Marc L Schermerhorn

Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States

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Publications (117)355.95 Total impact

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    ABSTRACT: Readmission is associated with high mortality, morbidity, and cost. We used the American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP) to determine risk factors for readmission after lower extremity bypass (LEB). We identified all patients who received LEB in the 2011 ACS-NSQIP database. Multivariable logistic regression was used to assess independent predictors of 30-day readmission. We also identified our institutional contribution of LEB patients to the ACS-NSQIP from 2005 to 2011 to determine our institution's rate of readmission and readmission indications. Among 5018 patients undergoing LEB, ACS-NSQIP readmission analysis was performed on 4512, excluding those whose readmission data were unavailable, who suffered a death on index admission, or who remained in the hospital at 30 days. Overall readmission rate was 18%, and readmission rate of those with NSQIP-captured complications was 8%. Multivariable predictors of readmission were dependent functional status (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.08-1.79), dyspnea (OR, 1.28; 95% CI, 1.02-1.60), cardiac comorbidity (OR, 1.46; 95% CI, 1.16-1.84), dialysis dependence (OR, 1.44; 95% CI, 1.05-1.97), obesity (OR, 1.28; 95% CI, 1.07-1.53), malnutrition (OR, 1.42; 95% CI, 1.12-1.79), critical limb ischemia operative indication (OR, 1.40; 95% CI, 1.10-1.79), and return to the operating room on index admission (OR, 8.0; 95% CI, 6.68-9.60). The most common postdischarge complications occurring in readmitted patients included wound complications (55%), multiple complications (22%), and graft failure (5%). Our institutional data contributed 465 LEB patients to the ACS-NSQIP from 2005 to 2012, with an overall readmission rate of 14%. Unplanned readmissions related to the original LEB (related unplanned) made up 75% of cases. The remainder 25% included readmissions that were planned staged procedures related to the original LEB (related planned, 11%) and admissions for a completely unrelated reason (unrelated unplanned, 14%). The most common readmission indications included wound infection (37%) and graft failure (10%). Readmissions were attributable to NSQIP-captured postdischarge complications in 44% of cases, an additional 44% had a non-NSQIP-defined reason for readmission, and the remainder (12%) included patients admitted for complications described in NSQIP but not meeting strict NSQIP criteria. Readmissions are common after LEB. Optimization of select chronic conditions, closer follow-up of patients in poor health and those who required return to the operating room, and early detection of surgical site infections may improve readmission rates. Our finding that 25% of readmissions after LEB are not procedure related informs the broader discussion of how a readmission penalty affects vascular surgery in particular.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 01/2014; · 3.52 Impact Factor
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    ABSTRACT: Background Outcomes for patients undergoing intervention for restenosis after prior ipsilateral carotid endarterectomy (CEA) in the era of carotid angioplasty and stenting (CAS) are unclear. We compared perioperative results and durability of CAS vs CEA in patients with symptomatic or asymptomatic restenosis after prior CEA and investigated the risk of reintervention compared with primary procedures. Methods Patients undergoing CAS and CEA for restenosis between January 2003 and March 2012 were identified within the Vascular Study Group of New England (VSGNE) database. End points included any stroke, death or myocardial infarction (MI) within 30 days, cranial nerve injury at discharge, and restenosis ≥70% at 1-year follow-up. Multivariable logistic regression was done to identify whether prior ipsilateral CEA was an independent predictor for adverse outcome. Results Out of 9305 CEA procedures, 212 patients (2.3%) underwent redo CEA (36% symptomatic). Of 663 CAS procedures, 220 patients (33%) underwent CAS after prior ipsilateral CEA (31% symptomatic). Demographics of patients undergoing redo CEA were comparable to patients undergoing CAS after prior CEA. Stroke/death/MI rates were statistically similar between redo CEA vs CAS after prior CEA in both asymptomatic (4.4% vs 3.3%; P = .8) and symptomatic patients (6.6% vs 5.8%; P = 1.0). No significant difference in restenosis ≥70% was identified between redo CEA and CAS after prior CEA (5.2% vs 3.0%; P = .5). Redo CEA vs primary CEA had increased stroke/death/MI rate in both symptomatic (6.6% vs 2.3%; P = .05) and asymptomatic patients 4.4% vs 1.7%; P = .03). Prior ipsilateral CEA was an independent predictor for stroke/death/MI among all patients undergoing CEA (odds ratio, 2.1; 95% confidence interval, 1.3-3.5). No difference in cranial nerve injury was identified between redo CEA and primary CEA (5.2% vs 4.7%; P = .8). Conclusions In the VSGNE, CEA and CAS showed statistically equivalent outcomes in asymptomatic and symptomatic patients treated for restenosis after prior ipsilateral CEA. However, regardless of symptom status, the risk of reintervention was increased compared with patients undergoing primary CEA.
    Journal of Vascular Surgery. 01/2014; 59(1):8–15.e2.
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    ABSTRACT: Objectives The benefit of carotid endarterectomy (CEA) may be diminished by cranial nerve injury (CNI). Using a quality improvement registry, we aimed to identify the nerves affected, duration of symptoms (transient vs. persistent), and clinical predictors of CNI. Methods We identified all patients undergoing CEA in the Vascular Study Group of New England (VSGNE) between 2003 and 2011. Surgeon-observed CNI rate was determined at discharge (postoperative CNI) and at follow-up to determine persistent CNI (CNIs that persisted at routine follow-up visit). Hierarchical multivariable model controlling for surgeon and hospital was used to assess independent predictors for postoperative CNI. Results A total of 6,878 patients (33.8% symptomatic) were included for analyses. CNI rate at discharge was 5.6% (n = 382). Sixty patients (0.7%) had more than one nerve affected. The hypoglossal nerve was most frequently involved (n = 185, 2.7%), followed by the facial (n = 128, 1.9%), the vagus (n = 49, 0.7%), and the glossopharyngeal (n = 33, 0.5%) nerve. The vast majority of these CNIs were transient; only 47 patients (0.7%) had a persistent CNI at their follow-up visit (median 10.0 months, range 0.3–15.6 months). Patients with perioperative stroke (0.9%, n = 64) had significantly higher risk of CNI (n = 15, CNI risk 23.4%, p < .01). Predictors for CNI were urgent procedures (OR 1.6, 95% CI 1.2–2.1, p < .01), immediate re-exploration after closure under the same anesthetic (OR 2.0, 95% CI 1.3–3.0, p < .01), and return to the operating room for a neurologic event or bleeding (OR 2.3, 95% CI 1.4–3.8, p < .01), but not redo CEA (OR 1.0, 95% CI 0.5–1.9, p = .90) or prior cervical radiation (OR 0.9, 95% CI 0.3–2.5, p = .80). Conclusions As patients are currently selected in the VSGNE, persistent CNI after CEA is rare. While conditions of urgency and (sub)acute reintervention carried increased risk for postoperative CNI, a history of prior ipsilateral CEA or cervical radiation was not associated with increased CNI rate.
    European Journal of Vascular and Endovascular Surgery. 01/2014; 47(1):2–7.
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    ABSTRACT: Patients with abdominal aortic aneurysms (AAAs) are usually treated with endovascular aneurysm repair (EVAR), which has become the standard of care in many hospitals for patients with suitable anatomy. Clinical evidence indicates that EVAR is associated with superior perioperative outcomes and similar long-term survival compared with open repair. Since the randomized, controlled trials that provided this evidence were conducted, however, the stent graft technology for infrarenal AAA has been further developed. Improvements include profile downsizing, optimization of sealing and fixation, and the use of low porosity fabrics. In addition, imaging techniques have improved, enabling better preoperative planning, stent graft placement, and postoperative surveillance. Also in the past few years, fenestrated and branched stent grafts have increasingly been used to manage anatomically challenging aneurysms, and experiments with off-label use of stent grafts have been performed to treat patients deemed unfit or unsuitable for other treatment strategies. Overall, the indications for endovascular management of AAA are expanding to include increasingly complex and anatomically challenging aneurysms. Ongoing studies and optimization of imaging, in addition to technological refinement of stent grafts, will hopefully continue to broaden the utilization of EVAR.
    Nature Reviews Cardiology 12/2013; · 10.40 Impact Factor
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    ABSTRACT: Endovascular aortic repair (EVAR) for abdominal aortic aneurysm (AAA) is increasingly used for emergent treatment of ruptured AAA (rAAA). We sought to compare the perioperative and long-term mortality, procedure-related complications, and rates of reintervention of EVAR vs open aortic repair of rAAA in Medicare beneficiaries. We examined perioperative and long-term mortality and complications after EVAR or open aortic repair performed for rAAA in all traditional Medicare beneficiaries discharged from a United States hospital from 2001 to 2008. Patients were matched by propensity score on baseline demographics, coexisting conditions, admission source, and hospital volume of rAAA repair. Sensitivity analyses were performed to evaluate the effect of bias that might have resulted from unmeasured confounders. Of 10,998 patients with repaired rAAA, 1126 underwent EVAR and 9872 underwent open repair. Propensity score matching yielded 1099 patient pairs. The average age was 78 years, and 72.4% were male. Perioperative mortality was 33.8% for EVAR and 47.7% for open repair (P < .001), and this difference persisted for >4 years. At 36 months, EVAR patients had higher rates of AAA-related reinterventions than open repair patients (endovascular reintervention, 10.9% vs 1.5%; P < .001), whereas open patients had more laparotomy-related complications (incisional hernia repair, 1.8% vs 6.2%; P < .001; all surgical complications, 4.4% vs 9.1%; P < .001). Use of EVAR for rAAA increased from 6% of cases in 2001 to 31% in 2008, whereas during the same interval, overall 30-day mortality for admission for rAAA, regardless of treatment, decreased from 55.8% to 50.9%. EVAR for rAAA is associated with lower perioperative and long-term mortality in Medicare beneficiaries. Increasing adoption of EVAR for rAAA is associated with an overall decrease in mortality of patients hospitalized for rAAA during the last decade.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 12/2013; · 3.52 Impact Factor
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    ABSTRACT: Prior studies have suggested treatment and outcome disparities between men and women for lower extremity peripheral arterial disease after surgical bypass. Given the recent shift toward endovascular therapy, which has increasingly been used to treat claudication, we sought to analyze sex disparities in presentation, revascularization, amputation, and inpatient mortality. We identified individuals with intermittent claudication and critical limb ischemia (CLI) using International Classification of Diseases, Ninth Revision codes in the Nationwide Inpatient Sample from 1998 to 2009. We compared presentation at time of intervention (intermittent claudication vs CLI), procedure (open surgery vs percutaneous transluminal angioplasty or stenting vs major amputation), and in-hospital mortality for men and women. Regional and ambulatory trends were evaluated by performing a separate analysis of the State Inpatient and Ambulatory Surgery Databases from four geographically diverse states: California, Florida, Maryland, and New Jersey. From the Nationwide Inpatient Sample, we identified 1,797,885 patients (56% male) with intermittent claudication (26%) and CLI (74%), who underwent 1,865,999 procedures (41% open surgery, 20% percutaneous transluminal angioplasty or stenting, and 24% amputation). Women were older at the time of intervention by 3.5 years on average and more likely to present with CLI (75.9% vs 72.3%; odds ratio [OR], 1.21; 95% confidence interval [CI], 1.21-1.23; P < .01). Women were more likely to undergo endovascular procedures for both intermittent claudication (47% vs 41%; OR, 1.27; 95% CI, 1.25-1.28; P < .01) and CLI (21% vs 19%; OR, 1.14; 95% CI, 1.13-1.15; P < .01). From 1998 to 2009, major amputations declined from 18 to 11 per 100,000 in men and 16 to 7 per 100,000 in women, predating an increase in total CLI revascularization procedures that was seen starting in 2005 for both men and women. In-hospital mortality was higher in women regardless of disease severity or procedure performed even after adjusting for age and baseline comorbidities (.5% vs .2% after percutaneous transluminal angioplasty or stenting for intermittent claudication; 1.0% vs .7% after open surgery for intermittent claudication; 2.3% vs 1.6% after percutaneous transluminal angioplasty or stenting for CLI; 2.7% vs 2.2% after open surgery for CLI; P < .01 for all comparisons). There appears to be a preference to perform endovascular over surgical revascularization among women, who are older and have more advanced disease at presentation. Percutaneous transluminal angioplasty or stenting continues to be popular and is increasingly being performed in the outpatient setting. Amputation and in-hospital mortality rates have been declining, and women now have lower amputation but higher mortality rates than men. Recent improvements in outcomes are likely the result of a combination of improved medical management and risk factor reduction.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 09/2013; · 3.52 Impact Factor
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    ABSTRACT: End-stage renal disease is a significant negative predictor of limb salvage and patient survival in patients with limb ischemia, but little is known of the overall effects of renal transplantation. Endovascular management may be less morbid than open surgery, but technical success and durability in these patients is not well established. All patients with functioning renal transplants and critical limb ischemia (CLI) treated with endovascular techniques between 2003 and 2010 were retrospectively reviewed for limb salvage, reintervention, pre- and postprocedure creatinine, and estimated glomerular filtration rate (eGFR), and overall survival. Contralateral common femoral access, low-profile techniques, and isosmolar contrast were standard for all interventions. Endovascular interventions were performed on 57 limbs in 28 patients with renal transplants. Mean age was 54 years, 78% were male, 85% were diabetic, 100% were hypertensive, and 64% had a positive smoking history. All patients were treated for CLI. Treated regions included 16 iliac, 19 superficial femoral, 16 popliteal, and 12 tibial arteries, as well as 1 bypass graft with initial technical success of 100% and 0% 30-day mortality. Of all lesions, 43% required reintervention during the follow-up period, the majority in the first year. There was no significant change in eGFR or creatinine comparing pre- and post-angiogram value. Limb salvage and 1-year survival were 83% and 82%, respectively. Endovascular management of CLI in renal transplant patients results in good technical success and can be accomplished without a measurable change in transplant kidney function, although it requires repeat interventions. Endovascular therapy is a reasonable first-line treatment option for this high-risk group.
    Annals of Vascular Surgery 09/2013; · 0.99 Impact Factor
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    ABSTRACT: Administrative data are often hampered by coding errors, absent data, and the difficulty of distinguishing pre-existing conditions from perioperative complications. We evaluated whether the introduction of the present on admission (POA) indicator improved outcome analysis of carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS) using administrative data. State inpatient databases from California (2005-2008), New York (2008), and New Jersey (2008) were used to identify patients undergoing CAS and CEA. We first analyzed morbidity data without the POA indicator, using International Classification of Diseases, Ninth Revision complication codes (eg, 997.02, iatrogenic cerebrovascular infarction or hemorrhage, postoperative stroke) and diagnosis codes (eg, 433.11, occlusion and stenosis of the carotid artery with cerebral infarction). Then, we applied the POA indicator to both diagnosis and complication codes and calculated the proportion of events that were labeled POA. Symptom status and perioperative stroke rate were compared using these coding approaches. We identified 21,639 patients who underwent CEA and 3688 patients who underwent CAS. Without the POA indicator, the complication code for stroke indicated a postoperative stroke rate of 1.4% for CEA and 2.4% for CAS. After applying the POA indicator, 54% (CEA) and 62% (CAS) of these strokes were labeled POA. These POA strokes were either preoperative or intraoperative events. Proportion of symptomatic patients ranged from 7% to 16% for CEA and from 5% to 22% for CAS. Perioperative stroke rate was the lowest in the POA method (1.1% CEA, 1.8% CAS) compared with two other methods without POA information (1.4% and 9.5% CEA and 2.4% and 16.4% CAS). Kappa indicated a poor (0.2) to fair (0.7) agreement between these approaches. Administrative data has known limitations for assignment of symptom status and nonfatal perioperative outcomes. Given the uncertain timing of POA events as preoperative vs intraoperative and its apparent underestimation of the perioperative stroke rate, the use of administrative data even with the POA indicator for symptom status and non-fatal outcomes after CEA and CAS is hazardous.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 08/2013; · 3.52 Impact Factor
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    ABSTRACT: Lower extremity amputation is often performed in patients where both lower extremities are at risk due to peripheral arterial disease or diabetes, yet the proportion of patients who progress to amputation of their contralateral limb is not well defined. We sought to determine the rate of subsequent amputation on both the ipsilateral and contralateral lower extremities following initial amputation. We conducted a retrospective review of all patients undergoing lower extremity amputation (exclusive of trauma or tumor) at our institution from 1998 to 2010. We used International Classification of Diseases-Ninth Revision codes to identify patients and procedures as well as comorbidities. Outcomes included the proportion of patients at 1 and 5 years undergoing contralateral and ipsilateral major and minor amputation stratified by initial major vs minor amputation. Cox proportional hazards regression analysis was performed to determine predictors of major contralateral amputation. We identified 1715 patients. Mean age was 67.2 years, 63% were male, 77% were diabetic, and 34% underwent an initial major amputation. After major amputation, 5.7% and 11.5% have a contralateral major amputation at 1 and 5 years, respectively. After minor amputation, 3.2% and 8.4% have a contralateral major amputation at 1 and 5 years while 10.5% and 14.2% have an ipsilateral major amputation at 1 and 5 years, respectively. Cox proportional hazards regression analysis revealed end-stage renal disease (hazard ratio [HR], 3.9; 95% confidence interval [CI], 2.3-6.5), chronic renal insufficiency (HR, 2.2; 95% CI, 1.5-3.3), atherosclerosis without diabetic neuropathy (HR, 2.9; 95% CI, 1.5-5.7), atherosclerosis with diabetic neuropathy (HR, 9.1; 95% CI, 3.7-22.5), and initial major amputation (HR, 1.8; 95% CI, 1.3-2.6) were independently predictive of subsequent contralateral major amputation. Rates of contralateral limb amputation are high and predicted by renal disease, atherosclerosis, and atherosclerosis with diabetic neuropathy. Physicians and patients should be alert to the high risk of subsequent amputation in the contralateral leg. All patients, but particularly those at increased risk, should undergo close surveillance and counseling to help prevent subsequent amputations in their contralateral lower extremity.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 08/2013; · 3.52 Impact Factor
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    ABSTRACT: Optimal management of renal artery stenosis (RAS) remains unclear. Recent randomized controlled trials have shown no clear benefit with percutaneous transluminal angioplasty with or without stenting (PTRA/S) over medical management. We hypothesize that interventions for RAS are decreasing nationally. The Nationwide Inpatient Sample, 1988-2009, was used to identify patients with a diagnosis of renal artery atherosclerosis undergoing open surgical repair (bypass or endarterectomy) or PTRA/S. The rate of interventions, in-hospital death, and perioperative outcomes were analyzed over time. Additionally, we used individual state inpatient and ambulatory databases to better understand the influence of outpatient procedures on current volume and trends. We identified 308,549 PTRA/S and 33,147 open surgical repairs. PTRA/S increased from 1.9/100K adults in 1988 to 13.7 in 2006 followed by a decrease to 6.7 in 2009. Open surgical repair steadily decreased from 1.3/100K adults in 1988 to 0.3 in 2009. In 2009, PTRA/S procedures (6.4/100K adults) greatly outnumbered procedures done by open repair alone (0.1/100K), combined open renal and aortic repair (0.2/100K), and combined PTRA/S and endovascular aneurysm repair (0.3/100K). From 2005 to 2009 33,953 patients underwent PTRA/S in the states of New Jersey Maryland, Florida, and California combined. The total number of PTRA/S performed in the outpatient setting remained stable from 2005 (3.8/100K) to 2009 (3.7/100K), whereas the total number of inpatient procedures mirrored the national trend, declining from 2006 (7.9/100K) to 2009 (4.2/100K). PTRA/S had lower in-hospital mortality (0.9% vs 4.1%; P < .001) compared with open repair. PTRA/S patients were more likely to be discharged home (86.2% vs 76.3%; P < .001) and had a shorter length of stay (4.4 vs 12.3 days; P < .001). Mortality was higher after combined open renal and open aortic surgery compared to open repair alone (6.5% vs 4.1%; P < .001). Mortality was similar for combined PTRA/S and endovascular aneurysm repair compared with PTRA/S alone (1.2% vs 0.9%; P = .04). The performance of PTRA/S procedures for the management of RAS has decreased significantly after 2006. An increasing proportion of these procedures are performed in the outpatient setting. PTRA/S remains the dominant revascularization procedure for RAS with lower in-hospital mortality and morbidity than surgery.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 06/2013; · 3.52 Impact Factor
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    ABSTRACT: OBJECTIVE: Open surgical repair of thoracoabdominal aortic aneurysms (TAAAs) is uncommon. Mortality rates of 20% are reported in studies using national data and are 5% to 8% in single-institution studies. Clinical trials are currently evaluating branched and fenestrated endografts. The purpose of this study is to establish a benchmark for future comparisons with endovascular trials using open repair of TAAAs in the National Surgical Quality Improvement Program (NSQIP) database. METHODS: We identified all patients undergoing open elective and emergency surgical repair of intact TAAAs in NSQIP (2005 to 2010) using Current Procedural Terminology (American Medical Association, Chicago, Ill) and International Classification of Diseases, 9th Edition codes. We analyzed demographics, comorbidities, 30-day mortality, postoperative complications, and length of stay. Multivariable logistic regression was used to identify predictors of mortality. RESULTS: We identified 450 patients who underwent open surgical repair (418 elective, 32 emergent) of an intact TAAA. Mean age was 69.4 years, 60.7% were male, and 85.6% were white. Comorbidities included hypertension (87.1%), chronic obstructive pulmonary disease (27.3%), prior stroke or transient ischemic attack (16.7%), diabetes (11.6%), and peripheral vascular disease (9.6%). Thirty-day mortality was 10.0%. Pulmonary complications were the most common: failure to wean from ventilator (39.1%), pneumonia (23.1%), and reintubation (13.8%). Acute renal failure requiring dialysis occurred in 10.7% of patients. Multivariable analysis (odds ratio [95% confidence interval]) showed predictors of mortality were emergent repair (3.3 [1.03-10.83]; P = .04), age >70 years (3.5 [1.03-7.56], P = .001), preoperative dialysis (8.4 [1.90-37.29], P = .005), cardiac complication (2.9 [1.05-8.21], P = .04), and renal complications (8.4 [3.41-20.56], P < .001). CONCLUSIONS: In this study of NSQIP hospitals, the first to analyze open surgical repair of TAAAs, the 30-day mortality rate of 10.0% is similar to single-institution reports. However, morbidity and mortality after open TAAA repair remain high, confirming the need for less invasive procedures.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 05/2013; · 3.52 Impact Factor
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    ABSTRACT: BACKGROUND: Long-term adhesion-related complications and incisional hernias after abdominal surgery are common and costly. There are few data on the risk of these complications after different abdominal operations. STUDY DESIGN: We identified Medicare beneficiaries who underwent endovascular repair of an abdominal aortic aneurysm from 2001-2008 who presumably are not at risk for laparotomy-related complications. We identified all laparoscopic and open operations involving the abdomen, pelvis, or retroperitoneum and categorized them into 5 groups according to invasiveness. We then identified laparotomy-related complications for up to 5 years after the index operation and compared these with the baseline rate of complications in a control group of patients who did not undergo an abdominal operation. RESULTS: We studied 85,663 patients, 7,513 (8.8%) of which underwent a laparotomy, including 2,783 major abdominal operations, 709 minor abdominal operations, 963 ventral hernia repairs, 493 retroperitoneal/pelvic operations, and 2,565 laparoscopic operations. Mean age was 76.7 years and 82.0% were male. Major abdominal operations carried the highest risk for adhesion-related complications (14.3% and 25.0% at 2 and 5 years compared with 4.0% and 7.8% for the control group; p < 0.001) and incisional hernias (7.8% and 12.0% compared with 0.6% and 1.2% for the control group; p < 0.001). Laparoscopic operations (4.6% and 10.7% for adhesions, 1.9% and 3.2% for incisional hernias) carried the lowest risk. CONCLUSIONS: Late-onset laparotomy-related complications are frequent and their risk extends through 5 years beyond the perioperative period. With the advancement and expansion of laparoscopic techniques and its attendant lower risk for long-term complications, these results can alter the risk-to-benefit profile of various types of abdominal operations and can also strengthen the rationale for additional development of laparoscopic approaches to abdominal operations.
    Journal of the American College of Surgeons 04/2013; · 4.50 Impact Factor
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    ABSTRACT: BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) have established guidelines that outline patients who are considered "high risk" for complications after carotid endarterectomy (CEA) for which carotid artery stenting (CAS) may provide benefit. The validity of these high-risk criteria are yet unproven. In this study, we stratified patients who underwent CAS or CEA by CMS high-risk criteria and symptom status and examined their 30-day outcomes. METHODS: A nonrandomized, retrospective cohort study was performed by chart review of all patients undergoing CEA or CAS from January 1, 2005, to December 31, 2010, at our institution. Demographic data and data pertaining to the presence or absence of high-risk factors were collected. Patients were stratified using symptom status and high-risk status as variables, and 30-day adverse events (stroke, death, myocardial infarction [MI]) were compared. RESULTS: A total of 271 patients underwent CAS, with 30-day complication rates of stroke (3.0%), death (1.1%), MI (1.5%), stroke/death (3.7%), and stroke/death/MI (5.2%). A total of 830 patients underwent CEA with 30-day complication rates of stroke (2.0%), death (0.1%), MI (0.6%), stroke/death (1.9%), and stroke/death/MI (2.7%). Among symptomatic patients, physiologic high-risk status was associated with increased stroke/death (6 of 42 [14.3%] vs 2 of 74 [2.7%]; P < .01), and anatomic high-risk status was associated with a trend toward increased stroke/death (5 of 31 [16.1%] vs 0 of 20 [0.0%]; P = .14) in patients who underwent CAS vs CEA. Analysis of asymptomatic patients showed no differences between the two groups overall, except for a trend toward a higher rate of MI after CAS than after CEA (3 of 71 [4.2%] vs 0 of 108 [0.0%]; P = .06) in those who were physiologically at high risk. Among symptomatic patients who underwent CAS, patients with physiologic and anatomic high-risk factors had a higher rate of stroke/death than non-high-risk patients (6 of 42 [14.3%] vs 0 of 24 [0.0%] and 5 of 31 [16.1%] vs 0 of 24 [0.0%], respectively; both P ≤ .05). CONCLUSIONS: Physiologic high-risk status was associated with increased stroke/death, whereas anatomic high-risk status showed a trend toward increased stroke/death in symptomatic patients undergoing CAS compared with non-high-risk patients undergoing CAS or physiologically high-risk patients undergoing CEA. Our results suggest that the current national criteria for CAS overestimate its efficacy in patients who are symptomatic and at high risk.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 04/2013; · 3.52 Impact Factor
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    ABSTRACT: OBJECTIVE: Administrative data have been used to compare carotid endarterectomy (CEA) and carotid artery stenting (CAS). However, there are limitations in defining symptom status, Centers for Medicare and Medicaid Services high-risk status, as well as complications. Therefore, we did a direct comparison between administrative data and physician chart review as well as between data collected for the National Surgical Quality Improvement Program (NSQIP) and physician chart review for CEA and CAS. METHODS: We performed an outcomes analysis on all CEA and CAS procedures from 2005 to 2011. We obtained International Classification of Diseases, Ninth Revision diagnosis codes from hospital discharge records regarding symptom status, high-risk status, and perioperative stroke. We also obtained data on all CEA patients submitted to NSQIP over the same time period. One of the study authors (R.B.) then performed a chart review of the same patients to determine symptom status, high-risk status, and perioperative strokes and the results were compared. RESULTS: We identified 1342 patients who underwent CEA or CAS between 2005 and 2011 and 392 patients who underwent CEA that were submitted to NSQIP. Administrative data identified fewer symptomatic patients (17.0% vs 34.0%), physiologic high-risk patients (9.3% vs 23.0%), and anatomic high-risk patients (0% vs 15.2%). Although administrative data identified a similar proportion of perioperative strokes (1.9% vs 2.0%), this was due to the fact that these data identified eight false positive and nine false negative perioperative strokes. NSQIP data identified more symptomatic patients compared with chart review (44.1% vs 30.3%), fewer physiologic high-risk patients (13.0% vs 18.6%), fewer anatomic high-risk patients (0% vs 6.6%), and a similar proportion of perioperative strokes (1.5% vs 1.8%, only one false negative stroke and no false positives). CONCLUSIONS: Administrative data are unreliable for determining symptom status, high-risk status, and perioperative stroke and should not be used to analyze CEA and CAS. NSQIP data do not adequately identify high-risk patients, but do accurately identify perioperative strokes and to a lesser degree, symptom status.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 03/2013; · 3.52 Impact Factor
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    ABSTRACT: BACKGROUND: Selective endarterectomy of external carotid artery (ECA) stenosis has been considered a therapeutic option for patients presenting with symptomatic ipsilateral internal carotid artery (ICA) occlusion to correct cerebral hypoperfusion or eliminate a source of emboli. However, data are scarce, and the long-term benefit of ECA revascularization remains unclear. Our objective was to study the operative results and durability of selective ECA endarterectomy in patients presenting with cerebrovascular symptoms in association with nonacute ipsilateral ICA occlusion. METHODS: This was a retrospective analysis of 27 consecutive patients who underwent selective ECA endarterectomy in a single center between 2000 and 2010. All patients presented with neurologic symptoms (<6 months of surgery, 78% repeat events) referable to an ipsilateral occlusion of the ICA and concomitant stenosis of the ECA. We assessed the perioperative clinical outcome <30 days and at midterm follow-up (mean, 31.6 months). Patency was defined as freedom of duplex ultrasound detected ≥50% restenosis. RESULTS: Endarterectomy of the ECA was successful in 26 patients (96.3%) with one ECA found occluded at surgery. No perioperative deaths occurred. In the 30 days after surgery, one patient developed an ipsilateral disabling ischemic stroke (3.7%), and one patient (3.7%) had a myocardial infarction. At follow-up, nine patients had died: one of a fatal ischemic stroke, six of non-vascular-related causes, and two of unknown causes. At 3 years, 83% (standard error, 8%) of patients were free from stroke or death, and 80% (standard error, 8%) of the operated-on arteries were patent. Five patients developed restenosis ≥50% (n = 2, asymptomatic) or occlusion (n = 3, one symptomatic) ≤3 months, and two other patients developed late asymptomatic restenosis. CONCLUSIONS: Selective endarterectomy of the ECA in symptomatic patients with an ipsilateral occlusion of the ICA is a feasible procedure with an acceptable perioperative risk. Most patients remain stroke-free during follow-up and have a low rate of symptomatic restenosis.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 03/2013; · 3.52 Impact Factor
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    ABSTRACT: OBJECTIVE: The Centers for Medicaid and Medicare Services (CMS) require high-risk (HR) criteria for carotid artery stenting (CAS) reimbursement. The impact of these criteria on outcomes after carotid endarterectomy (CEA) and CAS remains uncertain. Additionally, if these HR criteria are associated with more adverse events after CAS, then existing comparative effectiveness analysis of CEA vs CAS may be biased. We sought to elucidate this using data from the SVS Vascular Registry. METHODS: We analyzed 10,107 patients undergoing CEA (6370) and CAS (3737), stratified by CMS HR criteria. The primary endpoint was composite death, stroke, and myocardial infarction (MI) (major adverse cardiovascular event [MACE]) at 30 days. We compared baseline characteristics and outcomes using univariate and multivariable analyses. RESULTS: CAS patients were more likely to have preoperative stroke (26% vs 21%) or transient ischemic attack (23% vs 19%) than CEA. Although age ≥80 years was similar, CAS patients were more likely to have all other HR criteria. For CEA, HR patients had higher MACEs than normal risk in both symptomatic (7.3% vs 4.6%; P < .01) and asymptomatic patients (5% vs 2.2%; P < .0001). For CAS, HR status was not associated with a significant increase in MACE for symptomatic (9.1% vs 6.2%; P = .24) or asymptomatic patients (5.4% vs 4.2%; P = .61). All CAS patients had MACE rates similar to HR CEA. After multivariable risk adjustment, CAS had higher rates than CEA for MACE (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.0-1.5), death (OR, 1.5; 95% CI, 1.0-2.2), and stroke (OR, 1.3; 95% CI,1.0-1.7), whereas there was no difference in MI (OR, 0.8; 95% CI, 0.6-1.3). Among CEA patients, age ≥80 (OR, 1.4; 95% CI, 1.02-1.8), congestive heart failure (OR, 1.7; 95% CI, 1.03-2.8), EF <30% (OR, 3.5; 95% CI, 1.6-7.7), angina (OR, 3.9; 95% CI, 1.6-9.9), contralateral occlusion (OR, 3.2; 95% CI, 2.1-4.7), and high anatomic lesion (OR, 2.7; 95% CI, 1.33-5.6) predicted MACE. Among CAS patients, recent MI (OR, 3.2; 95% CI, 1.5-7.0) was predictive, and radiation (OR, 0.6; 95% CI, 0.4-0.8) and restenosis (OR, 0.5; 95% CI, 0.3-0.96) were protective for MACE. CONCLUSIONS: Although CMS HR criteria can successfully discriminate a group of patients at HR for adverse events after CEA, certain CMS HR criteria are more important than others. However, CEA appears safer for the majority of patients with carotid disease. Among patients undergoing CAS, non-HR status may be limited to restenosis and radiation.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 02/2013; · 3.52 Impact Factor
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    ABSTRACT: OBJECTIVE: Most studies based on state and nationwide registries evaluating perioperative outcome after carotid endarterectomy (CEA) rely on hospital discharge data only. Therefore, the true 30-day complication risk after carotid revascularization may be underestimated. METHODS: We used the National Surgical Quality Improvement Program database 2005-2010 to assess the in-hospital and postdischarge rate of any stroke, death, cardiac event (new Q-wave myocardial infarction or cardiac arrest), and combined stroke/death and combined adverse outcome (S/D/CE) at 30 days following CEA. Multivariable analyses were used to identify predictors for in-hospital and postdischarge events separately, and in particular, those that predict postdischarge events distinctly. RESULTS: A total of 35,916 patients who underwent CEA during 2005-2010 were identified in the National Surgical Quality Improvement Program database; 59% were male, median age was 72 years, and 44% had a previous neurologic event. Thirty-day stroke rate was 1.6% (n = 591), death rate was 0.8% (n = 272), cardiac event rate was 1.0% (n = 350), stroke or death rate was 2.2% (n = 794), and combined S/D/CE rate was 2.9% (n = 1043); 33% of strokes, 53% of deaths, 32% of cardiac events, 40% of combined stroke/death, and 38% of combined S/D/CE took place after hospital discharge. Patients with a prior stroke or transient ischemic attack had similar proportions of postdischarge events compared with patients without prior symptoms. Independent predictors for postdischarge events, but not for in-hospital events were female sex (stroke [odds ratio (OR), 1.6; 95% confidence interval (CI), 1.2-2.1] and stroke/death [OR, 1.4; 95% CI, 1.1-1.7]), renal failure (stroke [OR, 3.0; 95% CI, 1.4-6.2]) and chronic obstructive pulmonary disease (death [OR, 2.5; 95% CI, 1.6-3.7], stroke/death [OR, 1.8; 95% CI, 1.4-2.4], and S/D/CE [OR 1.8, 95% CI 1.4-2.3]). CONCLUSIONS: With 38% of perioperative adverse events after CEA happening posthospitalization, regardless of symptoms status, we need to be alert to the ongoing risks after discharge particularly in women, patients with renal failure, or chronic obstructive pulmonary disease. This emphasizes the need for reporting and comparing 30-day adverse event rates when evaluating outcomes for CEA, or comparing carotid stenting to CEA.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 02/2013; · 3.52 Impact Factor
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    ABSTRACT: OBJECTIVE: Prior studies of gender differences in abdominal aortic aneurysm (AAA) repair suggest there may be differences in presentation, suitability for endovascular aneurysm repair (EVAR), and outcomes between men and women. METHODS: We used the Vascular Study Group of New England database to identify all patients undergoing EVAR or open AAA repair. We analyzed demographics, comorbidities, and procedural, and perioperative data. Results were compared using the Fisher exact test and the Student t-test. Multivariable logistic regression and Cox proportional hazards modeling were performed to identify predictors of mortality. RESULTS: We identified 4026 patients (78% men) who underwent AAA repair (54% EVAR). Women were less likely than men to undergo EVAR for intact aneurysms (50% vs 60% of intact AAA repair; P < .001) but not for ruptured aneurysms (26% vs 20%; P = .23). Women were older (median age, 75 vs 72 years for intact; P < .001; 78 vs 73 years for rupture; P < .001) with smaller aortic diameters (57 vs 59 mm for elective; P < .001; 71 vs 79 mm for rupture; P < .001). Arterial injury was more common in women (5.4% vs 2.7%; P = .013) among patients undergoing EVAR for intact aneurysms. Women stayed in the hospital longer (4.3 vs 2.7 days; P = .018) and had lower odds of being discharged home, even after adjusting for age. Among patients undergoing open repair for intact aneurysms, women more frequently experienced leg ischemia/emboli (4% vs 1%; P = .001) and bowel ischemia (5% vs 3%; P = .044). Women had higher 30-day mortality after OAR for intact (4% vs 2%; P = .03) and rupture (48% vs 34%; P = .03) repairs. However, 30-day mortality after EVAR was similar for intact (1% in men vs 1% in women; P = .57) and rupture (29% in men vs 27% in women; P > .99) repairs. Late survival was worse in women than men only for patients undergoing open repair of ruptured aneurysms (hazard ratio, 1.8; 95% confidence interval, 1.0-3.1; P = .04). After controlling for age, type of repair, urgency at presentation (ie, elective/intact vs ruptured), comorbidities, and other relevant risk factors, gender was not predictive of 30-day or 1-year mortality. CONCLUSIONS: Women with AAAs are being treated at older ages and smaller AAA diameters and are undergoing rupture repair at smaller diameters than men. Women are more likely to experience perioperative complications as a result of less favorable vascular anatomy. Age >80 years, comorbidity, presentation, and type of repair are more important predictors of mortality than gender.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 02/2013; · 3.52 Impact Factor
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    ABSTRACT: OBJECTIVE: Infrapopliteal angioplasty (percutaneous transluminal angioplasty [PTA]) is routinely used to treat critical limb ischemia (CLI) despite limited data on long-term outcomes. METHODS: We reviewed all patients undergoing infrapopliteal PTA for CLI from 2004 to 2012 stratified by TransAtlantic Inter-Society Consensus (TASC) class. Outcomes included restenosis, primary patency, reintervention (w/PTA or bypass), amputation, procedural complications, wound healing, and survival. RESULTS: Infrapopliteal PTA (stenting 14%, multilevel intervention 50%) was performed in 459 limbs of 413 patients (59% male) with a technical success of 93% and perioperative complications in 11%. TASC class was 16% A, 22% B, 27% C, and 34% D. Multilevel interventions were performed in 50% of limbs and were evenly distributed among all TASC classes. All technical failures were TASC D lesions. Mean follow-up was 15 months; 5-year survival was 49%. One- and 5-year primary patency was 57% and 38% and limb salvage was 84% and 81%, respectively. Restenosis was associated with TASC C (hazard ratio [HR], 2.2; 95% CI, 1.2-3.9; P = .010) and TASC D (HR, 2.4; 95% CI, 1.3-4.4; P = .004) lesions. Amputation rates were higher in patients who were not candidates for bypass (HR, 4.4; 95% CI, 2.6-7.5; P < .001) and with TASC D lesions (HR, 3.8; 95% CI, 1.1-12.5; P = .03). Unsuitability for bypass was also predictive of repeat PTA (HR, 1.8; 95% CI, 1.0-3.4; P = .047). Postoperative clopidogrel use was associated with lower rates of any revascularization (HR, 0.46; 95% CI, 0.25-0.83; P = .011). CONCLUSIONS: Infrapopliteal PTA is effective primary therapy for TASC A, B, and C lesions. Surgical bypass should be offered to patients with TASC D disease who are suitable candidates. Multilevel intervention does not adversely affect outcome.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 01/2013; · 3.52 Impact Factor
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    ABSTRACT: BACKGROUND: Prosthetic graft infection is a major complication of peripheral vascular surgery. We investigated the experience of a single institution over 10 years with bypass grafts involving the femoral artery to determine the incidence and risk factors for prosthetic graft infection. METHODS: A retrospective cohort single-institution review of prosthetic bypass grafts involving the femoral artery from 2001 to 2010 evaluated patient demographics, body mass index, comorbidities, indications, location of bypass, type of prosthetic material, case urgency, and previous ipsilateral bypass or percutaneous interventions and evaluated the incidence of graft infections, amputations, and mortality. RESULTS: There were 496 prosthetic grafts identified with a graft infection rate of 3.8% (n = 19) at a mean follow-up of 27 months. Multivariable analysis showed that redo bypass (hazard ratio [HR], 5.8; 95% confidence interval [CI], 2.2-15.0), active infection at the time of bypass (HR, 5.2; 95% CI, 1.9-14.2), female gender (HR, 4.5; 95% CI, 1.6-12.7), and diabetes mellitus (HR, 4.6; 95% CI, 1.5-14.3) were significant predictors of graft infection. Graft infection was predictive of major lower extremity amputation (HR, 9.8; 95% CI, 3.5-27.1), as was preoperative tissue loss (HR, 4.7; 95% CI, 1.8-11.9). Graft infection did not predict long-term mortality; however, chronic renal insufficiency (HR, 2.3; 95% CI, 1.6-3.4), tissue loss (HR, 1.4; 95% CI, 1.0-1.9), and active infection (HR, 2.3; 95% CI, 1.6-3.4) did. Infected grafts were removed 79% of the time. Staphylococcus epidermidis (37%) and methicillin-sensitive Staphylococcus aureus (26%) were the most common pathogens isolated. CONCLUSIONS: Redo bypass, female gender, diabetes, and active infection at the time of bypass are associated with a higher risk for prosthetic graft infection and major extremity amputation but do not confer an increased risk of mortality. Autologous vein for lower extremity bypass and endovascular interventions should be considered when feasible in high-risk patients.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 01/2013; · 3.52 Impact Factor

Publication Stats

1k Citations
355.95 Total Impact Points

Institutions

  • 2005–2014
    • Beth Israel Deaconess Medical Center
      • • Division of Vascular and Endovascular Surgery
      • • Department of Surgery
      Boston, Massachusetts, United States
  • 2005–2011
    • Harvard Medical School
      • • Department of Health Care Policy
      • • Department of Surgery
      Boston, MA, United States
  • 2000–2008
    • Dartmouth–Hitchcock Medical Center
      • Department of Surgery
      Lebanon, New Hampshire, United States
  • 2004
    • New York Presbyterian Hospital
      • Department of Vascular Surgery
      New York City, New York, United States
  • 2003
    • Dartmouth Medical School
      Hanover, New Hampshire, United States