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Southern Association For Vascular Surgery

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Current Transthoracic Supra-Aortic Trunk Surgical Reconstruction has Similar 30-Day Cardiovascular Outcomes to Extra-Anatomic Revascularization but with Higher Morbidity Burden
Anthony V Norman, Mark E Smolkin, Behzad S Farivar, Margaret C Tracci, John A Kern, Sarah J Ratcliffe, W Darrin Clouse
University of Virginia Health System, Charlottesville, VA

Background: Operative risk for supra-aortic trunk (SAT) surgical revascularization for occlusive disease, particularly transthoracic reconstruction (TR), remains ill-defined. This study sought to describe and compare 30-day outcomes of TR and extra-anatomic (ER) SAT surgical reconstruction for an occlusive indication across the United States over a contemporary 15-year period.
Methods: Using the National Surgical Quality Improvement Program (NSQIP), TR and ER performed during 2005-2019 were identified. Procedures performed for non-occlusive indications and those concomitant with coronary or valve operations were excluded. Rates of stroke, death, myocardial infarction (MI) and these as composite outcome (S/D/M) were compared. Logistic regression with stabilized inverse probability weighting (IPW) was used to compare groups via average treatment effect (ATE) while adjusting for covariate imbalances.
Results: Over the 15-year period, 166 TR and 1900 ER patients were identified. TR consisted of aorto-SAT bypass (n=116; 69.9%) and endarterectomy or repair (n=50; 30.1%).The majority of ER were carotid-subclavian bypass (n=1344; 70.7%) followed by carotid-carotid bypass (n=261; 13.7%) and subclavian/carotid transpositions (n=123; 6.5%). Median age was 64 years for TR and 65 years in ER (p=0.039). Those undergoing TR were more often women (69.0% vs. 56.9%; p=0.001) and less likely to have undergone previous cardiac surgery (9.2% vs. 20.8%; p=0.006). TR were also less frequently hypertensive (68.1% vs. 75.4%; p=0.038), and had statistically lower preoperative creatinine levels (0.86 vs 0.91; p=0.002). Unadjusted rates of MI (0.6% vs. 1.3%; p=0.72) and stroke (3.6% vs. 1.9%; p=0.15) were similar between groups with mortality (3.6% vs. 1.5%; p=0.05) and S/D/M (6.6% vs. 3.9%; p= 0.10) trending higher with TR. IPWs could be calculated for 1,754 patients (148 TR; 1606 ER - Table 1). The estimated probability of S/D/M was 6.2% in TR and 3.8% in the ER group; no difference was seen in ATE (2.4%; 95%CI: -1.5-6.2; p=0.23). No differences were seen in individual component ATEs (stroke: 3.0% vs. 1.7%; ATE=1.3%; 95%CI: -1.3-3.9; p=0.32; mortality: 3.8% vs 1.4%; ATE=2.4%; 95%CI: -0.7-5.6; p=0.13). Secondary outcomes showed TR patients were less likely to be discharged home (81.3% vs. 93.4%; ATE=-12.1%; 95%CI: -19.2- -5.0; p<0.001) and had longer lengths of stay (6.1 vs. 4.0; ATE=2.2 days; 95%CI: 0.9-3.4; p<0.001). Moreover, TR patients were more likely to require transfusion (22.7% vs. 5.0%; ATE=17.7%; 95%CI: 10.2-25.2; p<0.001) and develop sepsis (2.7% vs. 0.2%; ATE=2.5%; 95%CI: 0.1-5.0; p=0.04).
Conclusions: Transthoracic and extra-anatomic surgical reconstruction of the supra-aortic trunks have similar operative cardiovascular risk. However, morbidity tends to be higher with TR due to higher transfusion requirements, sepsis risk, and need for facility stay. These results suggest ER as first line approach in those with proper disease anatomy is reasonable with lower morbidity, while TR remains justified in appropriate patients.

Table 1: Adjusted Primary Outcomes for Anatomic and Extra-Anatomic Reconstructions
Adjusted OutcomesTRERATE95% CIP-value

Table 2: Adjusted Secondary Outcomes for Anatomic and Extra-Anatomic Reconstructions
Adjusted OutcomesTRERATE95% CIP-value
Discharge Home81.3%93.4%-12.1%-19.2-5.0<.001
Total length of stay (days)6.1+0.64.0+<.001
Return to OR4.7%6.6%-1.9%-
Ventilator >48 Hours3.9%1.7%2.2%-
Unplanned Intubation4.0%2.2%1.7%-
Acute renal failure1.4%0.6%0.8%-

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