Contemporary comparison of supra-aortic trunk surgical reconstructions for occlusive disease.
OBJECTIVE
Open surgical reconstruction for supra-aortic trunk occlusive disease persists despite advances in endovascular therapy. Although extrathoracic reconstructions developed as a safer alternative to transthoracic reconstructions, contemporary national data evaluating relative rates of operative outcomes are lacking.


METHODS
With use of the National Surgical Quality Improvement Program (2005-2011), patients who underwent transthoracic or extrathoracic reconstruction were evaluated. Patients with nonocclusive indications were excluded. The primary outcome was a composite end point of stroke/myocardial infarction (MI)/death. Secondary outcomes were 30-day postoperative complications. Univariate and multivariable regression analyses were performed.


RESULTS
Overall, 83 patients (10.7%) underwent transthoracic reconstructions and 692 patients (89.3%) underwent extrathoracic reconstructions. Vascular surgeons performed most transthoracic (96%) and extrathoracic (97%) reconstructions. The most common extrathoracic reconstructions were carotid-subclavian bypass (68%), carotid-carotid bypass (14%), and subclavian transposition (7%). Less commonly, axillary-axillary bypass (6%), subclavian-axillary bypass (2%), subclavian-subclavian bypass (1%), and carotid transposition (1%) were performed. At the time of operation, 10% (transthoracic reconstructions) and 8% (extrathoracic reconstructions) of patients had a concurrent carotid endarterectomy (P < .60). Analysis of more than 20 characteristics showed that the groups did not differ significantly. The two groups had similar rates of postoperative stroke (1.2% in the transthoracic reconstruction group vs 2.2% in the extrathoracic reconstruction group; P > .99), MI (0% vs 1.3%; P = .61), death (2.4% vs 1.3%; P = .33), and stroke/MI/death (3.6% vs 3.8%; P > .99). Transthoracic reconstruction patients had longer hospital stays (6.3 days vs 4.0 days; P < .0002), received more transfusions (8.4% vs 2.5%; P < .0096), and had higher rates of postoperative sepsis (3.6% vs 0.3%; P < .01) and venous thromboembolic complications (3.6% vs 0.4%; P < .02). After adjustment for other factors, including surgical approach, stroke/MI/death was significantly associated with postoperative pneumonia (odds ratio [OR], 26.0; 95% confidence interval [CI], 6.29-108.28; P < .0001), postoperative ventilator dependence (OR, 12.45; 95% CI, 2.74-56.48; P = .001), and postoperative return to the operating room (OR, 4.75; 95% CI, 1.67-13.54; P = .004).


CONCLUSIONS
At U.S. hospitals, extrathoracic reconstruction is the more common reconstruction for supra-aortic trunk occlusive disease. Both approaches carry acceptably low rates of death, MI, and stroke. Transthoracic reconstruction results in more resource utilization because of its postoperative complications and greater complexity.
Boston University School of Medicine, Boston, Mass. Electronic address: v.m.thomas@gmail.com.
Vijaya T
VT
Daniel
Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass.
Arin L
AL
Madenci
Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass.
Louis L
LL
Nguyen
Division of Vascular and Endovascular Surgery, Boston University Medical Center, Boston, Mass.
Mohammad H
MH
Eslami
Division of Vascular and Endovascular Surgery, Boston University Medical Center, Boston, Mass.
Jeffrey A
JA
Kalish
Division of Vascular and Endovascular Surgery, Boston University Medical Center, Boston, Mass.
Alik
A
Farber
Boston University School of Medicine, Boston, Mass; Division of Vascular Surgery, VA Boston Healthcare, West Roxbury, Mass.
James T
JT
McPhee
D001366:Axillary Artery / Q000601:surgery*; D016893:Carotid Stenosis / Q000601:surgery*; D057186:Comparative Effectiveness Research / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology; D058996:Quality Improvement; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D015607:Stents; D013349:Subclavian Steal Syndrome / Q000601:surgery*; D015996:Survival Rate / Q000639:trends; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D014656:Vascular Surgical Procedures / Q000379:methods*