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Presence Of Atherosclerosis In Multiple Arterial Beds Is Associated With Increased Mortality In Patients Undergoing Open Abdominal Aortic Aneurysm Repair
Molly Ratner, MD1, Heepeel Chang, MD
1, Neal Cayne, MD
1, Virendra Patel, MD
2, Jeffrey J. Siracuse, MD MBA
3, Jae S. Cho, MD
4, Glenn Jacobowitz, MD
1, Frank Veith, MD
1, Thomas Maldonado, MD
1, Caron Rockman, MD
1, Karan Garg, MD
1.
1New York University Langone Hospital, New York, NY, USA,
2Columbia University Medical Center, New York, NY, USA,
3Boston Medical Center, Boston, MA, USA,
4Case Western Reserve University, Cleveland, OH, USA.
OBJECTIVES: Peripheral artery disease (PAD), coronary artery disease (CAD) and carotid artery stenosis (CAS) are independently associated with increased mortality after abdominal aortic aneurysm (AAA) repair. However, the effect of concomitant atherosclerotic disease across multiple arterial beds is not well defined. This project aims to quantify the effect of systemic atherosclerosis on outcomes after open AAA repair (OAR).
METHODS: The Vascular Quality Initiative was queried from to 2012-2022 for elective OAR. Patients were identified as having PAD, CAD or CAS and stratified on the number of arterial beds involved (1 through 3). Primary outcomes included post-operative morbidity/ mortality. Multivariate analysis was performed to find associations with the primary outcomes.
RESULTS: Of the 4013 patients included, 3353 had atherosclerosis in one arterial bed, 600 in two beds and 60 in three beds. Across the cohort, 76.8% were men and mean age was 69.9. +/- 8.2 years. Patients with concomitant atherosclerotic disease in 3 arterial beds, versus 2 or 1 beds, were more likely to have hypertension (96.6% vs 94.8% vs 91.8%) and COPD (53.3% vs 41.0% vs 37.5%, p = .014). However, the frequency of other comorbidities such as smoking, diabetes and hemodialysis were comparable. Patients with disease in 3 arterial beds were more likely to be prescribed a P2Y inhibitor (40% vs 25.6% 17.2%, p <.001), however aspirin and statin utilization was similar preoperatively. Perioperative mortality and myocardial infarction rates were increaed in patients with atherosclerotic disease in 3 beds (18.3% vs 8.7% vs 5.3% p <.01; 11.7% vs 5.2% vs 3.7% p <.01 respectively). There was no difference in the 30-day reintervention rates. At follow-up (mean: 13 +/- 7.5 months), the mortality rate was also higher in patients with involvement of 3 arterial beds (21.1% vs 13.9% vs 10.4% p <.01). On multivariate analysis, co-concomitant atherosclerotic disease in two or more arterial beds was independently associated with higher perioperative mortality (HR 2.3, 95% 95% CI 1.1-4.7, p <.03) and MI (HR 2.24, 95% CI 1.2-4.9, p = .01).
CONCLUSIONS: In this review of patients with systemic manifestations of atherosclerosis undergoing OAR, coexisting disease in multiple arterial territories was associated with worse perioperative morbidity and mortality. Given the 18% mortality rate in patients with coronary, peripheral, and carotid artery disease, appropriate patient selection is critical.
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