Journal of vascular surgery
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We aimed to achieve accurate statistical modeling of a putative relationship between carotid endarterectomy (CEA) annual surgeon and hospital volume and in-hospital mortality. ⋯ We have demonstrated a technique for rigorous statistical analysis of volume-outcome data and have found a volume effect for death after CEA in this 10-year Maryland dataset. Higher volume surgeons had lower estimated odds of death, particularly those performing four to 15 CEAs per year. These data suggest that a patient undergoing CEA by a surgeon performing an average of 16 CEAs annually has a statistically equivalent risk of death compared with one undergoing CEA by a surgeon performing any number higher than this, when controlling for hospital volume, patient comorbidity, and patient age. Hospital volume was not seen to be as significant a predictor of postoperative death in this study, with only high volume hospitals (>/=130 CEAs per year) showing a statistically significant decrease in the odds ratio of death. As studies on volume-outcome relationships can have important implications for health policy and surgical training, such studies should consider non-linear effects in their modeling of procedural volume.
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The management of concurrent carotid and coronary artery disease is controversial. Although single-center observational studies have revealed acceptable outcomes of combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG), community-based outcomes have been substantially inferior. Recently, carotid artery stenting (CAS) has been introduced for the management of high-risk patients with carotid stenosis, including those with severe coronary artery disease. This study was undertaken to evaluate the nationwide trends and outcomes of CAS before CABG vs combined CEA and CABG and to assess the risk for adverse events. ⋯ Although CAS may currently be performed for high-risk patients, it is still infrequently used in patients who require concurrent carotid and coronary interventions. In the United States, patients who undergo CAS-CABG have significantly decreased in-hospital stroke rates compared with patients undergoing CEA-CABG but similar in-hospital mortality. CAS may provide a safer carotid revascularization option for patients who require CABG.
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Preservation of spinal cord blood supply during descending thoracic (TAA) and thoracoabdominal aortic aneurysm (TAAA) surgery is mandatory to prevent neurologic complications. Although collateral arteries have been identified occasionally and are considered crucial for maintaining spinal cord function in the individual patient, their critical functionality is poorly understood and very little experience exists with visualization. This study investigated whether the preoperative and postoperative presence or absence of collateral arteries detected by magnetic resonance angiography (MRA) is related to spinal cord function during the intraoperative exclusion of the segmental supply to the Adamkiewicz artery. ⋯ Collateral arteries supplying the spinal cord can be systematically visualized using MRA. Spinal cord blood supply during open aortic surgery may crucially depend on collateral arteries. Preoperatively identified collateral supply was 97% predictive for stable intraoperative spinal cord function. Patients in whom no collaterals can be depicted preoperatively are at increased risk for spinal cord dysfunction.
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Comparative Study
Colonic ischemia complicating open vs endovascular abdominal aortic aneurysm repair.
Colonic ischemia (CI) is a known complication of both open abdominal aortic aneurysm (AAA) repair and endovascular aneurysm repair (EVAR). Despite a relatively low incidence of 1% to 6%, the associated morbidity and mortality are high. We sought to analyze factors that affect the development of CI on the basis of type of repair as well as associated outcomes from a large nationwide database. ⋯ CI is significantly more common after open AAA repair and is associated with increased morbidity and a two- to fourfold increase in mortality.