The financial implications of cardiac stress testing prior to abdominal aortic aneurysm repair.

Ponukumati AS ，Columbo JA ，Suckow BD ，Stableford JA ，Henkin S ，Beach JM ，Goodney PP ，Stone DH ... -  《-》

Stress testing before abdominal aortic aneurysm repair does not lead to a reduction in perioperative cardiac events.

Stress testing is often used before abdominal aortic aneurysm (AAA) repair. Whether stress testing leads to a reduction in cardiac events after AAA repair has remained unclear. Our objective was to study the national stress test usage rates and compare the perioperative outcomes between centers with high and low usage of stress testing. We used the Vascular Quality Initiative to study patients who had undergone elective endovascular AAA repair (EVAR) or open AAA repair (OAR). We measured the usage rates of stress testing across centers and compared the Vascular Study Group of New England cardiac risk index (VSG-CRI) among patients who had and had not undergone preoperative stress testing. We determined the rate of major adverse cardiac events (MACE), a composite of perioperative myocardial infarction, stroke, heart failure exacerbation, and death across the centers. We compared the MACE and 1-year mortality between the centers in the highest quintile of stress test usage and the lowest quintile. We studied 43,396 EVAR patients and 8935 OAR patients across 324 centers. The median proportion of stress test usage across centers before EVAR was 35.9% and varied from 10.2% (5th percentile) to 73.7% (95th percentile), with similar variability for OAR (median, 57.9%; 5th percentile, 13.0%; 95th percentile, 86.0%). The mean VSG-CRI for the EVAR group with preoperative stress testing was 5.6 ± 2.1 compared with 5.4 ± 2.1 (P < .001) for the EVAR group without preoperative stress testing. The findings were similar for OAR, with a VSG-CRI of 5.1 ± 2.0 vs 4.8 ± 2.1 (P < .001) for those with and without preoperative stress testing, respectively. The rate of MACE was 1.8% after EVAR and 11.6% after OAR. The 1-year mortality was 4.6% for EVAR and 6.6% for OAR. The centers in the highest quintile of stress testing had a higher adjusted likelihood of MACE after both EVAR (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.37-2.30) and OAR (OR, 1.99; 95% CI, 1.53-2.59) but similar 1-year mortality (EVAR: OR, 1.18; 95% CI, 1.02-1.37; OAR: OR, 0.87; 95% CI, 0.65-1.17) compared with the centers in the lowest quintile. The VSG-CRI was not different between the high stress test centers (EVAR, 5.5 ± 2.1; OAR: 5.0 ± 2.0), and low stress test centers (EVAR, 5.5 ± 2.1; P = .403; OAR, 4.9 ± 2.0; P = .563). Stress test usage before AAA repair varied widely across Vascular Quality Initiative centers despite similar patient risk profiles. No reduction was observed in MACE or 1-year mortality among centers with high stress test usage. The value of routine stress testing before AAA repair should be reconsidered, and stress testing should be used more selectively, given these findings and the associated costs of widespread testing.

Columbo JA ，Demsas F ，Wanken ZJ ，Suckow BD ，Beach JM ，Henkin S ，Goodney PP ，Stone DH ... -  《-》

Anemia and postoperative outcomes after open and endovascular repair of intact abdominal aortic aneurysms.

Anemia is associated with increased cardiac adverse events during the early postoperative period because of high physiologic stress and increased cardiac demand. The aim of this study was to assess the surgical outcomes and prognostic implications of anemia in patients undergoing repair of intact abdominal aortic aneurysms (AAAs). A retrospective analysis of all patients who underwent open aortic repair (OAR) or endovascular aneurysm repair (EVAR) in the Vascular Quality Initiative database (2008-2017) was performed. Patients with preoperative polycythemia, patients with ruptured aneurysms, and patients transfused with >4 units of packed red blood cells were excluded. Hemoglobin levels were categorized into three groups: moderate-severe anemia (<10 g/dL), mild anemia (10-12 g/dL in women and 10-13 g/dL in men), and no anemia (>12 g/dL in women and >13 g/dL in men). Multivariate logistic models and coarsened exact matching were used to analyze the association between anemia and 30-day mortality and between anemia and major in-hospital complications after OAR and EVAR. A total of 34,397 patients were identified undergoing AAA repair. Of those, 28.5% had mild anemia and 4.3% had moderate-severe anemia. In both OAR (n = 6112) and EVAR (n = 28,285), patients with moderate-severe anemia had significantly higher rates of in-hospital adverse events, such as in-hospital mortality, myocardial infarction, renal and respiratory complications, and reoperation, compared with patients with mild or no anemia. They also had higher rates of 30-day mortality. After multivariate analysis and 1:1 coarsened exact matching, no association was found between anemia and 30-day mortality and other in-hospital outcomes in patients undergoing OAR. On the other hand, in EVAR, moderate-severe anemia was associated with 2.7 times the odds of 30-day mortality (odds ratio [OR], 2.65; 95% confidence interval [CI], 1.69-4.18), 2.5 times the odds of renal complications (OR, 2.47; 95% CI, 1.78-3.43; P < .05), and twice the risk of acute congestive heart failure (OR, 1.96; 95% CI, 1.18-3.25) and respiratory complications (OR, 2.01; 95% CI, 1.26-3.19). Mild anemia was also associated with increased odds of 30-day mortality and renal and respiratory complications in patients undergoing EVAR. Interestingly, preoperative blood transfusion in mildly anemic patients undergoing EVAR was associated with double the odds of in-hospital major adverse cardiac events (stroke, death, and myocardial infarction; OR, 2.1; 95% CI, 1.38-3.11; P < .001). Preoperative anemia is associated with higher odds of 30-day mortality and in-hospital adverse outcomes after EVAR but not after OAR. These findings highlight the need to incorporate anemia into the preoperative risk assessment of patients undergoing EVAR. Future studies are needed to assess the efficacy of medical therapies in improving postoperative outcomes in anemic patients undergoing AAA repair.

Dakour-Aridi H ，Nejim B ，Locham S ，Alshwaily W ，Malas MB ... -  《-》

Predictors of acute kidney injury after infrarenal abdominal aortic aneurysm repair in octogenarians.

Dang T ，Dakour-Aridi H ，Rizwan M ，Nejim B ，Malas MB ... -  《-》

Decreasing prevalence of centers meeting the Society for Vascular Surgery abdominal aortic aneurysm guidelines in the United States.

Based on data supporting a volume-outcome relationship in elective aortic aneurysm repair, the Society of Vascular Surgery (SVS) guidelines recommend that endovascular aortic repair (EVAR) be localized to centers that perform ≥10 operations annually and have a perioperative mortality and conversion-to-open rate of ≤2% and that open aortic repair (OAR) be localized to centers that perform ≥10 open aortic operations annually and have a perioperative mortality ≤5%. However, the number and distribution of centers meeting the SVS criteria remains unclear. This study aimed to estimate the temporal trends and geographic distribution of Centers Meeting the SVS Aortic Guidelines (CMAG) in the United States. The SVS Vascular Quality Initiative was queried for all OAR, aortic bypasses, and EVAR from 2011 to 2019. Annual OAR and EVAR volume, 30-day elective operative mortality for OAR or EVAR, and EVAR conversion-to-open rate for all centers were calculated. The SVS guidelines for OAR and EVAR, individually and combined, were applied to each institution leading to a CMAG designation. The proportion of CMAGs by region (West, Midwest, South, and Northeast) were compared by year using a χ2 test. Temporal trends were estimated using a multivariable logistic regression for CMAG, adjusting by region. Overall, 67,865 patients (49,264 EVAR; 11,010 OAR; 7591 aortic bypasses) at 336 institutions were examined. The proportion of EVAR CMAGs increased nationally by 1.7% annually from 51.6% (n = 33/64) in 2011 to 67.1% (n = 190/283) in 2019 (β = .05; 95% confidence interval [CI], 0.01-0.09; P = .02). The proportion of EVAR CMAGs across regions ranged from 27.3% to 66.7% in 2011 to 63.9% to 72.9% in 2019. In contrast, the proportion of OAR CMAGs has decreased nationally by 1.8% annually from 32.8% (n = 21/64) in 2011 to 16.3% (n = 46/283) in 2019 (β = -.14; 95% CI, -0.19 to -0.10; P < .01). Combined EVAR and OAR CMAGs were even less frequent and decreased by 1.5% annually from 26.6% (n = 17/64) in 2011 to 13.1% (n = 37/283) in 2019 (β = -.12; 95% CI, -0.17 to -0.07; P < .01). In 2019, there was no significant difference in regional variation of the proportion of combined EVAR and OAR CMAGs (P = .82). Although an increasing proportion of institutions nationally meet the SVS guidelines for EVAR, a smaller proportion meet them for OAR, with a concerning downward trend. These data question whether we can safely offer OAR at most institutions, have important implications about sufficient OAR exposure for trainees, and support regionalization of OAR.

Ramirez JL ，Matthay ZA ，Lancaster E ，Smith EJT ，Gasper WJ ，Zarkowsky DS ，Doyle AJ ，Patel VI ，Schanzer A ，Conte MS ，Iannuzzi JC ... -  《-》