverse events [MAE]). Results: The MAE and stroke rates for the whole series were 4.7% and 2.2%. The stroke rate for asymptomatic patients was 0.46% (P ¼ .01). The MAE rates for patients with transient ischemic attacks (TIAs) were 7% vs 3.2% for other indications (P ¼ .077). The stroke rates for calcific lesions were 6.3% vs 1.2% for noncalcific lesions (P ¼ .046). There were no significant differences in stroke and MAE rates regarding other anatomic features. The stroke rate for patients with dilatation prior to filter insertion with prestent and/or poststent PTA was 9.1% vs 1.8% for patients without (P ¼ .07) and 2.6% for patients with poststenting dilatation vs 0% for patients without (P ¼ .36). MAE rates for patients with poststenting dilatation were 5.6% vs 0% for patients without (P ¼ .0536). MAE rates for patients with Accunet filters (Abbott, Abbott Park, Ill) were 1.9% vs 6.7% for other filters (P ¼ .029). There were no significant differences between stroke and MAE rates regarding stent type, number, diameter, length of stent, and time from filter insertion to recovery time. A regression analysis showed that the odds ratio for stroke was 0.1 (P ¼ .031) for asymptomatic indications, 13.7 (P ¼ .014) for TIA indications, 6.1 (P ¼ .0303) for dilatation performed prior to filter insertion, and 1.7 (P ¼ .4413) for PTA performed prior to stenting. It also showed that the MAE odds ratio was 0.46 (P ¼ .0858) for asymptomatic indications, 2.1 (P ¼ .35) for predilatations performed prior to filter insertion, and 2.2 (P ¼ .22) for poststent dilatations. A multivariate analysis showed that patients with TIA indications had an odds ratio of stroke of 15.26 (P ¼ .0113); and patients with dilations performed prior to filter insertion with prestent and/or poststent PTA had an odds ratio of 7.98 (P ¼ .0193). The MAE odds ratio for Accunet vs other filters was 0.27 (P ¼ .0389, Tables I and II). Conclusions: PTA prior to filter insertion had higher stroke rates and poststenting PTA was associated with higher MAE rates. The Accunet filter was associated with lower stroke and MAE rates. There was no correlation between other anatomical/technical variables. Author Disclosures: A. F. AbuRahma: None; J. E. Campbell: None; A. Nanjundappa: None; T. DerDerian: None; N. Hariri: None; E. Adams: None; L. S. Dean: None; J. AbuRahma: None.

Table I. Percutaneous transluminal angioplasty (PTA) combination and perioperative stroke and major adverse events (MAEs)

Fig. Kaplan-Meier survival plot (months).

Dilation

Stroke, No. (%)

MAE, No. (%)

None

0/26

0/26

Pre-EPD only

0/1

0/1

Prestent only

0/39

0/39

Poststent only

2/130 (1.5)

6/130 (4.6)

Pre-EPD and present

0/2

0/2 1/8 (12.5)

Pre-EPD and poststent

1/8 (12.5)

Prestent and poststent

5/192 (2.6)

11/192 (5.7)

Pre-EPD, prestent and post stent

1/11 (9.1)

1/11 (9.1)

EPD, Embolic protection device.

Journal of Vascular Surgery

Abstracts

e13

Volume 65, Number 1 Table II. Logistic regression analysis

Table I. Outcomes survey items summary

Univariateeearly stroke

Q1 eI am taking less pain medication now than just before the surgery?

Variables

OR

95% CI

P value

Age

1.03

(0.96,1.11)

.4058

0.86

(0.23,3.24)

.8223

Hypertension

1.04

(0.13,8.52)

.9683

Coronary artery disease

1.33

(0.27,6.51)

.7215

Congestive heart failure

1.63

(0.4,6.61)

.4977

Hypercholesterolemia

1.10

(0.23,5.4)

.9026

Renal failure

1.00

(0.21,4.91)

.9971

(0.01,0.81)

.031

Strongly agree Sex (male vs female)

N

%

53

85.5%

Somewhat agree

1

1.6%

Neutral/no option

5

8.1%

Somewhat disagree

2

3.2%

Strongly disagree

1

Q2 e How long did you attend supervised PT after your surgical procedure? (months, average, range)

12.0

1.6% 6.0-26

Q3 e In the future if I develop TOS symptoms on the opposite side I would undergo surgery

Asymptomatic indication

0.10

TIA indication

13.69

(1.7,110.47)

.014

Strongly agree

32

51.6%

1.10

(0.14,9.02)

.9273

Somewhat agree

11

17.7%

Preprocedure stenosis (70-99 vs 50-69)

0.56

(0.07,4.6)

.5852

Neutral/no option

4

6.5%

Lesion length ($15 mm)

0.96

(0.25,3.62)

.9501

Somewhat disagree

9

14.5%

Predilatation performed prior to EPD

6.09

(1.19,31.2)

.0303

Strongly disagree

6

9.7%

Predilatation performed prior to stent

1.73

(0.43,7.01)

.4413

Variables

OR

95% UCL

P value

Age

1.02

(0.97,1.06)

.5127

Sex (male vs female)

1.00

(0.42,2.38)

.9913

Stroke indication

Univariateeearly MI/stroke/death

Hypertension

Q4 e Overall, my symptoms related to TOS have fully resolved Strongly agree

26

41.9%

Somewhat agree

22

35.5%

Neutral/no option

3

4.8%

Somewhat disagree

6

9.7%

Strongly disagree

5

8.1%

0.42

(0.15,1.19)

.101

Coronary artery disease

1.01

(0.39,2.65)

.981

Congestive heart failure

0.94

(0.34,2.62)

.9102

Hypercholesterolemia

0.66

(0.26,1.66)

.3781

Strongly agree

50

80.6%

1.34

(0.51,3.51)

.5558

Somewhat agree

6

9.7%

Asymptomatic indication

0.46

(0.19,1.12)

.0858

Neutral/no option

2

3.2%

TIA indication

2.04

(0.86,4.82)

.1055

Somewhat disagree

3

4.8%

Stroke indication

0.88

(0.2,3.87)

.8603

Strongly disagree

1

1.6%

Preprocedure stenosis (70-99 vs 50-69)

0.58

(0.13,2.66)

.4833

Lesion length ($15 mm)

0.43

(0.17,1.12)

.0831

EPD (Accunet vs other)

0.27

(0.08,0.95)

.0413

Predilatation performed prior to EPD

2.07

(0.45,9.45)

.35

Renal failure

Predilatation performed prior to stent Poststent dilatation performed

1.03 2.16

(0.44,2.43) (0.63,7.43)

.9463 .2232

Multivariatee early stroke Variable TIA indication Predilatation performed prior to EPD

P value

Q5 eI am able to perform my ADLs without limitations related to my previous TOS symptoms

Q6 e My athletic performance after TOS surgery is (was) the same or better than before I developed TOS symptoms Strongly agree

36

58.1%

Somewhat agree

6

9.7%

Neutral/no option

3

4.8%

Somewhat disagree

6

9.7%

Strongly disagree

11

17.7%

OR

95% CI

15.26

(1.85,125.66)

.0113

3 Months

13

21.0%

(1.4,45.43)

.0193

6 Months

15

24.2%

7.98

Multivariatee early MI/stroke/death

Q7 e My athletics performance after surgery returned back to:

9 Months

5

8.1 %

Variables

OR

95% LCL

P value

1 Year

10

16.1%

EPD (Accunet vs other)

0.27

(0.08,0.94)

.0389

Never return

13

21.0%

N/A

6

9.7%

CI, Confidence interval; EPD, embolic protection device; LCL, lower confidence interval; MI, myocardial infarction; OR, odds ratio: TIA, transient ischemic attack; UCL, upper confidence interval.

Competitive Athletes: Immediate and Long-Term Results of First Rib Resection and Scalenectomy for Thoracic Outlet Syndrome William P. Shutze Sr,1 Allen Dao,2 Kimberly Tran,2 Ryan Shutze,3 Brad Richardson,4 Greg Pearl,1 Gerald Ogola,5 Allan Young,1 Pouria Parsa1. 1 Baylor University Medical Center, Dallas, Tex; 2University of Texas at Dallas, Richardson, Tex; 3Texas Vascular Associates, Dallas, Tex; 4 University of South Alabama Department of Surgery, Mobile, Ala; 5 Baylor Scott and White Health, Dallas, Tex

Q8 e Have you had any other surgery on your neck, or the same shoulder or arm since your rib was removed? Yes

23

37.1%

No

39

62.9%

48

77.4%

Q9 e Having my rib removed was the right decision Strongly agree Somewhat agree

6

9.7%

Neutral/no option

5

8.1%

Somewhat disagree

1

1.6%

Strongly disagree

2

3.2%

ADLs, Activities of daily living; TOS, thoracic outlet syndrome.