Journal of Vascular Surgery最新文献

Objective: Patients that survive acute aortic dissection (AD) remain at high risk of morbidity/mortality from structural changes of the aorta. Aortic surveillance is challenging, especially within a tertiary referral center. Our aim was to identify follow-up imaging and appointment rates, and factors associated with incomplete surveillance in patients with acute AD.

Methods: This was a single-center, retrospective study of acute AD patients at a tertiary care center from July 2012 to December 2022 who lived at least 1 year after AD. We defined complete surveillance as having computed tomography scans or magnetic resonance imaging scans of the chest and abdomen at 1 month (±14 days), 6 months (±1.5 months), 1 year (±3 months), and yearly thereafter. Data were obtained from the electronic health record. Predictors of absent imaging at the 1 year (±3 months) timepoint were evaluated using multivariable logistic regression.

Results: Of the 272 patients in the study, 63.2% were male and 39.3% were White. The average age was 60.7 ± 14.7 years. Acute type A AD comprised 47.1% of our cohort; 91.4% underwent open repair within 1 week of presentation. Of the acute type B AD patients (52.9% of the cohort), 41.7% underwent thoracic endovascular aortic repair at the index admission. At the 1-year follow-up interval (±3 months), 26.5% were confirmed to have undergone aortic surveillance imaging, and 27.6% had an appointment with a cardiovascular specialist. Only 9.6% of the cohort was fully concordant with the recommended surveillance imaging in the first year of follow-up. On multivariate regression, non-English speakers (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.05-3.99; P = .03) and residence outside of hospital region (OR, 1.66; 95% CI, 1.02-3.17; P = .04) were independently-associated with lack of follow-up imaging at the 1-year timepoint, whereas longer length of stay was independently-associated with completed imaging at the 1-year timepoint (OR, 0.78; 95% CI, 0.41-0.89; P = .04).

Conclusions: This study highlights a low rate of surveillance and clinical follow-up for patients with acute AD and a significant disparity for non-English speaking patients and those who reside outside of the hospital region. This information should inform future quality initiatives to improve aortic surveillance following AD.

Objective: It is estimated that 20% of patients undergoing elective abdominal aortic aneurysm repair suffer from cardiomyopathy. This study examines the impact of reduced ejection fraction (EF) on the outcomes of endovascular aneurysm repair (EVAR) and compares the different types of cardiomyopathies causing reduction of EF. Our hypothesis is that reduction in EF is associated with higher mortality after EVAR.

Methods: We examined the Vascular Quality Initiative database for EVAR from 2003 to 2020. Patients presenting with symptomatic abdominal aortic aneurysm or rupture were excluded. Patients were excluded if age, sex, mortality, and EF were not available. Patients were stratified into categories in two separate analyses. The first analysis examines differences between <30% EF, 30% to 50% EF, and EF >50%, and the second analysis examined differences between ischemic cardiomyopathy (ICM) and nonischemic cardiomyopathy in patients with reduced EF. Patients' demographics, comorbidities, operative characteristics, and outcomes were compared. Statistical comparisons were performed using χ² analysis for categorical variables and analysis of variance for continuous variables. Multivariable comparison was performed to find characteristics impacting mortality.

Results: There were 26,037 patients included and 20,127 (77.3%) had a normal EF (>50%), 4885 (18.7%) patients had a moderately reduced EF of 30% to 50%, and only 1025 (3.9%) patients had a severely reduced EF (<30%). The 30-day mortality was not significantly different between patients with very reduced (1.9%) and reduced EF (1.7%), but was significantly higher than patients with normal EF (0.8%) (P < .001). There was a nearly two-fold increase in 30-day mortality for ischemic cardiomyopathy (1.1% vs 2.0%; P = .024) compared with nonischemic cardiomyopathy, but there was no difference in long-term mortality between the two groups.

Conclusions: Elective EVAR in patients with reduced EF is associated with higher 30-day mortality compared with patients with a normal EF, but the overall mortality rate in the Vascular Quality Initiative falls within the acceptable range of Society for Vascular Surgery guidelines. Among patients with reduced EF, the type of cardiomyopathy seems to have a more important association with 30-day mortality than the severity of cardiomyopathy does.

Objective: Single-center studies have suggested that solid organ transplant recipients are at increased risk for arterial aneurysms. Moreover, they describe a more aggressive natural history with increased rates of expansion and rupture. In this exploratory analysis, we aimed to assess the frequency of arterial aneurysms in solid organ transplant recipients using a large-scale national database.

Methods: We queried the National Inpatient Sample dataset from 2016 to 2020 using International Classification of Disease, Tenth Revision, Clinical Modification codes to identify patients with solid organ transplants. We calculated the prevalence of aortoiliac aneurysms by organ transplant type and performed one:one propensity score matching to compare aneurysm rates between transplant recipients and nontransplant patients. Additionally, we used a multivariable model to determine whether the observed aneurysm frequency was due to the transplant intervention or attributable to variable baseline characteristics of the groups.

Results: A retrospective analysis of the National Inpatient Sample database identified 34,920,964 nontransplant patients and 34,288 transplant recipients. Among the transplant cohort, kidney transplant recipients made up the largest group at 57.5%. The median age of the transplant group was 55 years, with a predominance of male patients and a low smoking rate of 2.19%. The overall frequency of aortoiliac aneurysms in the transplant population was 0.48%. Specifically, the prevalence of thoracic aortic aneurysms, abdominal aortic aneurysms, and iliac artery aneurysms was 0.2%, 0.19%, and 0.06%, respectively. Thoracic organ transplant recipients had a higher frequency of aortoiliac aneurysms compared with those with abdominal organ transplants. The frequencies of aortoiliac aneurysms were 0.81% in heart transplant recipients, 1.37% in single lung recipients, 0.91% in double lung recipients, 0.42% in liver recipients, and 0.42% in kidney recipients. Additionally, the frequency of abdominal aortic aneurysms was 0.42% in heart transplant recipients and 0.51% in single lung transplant recipients.

Conclusions: As transplant patient survival continues to improve, monitoring for comorbid conditions will become increasingly important. Given the limited availability of organs and importance of post-transplant care, the observed prevalence of aortoiliac aneurysms in heart, lung, and liver transplant recipients highlights the need for enhanced screening and surveillance. Further studies are required to better understand the rates of aneurysm expansion and rupture in solid organ transplant recipients.

Objective: Current guidelines recommend treatment of patients with asymptomatic carotid stenosis when stroke/death rates less than 3% can be achieved. However, in the Pacific Northwest region of the Vascular Quality Initiative, elevated stroke/death rates have been reported. This study aims to characterize regional and center-specific outcomes for transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TF-CAS) and investigate potential underlying drivers.

Methods: A retrospective review of asymptomatic patients undergoing TCAR and TF-CAS in the Vascular Quality Initiative for the Pacific Northwest region from 2016 to 2022 was performed. The primary outcome was the composite of stroke or death within 30 days of index hospitalization. Overall regional outcomes and center-specific outcomes were assessed. A high stroke/death rate was defined as greater than 3%. Demographics, comorbidities, and operative risk factors were then compared between centers with high and low stroke/death rates.

Results: A total of 1154 asymptomatic patients across 27 centers underwent carotid stenting in the Pacific Northwest from 2016 to 2022, of which 886 (76.8%) underwent TCAR and 268 (23.2%) underwent TF-CAS. The overall stroke/death rates were 2.5% and 3.0% for TCAR and TF-CAS, respectively. Among centers with stroke/death rates above 3%, for both TCAR and TF-CAS, all were in the top one-half of centers by volume. When patients undergoing TCAR were assessed, those treated at centers with high stroke/death rate underwent revascularization at higher volume centers (12 vs 7 cases per year; P = .03), which treated fewer patients with >80% stenosis (42.1% vs 52.2%; P < .01) and more patients with high-risk anatomy (42.3% vs 35.3%; P = .01), and high-risk physiology as defined by an American Society of Anesthesiologists (ASA) class of 4 or 5 (25.5% vs 17.5%; P < .01). Among patients undergoing TF-CAS, those treated at centers with a high stroke/death rate were more likely to have high-risk anatomy (63.5% vs 48.6%; P = .03), and high-risk physiology as defined by an ASA class of 4 or 5 (23.5% vs 10.4%; P < .01).

Conclusions: High stroke/death rates in the Pacific Northwest appear to be driven by the selection of high-risk patients with less than 80% stenosis. Decreasing the frequency of carotid revascularization in asymptomatic patients with very high physiologic risk including those with ASA class 4 and those with less than 80% stenosis may offer the opportunity for improved outcomes.

Objectives: For men ages 65 to 75 years without a smoking history and for women ages 65 to 75 years with a smoking history, the United States Preventative Service Task Force recommends that primary care providers (PCPs) use their clinical judgement when offering abdominal aortic aneurysm (AAA) screening. This study describes the trends in screening for these cohorts, identifies factors that may influence screening rates, and compares outcomes between screened and unscreened patients.

Methods: The TriNetX population database was queried for subjects with routine PCP visit between ages 65 to 75 from 2007 to 2023 to create cohorts of male smokers, male nonsmokers, and female smokers. Prevalence and 1- and 3-year incidences of AAA screening by ultrasound and computed tomography scans/magnetic resonance imaging (CT/MRI) were calculated. Screened and unscreened patients' demographics, diagnoses, and medications were compared. Rates of AAA diagnosis and repair were compared between unmatched screened and unscreened patients.

Results: Screening for all groups peaked in 2023. Male smokers had the highest screening prevalence (21.2%), followed by male nonsmokers (3.1%) and female smokers (0.90%). The 1-year incidence of screening increased for male smokers, peaking at 8.2% in 2021. The 1-year incidence plateaued at 1.9% for male nonsmokers in 2020 and remained between 0.25% and 0.35% for female smokers for the whole observation period. By 2023, 23.6%, 14.3%, and 24.3% of male smokers, male nonsmokers, and female smokers had been screened via CT/MRI, respectively, with CT/MRI comprising the majority of screening events for all three cohorts. Hyperlipidemia and statin use were associated with screening for all groups (P < .05), whereas a personal history of coronary artery disease was associated with no screening. Screening for male nonsmokers was associated with hypertension, diabetes, and chronic pulmonary obstructive disease (P < .05). Screening in female smokers was associated with family history of coronary artery disease (odds ratio, 1.50; P < .001). For all groups, screening was associated with unruptured AAA diagnosis and endovascular aortic repair (P < .05). Screened female smokers had similar rates of AAA diagnosis as male nonsmokers (4.58% and 4.37%, respectively).

Conclusions: AAA screening in all at-risk populations increases diagnosis and treatment of AAA, but the screening rate is low for all groups, even with increasing CT/MRI use. Patients with strong risk factors for AAA are not undergoing screening. Collaboration with PCPs is necessary to increase screening rates and ensure that patients with the most clinically consequential risk factors are managed appropriately.

Objective: Zone 0 branched thoracic endovascular arch repair (Z0BTEVAR) has emerged as an alternative to open repair for high-risk patients with aortic arch pathology. However, it is unclear how disease characteristics in this population impacts clinical outcomes. The study aimed to compare Z0BTEVAR according to arch disease pathology and to identify potential predictors of postoperative outcomes.

Methods: From 2011 to 2023, patients who underwent Z0BTEVAR for chronic aortic dissection (C-AD) or for non-aortic dissection (N-AD) etiology at three European centers were included. The primary outcome was a composite of in-hospital mortality and disabling stroke. Multivariable logistic analyses were conducted to identify independent predictors of the outcomes.

Results: Overall, 213 patients underwent Z0BTEVAR, including 111 patients treated for C-AD and 102 patients treated for N-AD. The median age was 72 years old. Overall composite outcome was 10.3%, higher for patients with N-AD compared with patients with C-AD (15.7% vs 5.4%; P = .01). Similarly, patients with N-AD had more postoperative strokes (17.7% vs 4.5%; P < .01). On multivariable analysis, previous type A aortic dissection was protective for the composite outcome (odds ratio, 0.2; 95% confidence interval, 0.1-0.6), whereas degenerative aneurysm with zone 0 or 1 involvement was predictive of postoperative stroke (odds ratio, 3.7; 95% confidence interval, 1.2-11.8). At 4 years, survival for the N-AD group was 71.8% ± 6.6%, and for the C-AD group was 71.5% ± 6.5% (P = .81).

Conclusion: Z0BTEVAR could be performed with satisfactory short- and mid-term outcomes for high-risk patients, particularly those with previous dissection. Patient selection is important, and continued effort should be placed on minimizing postoperative stroke.

Objective: Participation in the Vascular Quality Initiative (VQI) provides important resources to surgeons, but the ability to do so is often limited by time and data entry personnel. Large language models (LLMs) such as ChatGPT (OpenAI) are examples of generative artificial intelligence products that may help bridge this gap. Trained on large volumes of data, the models are used for natural language processing and text generation. We evaluated the ability of LLMs to accurately populate VQI procedural databases using operative reports.

Methods: A single-center, retrospective study was performed using institutional VQI data from 2021 to 2023. The most recent procedures for carotid endarterectomy (CEA), endovascular aneurysm repair (EVAR), and infrainguinal lower extremity bypass (LEB) were analyzed using Versa, a HIPAA (Health Insurance Portability and Accountability Act)-compliant institutional version of ChatGPT. We created an automated function to analyze operative reports and generate a shareable VQI file using two models: gpt-35-turbo and gpt-4. Application of the LLMs was accomplished with a cloud-based programming interface. The outputs of this model were compared with VQI data for accuracy. We defined a metric as "unavailable" to the LLM if it was discussed by surgeons in <20% of operative reports.

Results: A total of 150 operative notes were analyzed, including 50 CEA, 50 EVAR, and 50 LEB. These procedural VQI databases included 25, 179, and 51 metrics, respectively. For all fields, gpt-35-turbo had a median accuracy of 84.0% for CEA (interquartile range [IQR]: 80.0%-88.0%), 92.2% for EVAR (IQR: 87.2%-94.0%), and 84.3% for LEB (IQR: 80.2%-88.1%). A total of 3 of 25, 6 of 179, and 7 of 51 VQI variables were unavailable in the operative reports, respectively. Excluding metric information routinely unavailable in operative reports, the median accuracy rate was 95.5% for each CEA procedure (IQR: 90.9%-100.0%), 94.8% for EVAR (IQR: 92.2%-98.5%), and 93.2% for LEB (IQR: 90.2%-96.4%). Across procedures, gpt-4 did not meaningfully improve performance compared with gpt-35 (P = .97, .85, and .95 for CEA, EVAR, and LEB overall performance, respectively). The cost for 150 operative reports analyzed with gpt-35-turbo and gpt-4 was $0.12 and $3.39, respectively.

Conclusions: LLMs can accurately populate VQI procedural databases with both structured and unstructured data, while incurring only minor processing costs. Increased workflow efficiency may improve center ability to successfully participate in the VQI. Further work examining other VQI databases and methods to increase accuracy is needed.

Objective: Whether high-density lipoprotein cholesterol (HDL-C) has a protective role against abdominal aortic aneurysm (AAA) development in both older males and females remains uncertain. This study aims to assess the sex-specific association between HDL-C and incident AAA in older adults from the UK Biobank.

Methods: This cohort study included 86,184 males and 95,682 females aged ≥60 years from the UK biobank. Baseline HDL-C was modelled either as a continuous or categorical variable. The primary outcome was incident AAA. Cox proportional hazard models were used for sex-stratified analysis, adjusting for baseline confounders. Restricted cubic splines were plotted to visualize any nonlinear relationship. Harrell's C-index was calculated to assess the added value of HDL-C to the discrimination of model including age and smoking.

Results: Over a mean follow-up of 14.4 years, 1549 and 328 incident AAA were observed in males and females, respectively. Adjusted hazard ratios for AAA with a 1-mmol/L HDL-C increase was 0.26 (95% confidence interval, 0.21- 0.32) and 0.31 (95% confidence interval, 0.21-0.46) in males and females, respectively (both P < .001). Consistent with the results from Cox model modelling HDL-C as a categorical variable showing an inverse and dose-dependent relationship between HDL-C and incident AAA in both sexes, restricted cubic splines confirmed the monotonic, inverse associations. Adding HDL-C to a model including age and smoking significantly improve the model discrimination for AAA in both sexes (C-index +2.1% in males and +1.5% in females; both P < .05).

Conclusions: This study revealed a significant association between low HDL-C levels and a high risk of incident AAA in both older males and females, suggesting the potential clinical usefulness of HDL-C for AAA risk stratification. Our study was limited by its observational design and the presence of possible residual confounding. Studies using real-world data are warranted to evaluate the practical implications of incorporating HDL-C into AAA screening guidelines and its impact on patient outcomes.