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Presence of External Carotid Artery Plaque Independently Predicts Mortality in Patients Without Internal Carotid Artery Atherosclerosis
1090 Abstracts
confidence interval, 0.4-1.8). Also, risk of restenosis during a median follow-up of 13 months was similar for both groups (hazard ratio, 1.4; 95% confidence interval, 0.9-2.2). Cranial nerve injury (CNI) was 5.5% in the CEA group, while CAS was associated with other procedural related complications in 5%. Comment: Overall the general impression that CAS is safer than CEA for repeat intervention following a previous CEA appears not to be true. While cranial nerve injuries were higher with CEA only 1 of 23 was persistent. Additional complications referred to with CAS included residual stenosis, technical failure and cardiac arrhythmia. Therefore, while the need for intervention following CEA is low, when such intervention is judged appropriate, the choice of CAS or CEA for that intervention should largely be based on patient and physician tolerance for complications other than subsequent restenosis or stroke as these appear to be the same for both CEA and CAS. Outcomes of Endovascular Management of Acute Thoracic Aorta Emergencies in an Academic Level 1 Trauma Center Echeverria AB, Branco BC, Goshima KR, et al. Am J Surg 2014;208:974-80. Conclusions: Adverse outcomes for thoracic endovascular aneurysm repair (TEVAR) performed for acute thoracic aortic emergencies include 24 hour packed red blood cell (pRBC) requirements $4 units, admission mean arterial pressure < 60 mm of Hg, and 24 hour fresh frozen plasma to pRBC ratio <1:1.5. Summary: Endovascular techniques for treatment of a wide variety of aortic pathologies in the acute setting have become relatively commonplace. As of yet, however, there are not widespread reports from multiple institutions evaluating this experience. The authors reviewed their experience with use of TEVAR in emergency settings for acute thoracic aortic pathology. In retrospect, they evaluated emergency descending thoracic aortic endovascular interventions at their level 1 trauma center between January 2005 and August 2013. They included all cases of traumatic aortic rupture, ruptured descending thoracic aneurysm, penetrating atherosclerotic ulcer, acute complicated type B dissection, and aortoenteric fistula. Analysis of clinical data and demographics and outcomes stepwise logistic regression was used to identify independent risk factors for death. During the study period, 51 patients underwent TEVAR; 22 cases (43%) were performed emergently (11 patients [50.0%] traumatic aortic injury; 4 [18.2%] ruptured descending thoracic aneurysm; 4 [18.2%] complicated type B dissection; 2 [9.1%] penetrating aortic ulcer; and 1 [4.5%] aortoenteric fistula). Overall, 72.7% (n ¼ 16) were male with a mean age of 54.8 6 15.9 years. A total of 86.4% (n ¼ 19) required only a single TEVAR procedure, whereas two (9.1%) required additional endovascular therapy and one (4.5%) open thoracotomy. Four traumatic aortic injury patients required exploratory laparotomy for concomitant intra-abdominal injuries. During a mean hospital stay of 18.9 days (range, 1-76 days), three patients (13.6%) developed major complications. In-hospital mortality was 27.2% and consisted of 6 deaths from traumatic brain injury, 1 death from exsanguination in the operating room before repair could be achieved, 2 deaths secondary to bowel ischemia, 1 secondary to multisystem organ failure, and 1 resulting from withdrawal of care. A stepwise logistic regression model identified 24 hour pRBC requirements $ 4 units, mean admission arterial blood pressure < 60 mm Hg, and 24 hour fresh frozen plasma to pRBC ratio <1.5 as independent risk factors for death. During a mean follow-up of 369 days (range, 35-957 days), no subsequent major complications or deaths occurred. No device-related problems were identified during intermediate follow-up. Comment: The authors dredged up every possible reason for performing TEVAR in their institution on an emergent basis and still had a relatively small (three cases per year) experience to report. In particular, the small number of patients treated with TEVAR for traumatic thoracic injuries and aortic dissection/penetrating ulcer seems low compared to many other academic medical centers. The data emphasize that the large majority of TEVAR procedures are performed off label. They were few graft related complications in this series suggesting that even institutions with relatively small experience in TEVAR can perform the procedure with reasonable, short-term results. Adverse events in these patients primarily result from variables not specifically associated with the TEVAR procedure.
International Validation of a Risk Score for Complications and Reinterventions After Endovascular Aneurysm Repair Karthikesalingam A, Vidal-Viez A, DeBruin JL, et al. Brit J Surg 2015;102:509-15. Conclusions: Morphologic risk score predicts midterm reinterventions and endograft complications. Summary: Longer-term outcomes of EVAR continue to be a concern. Key challenges relate to device durability and timely management
JOURNAL OF VASCULAR SURGERY October 2015
of endograft complications in the years following implantation. Such complications occur in one in five patients during the first 5 years after EVAR. (Lederle FA et al, N Eng J Med 2012;367:1988-97, and DeBruin JL et al, N Eng J Med 2010;362:1881-9). Surveillance therefore is recommended lifelong for patients after endograft treatment of their abdominal aortic aneurysms. However, there is considerable variation in timing and methods of surveillance, and many patients, perhaps most, do not remain compliant with imaging protocols after EVAR (Kret MR et al, J Vasc Surg 2013;58:25-32). Endograft complications and reinterventions can be related to preoperative aneurysm morphology. A risk score for predicting such events has been developed and validated at two UK centers (Karthikesalingam A et al, Brit J Surg 2013;100:1302-11), the so-called Saint George Vascular Institute Score (SGVI). The current study attempts to provide international validation of the SGVI and provide external validity of the score. The authors utilized the ENGAGE Registry which recruited patients undergoing EVAR in 79 centers in 30 countries. Reinterventions and endograft complications were recorded for up to three years after surgery. Preoperative aneurysm morphology was extracted from the registry database and used to predict whether patients would be at low or high risk of complications after EVAR based on SGVI score. Kaplan-Meier analysis was used to compare the incidence of endograft complications and reinterventions in patients predicted to be at low risk compared with those predicted to be at high risk. There were 1207 patients who underwent EVAR with follow-up up to three years. SGVI score accurately discriminated freedom from reintervention (90.5 vs 79.3% in low vs high risk patients; P < .001), freedom from endograft complications (77.9 vs 69.6% in low vs high risk patients; P ¼ .012), and freedom from a composite outcome measure of reinterventions or endograft complications (75.0 vs 66.1% in low- vs high-risk patients; P ¼ .006) during midterm follow-up. Comment: There is an old adage that a difference to be a difference has to make a difference. Simply put, this means that outcomes are more important that P values. While the authors have shown significant P values; differences between groups were not so great as to be clinically significant and therefore not likely to influence clinical practice. Based on these data, one cannot really recommend use of the SGVI score as a determining factor in whether to pursue endovascular therapy for an abdominal aortic aneurysm.
Presence of External Carotid Artery Plaque Independently Predicts Mortality in Patients Without Internal Carotid Artery Atherosclerosis Kim ES, Marycz M, Archinal D, et al. Vascular Medicine 2014;19:351-5. Conclusions: Presence of plaque isolated to the external carotid artery (ECA) independently predicts all-cause mortality. Summary: Internal carotid artery (ICA) stenosis is a risk factor for increased cardiovascular morbidity and mortality (Goessens BM et al, Stroke 2007;38:1470-5). There is also a known association with the presence of plaque in the peripheral arteries increasing morbidity and mortality compared to patients with minimal atherosclerosis. The authors’ hypothesis is that external carotid artery (ECA) plaque in the absence of plaque in other cervical vessels would also be a risk factor for increased all-cause mortality. They decided to determine all-cause mortality rates in patients with ECA plaque but no ICA or common carotid artery (CCA) plaque. They queried their noninvasive vascular laboratory database for duplex ultrasounds performed between January 1, 2005 to December 31, 2005. Studies were included if plaque was absent in both the CCA and ICA. Demographic characteristics and clinical information and all-cause mortality was determined. A total of 500 patient studies met the inclusion criteria. 64 patients (12.8%) had plaque in one or both ECAs. There was no significant difference in age (mean) 58.1 6 14.8 years, race (82.5% white), or sex (64.4% male) between those with and without ECA plaque. There was, however, a significant difference in all-cause mortality between patients with and without isolated ECA plaque after adjustments for age, sex, lowedensity lipoprotein cholesterol, smoking, hypertension, body mass index, and surgery within 30 days of the duplex study (adjusted hazard ratio, 2.60; 95% confidence interval, 1.46-4.66; P < .001). Comment: The authors’ data does not truly allow one to determine ECA plaque is alone a marker for increased mortality in that the objective determination of atherosclerosis in other vascular beds was not included in this study. Nevertheless, within the context of the performance of a carotid duplex examination, isolated plaque in the ECA may provide important prognostic information and therefore should be reported. Additional studies will be needed to determine whether the presence of isolated ECA plaque occurs independently of detectable atherosclerosis in other vascular beds.
confidence interval, 0.4-1.8). Also, risk of restenosis during a median follow-up of 13 months was similar for both groups (hazard ratio, 1.4; 95% confidence interval, 0.9-2.2). Cranial nerve injury (CNI) was 5.5% in the CEA group, while CAS was associated with other procedural related complications in 5%. Comment: Overall the general impression that CAS is safer than CEA for repeat intervention following a previous CEA appears not to be true. While cranial nerve injuries were higher with CEA only 1 of 23 was persistent. Additional complications referred to with CAS included residual stenosis, technical failure and cardiac arrhythmia. Therefore, while the need for intervention following CEA is low, when such intervention is judged appropriate, the choice of CAS or CEA for that intervention should largely be based on patient and physician tolerance for complications other than subsequent restenosis or stroke as these appear to be the same for both CEA and CAS. Outcomes of Endovascular Management of Acute Thoracic Aorta Emergencies in an Academic Level 1 Trauma Center Echeverria AB, Branco BC, Goshima KR, et al. Am J Surg 2014;208:974-80. Conclusions: Adverse outcomes for thoracic endovascular aneurysm repair (TEVAR) performed for acute thoracic aortic emergencies include 24 hour packed red blood cell (pRBC) requirements $4 units, admission mean arterial pressure < 60 mm of Hg, and 24 hour fresh frozen plasma to pRBC ratio <1:1.5. Summary: Endovascular techniques for treatment of a wide variety of aortic pathologies in the acute setting have become relatively commonplace. As of yet, however, there are not widespread reports from multiple institutions evaluating this experience. The authors reviewed their experience with use of TEVAR in emergency settings for acute thoracic aortic pathology. In retrospect, they evaluated emergency descending thoracic aortic endovascular interventions at their level 1 trauma center between January 2005 and August 2013. They included all cases of traumatic aortic rupture, ruptured descending thoracic aneurysm, penetrating atherosclerotic ulcer, acute complicated type B dissection, and aortoenteric fistula. Analysis of clinical data and demographics and outcomes stepwise logistic regression was used to identify independent risk factors for death. During the study period, 51 patients underwent TEVAR; 22 cases (43%) were performed emergently (11 patients [50.0%] traumatic aortic injury; 4 [18.2%] ruptured descending thoracic aneurysm; 4 [18.2%] complicated type B dissection; 2 [9.1%] penetrating aortic ulcer; and 1 [4.5%] aortoenteric fistula). Overall, 72.7% (n ¼ 16) were male with a mean age of 54.8 6 15.9 years. A total of 86.4% (n ¼ 19) required only a single TEVAR procedure, whereas two (9.1%) required additional endovascular therapy and one (4.5%) open thoracotomy. Four traumatic aortic injury patients required exploratory laparotomy for concomitant intra-abdominal injuries. During a mean hospital stay of 18.9 days (range, 1-76 days), three patients (13.6%) developed major complications. In-hospital mortality was 27.2% and consisted of 6 deaths from traumatic brain injury, 1 death from exsanguination in the operating room before repair could be achieved, 2 deaths secondary to bowel ischemia, 1 secondary to multisystem organ failure, and 1 resulting from withdrawal of care. A stepwise logistic regression model identified 24 hour pRBC requirements $ 4 units, mean admission arterial blood pressure < 60 mm Hg, and 24 hour fresh frozen plasma to pRBC ratio <1.5 as independent risk factors for death. During a mean follow-up of 369 days (range, 35-957 days), no subsequent major complications or deaths occurred. No device-related problems were identified during intermediate follow-up. Comment: The authors dredged up every possible reason for performing TEVAR in their institution on an emergent basis and still had a relatively small (three cases per year) experience to report. In particular, the small number of patients treated with TEVAR for traumatic thoracic injuries and aortic dissection/penetrating ulcer seems low compared to many other academic medical centers. The data emphasize that the large majority of TEVAR procedures are performed off label. They were few graft related complications in this series suggesting that even institutions with relatively small experience in TEVAR can perform the procedure with reasonable, short-term results. Adverse events in these patients primarily result from variables not specifically associated with the TEVAR procedure.
International Validation of a Risk Score for Complications and Reinterventions After Endovascular Aneurysm Repair Karthikesalingam A, Vidal-Viez A, DeBruin JL, et al. Brit J Surg 2015;102:509-15. Conclusions: Morphologic risk score predicts midterm reinterventions and endograft complications. Summary: Longer-term outcomes of EVAR continue to be a concern. Key challenges relate to device durability and timely management
JOURNAL OF VASCULAR SURGERY October 2015
of endograft complications in the years following implantation. Such complications occur in one in five patients during the first 5 years after EVAR. (Lederle FA et al, N Eng J Med 2012;367:1988-97, and DeBruin JL et al, N Eng J Med 2010;362:1881-9). Surveillance therefore is recommended lifelong for patients after endograft treatment of their abdominal aortic aneurysms. However, there is considerable variation in timing and methods of surveillance, and many patients, perhaps most, do not remain compliant with imaging protocols after EVAR (Kret MR et al, J Vasc Surg 2013;58:25-32). Endograft complications and reinterventions can be related to preoperative aneurysm morphology. A risk score for predicting such events has been developed and validated at two UK centers (Karthikesalingam A et al, Brit J Surg 2013;100:1302-11), the so-called Saint George Vascular Institute Score (SGVI). The current study attempts to provide international validation of the SGVI and provide external validity of the score. The authors utilized the ENGAGE Registry which recruited patients undergoing EVAR in 79 centers in 30 countries. Reinterventions and endograft complications were recorded for up to three years after surgery. Preoperative aneurysm morphology was extracted from the registry database and used to predict whether patients would be at low or high risk of complications after EVAR based on SGVI score. Kaplan-Meier analysis was used to compare the incidence of endograft complications and reinterventions in patients predicted to be at low risk compared with those predicted to be at high risk. There were 1207 patients who underwent EVAR with follow-up up to three years. SGVI score accurately discriminated freedom from reintervention (90.5 vs 79.3% in low vs high risk patients; P < .001), freedom from endograft complications (77.9 vs 69.6% in low vs high risk patients; P ¼ .012), and freedom from a composite outcome measure of reinterventions or endograft complications (75.0 vs 66.1% in low- vs high-risk patients; P ¼ .006) during midterm follow-up. Comment: There is an old adage that a difference to be a difference has to make a difference. Simply put, this means that outcomes are more important that P values. While the authors have shown significant P values; differences between groups were not so great as to be clinically significant and therefore not likely to influence clinical practice. Based on these data, one cannot really recommend use of the SGVI score as a determining factor in whether to pursue endovascular therapy for an abdominal aortic aneurysm.
Presence of External Carotid Artery Plaque Independently Predicts Mortality in Patients Without Internal Carotid Artery Atherosclerosis Kim ES, Marycz M, Archinal D, et al. Vascular Medicine 2014;19:351-5. Conclusions: Presence of plaque isolated to the external carotid artery (ECA) independently predicts all-cause mortality. Summary: Internal carotid artery (ICA) stenosis is a risk factor for increased cardiovascular morbidity and mortality (Goessens BM et al, Stroke 2007;38:1470-5). There is also a known association with the presence of plaque in the peripheral arteries increasing morbidity and mortality compared to patients with minimal atherosclerosis. The authors’ hypothesis is that external carotid artery (ECA) plaque in the absence of plaque in other cervical vessels would also be a risk factor for increased all-cause mortality. They decided to determine all-cause mortality rates in patients with ECA plaque but no ICA or common carotid artery (CCA) plaque. They queried their noninvasive vascular laboratory database for duplex ultrasounds performed between January 1, 2005 to December 31, 2005. Studies were included if plaque was absent in both the CCA and ICA. Demographic characteristics and clinical information and all-cause mortality was determined. A total of 500 patient studies met the inclusion criteria. 64 patients (12.8%) had plaque in one or both ECAs. There was no significant difference in age (mean) 58.1 6 14.8 years, race (82.5% white), or sex (64.4% male) between those with and without ECA plaque. There was, however, a significant difference in all-cause mortality between patients with and without isolated ECA plaque after adjustments for age, sex, lowedensity lipoprotein cholesterol, smoking, hypertension, body mass index, and surgery within 30 days of the duplex study (adjusted hazard ratio, 2.60; 95% confidence interval, 1.46-4.66; P < .001). Comment: The authors’ data does not truly allow one to determine ECA plaque is alone a marker for increased mortality in that the objective determination of atherosclerosis in other vascular beds was not included in this study. Nevertheless, within the context of the performance of a carotid duplex examination, isolated plaque in the ECA may provide important prognostic information and therefore should be reported. Additional studies will be needed to determine whether the presence of isolated ECA plaque occurs independently of detectable atherosclerosis in other vascular beds.