Background This study examined outcomes of endovascular repair of infrarenal abdominal aortic aneurysms (EVAR) using general, spinal, epidural, and local/monitored anesthesia care (MAC) in a multicenter North American hospital database reflecting contemporary anesthesia and surgical practices. Methods Elective EVAR cases performed between 2005 and 2008 were identified from the American College of Surgeons National Surgical Quality Improvement Program database using Current Procedural Terminology codes. Excluded were emergency cases and patients with concomitant procedures requiring general anesthesia. Patient-level comorbidities, characteristics, and intraoperative and postoperative details were examined. Complications were analyzed individually and in aggregate categories, including wound, pulmonary, renal, venous thromboembolic, cardiovascular, operative, and septic. Length of stay (LOS) and 30-day mortality were examined. Characteristics and outcomes were described using mean ± standard deviation or count (%), and comparisons were evaluated for statistical significance using χ2, Fisher exact test, and univariate linear regression. LOS was analyzed with linear regression techniques using a log transformation. Associations between anesthesia type and outcomes were examined using univariable and multivariable regression techniques. Results We identified 6009 elective EVAR procedures for analysis. General anesthesia was used in 4868 cases, spinal anesthesia in 419, epidural anesthesia in 331, and local/MAC in 391. Defined morbidity occurred in 11% of patients. Median LOS was 2 (interquartile range, 1–3) days, and mean LOS was 2.8 ± 4.3 days. The 30-day mortality rate was 1.1%. Significant multivariate associations were observed between anesthesia type, pulmonary morbidity, and log-LOS. General anesthesia was associated with an increase in pulmonary morbidity vs spinal (odds ratio [OR], 4.0; 95% confidence interval [CI], 1.3–12.5; P = .020) and local/MAC anesthesia (OR, 2.6; 95% CI, 1.0–6.4; P = .041). Use of general anesthesia was associated with a 10% increase in LOS for general vs spinal anesthesia (95% CI, 4.8%–15.5%; P = .001) and a 20% increase for general vs local/MAC anesthesia (95% CI, 14.1%–26.2%; P < .001). Trends toward increased pulmonary morbidity and LOS were not observed for general vs epidural anesthesia. No significant association between anesthesia type and mortality was observed. Conclusions In contemporary North American anesthetic and surgical practice, general anesthesia for EVAR was associated with increased postoperative LOS and pulmonary morbidity compared with spinal and local/MAC anesthesia. These data suggest that increasing the use of less-invasive anesthetic techniques may limit postoperative complications and decrease the overall costs of EVAR.

Background This report examines the effects of regional versus general anesthesia for infrainguinal bypass procedures performed in the treatment of critical limb ischemia (CLI). Methods Nonemergent infrainguinal bypass procedures for CLI (defined as rest pain or tissue loss) were identified using the 2005 to 2008 American College of Surgeons National Surgical Quality Improvement Program database using International Classification of Disease, ninth edition, and Current Procedure Terminology codes. Patients were classified according to National Surgical Quality Improvement Program data as receiving either general anesthesia or regional anesthesia. The regional anesthesia group included those specified as having regional, spinal, or epidural anesthesia. Demographic, medical, risk factor, operative, and outcomes data were abstracted for the study sample. Individual outcomes were evaluated according to the following morbidity categories: wound, pulmonary, venous thromboembolic, genitourinary, cardiovascular, and operative. Length of stay, total morbidity, and mortality were also evaluated. Associations between anesthesia types and outcomes were evaluated using linear or logistic regression. Results A total of 5,462 inpatient hospital visits involving infrainguinal bypasses for CLI were identified. Mean patient age was 69 ± 12 years; 69% were Caucasian; and 39% were female. In all, 4,768 procedures were performed using general anesthesia and 694 with regional anes­thesia. Patients receiving general anesthesia were younger and significantly more likely to have a history of smoking, previous lower-extremity bypass, previous amputation, previous stroke, and a history of a bleeding diathesis including the use of warfarin. Patients receiving regional anesthesia had a higher prevalence of chronic obstructive pulmonary disease. Tibial-level bypasses were performed in 51% of procedures, whereas 49% of procedures were popliteal-level bypasses. Cases performed using general anesthesia demonstrated a higher rate of resident involvement, need for blood transfusion, and operative time. There was no difference in the rate of popliteal-level and infrapopliteal-level bypasses between groups. Infrapopliteal bypass procedures performed using general anesthesia were more likely to involve prosthetic grafts and composite vein. Mortality occurred in 157 patients (3%). The overall morbidity rate was 37%. Mean and median lengths of stay were 7.5 days (±8.1) and 6.0 days (Q1: 4.0, Q3: 8.0), respectively. Multivariate analyses demonstrated no significant differences by anesthesia type in the incidence of morbidity, mortality, or length of stay. Conclusion These results provide no evidence to support the systematic avoidance of general anesthesia for lower-extremity bypass procedures. These data suggest that anesthetic choice should be governed by local expertise and practice patterns.

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Background: To define the relationship between left ventricular diastolic function and survival after renal revascularization.Methods: Seventy-six adult patients (49 women, 27 men; mean age: 63 years Ϯ 13 years) with preoperative echocardiography who underwent renal revascularization for atherosclerotic disease were identified. Echocardiograms were performed and interpreted according to American Society of Echocardiography Recommendations for Use of Echocardiography in Clinical Trials. Diastolic function was estimated by measuring the early diastolic JOURNAL OF VASCULAR SURGERY Volume 52, Number 6Abstracts 1745

Purpose To define the relationship between left ventricular diastolic function and survival after renal revascularization. Methods 76 adult patients (49 women, 27 men; mean age: 63 years ± 13 years) with preoperative echocardiography who underwent renal revascularization for atherosclerotic disease were identified. Diastolic function was estimated from the early diastolic transmitral flow velocity (E), the atrial transmitral flow velocity (A) and the mitral annular tissue doppler velocity (e’). Patients were divided into two groups of diastolic dysfunction as either none/mild (E/A≤0.75, E/e’<10) or moderate/severe (E/A>0.75, E/e’≥10). Perioperative and follow-up mortality were determined from a prospective vascular database and the National Death Index. Descriptive statistics were calculated. Postoperative survival was estimated by product-limit methods. Associations between preoperative factors, perioperative factors and follow-up survival were examined using proportional hazards regression models. A forward stepwise variable selection procedure was used to select a ‘best’ model to predict follow-up survival. Results 76 patients were followed for an average of 41.9 months after renal revascularization. Within this group 47/76 (61.8%) patients were identified as having moderate or severe diastolic dysfunction. Diastolic dysfunction had no apparent association with abnormal systolic function. The mean ejection fraction for those with moderate/severe diastolic dysfunction was 57.7% +/− 11.5%. When comparing the moderate/severe and none/mild groupings of diastolic dysfunction, there was a significant difference in left ventricular mass index (151.9 +/− 48.9 vs. 125.3 +/− 31.7, P = .0087). There were 5 deaths in the perioperative period and 20 deaths on follow-up. Among perioperative survivors, hypertension was cured or improved in 82% of the none/mild group and 53% of the moderate/severe group (P = .012). In multivariable analysis, none/mild diastolic dysfunction was significantly and independently associated with an improvement in blood pressure after revascularization (OR 6.2, 95% CI 1.4-28.6, P = .018). Ejection fraction was not associated with survival. After forward variable selection, moderate/severe diastolic dysfunction (HR 5.8, 95% CI 1.4–25, P = .018) was the only variable to demonstrate a significant and independent association with follow-up survival. Conclusion Diastolic dysfunction, but not systolic dysfunction, was frequent in patients with renovascular disease. Blood pressure response and follow-up survival after renal revascularization demonstrated significant and independent associations with diastolic function. Consideration of diastolic function should be included in the management of patients with atherosclerotic renovascular disease.