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Intraoperative Neuroprotective Interventions Prevent Spinal Cord Injury in Thoracic Endovascular Aortic Repair
JOURNAL OF VASCULAR SURGERY September 2015
830 Abstracts
Hospital Variation in 30-Day Stroke Outcomes for Patients Undergoing Carotid Endarterectomy for Asymptomatic Disease in Michigan Charles J. Shanley, MD1,2, Yeo J. Park, PhD3, Peter K. Henke, MD3. 1 Beaumont Health System, Detroit, Mich; 2Wayne State University School of Medicine, Detroit, Mich; 3University of Michigan, Ann Arbor, Mich Objectives: This study evaluated variables associated with increased rates of perioperative stroke in patients undergoing primary carotid endarterectomy (CEA) for asymptomatic disease in Michigan hospitals. Methods: Thirty-day outcomes for patients undergoing primary CEA for asymptomatic disease at 29 hospitals in Michigan between April 3, 2012 and December 31, 2014 were evaluated using a statewide registry and quality improvement platform (Blue Cross Blue Shield of Michigan-Vascular Interventions Collaborative). Primary outcomes of interest were the occurrence of any death or non-fatal stroke. Variables included patient demographics, comorbidities, and preoperative medical therapies as well as procedural, provider, and institutional variables. Analysis of variance was used to identify variables associated with perioperative stroke outcomes. Hospitals were classified as high stroke rate (>3%) and low stroke rate (<3%). A multilevel logistic regression model was constructed to assess the association between stroke and patient-level and hospital-level variables. Results: Of the 4556 primary CEA procedures identified, 2418 (53%) were performed for asymptomatic disease. The overall 30-day rate of any perioperative stroke or death for the group was 2.1%; however, nine hospitals (31%) had stroke rates exceeding 3%. Interestingly, the overall rate of stroke outcomes decreased from 3.4% in 2012 to 1.3% in 2014. Analysis of variance was used to identify variables having a significant effect on hospital stroke rate variability. Statistically significant variables included urban location, academic mission, nonelective procedure, median procedure volume per surgeon, non-white race, current smoking, eversion technique, shunt use, and protamine use. Conclusions: In Michigan, contemporary stroke rates for CEA in asymptomatic patients were within accepted benchmarks; however, considerable institutional variation was observed. Hospital-level variability in adverse stroke outcomes following CEA has important implications for providers and patients underscoring the need for regional collaborative quality improvement platforms to identify and share best practices. Author Disclosures: C. J. Shanley: None; Y. J. Park: None; P. K. Henke: None. Rupture of Abdominal Aortic and Iliac Aneurysms in Patients With and Without Antecedent Endovascular Repair Sachinder Singh Hans, MD1, Irina Catanescu2, Paul Bove, MD3, Graham Long, MD4, Michael Khoury, MD2, Maciej Uzieblo, MD5, Steven Rimar, MD5, William Brown, MD5. 1Department of Vascular Surgery, Henry Ford Macomb Hospital, Clinton Township, Mich; 2Henry Ford Macomb Hospital, Clinton Township, Mich; 3William Beaumont Royal Oak, Royal Oak, Mich; 4William Beaumont Hospital Royal Oak, Royal Oak, Mich; 5William Beaumont Hospital, Royal Oak, Mich
Objectives: Reported results of ruptured abdominal aortic aneurysms (rAAA) in patients with antecedent endovascular repair (EVAR) to those presenting with denovo rupture are contradictory. The aim of this study was to compare differences in the presentation and outcome of rAAAs and ruptured iliac aneurysms with and without prior EVAR. Methods: A retrospective review of 123 patients with rAAAs, ruptured common iliac aneurysms (rCIAs), or ruptured hypogastric aneurysms (rHAs) identified two groups. Group A (n ¼ 18; rAAA 16; rCIA 1; rHA 1) with antecedent EVAR and Group B (n ¼ 105; rAAA, 103; rCIA, 1; rHA, 1) with denovo rupture from January 2001 to March 2015 in three teaching hospitals. Patient characteristics and perioperative variables were evaluated and outcomes were compared. Fisher exact test was used for categorical variables. For continuous variables, the Student ttest and Mann-Whitney U test were used. Results: Both groups were similar in the incidence of hypertension, coronary artery disease, diabetes mellitus, chronic obstructive pulmonary disease, and nicotine abuse (Table). Mean time of presentation from EVAR to rAAA was 42 months. The devices involved in Group A were Zenith (Cook Medical Inc, Bloomington, Ind) 4, Endurant 3, Talent 2, AneuRx (Medtronic, Minneapolis, Minn) 6, Excluder (W. L Gore, Flagstaff, Ariz) 2, and Endologix (Endologix, Irvine, Calif) 1. Mean preoperative transverse/anteroposterior diameter of AAA was 6.6 cm in Group A and 7.1 cm in Group B. Types of endoleak at time of rupture in Group A were: Type IA, n ¼ 10; Type IB, n ¼ 3; Type II, n ¼ 3; and Type III, n ¼ 1. Three patients in Group A had secondary intervention for endoleaks prior to rupture of AAA. Five patients in Group A did not return for follow-up, and in two patients, opportunity to prevent rupture was missed. In Group A, 12 patients underwent open repair and six had EVAR. In Group B, 89 had open repair and 16 had EVAR. Conclusions: Patients presenting with rAAAs with antecedent EVAR are hemodynamically more stable as compared with patients with denovo rupture. Postoperative respiratory failure is more common in patients with denovo rupture of AAAs. Ruptured AAAs and iliac aneurysms have a high mortality in patients with and without prior EVAR. Author Disclosures: S. S. Hans: None; I. Catanescu: None; P. Bove: None; G. Long: None; M. Khoury: None; M. Uzieblo: None; S. Rimar: None; W. Brown: None. Intraoperative Neuroprotective Interventions Prevent Spinal Cord Injury in Thoracic Endovascular Aortic Repair Martha M. Wynn, MD, Charles Acher, MD, Erich Marks, MD, C.W. Acher, MD. University of Wisconsin School of Medicine and Public Health, Madison, Wisc Objectives: Transient and permanent paraparesis and paralysis (SCI) are reported in 4% to 20% of patients having thoracic endovascular aortic repair (TEVAR) for thoracic (TAA) or thoracoabdominal aneurysm (TAAA) and thoracic dissection. We hypothesize that intraoperative neuroprotective interventions prevent SCI in TEVAR.
Table. Baseline characteristics and demographics comparison of rAAA, rCIA, and rHA patients with and without antecedent endovascular aneurysm repair. Variable Preoperative characteristics Age, years Gender (male) Preoperative variables Systolic blood pressure <80 Mean HgB (g/dl) Mean platelet (thousands) Intraoperative Variables RBC transfusion in units (mean) FFP transfusion in units (mean) Platelets transfusion in packs Postoperative complications 30-day mortality Renal failure Myocardial infarction Respiratory failure Ischemic colitis Paraparesis Stroke Abdominal compartment syndrome a
Significant.
Group A (n ¼ 15), No. (%) 75.25 6 10.8 14 (87)
Group B (n ¼ 105), No. (%) 72 6 10.9 75 (71.4)
P value
.25 .20
3 (18.8) 11.8 6 3.2 191 6 102
48 (45.7) 11.9 6 7.3 183 6 91
.03a .99 .79
5 4 4
8.94 5 7
.12 .35 .24
45 (42.8) 33 (31.4) 5 (4.7) 40 (38) 21 (20) 2 (1.9) 4(3.8) 7(6.7)
1.00 .26 1.00 .001a .19 .37 l.00 l.00
7 3 1 2 1 1 0 1
(38) (16.7) (5.6) (11.1) (5.6) (5.6) (0) (5.6)
JOURNAL OF VASCULAR SURGERY Volume 62, Number 3
Methods: We analyzed all TEVARs from 2005 to 2014 using a prospectively maintained, institutional review board-approved database to study all transient and permanent paraparesis and paralysis. TEVARs for trauma were excluded. Arch debranching was performed before TEVAR in patients with arch involvement. All patients had hypothermia (34 Centigrade), mean arterial pressure (MAP) >90 mm Hg, hemoglobin (Hb) >10 mg/ dL, mannitol 12.5 g, methylprednisolone 30 mg/kg, and naloxone 1 mcg/kg/hr for spinal cord protection. Patients where >12 cm of aortic coverage was planned had spinal fluid drainage (SFD) to <8 mm Hg pressure during surgery and postoperatively until normal leg strength was confirmed. We studied demographics, intraoperative variables, SCI, and calculated observed/expected ratio (O/E) for SCI. Results: A total of 155 patients had TEVAR from 2005 to 2014. Median age was 74 years (range, 21-88 years). Fifty-six percent were male, 91% (141/155) had TAA, and 9% (14/155) had TAAA. Twenty-six percent (40/155) had dissection. Forty-two percent (65/155) were acute. Nineteen percent (29/155) had arch debranching, and 72% (111/155) had SFD. Mean aortic coverage was 22 cm (range, 3.5-50 cm). Eighty-one percent (125/155) had >12 cm thoracic aortic coverage, and 48% (75/ 155) had complete coverage from subclavian to celiac artery. Hospital mortality was 2% (3/155). One percent (2/155) had stroke. One patient had delayed transient paraparesis (0.64% SCI). O/E ratio for SCI was 0.029. Conclusions: SCI in TEVAR can be prevented by using intraoperative neuroprotective interventions to prolong spinal cord ischemic tolerance and increase spinal cord perfusion and oxygen delivery. Author Disclosures: M. M. Wynn: None; C. Acher: None; E. Marks: None; C. Acher: None. Basilic Vein Transposition; What Determines Long Term Access Success? Farah Hanif Ali Mohammad, MD, Loay Kabbani, MD, Lalathaksha M. Kumbar, Alexander Shepard, Mitchell Weaver, MD, Sherazuddin Qureshi, MD, Efstathios Karamanos, Geroge Haddad, MD. Henry Ford Hospital, Detroit, Mich Purpose: The aim of this study was to evaluate the performance of arterial venous fistulae (AVF) constructed with basilic vein transposition (BVT). Methods: All patients who underwent BVT between August 2007 and September 2012 at our institution were retrospectively reviewed. Data collected included demographics, postoperative complications, maturation rates, patency rates, secondary interventions (endovascular and open surgical revision), and overall mortality. A retrospective analysis was performed. Results: One hundred ninety-seven patients underwent BVT surgery. Mean age was 62 years (range, 23-88 years), 46% were female, 85% were African American, 58% had diabetes, and 97% had hypertension. Seventythree percent had the fistula on the left arm. Of these, 12 were one-stage BVT, and 185 were two-stage BVT. The procedural mortality rate was 0%. Fifty-three percent had the BVT as their first dialysis fistula. Seventytwo patients never had documented use of their fistula (36%): 17 (24%) due to patient factors (death, illness, lost to follow-up), 42 (58%) due to failure to mature or fistula thrombosis, and 15 (21%) developed steal or swelling severe enough to require fistula ligation. For the 125 patients who used their fistula at least once, 50% required at least one intervention to maintain patency. In these patients, mean follow-up was 21 months. Primary unassisted patency at 6, 12, and 24 months was 60%, 46%, and 32%, respectively, and cumulative patency at 6, 12, and 24 months was 90%, 83%, and 70% respectively. Using a linear regression model, cumulative fistula patency was positively related to male gender (P ¼ .01), but negatively related to a history of prior previous fistula or graft (P ¼ .001). Age, race, size of basilic vein prior to procedure, and history of diabetes were not associated with a greater risk of BVT failure. Conclusions: Brachial vein transposition is a reliable AVF for dialysis access and should be considered in patients with end-stage renal disease who require dialysis. Patients with a previous graft or AVF have decreased longterm patency. Author Disclosures: F. Mohammad: None; L. kabbani: None; L. Kumbar: None; A. Shepard: None; M. Weaver: None; S. Qureshi: None; E. Karamanos: None; G. Haddad: None.
Narrow Aortic Bifurcation May Be Associated With Increase in Type 2 Endoleak Charles S. Briggs, MD, Ross Milner, MD. Department of Vascular Surgery, University of Chicago Medical Center, Chicago, Ill
Abstracts 831
Objectives: Endovascular aortic aneurysm repair (EVAR) in patients with narrow aortic bifurcations can be complicated by iliac limb compression and aortic disruption. The Global Registry for Endovascular Aortic Treatment (GREAT) actively tracks Gore (W.L. Gore, Flagstaff, Ariz) commercial aortic endovascular device performance and associated patient outcomes. We hypothesized that a narrow aortic bifurcation may predispose to the development of iliolumbar collaterals increasing the risk of type 2 endoleak. Methods: Between August 2010 and December 2014, 1935 patients (84.8% male; mean age, 73.3 6 8.1 years) from 83 global sites were enrolled in this registry. Patients with diameter #16 mm at the distal aortic bifurcation (AoB) were included in our study. Primary endpoint was serious adverse events (SAEs). Patient demographics, treatment indication, case planning, operative details, and clinical outcome were analyzed. Only serious endoleaks requiring a secondary intervention are reported in the registry. Results: There were 666 patients with reported AoB measurements. Of those, 95 patients (14.3%) had an AoB #16 mm and were treated by EVAR, using the Gore Excluder bifurcated stent graft. All stent grafts were successfully implanted, with no conversions to open repair. One patient did require femoral-femoral bypass for limb thrombosis. At a median follow-up of 332 days, SAEs had been reported in 18 patients (23.6%). There was one death (1.0%) 4 months after EVAR, which was not attributable to the device. Iliac limb occlusion or stenosis occurred in two patients (2.1%). Endoleak was reported in six patients (6.3%). Of those, five were type II endoleaks (5.3%), and one was type Ib (1.0%). In the 571 patients with AoB $16 mm, there were two type II endoleaks (0.4%), one type Ib (0.2%), one type Ia (0.2%), and one type III (0.2%). Conclusions: EVAR in patients with narrow distal aortic diameter is safe and effective using the Gore Excluder bifurcated stent graft, even when the AoB measures #16 mm. Incidence of significant type II endoleak may be increased in patients with narrow AoB. These data may suggest that more aggressive adjuncts during initial EVAR with a narrow AoB are necessary to prevent future secondary interventions for type 2 endoleaks. Author Disclosures: C. S. Briggs: None; R. Milner: Consulting Fee; My Role; Consultant for W. L. Gore. Simultaneous Carotid Endarterectomy and Coronary Artery Bypass Grafting Is Associated With Similar Clinical Outcomes With Lower Length of Stay and Hospital Charges Sohaib M. Khan, MD, Munier Nazzal, MD, Gerald Zelenock, MD, Weikai Qu, MD, Abdulaziz Arishi, MD, Jeremy Stoller, MD. Department of Vascular and Endovascular Surgery, University of Toledo Medical Center, Toledo, Ohio Objectives: The correct timing of carotid endarterectomy (CEA) and coronary artery bypass graft (CABG) in patients with concurrent coronary and carotid artery disease is controversial. We evaluated short-term outcomes of simultaneous against same admission staged CEA and CABG in the Nationwide Inpatient Sample database. Methods: An analysis of approximately 8 million hospital admissions per year from 2008 to 2012 was obtained from the Healthcare Cost and Utilization Project National Inpatient Sample database. Using International Classification of Diseases, Ninth Revision, Clinical Modification codes, we selected patients who underwent CEA and CABG in the same admission and excluded those who had other cardiac or carotid interventions. We divided them into two groupsdsimultaneous (SmCC) or staged (StCC)dbased on whether the procedures were done on the same day or on different days. Statistical analysis was done with Statistical Package for Social Sciences (SPSS) software version 21 (IBM Corp, Armonk, NY). Results: After weighted adjustment, a total of 6174 (66.9%) underwent SmCC and 3021 (32.8%) underwent StCC from 2008 to 2012. The average age of SmCC and StCC patients was 68.7 6 9.0 and 67.9 6 8.9 (P ¼ .04). Gender composition of the groups was similar (P ¼ .462). Mean Elixhauser Comorbidity Index for the SmCC was 3.33 6 1.7 and for StCC was 3.22 6 1.7 (P ¼ .22). There were no significant differences between the two groups in terms of postoperative stroke rate (2.7% vs 2.3%; odds ratio [OR], 0.85; 95% confidence interval [CI], 0.45-1.61; P ¼ .62); perioperative myocardial infarction (25.3% vs 28.9%; OR, 1.20; 95% CI, 0.97-1.45; P ¼ .09); and in-hospital mortality (3.1% vs 2.9%; OR, 0.93; 95% CI, 0.53-1.64; P ¼ .80). We grouped the primary outcomes of stroke, myocardial infarction, and in-hospital death into a single composite endpoint but the difference did not reach statistical significance (28.4% vs 32.4%; OR, 1.20; 95% CI, 0.98-1.48; P ¼ .08). Both median length of stay and hospital charge were higher (P ¼ 0) for the staged group (Table). Conclusions: Simultaneous CEA and CABG can be performed safely with lower length of stay and hospital charges.
830 Abstracts
Hospital Variation in 30-Day Stroke Outcomes for Patients Undergoing Carotid Endarterectomy for Asymptomatic Disease in Michigan Charles J. Shanley, MD1,2, Yeo J. Park, PhD3, Peter K. Henke, MD3. 1 Beaumont Health System, Detroit, Mich; 2Wayne State University School of Medicine, Detroit, Mich; 3University of Michigan, Ann Arbor, Mich Objectives: This study evaluated variables associated with increased rates of perioperative stroke in patients undergoing primary carotid endarterectomy (CEA) for asymptomatic disease in Michigan hospitals. Methods: Thirty-day outcomes for patients undergoing primary CEA for asymptomatic disease at 29 hospitals in Michigan between April 3, 2012 and December 31, 2014 were evaluated using a statewide registry and quality improvement platform (Blue Cross Blue Shield of Michigan-Vascular Interventions Collaborative). Primary outcomes of interest were the occurrence of any death or non-fatal stroke. Variables included patient demographics, comorbidities, and preoperative medical therapies as well as procedural, provider, and institutional variables. Analysis of variance was used to identify variables associated with perioperative stroke outcomes. Hospitals were classified as high stroke rate (>3%) and low stroke rate (<3%). A multilevel logistic regression model was constructed to assess the association between stroke and patient-level and hospital-level variables. Results: Of the 4556 primary CEA procedures identified, 2418 (53%) were performed for asymptomatic disease. The overall 30-day rate of any perioperative stroke or death for the group was 2.1%; however, nine hospitals (31%) had stroke rates exceeding 3%. Interestingly, the overall rate of stroke outcomes decreased from 3.4% in 2012 to 1.3% in 2014. Analysis of variance was used to identify variables having a significant effect on hospital stroke rate variability. Statistically significant variables included urban location, academic mission, nonelective procedure, median procedure volume per surgeon, non-white race, current smoking, eversion technique, shunt use, and protamine use. Conclusions: In Michigan, contemporary stroke rates for CEA in asymptomatic patients were within accepted benchmarks; however, considerable institutional variation was observed. Hospital-level variability in adverse stroke outcomes following CEA has important implications for providers and patients underscoring the need for regional collaborative quality improvement platforms to identify and share best practices. Author Disclosures: C. J. Shanley: None; Y. J. Park: None; P. K. Henke: None. Rupture of Abdominal Aortic and Iliac Aneurysms in Patients With and Without Antecedent Endovascular Repair Sachinder Singh Hans, MD1, Irina Catanescu2, Paul Bove, MD3, Graham Long, MD4, Michael Khoury, MD2, Maciej Uzieblo, MD5, Steven Rimar, MD5, William Brown, MD5. 1Department of Vascular Surgery, Henry Ford Macomb Hospital, Clinton Township, Mich; 2Henry Ford Macomb Hospital, Clinton Township, Mich; 3William Beaumont Royal Oak, Royal Oak, Mich; 4William Beaumont Hospital Royal Oak, Royal Oak, Mich; 5William Beaumont Hospital, Royal Oak, Mich
Objectives: Reported results of ruptured abdominal aortic aneurysms (rAAA) in patients with antecedent endovascular repair (EVAR) to those presenting with denovo rupture are contradictory. The aim of this study was to compare differences in the presentation and outcome of rAAAs and ruptured iliac aneurysms with and without prior EVAR. Methods: A retrospective review of 123 patients with rAAAs, ruptured common iliac aneurysms (rCIAs), or ruptured hypogastric aneurysms (rHAs) identified two groups. Group A (n ¼ 18; rAAA 16; rCIA 1; rHA 1) with antecedent EVAR and Group B (n ¼ 105; rAAA, 103; rCIA, 1; rHA, 1) with denovo rupture from January 2001 to March 2015 in three teaching hospitals. Patient characteristics and perioperative variables were evaluated and outcomes were compared. Fisher exact test was used for categorical variables. For continuous variables, the Student ttest and Mann-Whitney U test were used. Results: Both groups were similar in the incidence of hypertension, coronary artery disease, diabetes mellitus, chronic obstructive pulmonary disease, and nicotine abuse (Table). Mean time of presentation from EVAR to rAAA was 42 months. The devices involved in Group A were Zenith (Cook Medical Inc, Bloomington, Ind) 4, Endurant 3, Talent 2, AneuRx (Medtronic, Minneapolis, Minn) 6, Excluder (W. L Gore, Flagstaff, Ariz) 2, and Endologix (Endologix, Irvine, Calif) 1. Mean preoperative transverse/anteroposterior diameter of AAA was 6.6 cm in Group A and 7.1 cm in Group B. Types of endoleak at time of rupture in Group A were: Type IA, n ¼ 10; Type IB, n ¼ 3; Type II, n ¼ 3; and Type III, n ¼ 1. Three patients in Group A had secondary intervention for endoleaks prior to rupture of AAA. Five patients in Group A did not return for follow-up, and in two patients, opportunity to prevent rupture was missed. In Group A, 12 patients underwent open repair and six had EVAR. In Group B, 89 had open repair and 16 had EVAR. Conclusions: Patients presenting with rAAAs with antecedent EVAR are hemodynamically more stable as compared with patients with denovo rupture. Postoperative respiratory failure is more common in patients with denovo rupture of AAAs. Ruptured AAAs and iliac aneurysms have a high mortality in patients with and without prior EVAR. Author Disclosures: S. S. Hans: None; I. Catanescu: None; P. Bove: None; G. Long: None; M. Khoury: None; M. Uzieblo: None; S. Rimar: None; W. Brown: None. Intraoperative Neuroprotective Interventions Prevent Spinal Cord Injury in Thoracic Endovascular Aortic Repair Martha M. Wynn, MD, Charles Acher, MD, Erich Marks, MD, C.W. Acher, MD. University of Wisconsin School of Medicine and Public Health, Madison, Wisc Objectives: Transient and permanent paraparesis and paralysis (SCI) are reported in 4% to 20% of patients having thoracic endovascular aortic repair (TEVAR) for thoracic (TAA) or thoracoabdominal aneurysm (TAAA) and thoracic dissection. We hypothesize that intraoperative neuroprotective interventions prevent SCI in TEVAR.
Table. Baseline characteristics and demographics comparison of rAAA, rCIA, and rHA patients with and without antecedent endovascular aneurysm repair. Variable Preoperative characteristics Age, years Gender (male) Preoperative variables Systolic blood pressure <80 Mean HgB (g/dl) Mean platelet (thousands) Intraoperative Variables RBC transfusion in units (mean) FFP transfusion in units (mean) Platelets transfusion in packs Postoperative complications 30-day mortality Renal failure Myocardial infarction Respiratory failure Ischemic colitis Paraparesis Stroke Abdominal compartment syndrome a
Significant.
Group A (n ¼ 15), No. (%) 75.25 6 10.8 14 (87)
Group B (n ¼ 105), No. (%) 72 6 10.9 75 (71.4)
P value
.25 .20
3 (18.8) 11.8 6 3.2 191 6 102
48 (45.7) 11.9 6 7.3 183 6 91
.03a .99 .79
5 4 4
8.94 5 7
.12 .35 .24
45 (42.8) 33 (31.4) 5 (4.7) 40 (38) 21 (20) 2 (1.9) 4(3.8) 7(6.7)
1.00 .26 1.00 .001a .19 .37 l.00 l.00
7 3 1 2 1 1 0 1
(38) (16.7) (5.6) (11.1) (5.6) (5.6) (0) (5.6)
JOURNAL OF VASCULAR SURGERY Volume 62, Number 3
Methods: We analyzed all TEVARs from 2005 to 2014 using a prospectively maintained, institutional review board-approved database to study all transient and permanent paraparesis and paralysis. TEVARs for trauma were excluded. Arch debranching was performed before TEVAR in patients with arch involvement. All patients had hypothermia (34 Centigrade), mean arterial pressure (MAP) >90 mm Hg, hemoglobin (Hb) >10 mg/ dL, mannitol 12.5 g, methylprednisolone 30 mg/kg, and naloxone 1 mcg/kg/hr for spinal cord protection. Patients where >12 cm of aortic coverage was planned had spinal fluid drainage (SFD) to <8 mm Hg pressure during surgery and postoperatively until normal leg strength was confirmed. We studied demographics, intraoperative variables, SCI, and calculated observed/expected ratio (O/E) for SCI. Results: A total of 155 patients had TEVAR from 2005 to 2014. Median age was 74 years (range, 21-88 years). Fifty-six percent were male, 91% (141/155) had TAA, and 9% (14/155) had TAAA. Twenty-six percent (40/155) had dissection. Forty-two percent (65/155) were acute. Nineteen percent (29/155) had arch debranching, and 72% (111/155) had SFD. Mean aortic coverage was 22 cm (range, 3.5-50 cm). Eighty-one percent (125/155) had >12 cm thoracic aortic coverage, and 48% (75/ 155) had complete coverage from subclavian to celiac artery. Hospital mortality was 2% (3/155). One percent (2/155) had stroke. One patient had delayed transient paraparesis (0.64% SCI). O/E ratio for SCI was 0.029. Conclusions: SCI in TEVAR can be prevented by using intraoperative neuroprotective interventions to prolong spinal cord ischemic tolerance and increase spinal cord perfusion and oxygen delivery. Author Disclosures: M. M. Wynn: None; C. Acher: None; E. Marks: None; C. Acher: None. Basilic Vein Transposition; What Determines Long Term Access Success? Farah Hanif Ali Mohammad, MD, Loay Kabbani, MD, Lalathaksha M. Kumbar, Alexander Shepard, Mitchell Weaver, MD, Sherazuddin Qureshi, MD, Efstathios Karamanos, Geroge Haddad, MD. Henry Ford Hospital, Detroit, Mich Purpose: The aim of this study was to evaluate the performance of arterial venous fistulae (AVF) constructed with basilic vein transposition (BVT). Methods: All patients who underwent BVT between August 2007 and September 2012 at our institution were retrospectively reviewed. Data collected included demographics, postoperative complications, maturation rates, patency rates, secondary interventions (endovascular and open surgical revision), and overall mortality. A retrospective analysis was performed. Results: One hundred ninety-seven patients underwent BVT surgery. Mean age was 62 years (range, 23-88 years), 46% were female, 85% were African American, 58% had diabetes, and 97% had hypertension. Seventythree percent had the fistula on the left arm. Of these, 12 were one-stage BVT, and 185 were two-stage BVT. The procedural mortality rate was 0%. Fifty-three percent had the BVT as their first dialysis fistula. Seventytwo patients never had documented use of their fistula (36%): 17 (24%) due to patient factors (death, illness, lost to follow-up), 42 (58%) due to failure to mature or fistula thrombosis, and 15 (21%) developed steal or swelling severe enough to require fistula ligation. For the 125 patients who used their fistula at least once, 50% required at least one intervention to maintain patency. In these patients, mean follow-up was 21 months. Primary unassisted patency at 6, 12, and 24 months was 60%, 46%, and 32%, respectively, and cumulative patency at 6, 12, and 24 months was 90%, 83%, and 70% respectively. Using a linear regression model, cumulative fistula patency was positively related to male gender (P ¼ .01), but negatively related to a history of prior previous fistula or graft (P ¼ .001). Age, race, size of basilic vein prior to procedure, and history of diabetes were not associated with a greater risk of BVT failure. Conclusions: Brachial vein transposition is a reliable AVF for dialysis access and should be considered in patients with end-stage renal disease who require dialysis. Patients with a previous graft or AVF have decreased longterm patency. Author Disclosures: F. Mohammad: None; L. kabbani: None; L. Kumbar: None; A. Shepard: None; M. Weaver: None; S. Qureshi: None; E. Karamanos: None; G. Haddad: None.
Narrow Aortic Bifurcation May Be Associated With Increase in Type 2 Endoleak Charles S. Briggs, MD, Ross Milner, MD. Department of Vascular Surgery, University of Chicago Medical Center, Chicago, Ill
Abstracts 831
Objectives: Endovascular aortic aneurysm repair (EVAR) in patients with narrow aortic bifurcations can be complicated by iliac limb compression and aortic disruption. The Global Registry for Endovascular Aortic Treatment (GREAT) actively tracks Gore (W.L. Gore, Flagstaff, Ariz) commercial aortic endovascular device performance and associated patient outcomes. We hypothesized that a narrow aortic bifurcation may predispose to the development of iliolumbar collaterals increasing the risk of type 2 endoleak. Methods: Between August 2010 and December 2014, 1935 patients (84.8% male; mean age, 73.3 6 8.1 years) from 83 global sites were enrolled in this registry. Patients with diameter #16 mm at the distal aortic bifurcation (AoB) were included in our study. Primary endpoint was serious adverse events (SAEs). Patient demographics, treatment indication, case planning, operative details, and clinical outcome were analyzed. Only serious endoleaks requiring a secondary intervention are reported in the registry. Results: There were 666 patients with reported AoB measurements. Of those, 95 patients (14.3%) had an AoB #16 mm and were treated by EVAR, using the Gore Excluder bifurcated stent graft. All stent grafts were successfully implanted, with no conversions to open repair. One patient did require femoral-femoral bypass for limb thrombosis. At a median follow-up of 332 days, SAEs had been reported in 18 patients (23.6%). There was one death (1.0%) 4 months after EVAR, which was not attributable to the device. Iliac limb occlusion or stenosis occurred in two patients (2.1%). Endoleak was reported in six patients (6.3%). Of those, five were type II endoleaks (5.3%), and one was type Ib (1.0%). In the 571 patients with AoB $16 mm, there were two type II endoleaks (0.4%), one type Ib (0.2%), one type Ia (0.2%), and one type III (0.2%). Conclusions: EVAR in patients with narrow distal aortic diameter is safe and effective using the Gore Excluder bifurcated stent graft, even when the AoB measures #16 mm. Incidence of significant type II endoleak may be increased in patients with narrow AoB. These data may suggest that more aggressive adjuncts during initial EVAR with a narrow AoB are necessary to prevent future secondary interventions for type 2 endoleaks. Author Disclosures: C. S. Briggs: None; R. Milner: Consulting Fee; My Role; Consultant for W. L. Gore. Simultaneous Carotid Endarterectomy and Coronary Artery Bypass Grafting Is Associated With Similar Clinical Outcomes With Lower Length of Stay and Hospital Charges Sohaib M. Khan, MD, Munier Nazzal, MD, Gerald Zelenock, MD, Weikai Qu, MD, Abdulaziz Arishi, MD, Jeremy Stoller, MD. Department of Vascular and Endovascular Surgery, University of Toledo Medical Center, Toledo, Ohio Objectives: The correct timing of carotid endarterectomy (CEA) and coronary artery bypass graft (CABG) in patients with concurrent coronary and carotid artery disease is controversial. We evaluated short-term outcomes of simultaneous against same admission staged CEA and CABG in the Nationwide Inpatient Sample database. Methods: An analysis of approximately 8 million hospital admissions per year from 2008 to 2012 was obtained from the Healthcare Cost and Utilization Project National Inpatient Sample database. Using International Classification of Diseases, Ninth Revision, Clinical Modification codes, we selected patients who underwent CEA and CABG in the same admission and excluded those who had other cardiac or carotid interventions. We divided them into two groupsdsimultaneous (SmCC) or staged (StCC)dbased on whether the procedures were done on the same day or on different days. Statistical analysis was done with Statistical Package for Social Sciences (SPSS) software version 21 (IBM Corp, Armonk, NY). Results: After weighted adjustment, a total of 6174 (66.9%) underwent SmCC and 3021 (32.8%) underwent StCC from 2008 to 2012. The average age of SmCC and StCC patients was 68.7 6 9.0 and 67.9 6 8.9 (P ¼ .04). Gender composition of the groups was similar (P ¼ .462). Mean Elixhauser Comorbidity Index for the SmCC was 3.33 6 1.7 and for StCC was 3.22 6 1.7 (P ¼ .22). There were no significant differences between the two groups in terms of postoperative stroke rate (2.7% vs 2.3%; odds ratio [OR], 0.85; 95% confidence interval [CI], 0.45-1.61; P ¼ .62); perioperative myocardial infarction (25.3% vs 28.9%; OR, 1.20; 95% CI, 0.97-1.45; P ¼ .09); and in-hospital mortality (3.1% vs 2.9%; OR, 0.93; 95% CI, 0.53-1.64; P ¼ .80). We grouped the primary outcomes of stroke, myocardial infarction, and in-hospital death into a single composite endpoint but the difference did not reach statistical significance (28.4% vs 32.4%; OR, 1.20; 95% CI, 0.98-1.48; P ¼ .08). Both median length of stay and hospital charge were higher (P ¼ 0) for the staged group (Table). Conclusions: Simultaneous CEA and CABG can be performed safely with lower length of stay and hospital charges.