Publications

OBJECTIVE: Several studies comparing the transperitoneal (TP) and retroperitoneal (RP) approach for abdominal aortic aneurysm (AAA) repair suggest that the RP approach may result in lower rates of perioperative mortality and morbidity. However, data comparing these approaches for open conversion are lacking. This study aims to evaluate the association between the type of approach and outcomes following open conversion after endovascular aneurysm repair (EVAR).

METHODS: We included all patients who underwent open conversion after EVAR between 2010 and 2022 in the Vascular Quality Initiative. Patients presenting with rupture were excluded. The primary outcome was perioperative mortality. The secondary outcomes included perioperative complications and 5-year mortality. Inverse probability weighting was used to adjust for factors with statistical or clinical significance. Logistic regression was used to assess perioperative mortality and complications in the weighted cohort. The 5-year mortality was evaluated using Kaplan-Meier and Cox regression.

RESULTS: We identified 660 patients (39% RP) who underwent open conversion after EVAR. Compared with TP, RP patients were older (75 years [interquartile range, 70-79 years] vs 73.5 years [interquartile range, 68-79 years]; P < .001), and more frequently had prior myocardial infarction (33% vs 22%; P = .002). Compared with the TP approach, the RP approach was used less frequently in cases of associated iliac aneurysm (19% vs 27%; P = .026), but more frequently with associated renal bypass (7.8% vs 1.7%; P < .001) and by high-volume physicians (highest quintile, >7 AAA annually: 41% vs 17%; P < .001) and in high-volume centers (highest quintile, >35 AAA annually: 36% vs 20%; P < .001). RP patients, compared with TP patients, were less likely to have external iliac or femoral distal anastomosis (8.2% vs 21%; P < .001), and an infrarenal clamp (25% vs 36%; P < .001). Unadjusted perioperative mortality was not significantly different between approaches (RP vs TP: 3.8% vs 7.5%; P = .077). After risk adjustment, RP patients had similar odds of perioperative mortality (adjusted odds ratio [aOR], 0.49; 95% confidence interval [CI], 0.22-1.10; P = .082), and lower odds of intestinal ischemia (aOR, 0.26; 95% CI, 0.08-0.86; P = .028) and in-hospital reintervention (aOR, 0.43; 95% CI, 0.22-0.85; P = .015). No significant differences were found in the other perioperative complications or 5-year mortality (aHR, 0.79; 95% CI, 0.47-1.32; P = .37).

CONCLUSIONS: Our findings suggest that the RP approach may be associated with a lower adjusted odds of perioperative complications compared with the TP approach. The RP approach should be considered for open conversion after EVAR when feasible.

OBJECTIVES: Endovascular aneurysm repair (EVAR) for large infrarenal abdominal aortic aneurysms (AAAs) has been associated with worse outcomes compared with EVAR for smaller AAAs. Whether these findings apply to complex AAAs (cAAA) remains uncertain.

METHODS: We identified all intact complex EVAR (cEVAR) from 2012 to 2024 in the Vascular Quality Initiative. cEVAR was defined as having a proximal extent between zones 6 and 9 and at least one side branch/fenestration/chimney/parallel grafting. Aneurysm size was defined as follows: large: >65 mm (males), >60 mm (females); medium: 55 to 65 mm (males), 50 to 60 mm (females); and small: <55 mm (males), <50 mm (females). We assessed perioperative death, any complication, and in-hospital reintervention using logistic regression and midterm mortality using adjusted Kaplan-Meier methods and Cox regression analyses. Medium-sized aneurysms were compared with large and small aneurysms.

RESULTS: Of the 3426 patients, 22.6% had large, 60.4% medium, and 17.0% had small aneurysms. As compared with medium and small aneurysms, large aneurysms demonstrated higher rates of perioperative death (4.8% vs 2.6% vs 0.5%), any complication (33.3% vs 23.6% vs 19.4%), and in-hospital reintervention (6.2% vs 4.0% vs 2.6%) (all P < .05). The median follow-up was 445 days. One-year mortality rates were higher in large aneurysms (12.3% vs 7.8% vs 3.8%; P < .001). After adjustment, when compared with medium-sized aneurysms, large aneurysms were associated with a significantly higher risk of perioperative death (adjusted odds ratio [aOR], 1.73; 95% confidence interval [CI], 1.09-2.72), any complication (aOR, 1.44; 95% CI, 1.18-1.76), and midterm mortality (adjusted hazard ratio, 1.50; 95% CI, 1.19-1.88), but not in-hospital reintervention (aOR, 1.46; 95% CI, 0.99-2.13). Although small aneurysms, as compared with medium-sized aneurysms, did not demonstrate a difference in any complication (aOR, 0.87; 95% CI, 0.68-1.10), in-hospital reintervention (aOR, 0.77; 95% CI, 0.42-1.33), and midterm mortality (adjusted hazard ratio, 0.78; 95% CI, 0.57-1.08], they did demonstrate a lower risk of perioperative death (aOR, 0.26; 95% CI, 0.06-0.71).

CONCLUSIONS: In cEVAR for cAAA, large aneurysms, compared with medium-sized aneurysms, were associated with higher rates of perioperative death, any complication, and midterm mortality, with in-hospital reinterventions trending toward a statistically significant higher risk. Although these results align with expectations, they emphasize the importance of effectively managing patients with large cAAAs and highlight the need for future research to determine whether patients might benefit more from medical therapy or open repair.

OBJECTIVE: BEST-CLI established the superiority of single-segment great saphenous vein (ssGSV) conduits for revascularization in patients with chronic limb-threatening ischemia (CLTI); however, the generalizability of these data is unknown. Thus, we aimed to validate the long-term results of open surgical bypass (BPG) vs percutaneous transluminal angioplasty with or without stenting (PTA/S) using the BEST-CLI inclusion and randomization criteria.

METHODS: All patients undergoing a first-time lower extremity revascularization for CLTI at our institution from 2005 to 2022 were retrospectively reviewed. To approximate BEST-CLI, one-to-one propensity score matching was used. Cohort 1 included BPG with ssGSV vs PTA/S; Cohort 2 included BPG without ssGSV vs PTA/S. Primary outcomes included wound healing, major amputation, major reintervention, major amputation/death (amputation/death), and major adverse limb events (MALE) or death (MALE/death) and were evaluated using Kaplan-Meier estimates and log-rank tests.

RESULTS: Of 1946 limbs undergoing a first-time intervention for CLTI between 2005 and 2022, 765 underwent BPG and 1181 underwent PTA/S. After matching, 862 fit Cohort 1 (431 BPG and 431 PTA/S), and 274 fit Cohort 2 (137 BPG and 137 PTA/S). Both cohorts exhibited a median follow-up of 2.7 years. In Cohort 1, major reintervention and MALE/death were both noted to be significantly lower following ssGSV BPG, as compared with PTA/S (at 7 years: 11% vs 24%; P = .001 and 72% vs 78%; P = .03, respectively). These findings correlated with a 53% and 28% reduction in the aforementioned adjusted events (hazard ratio, 0.47; 95% confidence interval, 0.30-0.74 and hazard ratio, 0.82; 95% confidence interval, 0.69-0.98, respectively). These significant differences in major reintervention and MALE/death were not noted in Cohort 2 (at 7 years: 25% vs 24%; P = .92 and 82% vs 80%; P = .31, respectively). Further, neither cohort demonstrated significant differences in complete wound healing (at 6 months, Cohort 1: 47% vs 40%; P = .32; Cohort 2: 40% vs 38%; P = .12), major amputation (at 7 years: Cohort 1: 15% vs 15%; P = .89; Cohort 2: 35% vs 25%; P = .86), or amputation/death (at 7 years, Cohort 1: 70% vs 66%; P = .99; Cohort 2: 78% vs 76%; P = .45).

CONCLUSIONS: Patients undergoing revascularization using ssGSV demonstrate significantly lower rates of major reintervention and MALE/death compared with those undergoing endovascular interventions for CLTI. However, similar outcomes are not seen among patients undergoing revascularization without a suitable ssGSV. These findings correlate with those demonstrated in BEST-CLI, suggesting generalizability.

OBJECTIVE: Because aneurysmal disease is progressive, proximal disease progression and para-anastomotic aneurysms are complications experienced after open infrarenal abdominal aortic aneurysm (AAA) repair. As such, fenestrated or branched endovascular repair (F/BEVAR) may be indicated in these patients. Data describing fenestrated endovascular aneurysm repair after prior open surgical repair (OSR) are limited to institutional databases. The aim of our study is to describe the safety and efficacy of fenestrated/branched endovascular aneurysm repair (F/BEVAR) in patients with prior OSR compared with primary F/BEVAR using the Vascular Quality Initiative.

METHODS: Using the VQI complex endovascular AAA module from 2014 to 2022, we identified all single-staged F/BEVAR repair in patients having prior OSR or no prior aortic surgery (primary F/BEVAR). The primary outcomes were perioperative mortality and completion endoleaks. Secondary outcomes were 5-year survival and 1-year sac dynamics. Between the two cohorts, differences in the primary and secondary outcomes were evaluated using Wilcoxon rank-sum tests for continuous variables and χ2 analysis for categorical variables. Kaplan-Meier methods and Cox regression were used to examine 5-year mortality.

RESULTS: We identified 3331 primary F/BEVAR patients and 102 prior OSR patients. Patients with prior OSR were more likely to have peripheral arterial disease (22.0% vs 7.4%), prior smoking (67% vs 56%), and undergo F/BEVAR with medium-/high-volume physicians (74% vs 62%), but less likely to be female (8.8% vs 23.0%) (all P < .05). Patients with prior OSR were also more likely to have a more proximal aneurysm extent (median zone 7 [interquartile range (IQR), zones 6-8] vs zone 8 [IQR, zones 7-8]), larger AAA diameters (62 mm [IQR, 56-66 mm] vs 58 mm [IQR, 55-63 mm]), receive a physician-modified endograft (PMEG) vs commercial custom-made device (36% vs 20% physician-modified endograft), have longer surgery times (240 minutes [IQR, 186-308 minutes] vs 206 minutes [IQR, 155-272 minutes]), and have a higher rate of celiac artery (51% vs 26%) and superior mesenteric artery (86% v 73%) artery involvement (all P < .05). Patients with prior OSR had lower rates of completion endoleaks (25% vs 36%), driven by lower rates of type II leaks (11% vs 20%) despite higher rates of indeterminate leaks (11% vs 5.1%) (all P < .01). There was, however, no difference in perioperative mortality (2% vs 2.9%; P = .78). They had similar 1-year sac dynamics (48% vs 50% regression; 12% vs 8% expansion; P > .5) and 5-year mortality (23% vs 18%; hazard ratio [HR], 1.44 [IQR, 0.89-2.31]; P = .13).

CONCLUSIONS: Based on VQI data, F/BEVAR after prior OSR seems to be well-tolerated and safe. Prior OSR patients also had lower rates of completion type II endoleaks and similar sac dynamics and 5-year mortality compared with primary F/BEVAR patients.

OBJECTIVE: Outcomes following redo carotid endarterectomy (rCEA) have been shown to be worse than those after primary CEA (pCEA). Additional research has shown that outcomes are better with transcarotid artery revascularization (TCAR) for restenosis after CEA compared with rCEA and transfemoral carotid artery stenting; however, not all patients are eligible for TCAR or transfemoral carotid artery stenting. Given the increasing utilization of endovascular techniques, this study aims to evaluate changes in outcomes of rCEA vs pCEA before and after the approval of TCAR by the United States Food and Drug Administration in 2015.

METHODS: All patients between 2003 and 2023 who underwent CEA in the Vascular Quality Initiative were included and categorized as pCEA or rCEA. Cochrane-Armitage trend testing was used to examine trends in proportion of rCEA compared with pCEA, and the Mann-Kendall trend test was used for perioperative outcomes following rCEA overtime. Multivariable logistic regression was used to compare in-hospital stroke/death, stroke, death, and stroke/death/myocardial infarction following rCEA vs pCEA after stratifying patients into two cohorts: 2003 to 2015 and 2016 to 2023 (before and after introduction of TCAR). Analysis was also performed based on preoperative symptoms.

RESULTS: Of 198,150 patients undergoing CEA, 98.4% were pCEA and 1.6% were rCEA. During the study period, the proportion of rCEA in the Vascular Quality Initiative decreased from 2.3% to 1.0% as endovascular methods became more available (P < .001). Trend testing of individual outcomes showed an increase in the stroke/death rate following rCEA over time (P = .019) despite an improvement in the death rate (P = .009). From 2003 to 2015, patients undergoing rCEA had higher odds of stroke/death compared with pCEA (2.4% vs 1.2%; adjusted odds ratio [aOR], 1.81; 95% confidence interval [CI], 1.14-2.73; P = .007). Higher stroke/death rates after rCEA persisted only in asymptomatic patients (2.3% vs 1.1%; aOR, 2.03; 95% CI, 1.19-3.25; P = .006); however, there was no difference in symptomatic patients (3.0% vs 2.0%; aOR, 1.37; 95% CI, 0.51;3.01; P = .50). In the late period, rCEA had higher odds of stroke/death compared with pCEA (3.1% vs 1.3%; aOR, 2.45; 95% CI, 1.85-3.18; P < .001), and the association was seen in asymptomatic patients (1.9% vs 1.0%; aOR, 1.95; 95% CI, 1.29-2.82; P < .001) and symptomatic patients (6.3% vs 2.0%; aOR, 3.23; 95% CI, 2.17-4.64; P < .001).

CONCLUSIONS: The proportion of rCEAs done yearly in the United States has been decreasing as endovascular options became available. As the rate of rCEA has decreased, outcomes have been worsening, with an increasing stroke/death rate seen over time, driven primarily by worse outcomes in symptomatic patients. Stroke/death rates for asymptomatic patients fall within Society for Vascular Surgery guidelines, and so the choice between rCEA, CAS, or medical management should be made after shared decision-making between a patient and their surgeon. However, with an in-hospital stroke death rate of over 6% symptomatic patients should be selected very carefully, as some are less likely to benefit from rCEA.

BACKGROUND: Drug-coated balloons and drug-eluting stents (DCB/DES) have shown promise in improving outcomes for patients with peripheral artery disease (PAD); however, more real-world analyses are needed to better understand the role of this technology within current practice. As such, we compared our institution's experience with DCB/DES vs percutaneous transluminal angioplasty with or without stenting (PTA/S) for the treatment of PAD.

METHODS: All patients undergoing an infrainguinal endovascular intervention for PAD at our institution between 2016 and 2022 were reviewed retrospectively. Patients undergoing isolated supra-inguinal or tibial interventions were excluded. Outcomes included primary patency, freedom from major adverse limb events (MALE), limb salvage, and amputation-free survival. To account for baseline differences, one-to-one propensity score matching was performed between DCB/DES and PTA/S groups. Outcomes were further evaluated using χ2, Kaplan-Meier analyses, and Cox regression analyses.

RESULTS: Between 2016 and 2022, 800 patients underwent an endovascular infrainguinal intervention for PAD: 224 DCB/DES and 576 PTA/S. Before matching, DCB/DES patients were younger (69 vs 72 years), more often male (72% vs 65%), non-White (58%, vs 34%), had a history of smoking (77% vs 64%), were more likely to have had a prior ipsilateral intervention (45% vs 10%), and more often presented with claudication (44% vs 18%) (all P < .05). After matching, 211 patients were included in each group, where the only remaining difference between DCB/DES and PTA/S was prior ipsilateral intervention (40% vs 15%; P < .001). After DCB/DES, Kaplan-Meier analyses demonstrated higher rates of primary patency (65% vs 54%; P < .01) and higher freedom from MALE (3-year rates: 84% vs 75%; P = .04), correlating with a 38% lower event risk in both outcomes (hazard ratio [HR], 0.62 [95% confidence interval, 0.44-0.89] and hazard ratio, 0.62 [0.39-0.99], respectively). No differences were noted in rates of limb salvage (3-year rates: 94% vs 90%; P = .63) or amputation-free survival (3-year rates: 78% vs 71%; P = .13). When stratifying by indication, DCB/DES demonstrated higher rates of freedom from MALE among patients with chronic limb-threatening ischemia (3-year rates: 85% vs 66%; P = .02).

CONCLUSIONS: Among a matched cohort of patients with PAD undergoing endovascular intervention, DCB/DES, as compared with PTA/S, demonstrated higher rates of primary patency and freedom from MALE, the former treatment effect remaining notable among patients with claudication and the latter among patients with chronic limb-threatening ischemia. These data demonstrate the importance of further analyses on this evolving technology.

OBJECTIVE: Despite few clinical indications, numerous urgent or emergent carotid procedures have been recorded in the Vascular Quality Initiative (VQI) database. As such, we sought to assess outcomes of urgent and emergent carotid revascularization in the VQI.

METHODS: We identified all patients who underwent carotid revascularization in the VQI from 2011 to 2024. Patients were stratified by urgency status, preoperative symptom status, and procedure type. Elective revascularization was defined by the VQI as a planned or scheduled procedure, urgent as surgery within 24 hours, and emergent as surgery within 6 hours. We excluded patients whose primary procedure was a planned intracranial treatment, as well as patients presenting with trauma, dissection, or other nonatherosclerotic indications. The primary outcome was perioperative stroke or death. Secondary outcomes included perioperative death and stroke. We used χ2 and logistic regression to evaluate perioperative outcomes.

RESULTS: Of the 317,163 carotid revascularizations performed, 268,091 (84%) were elective, 45,021 (14%) were urgent, and 4051 (1%) were emergent. Most urgent (29,958, 67%) or emergent (2,956, 73%) cases were symptomatic, although there were 15,063 urgent (34%) and 1095 emergent (27%) among asymptomatic patients. Stroke was the indication for 44% of urgent procedures and 62% of emergent procedures. There 45,021 cases classified as urgent, of which 28,063 (62%) were carotid endarterectomy, 8172 (18%) transcarotid artery revascularization, and 8786 (19.5%) transfemoral carotid artery stenting. Of the 4051 emergent procedures, 1235 (31%) were carotid endarterectomy, 182 (4.5%) transcarotid artery revascularization, and 2634 (65%) transfemoral carotid artery stenting. Compared with elective procedures, among all patients, urgent procedures were associated with increased odds of stroke/death (3.2% vs 1.2%; adjusted odds ratio [aOR], 1.99; 95% confidence interval [CI], 1.80-2.18; P < .01), as were emergent procedures (10.4% vs 1.2%; aOR, 3.67; 95% CI, 3.03-4.44; P < .01). These differences were also noted following subset analyses of asymptomatic (urgent, 3.0% vs 1.0%; aOR, 2.52; 95% CI, 2.16-2.92; P < .01) and (emergent, 9.9% vs 1.0%; aOR, 5.5; 95% CI, 3.91-7.63; P < .01) and symptomatic patients (urgent, 3.3% vs 1.7%; aOR, 1.65; 95% CI, 1.46-1.86; P < .01) and (emergent, 11% vs 1.7%; aOR, 3.07; 95% CI, 2.43-3.86; P < .01). These differences persisted after stratifying by procedure type, for both asymptomatic and symptomatic patients.

CONCLUSIONS: Urgent or emergent carotid revascularization was associated with higher odds of perioperative stroke or death, stroke, and death. Given the increased risks of urgent or emergent surgery, careful consideration should be given when assessing patients who may ostensibly benefit from expedited surgery, where possible.

OBJECTIVE: The high frequency of reinterventions after fenestrated endovascular aortic repair (FEVAR) with physician-modified endografts (PMEGs) has been well-studied. However, the impact of prior EVAR on reinterventions and sac behavior following these procedures remains unknown. We analyzed 3-year rates of reinterventions and sac dynamics following PMEG for index aneurysm repair compared with PMEG for prior EVAR with loss of proximal seal.

METHODS: We performed a retrospective analysis of 122 consecutive FEVARs with PMEGs at a tertiary care center submitted to the United States Food and Drug Administration in support of an investigational device exemption trial. We excluded patients with aortic dissection (n = 5), type I to III thoracoabdominal aneurysms (n = 13), non-elective procedures (n = 4), and prior aortic surgery other than EVAR (n = 8), for a final cohort of 92 patients. Patients were divided into those who underwent PMEG for index aneurysm repair (primary FEVAR) and those who underwent PMEG for rescue of prior EVAR with loss of proximal seal (secondary FEVAR). The primary outcomes were freedom from reintervention and sac dynamics (regression as ≥5 mm decrease, expansion as ≥5 mm increase, and stability as <5 mm increase or decrease) at 3 years. Secondary outcomes were perioperative mortality and 3-year survival.

RESULTS: Of the 92 patients included, 56 (61%) underwent primary FEVAR and 36 (39%) underwent secondary FEVAR. Secondary FEVAR patients were older (78 years [interquartile range (IQR), 74.5-83.5 years] vs 73 years [IQR, 69-78.5 years]; P < .001), more frequently male (86% vs 68%; P = .048), and had larger aneurysms (72.5 mm [IQR, 65.5-81 mm] vs 59 mm [IQR, 55-65 mm]; P < .001). Perioperative mortality was 1.8% for primary FEVAR and 2.7% for secondary FEVAR (P = .75). At 3 years, overall survival was 84% for primary FEVAR and 71% for secondary FEVAR (P = .086). Freedom-from reintervention was significantly higher for primary FEVAR than secondary FEVAR, specifically 82% vs 38% at 3 years (P < .001). Primary FEVAR also had more desirable sac dynamics relative to secondary FEVAR at 3 years (primary: 54% stable, 46% regressed, 0% expanded vs secondary: 33% stable, 28% regressed, and 39% expanded; P = .038).

CONCLUSIONS: FEVAR for primary aortic repair and FEVAR for rescue of prior EVAR with loss of proximal seal are two distinct entities. Following primary FEVAR, less than a quarter of patients have undergone reintervention at 3 years, and sac expansion was not seen in our cohort. Comparatively, 3 years after secondary FEVAR, over one-half of patients have undergone reintervention and over one-third have had ongoing sac expansion. Vigilant surveillance and a low threshold for further interventions are crucial following secondary FEVAR.

OBJECTIVE: In patients undergoing elective thoracic endovascular aortic repair (TEVAR) and left subclavian artery (LSA) coverage, routine preoperative LSA revascularization is recommended. However, in the current endovascular era, the optimal surgical approach is debated. We compared baseline characteristics, procedural details, and perioperative outcomes of patients undergoing open or endovascular LSA revascularization in the setting of TEVAR.

METHODS: Adult patients undergoing TEVAR with zone 2 proximal landing and LSA revascularization between 2013 and 2023 were identified in the Vascular Quality Initiative. We excluded patients with traumatic aortic injury, aortic thrombus, or ruptured presentations, and stratified based on revascularization type (open vs any endovascular). Open LSA revascularization included surgical bypass or transposition. Endovascular LSA revascularization included single-branch, fenestration, or parallel stent grafting. Primary outcomes were stroke, spinal cord ischemia (SCI), and perioperative mortality (Pearson's χ2 test). Multivariable logistic regression was used to evaluate associations between revascularization type and primary outcomes. Secondarily, we studied other in-hospital complications and 5-year mortality (Kaplan-Meier, multivariable Cox regression). Sensitivity analyses were performed in patients undergoing concomitant LSA revascularization to TEVAR.

RESULTS: Of 2489 patients, 1842 (74%) underwent open and 647 (26%) endovascular LSA revascularization. Demographics and comorbidities were similar between open and endovascular cohorts. Compared with open, endovascular revascularization had shorter procedure times (median, 135 minutes vs 174 minutes; P < .001), longer fluoroscopy times (median, 23 minutes vs 16 minutes; P < .001), lower estimated blood loss (median, 100 mL vs 123 mL; P < .001), and less preoperative spinal drain use (40% vs 49%; P < .001). Patients undergoing endovascular revascularization were more likely to present urgently (24% vs 19%) or emergently (7.4% vs 3.4%) (P < .001). Compared with open, endovascular patients experienced lower stroke rates (2.6% vs 4.8%; P = .026; adjusted odds ratio [aOR], 0.50 [95% confidence interval (CI), 0.25-0.90]), but had comparable SCI (2.9% vs 3.5%; P = .60; aOR, 0.64 [95% CI, 0.31-1.22]) and perioperative mortality (3.1% vs 3.3%; P = .94; aOR, 0.71 [95% CI, 0.34-1.37]). Compared with open, endovascular LSA revascularization had lower rates of overall composite in-hospital complications (20% vs 27%; P < .001; aOR, 0.64 [95% CI, 0.49-0.83]) and shorter overall hospital stay (7 vs 8 days; P < .001). After adjustment, 5-year mortality was similar among groups (adjusted hazard ratio, 0.85; 95% CI, 0.64-1.13). Sensitivity analyses supported the primary analysis with similar outcomes.

CONCLUSIONS: In patients undergoing TEVAR starting in zone 2, endovascular LSA revascularization had lower rates of postoperative stroke and overall composite in-hospital complications, but similar SCI, perioperative mortality, and 5-year mortality rates compared with open LSA revascularization. Future comparative studies are needed to evaluate the mid- to long-term safety of endovascular LSA revascularization and assess differences between specific endovascular techniques.

OBJECTIVE: Prior literature has found worse outcomes for female patients after endovascular repair of abdominal aortic aneurysm and mixed findings after thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysm. However, the influence of sex on outcomes after TEVAR for acute type B aortic dissection (aTBAD) is not fully elucidated.

METHODS: We identified patients who underwent TEVAR for aTBAD (<30 days) in the Vascular Quality Initiative from 2014 to 2022. We excluded patients with an entry tear or stent seal within the ascending aorta or aortic arch and patients with an unknown proximal tear location. Included patients were stratified by biological sex, and we analyzed perioperative outcomes and 5-year mortality with multivariable logistic regression and Cox regression analysis, respectively. Furthermore, we analyzed adjusted variables for interaction with female sex.

RESULTS: We included 1626 patients, 33% of whom were female. At presentation, female patients were significantly older (65 [interquartile range: 54, 75] years vs 56 [interquartile range: 49, 68] years; P = .01). Regarding indications for repair, female patients had higher rates of pain (85% vs 80%; P = .02) and lower rates of malperfusion (23% vs 35%; P < .001), specifically mesenteric, renal, and lower limb malperfusion. Female patients had a lower proportion of proximal repairs in zone 2 (39% vs 48%; P < .01). After TEVAR for aTBAD, female sex was associated with comparable odds of perioperative mortality to males (8.1 vs 9.2%; adjusted odds ratio [aOR]: 0.79 [95% confidence interval (CI): 0.51-1.20]). Regarding perioperative complications, female sex was associated with lower odds for cardiac complications (2.3% vs 4.7%; aOR: 0.52 [95% CI: 0.26-0.97]), but all other complications were comparable between sexes. Compared with male sex, female sex was associated with similar risk for 5-year mortality (26% vs 23%; adjusted hazard ratio: 1.01 [95% CI: 0.77-1.32]). On testing variables for interaction with sex, female sex was associated with lower perioperative and 5-year mortality at older ages relative to males (aOR: 0.96 [0.93-0.99] | adjusted hazard ratio: 0.97 [0.95-0.99]) and higher odds of perioperative mortality when mesenteric malperfusion was present (OR: 2.71 [1.04-6.96]).

CONCLUSIONS: Female patients were older, less likely to have complicated dissection, and had more distal proximal landing zones. After TEVAR for aTBAD, female sex was associated with similar perioperative and 5-year mortality to male sex, but lower odds of in-hospital cardiac complications. Interaction analysis showed that females were at additional risk for perioperative mortality when mesenteric ischemia was present. These data suggest that TEVAR for aTBAD overall has a similar safety profile in females as it does for males.