Shipra Arya, MD SM FACS is a Professor of Surgery at the Stanford University School of Medicine and section chief of vascular surgery at VA Palo Alto Healthcare System. She has a Master’s degree in epidemiology from the Harvard School of Public Health with focus on research methodology and cardiovascular epidemiology. She completed her General Surgery Residency at Creighton University Medical Center followed by a Vascular Surgery Fellowship at University of Michigan. She has been funded by American Heart Association (AHA), NIH/NIA GEMSSTAR grant, VA Palo Alto Center for Innovation and Implementation (Ci2i), and is currently funded by VA HSR&D for a multicenter stepped wedge cluster randomized clinical trial called “PAtient-centered mUltidiSciplinary Care for vEterans Undergoing Surgery (PAUSE) trial”. Her current work focuses on streamlining frailty evaluation, as well as implementation of patient and system level interventions to improve surgical quality and to provide high-value and patient centered care.

She has multiple administrative roles in surgical quality improvement as Director of Surgical Quality at VAPAHCS; Center director for Stanford University in the Vascular Quality Initiative (VQI); and the Associate Medical Director of the Northern California region for VQI, which is the national registry database and patient safety organization for Society for Vascular Surgery (SVS). Her involvement in SVS VQI also extends to being a member of the steering committee of the Vascular Implant Surveillance and Interventional Outcomes Network (VISION) to improve the quality, safety and effectiveness of vascular care. She also serves as the President of the Surgical Outcomes Club, a national organization of surgical health services researchers, and chairs multiple national committees: VA surgeons committee for the SVS and Diversity and Inclusion Committee for the Association of VA surgeons.

Clinical Focus

  • Vascular Surgery
  • Peripheral Arterial Disease
  • Aortic Aneurysms
  • Carotid artery disease

Academic Appointments

Administrative Appointments

  • Director of Quality, VA Palo Alto Healthcare System (2020 - Present)
  • Section Chief- Vascular Surgery, VA Palo Alto Healthcare System (2018 - Present)

Professional Education

  • Fellowship: University of Michigan (2013) MI
  • Board Certification: American Board of Surgery, Vascular Surgery (2014)
  • Board Certification: American Board of Surgery, General Surgery (2012)
  • Residency: Creighton University General Surgery Residency (2011) NE
  • Medical Education: All India Institute of Medical Sciences (2005) India

Clinical Trials

  • Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial Recruiting

    Carotid revascularization for primary prevention of stroke (CREST-2) is two independent multicenter, randomized controlled trials of carotid revascularization and intensive medical management versus medical management alone in patients with asymptomatic high-grade carotid stenosis. One trial will randomize patients in a 1:1 ratio to endarterectomy versus no endarterectomy and another will randomize patients in a 1:1 ratio to carotid stenting with embolic protection versus no stenting. Medical management will be uniform for all randomized treatment groups and will be centrally directed.

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  • PAtient-centered mUltidiSciplinary Care for vEterans Undergoing Surgery (PAUSE) Not Recruiting

    The PAUSE Trial is a pragmatic, randomized clinical trial for Veterans scheduled for elective surgery at 3 large VA facilities (Palo Alto, Houston, and Nashville). The PAUSE Trial focuses on cooperation between providers of various disciplines in order to provide better care. Veterans identified as frail upon standardized will be referred to a multidisciplinary "PAUSE Board" comprised of members from surgery, anesthesia, geriatrics, palliative care, case management, rehabilitation, and nutrition. Diverse specialists will come together in a team environment to discuss care options, scientific evidence, and patient goals and expectations, creating individual patient recommendations. The investigators hypothesize that the PAUSE Board model will improve quality and outcomes by promoting guidelines and evidence-based care recommendations as well as constructive team-based discussions to align care with patient goals and expectations.

    Stanford is currently not accepting patients for this trial. For more information, please contact Ashley Langston, MS MA, 605-493-5000 Ext. 62923.

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All Publications

  • Perspectives on Home Time and Its Association With Quality of Life After Inpatient Surgery Among US Veterans. JAMA network open Arya, S., Langston, A. H., Chen, R., Sasnal, M., George, E. L., Kashikar, A., Barreto, N. B., Trickey, A. W., Morris, A. M. 1800; 5 (1): e2140196


    Importance: Home time, defined as time spent at home after hospital discharge, is emerging as a novel, patient-oriented outcome in stroke recovery and end-of-life care. Longer home time is associated with lower mortality and higher patient satisfaction. However, a knowledge gap exists in the measurement and understanding of home time in the population undergoing surgery.Objectives: To examine the association between postoperative home time and quality of life (QoL), functional status, and decisional regret and to identify themes regarding the meaning of time spent at home after surgery.Design, Setting, and Participants: This mixed-methods study including a survey and qualitative interviews used an explanatory sequential design involving 152 quantitative surveys followed by in-depth interviews with 12 participants from February 26, 2020, to December 17, 2020. US veterans older than 65 years who underwent inpatient surgery at a single-center veterans hospital within the prior 6 to 12 months were studied.Exposures: Quality of life, measured by the Veterans RAND 12-item Health Survey and 19-item Control, Autonomy, Self-realization, and Pleasure scale; functional status, measured by activities of daily living (ADL) and instrumental ADL scales; and regret, measured by the Decision Regret Scale.Main Outcomes and Measures: Home time, standardized as percentage of total time spent at home from the time of surgery to the time of survey administration. Associations between home time and QoL, function, and decisional regret in the survey data were analyzed using Spearman correlation in the overall cohort and in operative stress score subcohorts (1-2 [low] vs 3-5 [high]) in a stratified analysis. The 12 semistructured interviews were analyzed to elicit patients' perspectives on home time in postoperative recovery. Qualitative data were coded and analyzed using content and thematic analysis and integrated with quantitative data in joint displays.Results: A total of 152 patients (mean [SD] age, 72.3 [4.4] years; 146 [96.0%] male) were surveyed, and 12 patients (mean [SD] age, 72.3 [4.8] years; 11 [91.7%] male) were interviewed. The median time to survey completion was 307 days (IQR, 265-344 days). The median home time was 97.8% (IQR, 94.6%-98.6%; range, 22.2%-99.5%). Increased home time was associated with better physical health-related QoL in the Veterans RAND 12-item Health Survey (r=0.33; 95% CI, 0.18-0.47; P<.001) and higher ADL scores (r=0.21; 95% CI, 0.06-0.36; P=.008) and instrumental ADL functional scores (r=0.21; 95% CI, 0.04-0.37; P=.009). Decisional regret was inversely associated with home time in only the high operative stress score subcohort (r=-0.22; 95% CI, -0.47 to -0.04; P=.047). Home was perceived as a safe and familiar environment that accelerated recovery through nurturing support of loved ones.Conclusions and Relevance: In this mixed-methods study including a survey and qualitative interviews, increased home time in the first year after major surgery was associated with improved daily function and physical QoL among US veterans. Interviewees considered the transition to home to be an indicator of recovery, suggesting that home time may be a promising, patient-oriented quality outcome measure for surgical recovery that warrants further study.

    View details for DOI 10.1001/jamanetworkopen.2021.40196

    View details for PubMedID 35015066

  • Association Between Patient Frailty and Postoperative Mortality Across Multiple Noncardiac Surgical Specialties. JAMA surgery George, E. L., Hall, D. E., Youk, A., Chen, R., Kashikar, A., Trickey, A. W., Varley, P. R., Shireman, P. K., Shinall, M. C., Massarweh, N. N., Johanning, J., Arya, S. 2020: e205152


    Importance: Frailty is an important risk factor for postoperative mortality. Whether the association between frailty and mortality is consistent across all surgical specialties, especially those predominantly performing lower stress procedures, remains unknown.Objective: To examine the association between frailty and postoperative mortality across surgical specialties.Design, Setting, and Participants: A cohort study was conducted across 9 noncardiac specialties in hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) and Veterans Affairs Surgical Quality Improvement Program (VASQIP) from January 1, 2010, through December 31, 2014, using multivariable logistic regression to evaluate the association between frailty and postoperative mortality. Data analysis was conducted from September 15, 2019, to April 30, 2020. Patients 18 years or older undergoing noncardiac procedures were included.Exposures: Risk Analysis Index measuring preoperative frailty categorized patients as robust (Risk Analysis Index ≤20), normal (21-29), frail (30-39), or very frail (≥40). Operative Stress Score (OSS) categorized procedures as low (1-2), moderate (3), and high (4-5) stress. Specialties were categorized by case-mix as predominantly low intensity (>75% OSS 1-2), moderate intensity (50%-75%), or high intensity (<50%).Main Outcomes and Measures: Thirty-day (both measures) and 180-day (VASQIP only) postoperative mortality.Results: Of the patients evaluated in NSQIP (n=2 339 031), 1 309 795 were women (56.0%) and mean (SD) age was 56.49 (16.4) years. Of the patients evaluated in VASQIP (n=426 578), 395 761 (92.78%) were men and mean (SD) age was 61.1 (12.9) years. Overall, 30-day mortality was 1.2% in NSQIP and 1.0% in VASQIP, and 180-day mortality in VASQIP was 3.4%. Frailty and OSS distributions differed substantially across the 9 specialties. Patterns of 30-day mortality for frail and very frail patients were similar in NSQIP and VASQIP for low-, moderate-, and high-intensity specialties. Frailty was a consistent, independent risk factor for 30- and 180-day mortality across all specialties. For example, in NSQIP, for plastic surgery, a low-intensity specialty, the odds of 30-day mortality in very frail (adjusted odds ratio [aOR], 27.99; 95% CI, 14.67-53.39) and frail (aOR, 5.1; 95% CI, 3.03-8.58) patients were statistically significantly higher than for normal patients. This was also true in neurosurgery, a moderate-intensity specialty, for very frail (aOR, 9.8; 95% CI, 7.68-12.50) and frail (aOR, 4.18; 95% CI, 3.58-4.89) patients and in vascular surgery, a high-intensity specialty, for very frail (aOR, 10.85; 95% CI, 9.83-11.96) and frail (aOR, 3.42; 95% CI, 3.19-3.67) patients.Conclusions and Relevance: In this study, frailty was associated with postoperative mortality across all noncardiac surgical specialties regardless of case-mix. Preoperative frailty assessment could be implemented across all specialties to facilitate risk stratification and shared decision-making.

    View details for DOI 10.1001/jamasurg.2020.5152

    View details for PubMedID 33206156

  • Association of Preoperative Patient Frailty and Operative Stress With Postoperative Mortality. JAMA surgery Shinall, M. C., Arya, S., Youk, A., Varley, P., Shah, R., Massarweh, N. N., Shireman, P. K., Johanning, J. M., Brown, A. J., Christie, N. A., Crist, L., Curtin, C. M., Drolet, B. C., Dhupar, R., Griffin, J., Ibinson, J. W., Johnson, J. T., Kinney, S., LaGrange, C., Langerman, A., Loyd, G. E., Mady, L. J., Mott, M. P., Patri, M., Siebler, J. C., Stimson, C. J., Thorell, W. E., Vincent, S. A., Hall, D. E. 2019: e194620


    Importance: Patients with frailty have higher risk for postoperative mortality and complications; however, most research has focused on small groups of high-risk procedures. The associations among frailty, operative stress, and mortality are poorly understood.Objective: To assess the association between frailty and mortality at varying levels of operative stress as measured by the Operative Stress Score, a novel measure created for this study.Design, Setting, and Participants: This retrospective cohort study included veterans in the Veterans Administration Surgical Quality Improvement Program from April 1, 2010, through March 31, 2014, who underwent a noncardiac surgical procedure at Veterans Health Administration Hospitals and had information available on vital status (whether the patient was alive or deceased) at 1 year postoperatively. A Delphi consensus method was used to stratify surgical procedures into 5 categories of physiologic stress.Exposures: Frailty as measured by the Risk Analysis Index and operative stress as measured by the Operative Stress Score.Main Outcomes and Measures: Postoperative mortality at 30, 90, and 180 days.Results: Of 432 828 unique patients (401 453 males [92.8%]; mean (SD) age, 61.0 [12.9] years), 36 579 (8.5%) were frail and 9113 (2.1%) were very frail. The 30-day mortality rate among patients who were frail and underwent the lowest-stress surgical procedures (eg, cystoscopy) was 1.55% (95% CI, 1.20%-1.97%) and among patients with frailty who underwent the moderate-stress surgical procedures (eg, laparoscopic cholecystectomy) was 5.13% (95% CI, 4.79%-5.48%); these rates exceeded the 1% mortality rate often used to define high-risk surgery. Among patients who were very frail, 30-day mortality rates were higher after the lowest-stress surgical procedures (10.34%; 95% CI, 7.73%-13.48%) and after the moderate-stress surgical procedures (18.74%; 95% CI, 17.72%-19.80%). For patients who were frail and very frail, mortality continued to increase at 90 and 180 days, reaching 43.00% (95% CI, 41.69%-44.32%) for very frail patients at 180 days after moderate-stress surgical procedures.Conclusions and Relevance: We developed a novel operative stress score to quantify physiologic stress for surgical procedures. Patients who were frail and very frail had high rates of postoperative mortality across all levels of the Operative Stress Score. These findings suggest that frailty screening should be applied universally because low- and moderate-stress procedures may be high risk among patients who are frail.

    View details for DOI 10.1001/jamasurg.2019.4620

    View details for PubMedID 31721994

  • Recalibration and External Validation of the Risk Analysis Index: A Surgical Frailty Assessment Tool. Annals of surgery Arya, S., Varley, P., Youk, A., Borrebach, J. A., Perez, S., Massarweh, N. N., Johanning, J. M., Hall, D. E. 2019


    OBJECTIVE AND BACKGROUND: The Risk Analysis Index (RAI) predicts 30-, 180-, and 365-day mortality based on variables constitutive of frailty. Initially validated, in a single-center Veteran hospital, we sought to improve model performance by recalibrating the RAI in a large, veteran surgical registry, and to externally validate it in both a national surgical registry and a cohort of surgical patients for whom RAI was measured prospectively before surgery.METHODS: The RAI was recalibrated among development and confirmation samples within the Veterans Affairs Surgical Quality Improvement Program (VASQIP; 2010-2014; N = 480,731) including major, elective noncardiac surgery patients to create the revised RAI (RAI-rev), comparing discrimination and calibration. The model was tested externally in the American College of Surgeons National Surgical Quality Improvement Program dataset (NSQIP; 2005-2014; N = 1,391,785), and in a prospectively collected cohort from the Nebraska Western Iowa Health Care System VA (NWIHCS; N = 6,856).RESULTS: Recalibrating the RAI significantly improved discrimination for 30-day [c = 0.84-0.86], 180-day [c = 0.81-0.84], and 365-day mortality [c = 0.78-0.82] (P < 0.001 for all) in VASQIP. The RAI-rev also had markedly better calibration (median absolute difference between observed and predicted 180-day mortality: decreased from 8.45% to 1.23%). RAI-rev was highly predictive of 30-day mortality (c = 0.87) in external validation with excellent calibration (median absolute difference between observed and predicted 30-day mortality: 0.6%). The discrimination was highly robust in men (c = 0.85) and women (c = 0.89). Discrimination also improved in the prospectively measured cohort from NWIHCS for 180-day mortality [c = 0.77 to 0.80] (P < 0.001).CONCLUSIONS: The RAI-rev has improved discrimination and calibration as a frailty-screening tool in surgical patients. It has robust external validity in men and women across a wide range of surgical settings and available for immediate implementation for risk assessment and counseling in preoperative patients.

    View details for PubMedID 30907757

  • Association of Statin Dose With Amputation and Survival in Patients With Peripheral Artery Disease. Circulation Arya, S., Khakharia, A., Binney, Z. O., DeMartino, R. R., Brewster, L. P., Goodney, P. P., Wilson, P. W. 2018; 137 (14): 1435–46


    BACKGROUND: Statin dose guidelines for patients with peripheral artery disease (PAD) are largely based on coronary artery disease and stroke data. The aim of this study is to determine the effect of statin intensity on PAD outcomes of amputation and mortality.METHODS: Using an observational cohort study design and a validated algorithm, we identified patients with incident PAD (2003-2014) in the national Veterans Affairs data. Highest statin intensity exposure (high-intensity versus low-to-moderate-intensity versus antiplatelet therapy but no statin use) was determined within 1 year of diagnosis of PAD. Outcomes of interest were lower extremity amputations and death. The association of statin intensity with incident amputation and mortality was assessed with Kaplan-Meier plots, Cox proportional hazards modeling, propensity score-matched analysis, and sensitivity and subgroup analyses, as well, to reduce confounding.RESULTS: In 155647 patients with incident PAD, more than a quarter (28%) were not on statins. Use of high-intensity statins was lowest in patients with PAD only (6.4%) in comparison with comorbid coronary/carotid disease (18.4%). Incident amputation and mortality risk declined significantly with any statin use in comparison with the antiplatelet therapy-only group. In adjusted Cox models, the high-intensity statin users were associated with lower amputation risk and mortality in comparison with antiplatelet therapy-only users (hazard ratio, 0.67; 95% confidence interval, 0.61-0.74 and hazard ratio, 0.74; 95% confidence interval, 0.70-0.77, respectively). Low-to-moderate-intensity statins also had significant reductions in the risk of amputation and mortality (hazard ratio amputation, 0.81; 95% confidence interval, 0.75- 0.86; hazard ratio death, 0.83; 95% confidence interval, 0.81-0.86) in comparison with no statins (antiplatelet therapy only), but effect size was significantly weaker than the high-intensity statins (P<0.001). The association of high-intensity statins with lower amputation and death risk remained significant and robust in propensity score-matched, sensitivity, and subgroup analyses.CONCLUSIONS: Statins, especially high-intensity formulations, are underused in patients with PAD. This is the first population-based study to show that high-intensity statin use at the time of PAD diagnosis is associated with a significant reduction in limb loss and mortality in comparison with low-to-moderate-intensity statin users, and patients treated only with antiplatelet medications but not with statins, as well.

    View details for DOI 10.1161/CIRCULATIONAHA.117.032361

    View details for PubMedID 29330214

  • The performance status gap in immunotherapy for frail patients with advanced non-small cell lung cancer. Cancer immunology, immunotherapy : CII Wu, J. T., Corrigan, J., Su, C., Dumontier, C., La, J., Khan, A., Arya, S., Harris, A. H., Backhus, L., Das, M., Do, N. V., Brophy, M. T., Han, S. S., Kelley, M., Fillmore, N. R. 2024; 73 (9): 172


    In advanced non-small cell lung cancer (NSCLC), immune checkpoint inhibitor (ICI) monotherapy is often preferred over intensive ICI treatment for frail patients and those with poor performance status (PS). Among those with poor PS, the additional effect of frailty on treatment selection and mortality is unknown.Patients in the veterans affairs national precision oncology program from 1/2019-12/2021 who received first-line ICI for advanced NSCLC were followed until death or study end 6/2022. Association of an electronic frailty index with treatment selection was examined using logistic regression stratified by PS. We also examined overall survival (OS) on intensive treatment using Cox regression stratified by PS. Intensive treatment was defined as concurrent use of platinum-doublet chemotherapy and/or dual checkpoint blockade and non-intensive as ICI monotherapy.Of 1547 patients receiving any ICI, 66.2% were frail, 33.8% had poor PS (≥ 2), and 25.8% were both. Frail patients received less intensive treatment than non-frail patients in both PS subgroups (Good PS: odds ratio [OR] 0.67, 95% confidence interval [CI] 0.51 - 0.88; Poor PS: OR 0.69, 95% CI 0.44 - 1.10). Among 731 patients receiving intensive treatment, frailty was associated with lower OS for those with good PS (hazard ratio [HR] 1.53, 95% CI 1.2 - 1.96), but no association was observed with poor PS (HR 1.03, 95% CI 0.67 - 1.58).Frail patients with both good and poor PS received less intensive treatment. However, frailty has a limited effect on survival among those with poor PS. These findings suggest that PS, not frailty, drives survival on intensive treatment.

    View details for DOI 10.1007/s00262-024-03763-w

    View details for PubMedID 38954019

    View details for PubMedCentralID 9359868

  • The Association Between Frailty and Outcomes Following Ruptured Abdominal Aortic Aneurysm Repair. Journal of vascular surgery Yu, J., Khamzina, Y., Kennedy, J., Liang, N. L., Hall, D. E., Arya, S., Tzeng, E., Reitz, K. M. 2024


    BACKGROUND: Endovascular aortic repair (EVAR) is a less invasive method than the more physiologically stressful open surgical repair (OSR) for patients with anatomically appropriate abdominal aortic aneurysm (AAA). Early postoperative outcomes are associated with both patients' physiologic reserve and the physiologic stresses of the surgical intervention. Among frail patients with reduced physiologic reserve, the stress of an aortic rupture in combination with the stress of an operative repair are less well tolerated, raising the risk of complications and mortality. This study aims to evaluate the difference in association between frailty and outcomes among patients undergoing minimally invasive EVAR and the physiologically more stressful OSR for ruptured AAA (rAAA).STUDY DESIGN: Our retrospective cohort study included adults undergoing rAAA repair in the Vascular Quality Initiative from 2010 to 2022. The validated Risk Analysis Index (RAI; robust≤20, normal 21-29, frail 30-39, very frail≥40) quantified frailty. The association between the primary outcome of 1-year mortality and frailty status as well as repair type were compared using multivariable Cox models generating adjusted hazard ratios (aHR) with 95% confidence intervals (95%CI). Interaction terms evaluated the association's moderation.RESULTS: We identified 5,806 patients (age 72±9 years; 77% male; EVAR 65%; robust 6%; normal 48%; frail 36%; very frail 10%) with a 53% observed 1-year mortality rate following rAAA repair. OSR [aHR = 1.43 (95%CI 1.19-1.73)] was associated with increased 1-year mortality when compared to EVAR. Increasing frailty status [frail aHR = 1.26 (95%CI 1.00-1.59); very frail aHR =1.64 (95%CI 1.26-2.13)] was associated with increased 1-year mortality, which was moderated by repair type (P-interaction<.05). OSR was associated with increased 1-year mortality in normal [aHR = 1.49 (95%CI 1.20-1.87)] and frail [aHR = 1.51 (95%CI 1.20-1.89)], but not among robust [aHR = 0.88 (95%CI 0.59-1.32)] and very frail [aHR = 1.29 (95%CI 0.97-1.72)] patients.CONCLUSION: Frailty and OSR were associated with increased adjusted risk of 1-year mortality following rAAA repair. Among normal and frail patients, OSR was associated with an increased adjusted risk of 1-year mortality when compared to EVAR. However, there was no difference between OSR and EVAR among robust patients who can well-tolerate the stress of OSR and among very frail patients who are unable to withstand the surgical stress from rAAA regardless of repair type.

    View details for DOI 10.1016/j.jvs.2024.04.021

    View details for PubMedID 38614142

  • Outcomes of Women Undergoing Noncardiac Surgery in Veterans Affairs Compared With Non-Veterans Affairs Care Settings. JAMA surgery George, E. L., Jacobs, M. A., Reitz, K. M., Massarweh, N. N., Youk, A. O., Arya, S., Hall, D. E. 2024


    Recent legislation facilitates veterans' ability to receive non-Veterans Affairs (VA) surgical care. Although veterans are predominantly male, the number of women receiving care within the VA has nearly doubled to 10% over the past decade and recent data comparing the surgical care of women in VA and non-VA care settings are lacking.To compare postoperative outcomes among women treated in VA hospitals vs private-sector hospitals.This coarsened exact-matched cohort study across 9 noncardiac specialties in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) took place from January 1, 2016, to December 31, 2019. Multivariable Poisson models with robust standard errors were used to evaluate the association between VA vs private-sector care settings and 30-day mortality. Hospitals participating in American College of Surgeons NSQIP and VASQIP were included. Data analysis was performed in January 2023. Participants included female patients 18 years old or older.Surgical care in VA or private-sector hospitals.Postoperative 30-day mortality and failure to rescue (FTR).Among 1 913 033 procedures analyzed, patients in VASQIP were younger (VASQIP: mean age, 49.8 [SD, 13.0] years; NSQIP: mean age, 55.9 [SD, 16.9] years; P < .001) and although most patients in both groups identified as White, there were significantly more Black women in VASQIP compared with NSQIP (29.6% vs 12.7%; P < .001). The mean risk analysis index score was lower in VASQIP (13.9 [SD, 6.4]) compared with NSQIP (16.3 [SD, 7.8]) (P < .001 for both). Patients in the VA were more likely to have a preoperative acute serious condition (2.4% vs 1.8%: P < .001), but cases in NSQIP were more frequently emergent (6.9% vs 2.6%; P < .001). The 30-day mortality, complications, and FTR were 0.2%, 3.2%, and 0.1% in VASQIP (n = 36 762 procedures) as compared with 0.8%, 5.0%, and 0.5% in NSQIP (n = 1 876 271 procedures), respectively (all P < .001). Among 1 763 540 matched women (n = 36 478 procedures in VASQIP; n = 1 727 062 procedures in NSQIP), these rates were 0.3%, 3.7%, and 0.2% in NSQIP and 0.1%, 3.4%, and 0.1% in VASQIP (all P < .01). Relative to private-sector care, VA surgical care was associated with a lower risk of death (adjusted risk ratio [aRR], 0.41; 95% CI, 0.23-0.76). This finding was robust among women undergoing gynecologic surgery, inpatient surgery, and low-physiologic stress procedures. VA surgical care was also associated with lower risk of FTR (aRR, 0.41; 95% CI, 0.18-0.92) for frail or Black women and inpatient and low-physiologic stress procedures.Although women comprise the minority of veterans receiving care within the VA, in this study, VA surgical care for women was associated with half the risk of postoperative death and FTR. The VA appears better equipped to meet the unique surgical needs and risk profiles of veterans, regardless of sex and health policy decisions, including funding, should reflect these important outcome differences.

    View details for DOI 10.1001/jamasurg.2023.8081

    View details for PubMedID 38416481

  • Preoperative Proteinuria is Independently Associated with Mortality after Fenestrated Endovascular Aneurysm Repair. Journal of vascular surgery Dossabhoy, S. S., Fisher, A. T., Chang, T. I., Owens, D. K., Arya, S., Stern, J. R., Lee, J. T. 2024


    Fenestrated endovascular aneurysm repair (FEVAR) has become mainstay in treating complex aortic aneurysms, though baseline patient factors predicting long-term outcomes remain poorly understood. Proteinuria is an early marker for chronic kidney disease and associated with adverse cardiovascular outcomes, but its utility in aneurysm patients is unknown. We aimed to determine whether preoperative proteinuria impacts long-term survival after FEVAR.A single-institution retrospective review of all elective FEVAR was performed. Preoperative proteinuria was assessed by urinalysis: negative (0-29 mg/dL), 1+ (30-100 mg/dL), 2+ (101-299 mg/dL), and 3+ (≥300 mg/dL). The cohort was stratified by patients with proteinuria (≥30 mg/dL) vs those without (<30 mg/dL). Baseline, perioperative, and long-term outcomes were compared. The primary outcome, all-cause mortality, was evaluated by Kaplan-Meier analysis and independent predictors with Cox proportional hazards modeling.Among 181 patients undergoing standard FEVAR from 2012-2022 (mean follow-up 33 months), any proteinuria was noted in 30 patients (16.6%). Those with proteinuria were more likely to be Black (10.0% vs 1.3%) with lower estimated glomerular filtration rate ([eGFR] 52.7 ± 24.7 vs 67.7 ± 20.5 mL/min/1.73m2), higher Society for Vascular Surgery comorbidity score (10.9 ± 4.3 vs 8.2 ± 4.7) and calcium channel blocker therapy (50.0% vs 29.1%), and larger maximal aneurysm diameter (67.2 ± 16.9 vs 59.8 ± 9.8) (all P<.05). Thirty-day mortality was higher in the proteinuria group (10.0% vs 1.3%, P=.03). Overall survival at 1 and 5 years was significantly lower for those with proteinuria (71.5% vs 92.3% and 29.5% vs 68.1%, log-rank P<.001). On multivariable analysis, preoperative proteinuria was independently associated with over three-fold higher hazard of mortality (hazard ratio [HR] 3.21, 95% confidence interval [CI] 1.66-6.20, P<.001), while preoperative eGFR was not predictive (HR 0.99, 95% CI 0.98-1.01, P=.28). Additional significant predictors included chronic obstructive pulmonary disease (HR 2.04), older age (HR 1.05), and larger maximal aneurysm diameter (HR 1.03, all P<.05).In our ten-year experience with FEVAR, preoperative proteinuria was observed in 17% of patients and was significantly associated with worse survival. In this cohort, proteinuria was independently associated with all-cause mortality, while eGFR was not, suggesting that urinalysis may provide an additional simple metric for risk stratifying patients prior to FEVAR.

    View details for DOI 10.1016/j.jvs.2024.01.013

    View details for PubMedID 38219966

  • Comprehensive framework of factors accounting for worse aortic aneurysm outcomes in females: A scoping review. Seminars in vascular surgery De Freitas, S., Falls, G., Weis, T., Bakhshi, K., Korepta, L. M., Bechara, C. F., Erben, Y., Arya, S., Fatima, J. 2023; 36 (4): 508-516


    Sex-based outcome studies have consistently documented worse results for females undergoing care for abdominal aortic aneurysms. This review explores the underlying factors that account for worse outcomes in the females sex. A scoping review of studies reporting sex-based disparities on abdominal aortic aneurysms was performed. The review was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews. Factors that account for worse outcomes in the females sex were identified, grouped into themes, and analyzed. Key findings of each study are reported and a comprehensive framework of these factors is presented. A total of 35 studies were identified as critical in highlighting sex-based disparities in care of patients with aortic aneurysms. We identified the following 10 interrelated themes in the chain of aneurysm care that account for differential outcomes in females: natural history, risk factors, pathobiology, biomechanics, screening, morphology, device design and adherence to instructions for use, technique, trial enrollment, and social determinants. Factors accounting for worse outcomes in the care of females with aortic aneurysms were identified and described. Some factors are immediately actionable, such as screening criteria, whereas device design improvement will require further research and development. This comprehensive framework of factors affecting care of aneurysms in females should serve as a blueprint to develop education, outreach, and future research efforts to improve outcomes in females.

    View details for DOI 10.1053/j.semvascsurg.2023.10.007

    View details for PubMedID 38030325

  • Artificial intelligence in clinical workflow processes in vascular surgery and beyond. Seminars in vascular surgery Dossabhoy, S. S., Ho, V. T., Ross, E. G., Rodriguez, F., Arya, S. 2023; 36 (3): 401-412


    In the past decade, artificial intelligence (AI)-based applications have exploded in health care. In cardiovascular disease, and vascular surgery specifically, AI tools such as machine learning, natural language processing, and deep neural networks have been applied to automatically detect underdiagnosed diseases, such as peripheral artery disease, abdominal aortic aneurysms, and atherosclerotic cardiovascular disease. In addition to disease detection and risk stratification, AI has been used to identify guideline-concordant statin therapy use and reasons for nonuse, which has important implications for population-based cardiovascular disease health. Although many studies highlight the potential applications of AI, few address true clinical workflow implementation of available AI-based tools. Specific examples, such as determination of optimal statin treatment based on individual patient risk factors and enhancement of intraoperative fluoroscopy and ultrasound imaging, demonstrate the potential promise of AI integration into clinical workflow. Many challenges to AI implementation in health care remain, including data interoperability, model bias and generalizability, prospective evaluation, privacy and security, and regulation. Multidisciplinary and multi-institutional collaboration, as well as adopting a framework for integration, will be critical for the successful implementation of AI tools into clinical practice.

    View details for DOI 10.1053/j.semvascsurg.2023.07.002

    View details for PubMedID 37863612

  • A Retrospective Cohort Study to Evaluate Adding Biomarkers to the Risk Analysis Index of Frailty. The Journal of surgical research Estock, J. L., Pandalai, P. K., Johanning, J. M., Youk, A. O., Varley, P. R., Arya, S., Massarweh, N. N., Hall, D. E. 2023; 292: 130-136


    The Risk Analysis Index (RAI) is a frailty assessment tool associated with adverse postoperative outcomes including 180 and 365-d mortality. However, the RAI has been criticized for only containing subjective inputs rather than including more objective components such as biomarkers.We conducted a retrospective cohort study to assess the benefit of adding common biomarkers to the RAI using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. RAI plus body mass index (BMI), creatinine, hematocrit, and albumin were evaluated as individual and composite variables on 180-d postoperative mortality.Among 480,731 noncardiac cases in VASQIP from 2010 to 2014, 324,320 (67%) met our inclusion criteria. Frail patients (RAI ≥30) made up to 13.0% of the sample. RAI demonstrated strong discrimination for 180-d mortality (c = 0.839 [0.836-0.843]). Discrimination significantly improved with the addition of Hematocrit (c = 0.862 [0.859-0.865]) and albumin (c = 0.870 [0.866-0.873]), but not for body mass index (BMI) or creatinine. However, calibration plots demonstrate that the improvement was primarily at high RAI values where the model overpredicts observed mortality.While RAI's ability to predict the risk of 180-d postoperative mortality improves with the addition of certain biomarkers, this only observed in patients classified as very frail (RAI >49). Because very frail patients have significantly elevated observed and predicted mortality, the improved discrimination is likely of limited clinical utility for a frailty screening tool.

    View details for DOI 10.1016/j.jss.2023.07.034

    View details for PubMedID 37619497

  • Sex differences in outcomes among adults undergoing abdominal aortic aneurysm repair. Journal of vascular surgery Ramkumar, N., Suckow, B. D., Columbo, J. A., Arya, S., Sedrakyan, A., Mackenzie, T. A., Brown, J. R., Goodney, P. P. 2023


    While the differences in short-term outcomes between males and females in abdominal aortic aneurysm (AAA) repair have been well studied, it remains unclear if these sex disparities extend to other long-term adverse outcomes after AAA repair, such as reintervention and late rupture.We performed a retrospective cohort study of 13,007 patients undergoing either endovascular (EVAR) or open AAA repair (OAR) between 2003-2015 using data from the Vascular Quality Initiative registries. Eligible patients were linked to fee-for-service Medicare claims to identify late outcomes of rupture and aneurysm-specific reintervention.The mean age of our cohort was 76 ± 6.7 years, 22% were females, 94% were white, and 77% underwent EVAR. The 10-year rupture incidence was slightly higher for females at 4.8 per 1000 person-years, versus 3.9 for males, but this difference was not statistically significant after risk adjustment (HR=1.13, 95% CI:0.74-1.73). Likewise, we found no sex difference in reintervention rates (5.1 versus 4.8 in females per 1000 person-years) even after risk adjustment (HR=0.95, 95% CI:0.83-1.09). Regression models suggest effect modification by repair type for reintervention, where females who underwent index EVAR had a higher risk of reintervention than males (HR=1.08, 95% CI:0.93-1.26), while females who underwent OAR were at a lower risk of reintervention compared to males (HR=0.79, 95% CI: 0.58-1.08); however, neither effect reached statistical significance within each subgroup. Additionally, we found that the risk of reintervention for females versus males varied by clinical presentation, where females were less likely to undergo reintervention after an elective or symptomatic AAA repair but were more likely to undergo reintervention after a repair for AAA rupture (HR=1.70, 95% CI: 1.05-2.75).Males and females undergoing AAA repair had similar rates of reintervention and late aneurysm rupture in the 10 years following their procedure. However, our findings suggest that repair type and clinical presentation may affect the role of sex in clinical outcomes and warrants further exploration in these subgroups.

    View details for DOI 10.1016/j.jvs.2023.06.105

    View details for PubMedID 37442215

  • Optimal Medical Therapy: Key to Improved Lower Extremity Outcomes, Especially Following Endovascular and Infrainguinal Revascularization for Intermittent Claudication Hafeez, M., Khamzina, Y., Andraska, E., Meyer, J., Liang, N. L., Sridharan, N. D., Hall, D., Arya, S., Tzeng, E., Reitz, K. M. MOSBY-ELSEVIER. 2023: E245-E246
  • Sex-stratified 5-Year Outcomes Following Endovascular Versus Open Repair of Complex Abdominal Aortic Aneurysms Yadavalli, S., Rastogi, V., Mehta, A., Allievi, S., de Bruin, J. L., Arya, S., Stangenberg, L., Verhagen, H. M., Schermerhorn, M. L. MOSBY-ELSEVIER. 2023: E105-E106
  • Procedure Mix and Regional Variation in Vascular Community Care Referrals in the Veterans Administration Health Care System Costanza, M., Kiang, S. C., Tang, G. L., Hal-Pern, V., Summers, K., Feghali, A., Tsai, S., Alabi, O., Carlson, S., Beavers, F., Mouawad, N. J., Morgan, C., Arya, S. MOSBY-ELSEVIER. 2023: E349-E350
  • SVM Communications: Using registries to investigate vascular disease. Vascular medicine (London, England) Holder, T. A., Alabi, O., Arya, S., Beach, J. M., Eagle, K., Kim, E. S., Shalhub, S., Gornik, H. L. 2023: 1358863X231169808

    View details for DOI 10.1177/1358863X231169808

    View details for PubMedID 37154392

  • Simplifying Hospital Quality Comparisons for Vascular Surgery Using Center-level Frailty Burden Rather than Comorbidities. Annals of vascular surgery George, E. L., Rothenberg, K. A., Barreto, N. B., Chen, R., Trickey, A. W., Arya, S. 2023


    Failure to rescue (FtR), or inpatient death following complication, is a publicly reported hospital quality measure. Previous work has demonstrated significant variation in the proportion of frail patients across hospitals. However, frailty is not incorporated into risk-adjustment algorithms for hospital quality comparisons and risk adjustment is made by comorbidity scores. Our aim was to assess the impact of frailty on FtR quality measurement and as a means of risk adjustment.Patients undergoing open or endovascular aneurysm repair or lower extremity bypass in the Vascular Quality Initiative (VQI) at centers performing > 25 vascular procedures annually (2003-2019) were included. Multivariable logistic regression evaluated in-hospital death using scaled hierarchical modeling clustering at the center-level. Center FtR observed/expected (O/E) ratios were compared with expected values adjusted for either standard comorbidity profiles or frailty as measured by the VQI Risk Analysis Index (RAI). Centers were divided into quartiles using VQI-linked American Hospital Association data to describe the hospital characteristics of centers whose ranks changed.A total of 63,143 patients (213 centers) were included; 1,630 patients (2.58%) were classified as FtR. After accounting for center-level variability, frailty was associated with FtR [scaled odds ratio 1.9 (1.8-2.0), p<0.001]. The comorbidity-centric and frailty-based models performed similarly in predicting FtR with C-statistics of 0.85 (0.84-0.86) and 0.82 (0.82-0.84), respectively. Overall changes in ranking based on O/E ratios were not statistically significant (p=0.48). High and low performing centers had similar ranking using comorbidity-centric and frailty-based methods; however, centers in the middle of the performance spectrum saw more variability in ranking alterations. Forty-nine (23%) of hospitals improved their ranking by 5 or more positions when using frailty vs comorbidity risk adjustment. The centers in Quartile 4, those who performed the highest number of vascular procedures annually, experience on average a significant improvement in hospital ranking when frailty was used for risk adjustment, whereas centers performing the fewest number of vascular procedures and the lowest proportion of vascular surgery cases annually (Quartile 1) saw a significant worsening of ranking position (all p < 0.05). However, total number of surgical procedures annually, total hospital beds, for-profit status and teaching hospital status were not significantly associated with changes in rank.A simple frailty-adjusted model has similar predictive abilities as a comorbidity-focused model for predicting a common quality metric that influences reimbursement. In addition to distilling the risk-adjustment algorithm to a few variables, frailty can be assessed preoperatively to develop quality improvement efforts for rescuing frail patients. Centers treating a greater proportion of frail patients and those who perform higher volumes of vascular surgery benefit from a risk adjustment strategy based on frailty.

    View details for DOI 10.1016/j.avsg.2023.04.024

    View details for PubMedID 37121337

  • A framework for perioperative care for lower extremity vascular bypasses: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery. Journal of vascular surgery McGinigle, K. L., Spangler, E. L., Ayyash, K., Arya, S., Settembrini, A. M., Thomas, M. M., Dell, K. E., Swiderski, I. J., Davies, M. G., Setacci, C., Urman, R. D., Howell, S. J., Garg, J., Ljungvist, O., de Boer, H. D. 2023


    The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS®) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based suggestions for coordinated peri-operative care for patients undergoing infrainguinal bypass surgery for peripheral artery disease. Structured around the ERAS® core elements, 26 suggestions were made and organized into preadmission, preoperative, intraoperative, and postoperative sections.

    View details for DOI 10.1016/j.jvs.2023.01.018

    View details for PubMedID 36931611

  • Evaluation of Lower Extremity Calcium Score as a Measure of Peripheral Arterial Disease Burden and Amputation Risk. Annals of vascular surgery Lee, S., Kalra, K., Kashikar, A., Redpath, B., Bernheim, A., Brewster, L., Shaw, L., Arya, S. 2023


    The ankle-brachial pressure index (ABI) and toe-brachial pressure index (TBI) are commonly used diagnostic tools for peripheral artery disease (PAD) that are unreliable in the presence of calcified vessels.In this study, we aimed to demonstrate the utility of lower extremity calcium score (LECS) in addition to ABI and TBI in measuring disease burden and predicting the risk of amputation in patients with PAD.Patients who were evaluated in the vascular surgery clinic at Emory University for PAD and who underwent non-contrast CT of the aorta and lower extremities were included in the study. Aorto-iliac, femoral-popliteal, and tibial calcium scores were measured using the Agatston method. ABI and TBI that were obtained within 6 months of the CT scan were noted and divided into categories of PAD severity. Associations between ABI, TBI, and LECS of each anatomic segment were evaluated. Univariate and multivariate ordinal regression analysis were performed to predict the outcome of amputation. ROC analysis was performed to compare LECS with other variables in its ability to predict amputation.50 patients included in the study cohort were divided into LECS quartiles, with 12-13 patients in each quartile. The highest quartile tended to be older (p=0.016), had higher percentage of diabetics (p=0.034), and higher frequency of major amputation (p=0.004) compared to the other quartiles. Patients in the highest quartile of tibial calcium score were more likely to have stage 3 CKD or greater (p=0.011) and also had a higher frequency of amputation (p<0.005) and mortality (p=0.041). We found no significant association between each anatomic LECS and ABI/TBI categories. On univariate analysis, CKD (OR 12.92 [95% CI 2.01-82.83], p=0.007), DM (OR 5.47 [95% CI 1.27-23.64], p=0.023), tibial calcium score (OR 6.62 [95% CI 1.79-24.54], p=0.005) and total bilateral calcium score (OR 6.32 [95% CI 1.18-33.78], p=0.031) were associated with increased risk of amputation. On multivariate stepwise ordinal regression, TBI and tibial calcium score were identified as important predictors of amputation with HLD and CKD increasing the overall prediction of the model. On ROC analysis, the addition of tibial calcium score (AUC 0.94, SE 0.048). significantly improved the prediction of amputation compared to HLD, CKD and TBI alone (AUC 0.82, SE0.071, p=0.022).The addition of tibial calcium score to other known PAD risk factors may improve the prediction of amputation in patients with PAD.

    View details for DOI 10.1016/j.avsg.2023.02.009

    View details for PubMedID 36889632

  • Racial, ethnic, and socioeconomic inequities in amputation risk for patients with peripheral artery disease and diabetes. Seminars in vascular surgery Fereydooni, A., Patel, J., Dossabhoy, S. S., George, E. L., Arya, S. 2023; 36 (1): 9-18


    Peripheral artery disease and diabetes are highly prevalent diseases and the leading cause of limb loss. Despite advances in medical and surgical techniques, there are stark differences in delivery and outcomes of lower extremity amputation among populations when stratified by race, ethnicity, and socioeconomic status. We reviewed studies from the last 2 decades (1999-2022) to provide a comprehensive assessment of the current impact of disparities on the risk for, and management of, lower extremity amputation and offer action items that can optimize health outcomes.

    View details for DOI 10.1053/j.semvascsurg.2023.01.005

    View details for PubMedID 36958903

  • Transfusion trigger after operations in high cardiac risk patients (TOP) trial protocol. Protocol for a multicenter randomized controlled transfusion strategy trial. Contemporary clinical trials Kougias, P., Mi, Z., Zhan, M., Carson, J. L., Dosluoglu, H., Nelson, P., Sarosi, G. A., Sm, S. A., Norman, L. E., Sharath, S., Scrymgeour, A., Ollison, J., Calais, L. A., Biswas, K. 2023: 107095


    There is substantial uncertainty regarding the effects of restrictive postoperative transfusion among patients who have underlying cardiovascular disease. The TOP Trial's objective is to compare adverse outcomes between liberal and restrictive transfusion strategies in patients undergoing vascular and general surgery operations, and with a high risk of postoperative cardiac events.A two-arm, single-blinded, randomized controlled superiority trial will be used across 15 Veterans Affairs hospitals with expected enrollment of 1520 participants. Postoperative transfusions in the liberal arm commence when Hb is <10 g/ dL and continue until Hb is greater than or equal to 10 g/dL. In the restrictive arm, transfusions begin when Hb is <7 g/dL and continue until Hb is greater than or equal to 7 g/dL. Study duration is estimated to be 5 years including a 3-month start-up period and 4 years of recruitment. Each randomized participant will be followed for 90 days after randomization with a mortality assessment at 1 year.The primary outcome is a composite endpoint of all-cause mortality, myocardial infarction (MI), coronary revascularization, acute renal failure, or stroke occurring up to 90-days after randomization. Events rates will be compared between restrictive and liberal transfusion groups.The TOP Trial is uniquely positioned to provide high quality evidence comparing transfusion strategies among patients with high cardiac risk. Results will clarify the effect of postoperative transfusion strategies on adverse outcomes and inform postoperative management identifier: NCT03229941.

    View details for DOI 10.1016/j.cct.2023.107095

    View details for PubMedID 36690072

  • Atherectomy Overuse: Do Policy Solutions Exist? Journal of the American Heart Association George, E. L., Wagner, T. H., Arya, S. 2022; 11 (22): e027422

    View details for DOI 10.1161/JAHA.122.027422

    View details for PubMedID 36373835

  • Quantifying Frailty Requires a Conceptual Model Before a Statistical Model JAMA SURGERY Reitz, K. M., Arya, S., Hall, D. E. 2022; 157 (11): 1065
  • Use of linked registry claims data for long term surveillance of devices after endovascular abdominal aortic aneurysm repair: observational surveillance study. BMJ (Clinical research ed.) Goodney, P., Mao, J., Columbo, J., Suckow, B., Schermerhorn, M., Malas, M., Brooke, B., Hoel, A., Scali, S., Arya, S., Spangler, E., Alabi, O., Beck, A., Gladders, B., Moore, K., Zheng, X., Eldrup-Jorgensen, J., Sedrakyan, A., Society for Vascular Surgerys Patient Safety Organization, Giles, K., Beach, J., Clouse, W. D., Stone, D., Randall, M. D., Mansukhani, N., Wang, G., Woo, K., Mureebe, L., Dalsing, M., Maijub, J., Chaar, C., Duwayri, Y., Bertges, D., Mena-Hurtado, C., Smolderen, K., Berman, S., Osborne, N., Henke, P., Cronenwett, J. 2022; 379: e071452


    OBJECTIVE: To evaluate long term outcomes (reintervention and late rupture of abdominal aortic aneurysm) of aortic endografts in real world practice using linked registry claims data.DESIGN: Observational surveillance study.SETTING: 282 centers in the Vascular Quality Initiative Registry linked to United States Medicare claims (2003-18).PARTICIPANTS: 20489 patients treated with four device types used for endovascular abdominal aortic aneurysm repair (EVAR): 40.6% (n=8310) received the Excluder (Gore), 32.2% (n=6606) the Endurant (Medtronic), 16.0% (n=3281) the Zenith (Cook Medical), and 11.2% (n=2292) the AFX (Endologix). Given modifications to AFX in late 2014, patients who received the AFX device were categorized into two groups: the early AFX group (n=942) and late AFX group (n=1350) and compared with patients who received the other devices, using propensity matched Cox models.MAIN OUTCOME MEASURES: Reintervention and rupture of abdominal aortic aneurysm post-EVAR; all patients (100%) had complete follow-up via the registry or claims based outcome assessment, or both.RESULTS: Median age was 76 years (interquartile range (IQR) 70-82 years), 80.0% (16386/20489) of patients were men, and median follow-up was 2.3 years (IQR 0.9-4.1 years). Crude five year reintervention rates were significantly higher for patients who received the early AFX device compared with the other devices: 14.9% (95% confidence interval 13.7% to 16.2%) for Excluder, 19.5% (18.1% to 21.1%) for Endurant, 16.7% (15.0% to 18.6%) for Zenith, and early 27.0% (23.7% to 30.6%) for the early AFX. The risk of reintervention for patients who received the early AFX device was higher compared with the other devices in propensity matched Cox models (hazard ratio 1.61, 95% confidence interval 1.29 to 2.02) and analyses using a surgeon level instrumental variable of >33% AFX grafts used in their practice (1.75, 1.19 to 2.59). The linked registry claims surveillance data identified the increased risk of reintervention with the early AFX device as early as mid-2013, well before the first regulatory warnings were issued in the US in 2017.CONCLUSIONS: The linked registry claims surveillance data identified a device specific risk in long term reintervention after EVAR of abdominal aortic aneurysm. Device manufacturers and regulators can leverage linked data sources to actively monitor long term outcomes in real world practice after cardiovascular interventions.

    View details for DOI 10.1136/bmj-2022-071452

    View details for PubMedID 36283705

  • A Systematic Review of the Recruitment and Outcome Reporting by Sex and Race/Ethnicity in Stent Device Development Trials for Endovascular Abdominal Aortic Aneurysm Repair. Annals of vascular surgery Patel, J., Pallapothu, S., Langston, A., Trickey, A. W., Burdon, T., Goodney, P., Arya, S. 2022


    OBJECTIVE: Women and racial/ethnic minority groups have been shown to experience poor outcomes after endovascular aortic aneurysm repair (EVAR). One potential reason is the rare inclusion of these populations in initial phases of device development. The objective of this systematic review is to understand enrollment and outcome reporting by Sex and Race/Ethnicity in industry-funded EVAR device development trials.METHODS: MEDLINE, PubMed, and Embase, were searched from inception to January 2022 without language restrictions using the following terminology: "stent", "graft", "endograft", "device", "abdominal aortic aneurysm".CLINICALTRIALS: gov was also searched from inception to January 2022 for "abdominal aortic aneurysm." Two independent reviewers screened and extracted data. All phase I-III and post-market evaluation trials that included patients ≥ 18 years of age, who underwent EVAR were assessed. Participation-to-prevalence ratios (PPR) were calculated to estimate representation of participants by sex and race/ethnicity in trials compared with their share of disease burden.RESULTS: Among the 4,780 retrieved articles, 55 industry-funded trials met inclusion criteria for this review. A total of 51 trials (93%) reported enrolment by sex/gender, and only 7 trials (13%) reported enrolment by race/ethnicity of the participants. A median of 19 (IQR 4.5, 51) women participants were recruited compared to 171 (IQR 57, 311.5) men, and 17 (IQR 7.5, 21.5) racial/minority patients were recruited compared to 241 (IQR 123, 463.5) White participants. Women represent 16.6% of the disease population, and the median PPR is 0.62 (IQR 0.42, 0.88), which has remained constant over time (Figure 1). None of the device trials reported outcomes based on sex/gender or race/ethnicity.CONCLUSIONS: This systematic review to highlights the disparities in recruitment and outcome reporting based on sex and race/ethnicity in EVAR device development trials. While most trials may be underpowered to study these differences, recent registry studies show differential outcomes based on sex and race/ethnicity of vascular patients. Therefore, it is imperative to include and report outcomes in these participants, starting from the initial device development phases to improve generalizability of device-use and understand sources of variation in device performance.

    View details for DOI 10.1016/j.avsg.2022.09.059

    View details for PubMedID 36272665

  • Quantifying Frailty Requires a Conceptual Model Before a Statistical Model. JAMA surgery Reitz, K. M., Arya, S., Hall, D. E. 2022

    View details for DOI 10.1001/jamasurg.2022.3110

    View details for PubMedID 35947376

  • Patient Perspectives on Recovery and Information Needs After Surgery: A Qualitative Study of Veterans. The Journal of surgical research Sasnal, M., Langston, A. H., Morris, A. M., Harris, A. H., Arya, S. 2022; 279: 765-773


    INTRODUCTION: Little is known about patients' postoperative emotional and social functioning and preferences for recovery settings. This qualitative study explores patients' perspectives on factors influencing postoperative recovery, including the proportion of time recovering at home (home time) and unmet information needs.METHODS: Semistructured interviews were conducted between September and December 2020 with veteran patients aged 65y or older who underwent surgery at a single hospital. A purposeful sampling strategy was used to identify patients with a broad representation of major operations and various amounts of home time. One-hour interviews were audio-recorded, transcribed verbatim, and anonymized for analysis. A rigorous team-based in-depth thematic analysis was performed. Validation techniques to enhance the quality and credibility of the study included triangulation, independent coding, and search for disconfirming evidence.RESULTS: Twelve patients were interviewed (11 [91.7%] males; mean (standard deviation) age, 72.3 [4.8] y). Five factors that influenced the recovery process emerged: (1) professional support services, (2) informal caregiver support, (3) environment for recovery, (4) individual traits, and (5) physical and functional impairments. The analysis also elucidated four unmet information needs regarding recovery: (1) personalized and detailed information, (2) anticipated recovery time, (3) possible complications, and (4) comprehensive information about discharge location options.CONCLUSIONS: The study demonstrated that patients recovering from surgery require wide-ranging levels of support to meet their unique needs and preferences. Patients value easy-to-understand and personalized information about recovery from providers. These findings may be helpful to develop strategies that better support patients in their postoperative recovery and post-acute care transition pathways.

    View details for DOI 10.1016/j.jss.2022.06.050

    View details for PubMedID 35944331

  • A Personalized Approach to Prevention of Venous Thromboembolism: One Size Does Not Fit All. JAMA surgery Dua, A., Majumdar, M., Arya, S. 2022

    View details for DOI 10.1001/jamasurg.2022.2204

    View details for PubMedID 35731539

  • Cardiovascular and Limb Events Following Endovascular Revascularization Among Patients ≥65Years Old: An American College of Cardiology PVI Registry Analysis. Journal of the American Heart Association Weissler, E. H., Wang, Y., Gales, J. M., Feldman, D. N., Arya, S., Secemsky, E. A., Aronow, H. D., Hawkins, B. M., Gutierrez, J. A., Patel, M. R., Curtis, J. P., Jones, W. S., Swaminathan, R. V. 2022: e024279


    Background We aimed to characterize the occurrence of major adverse cardiovascular and limb events (MACE and MALE) among patients with peripheral artery disease (PAD) undergoing peripheral vascular intervention (PVI), as well as associated factors in patients with chronic limb threatening ischemia (CLTI). Methods and Results Patients undergoing PVI in the American College of Cardiology's (ACC) National Cardiovascular Data Registry's PVI Registry who could be linked to Centers for Medicare and Medicaid Services data were included. The primary outcomes were MACE, MALE, and readmission within 1month and 1year following index CLTI-PVI or non-CLTI-PVI. Cox proportional hazards regression was used to identify factors associated with the development of the primary outcomes among patients undergoing CLTI-PVI. There were 1758 (49.7%) patients undergoing CLTI-PVI and 1779 (50.3%) undergoing non-CLTI-PVI. By 1year, MACE occurred in 29.5% of patients with CLTI (n=519), and MALE occurred in 34.0% of patients with CLTI (n=598). By 1year, MACE occurred in 8.2% of patients with non-CLTI (n=146), and MALE occurred in 26.1% of patients with non-CLTI (n=465). Predictors of MACE at 1year in CLTI-PVI included end-stage renal disease on hemodialysis, congestive heart failure, prior CABG, and severe lung disease. Predictors of MALE at 1year in CLTI-PVI included treatment of a prior bypass graft, profunda femoral artery treatment, end-stage renal disease on hemodialysis, and treatment of a previously treated lesion. Conclusions Patients ≥65years old undergoing PVI experience high rates of MACE and MALE. A range of modifiable and non-modifiable patient factors, procedural characteristics, and medications are associated with the occurrence of MACE and MALE following CLTI-PVI.

    View details for DOI 10.1161/JAHA.121.024279

    View details for PubMedID 35723018

  • A Vascular Quality Initiative Frailty Assessment Predicts Post-Discharge Mortality in Patients Undergoing Arterial Reconstruction. Journal of vascular surgery Kraiss, L. W., Al-Dulaimi, R., Allen, C. M., Mell, M. W., Arya, S., Presson, A. P., Brooke, B. S. 2022


    INTRODUCTION: Frailty assessment adds important prognostic information during pre-operative decision-making but can be cumbersome to implement into routine clinical care. We developed and tested an abbreviated method of frailty assessment using variables routinely collected by the Vascular Quality Initiative (VQI) registry.METHODS: An abbreviated frailty score (VQI-FS) was developed using eleven or fewer VQI variables (hypertension, congestive heart failure, coronary artery disease, peripheral vascular disease, diabetes, COPD, renal impairment, anemia, underweight, non-home residence, non-ambulatory status) that map to recognized frailty domains in the Comprehensive Geriatric Assessment and the literature. Non-emergent cases registered in the VQI from 2010-2017 (n=265,632) in seven registries (CEA, N=77,111; CAS, N=13,215; EVAR, N=29,607; OAAA, N=7442; INFRA, N=33,128; SUPRA, N=10,661; PVI, N=94,468) were analyzed using logistic regression models to determine the predictive power of the VQI-FS for perioperative and longer-term (9-month) mortality. Nomograms were created using weighted regression coefficients to assist in individualized frailty assessment and estimation of 9-month mortality.RESULTS: The VQI-FS using equal weighting of eleven VQI variables effectively predicted 9-month mortality with an area under the curve (AUC) of 0.724 by receiver operating characteristic (ROC) curve analysis. However, differential weighting of the variables allowed simplification of the model to only seven variables (CHF, renal impairment, COPD, not living at home, not ambulatory, anemia, underweight status) as hypertension, coronary artery disease, peripheral vascular disease and diabetes had relatively low predictive power. Adding procedure-specific risk further improved performance of the model with a final AUC on ROC analysis of 0.758. Model calibration was excellent with predicted/observed regression line slope of 0.991 and intercept of 5.449e-04.CONCLUSIONS: A differentially weighted abbreviated VQI-FS using seven variables in addition to procedure-specific risk has strong correlation with 9-month mortality. Nomograms incorporating patient- and procedure-adjusted risk can effectively predict 9-month mortality. Reliable estimates of longer-term mortality should assist in pre-operative decision-making for vascular procedures that often carry substantial risk of mortality.

    View details for DOI 10.1016/j.jvs.2022.05.017

    View details for PubMedID 35709866

  • Reply. Journal of vascular surgery Arya, S., Erben, Y. 2022; 75 (6): 2099-2100

    View details for DOI 10.1016/j.jvs.2022.01.128

    View details for PubMedID 35598938

  • Trends in annual open abdominal aortic surgical volumes for vascular trainees compared to annual national volumes in the endovascular era. Journal of vascular surgery George, E. L., Arya, S., Ho, V. T., Stern, J. R., Sgroi, M. D., Chandra, V., Lee, J. T. 2022


    OBJECTIVE: Prior analysis predicted a shortfall in open abdominal aortic repair (OAR) experience for vascular trainees resulting from the rapid adoption of and increased anatomic suitability of endovascular aortic repair (EVAR) technology. We explored how EVAR has transformed contemporary open aortic surgical education for vascular trainees.METHODS: We examined ACGME case volumes of open abdominal aortic aneurysm (AAA) repair and reconstruction for aorto-iliac occlusive disease (AIOD) via aorto-iliac/femoral bypass (AFB) from integrated vascular surgery residents (VSR) and fellows (VSF) graduating 2006-2017 and compared them to national estimates of total OAR (open AAA repair + AFB) in the Agency for Healthcare Research and Quality National Inpatient Sample based on ICD-9 and ICD-10 procedural codes. Changes over time were assessed using Chi-square test, Student's t-test, and linear regression.RESULTS: During the twelve-year study period, the national annual total OAR and open AAA repair estimates decreased: total OAR by 72.5% (2006: estimate (standard error) 24,255 (1185) vs. 2017: 6,690 (274); p<0.001) and open AAA repair by 84.7% (2006: 18,619 (924) vs. 2017: 2,850 (168); p<0.001); AFB estimates decreased by 33.0% (p<0.001). The percentage of total OAR, open AAA repair, and AFB performed at teaching hospitals significantly increased from 55 to 80% (all p<0.001). There was a 40.9% decrease in open AAA repairs logged by graduating VSF (mean 18.6 vs. 11) but only a 6.9% decrease in total OAR cases (mean 27.6 vs. 25.7) due to increasing AFB volumes (mean 9.0 vs. 14.7). VSR graduates consistently logged an average of 10 open AAA repairs and there was a 31.0% increase in total OAR (mean 23.2 vs. 30.4), again secondary to rising AFB volumes (mean 11.4 vs 17.5). Although there was an absolute decrease in open aortic experience for VSF, the rate of decline for total OAR case volumes was not significantly different after VSR programs were established (p=0.40).CONCLUSIONS: As incidence decreases nationally, OAR is shifting towards teaching hospitals. While open AAA procedures for trainees are declining due to EVAR, open aortic reconstruction for AIOD is rising and plays an important role in ensuring that vascular trainees continue to have satisfactory OAR experience sufficient for meeting minimum graduation requirements. Strategies to maintain and maximize the education and experience from these cases should be top priority for vascular surgery program directors.

    View details for DOI 10.1016/j.jvs.2022.03.887

    View details for PubMedID 35598821

  • Closing the Gaps in Racial Disparities in Critical Limb Ischemia Outcome and Amputation Rates: Proceedings from a Society of Interventional Radiology Foundation Research Consensus Panel. Journal of vascular and interventional radiology : JVIR Bryce, Y., Katzen, B., Patel, P., Moreira, C. C., Fakorede, F. A., Arya, S., D'Andrea, M., Mustapha, J., Rowe, V., Rosenfield, K., Vedantham, S., Abi-Jaoudeh, N., Rochon, P. J. 2022; 33 (5): 593-602


    Minority patients such as Blacks, Hispanics, and Native Americans are disproportionately impacted by critical limb ischemia and amputation due to multiple factors such as socioeconomic status, type or lack of insurance, lack of access to health care, capacity and expertise of local hospitals, prevalence of diabetes, and unconscious bias. The Society of Interventional Radiology Foundation recognizes that it is imperative to close the disparity gaps and funded a Research Consensus Panel to prioritize a research agenda. The following research priorities were ultimately prioritized: (a) randomized controlled trial with peripheral arterial disease screening of at-risk patients with oversampling of high-risk racial groups, (b) prospective trial with the introduction of an intervention to alter a social determinant of health, and (c) a prospective trial with the implementation of an algorithm that requires criteria be met prior to an amputation. This article presents the proceedings and recommendations from the panel.

    View details for DOI 10.1016/j.jvir.2022.02.010

    View details for PubMedID 35489789

  • A National Study of Surgical Palliative and End-of-Life Facility-Level Measures and Outcomes in the Department of Veterans Affairs Lorenz, K., Aslakson, R., Garcia, A., Boothroyd, D., Morris, A., Arya, S., Giannitrapani, K., Shreve, S. ELSEVIER SCIENCE INC. 2022: 912
  • Society for Vascular Surgery Appropriate Use Criteria for Management of Intermittent Claudication. Journal of vascular surgery Woo, K., Siracuse, J. J., Klingbeil, K., Kraiss, L. W., Osborne, N., Singh, N., Tan, T., Arya, S., Banerjee, S., Bonaca, M. P., Brothers, T., Conte, M. S., Dawson, D. L., Erben, Y., Lerner, B. M., Lin, J. C., Mills, J. L., Mittleider, D., Nair, D. G., O'Banion, L. A., Patterson, R. B., Scheidt, M. J., Simons, J. P., Society for Vascular Surgery Appropriateness Committee 2022


    The Society for Vascular Surgery (SVS) Appropriate Use Criteria (AUC) for Management of Intermittent Claudication were created using the RAND appropriateness method (RAM) which is a validated and standardized methodology that combines best-available evidence from medical literature with expert opinion, using a modified-Delphi process. These criteria serve as a framework upon which individualized patient and clinician shared decision-making can grow. These criteria are not absolute. AUC should not be interpreted as a requirement to administer treatments rated as appropriate (benefit outweighs risk). Nor should AUC be interpreted as a prohibition on treatments rated as inappropriate (risk outweighs benefit). There will be clinical situations in which moderating factors, not included in these AUC, will shift the appropriateness level of a treatment for an individual patient. Proper implementation of AUC calls for a description of those moderating patient factors. For scenarios with an indeterminate rating, clinician judgement combined with best available evidence should determine treatment strategy. Importantly, these are scenarios in need of mechanisms to track treatment decisions and outcomes. AUC should be revisited on a periodic basis to ensure that these criteria remain relevant. The panelists rated 2280 unique scenarios for the treatment of intermittent claudication (IC) in the aortoiliac, common femoral and femoropopliteal segment in Round 2 rating. Of these, only 9 (0.4%) had disagreement according to the IPRAS formula, indicating an exceptionally high degree of consensus among the panelists. [Note, post-hoc, the term, "inappropriate," was replaced with the term "R>B" (risk outweighs benefit). The term "appropriate" was also replaced with "B>R" (benefit outweighs risk)]. The key principles for the management of intermittent claudication reflected within these AUC are: (1) Exercise therapy is a preferred initial management strategy for all patients with IC. (2) For patients who have not completed exercise therapy, invasive therapy may provide net benefit in selected patients with IC who are non-smokers, are taking optimal medical therapy, are considered low physiologic and technical risk, and who are experiencing severe lifestyle limitation and/or short walking distance. (3) Considering the long-term durability of currently available technology, invasive interventions for femoropopliteal disease should be reserved for patients with severe lifestyle limitation and short walking distance. (4) In the common femoral segment, open common femoral endarterectomy provides greater net benefit than endovascular intervention for the treatment of IC. (5) In the infrapopliteal segment, invasive intervention for the treatment of intermittent claudication is of unclear benefit and may be harmful.

    View details for DOI 10.1016/j.jvs.2022.04.012

    View details for PubMedID 35470016

  • Ankle- and Toe-Brachial Index for Peripheral Artery Disease Identification: Unlocking Clinical Data Through Novel Methods. Circulation. Cardiovascular interventions Friberg, J. E., Qazi, A. H., Boyle, B., Franciscus, C., Vaughan-Sarrazin, M., Westerman, D., Patterson, O. V., Parr, S. K., Matheny, M. E., Arya, S., Smolderen, K. G., Lund, B. C., Gobbel, G. T., Girotra, S. 2022: CIRCINTERVENTIONS121011092


    BACKGROUND: Despite its high prevalence and clinical impact, research on peripheral artery disease (PAD) remains limited due to poor accuracy of billing codes. Ankle-brachial index (ABI) and toe-brachial index can be used to identify PAD patients with high accuracy within electronic health records.METHODS: We developed a novel natural language processing (NLP) algorithm for extracting ABI and toe-brachial index values and laterality (right or left) from ABI reports. A random sample of 800 reports from 94 Veterans Affairs facilities during 2015 to 2017 was selected and annotated by clinical experts. We trained the NLP system using random forest models and optimized it through sequential iterations of 10-fold cross-validation and error analysis on 600 test reports and evaluated its final performance on a separate set of 200 reports. We also assessed the accuracy of NLP-extracted ABI and toe-brachial index values for identifying patients with PAD in a separate cohort undergoing ABI testing.RESULTS: The NLP system had an overall precision (positive predictive value) of 0.85, recall (sensitivity) of 0.93, and F1 measure (accuracy) of 0.89 to correctly identify ABI/toe-brachial index values and laterality. Among 261 patients with ABI testing (49% PAD), the NLP system achieved a positive predictive value of 92.3%, sensitivity of 83.1%, and specificity of 93.1% to identify PAD when compared with a structured chart review. The above findings were consistent in a range of sensitivity analysis.CONCLUSIONS: We successfully developed and validated an NLP system for identifying patients with PAD within the Veterans Affairs electronic health record. Our findings have broad implications for PAD research and quality improvement.

    View details for DOI 10.1161/CIRCINTERVENTIONS.121.011092

    View details for PubMedID 35176872

  • Perioperative care in open aortic vascular surgery: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS) Society and Society for Vascular Surgery. Journal of vascular surgery McGinigle, K. L., Spangler, E. L., Pichel, A. C., Ayyash, K., Arya, S., Settembrini, A. M., Thomas, M. M., Dell, K. E., Swiderski, I. J., Lindo, F., Davies, M. G., Setacci, C., Urman, R. D., Howell, S. J., Ljungqvist, O., de Boer, H. D. 2022


    The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based recommendations related to all of the health care received in the perioperative period for patients undergoing open abdominal aortic operations (both transabdominal and retroperitoneal approaches, including supraceliac, suprarenal, and infrarenal clamp sites, for aortic aneurysm and aortoiliac occlusive disease). Structured around the ERAS core elements, 36 recommendations were made and organized into preadmission, preoperative, intraoperative, and postoperative recommendations.

    View details for DOI 10.1016/j.jvs.2022.01.131

    View details for PubMedID 35181517

  • Comparing Veterans Affairs and Private Sector Perioperative Outcomes After Noncardiac Surgery. JAMA surgery George, E. L., Massarweh, N. N., Youk, A., Reitz, K. M., Shinall, M. C., Chen, R., Trickey, A. W., Varley, P. R., Johanning, J., Shireman, P. K., Arya, S., Hall, D. E. 1800


    Importance: Recent legislation facilitates veterans' ability to receive non-Veterans Affairs (VA) surgical care. However, contemporary data comparing the quality and safety of VA and non-VA surgical care are lacking.Objective: To compare perioperative outcomes among veterans treated in VA hospitals with patients treated in private-sector hospitals.Design, Setting, and Participants: This cohort study took place across 8 noncardiac specialties in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from January 1, 2015, through December 31, 2018. Multivariable log-binomial modeling was used to evaluate the association between VA vs private sector care settings and 30-day mortality. Unmeasured confounding was quantified using the E-value. Patients 18 years and older undergoing a noncardiac procedures were included.Exposures: Surgical care in either a VA or private sector setting.Main Outcomes and Measures: Primary outcome was 30-day postoperative mortality. Secondary outcome was failure to rescue, defined as a postoperative death after a complication.Results: Of 3 910 752 operations (3 174 274 from VASQIP and 736 477 from NSQIP), 1 498 984 (92.1%) participants in VASQIP were male vs 678 382 (47.2%) in NSQIP (mean difference, -0.449 [95% CI, -0.450 to -0.448]; P<.001), and 441 894 (60.0%) participants in VASQIP were frail or very frail vs 676 525 (21.3%) in NSQIP (mean difference, -0.387 [95% CI, -0.388 to -0.386]; P<.001). Overall, rates of 30-day mortality, complications, and failure to rescue were 0.8%, 9.5%, and 4.7%, respectively, in NSQIP (n=3 174 274 operations) and 1.1%, 17.1%, and 6.7%, respectively in VASQIP (736 477) (differences in proportions, -0.003 [95% CI, -0.003 to -0.002]; -0.076 [95% CI, -0.077 to -0.075]; 0.020 [95% CI, 0.018-0.021], respectively; P<.001). Compared with private sector care, VA surgical care was associated with a lower risk of perioperative death (adjusted relative risk, 0.59 [95% CI, 0.47-0.75]; P<.001). This finding was robust in multiple sensitivity analyses performed, including among patients who were frail and nonfrail, with or without complications, and undergoing low and high physiologic stress procedures. These findings were also consistent when year was included as a covariate and in nonparsimonious modeling for patient-level factors. Compared with private sector care, VA surgical care was also associated with a lower risk of failure to rescue (adjusted relative risk, 0.55 [95% CI, 0.44-0.68]). An unmeasured confounder (present disproportionately in NSQIP data) would require a relative risk of 2.78 [95% CI, 2.04-3.68] to obviate the main finding.Conclusions and Relevance: VA surgical care is associated with lower perioperative mortality and decreased failure to rescue despite veterans having higher-risk characteristics. Given the unique needs and composition of the veteran population, health policy decisions and budgetary appropriations should reflect these important differences.

    View details for DOI 10.1001/jamasurg.2021.6488

    View details for PubMedID 34964818

  • Association of Smoking With Postprocedural Complications Following Open and Endovascular Interventions for Intermittent Claudication. JAMA cardiology Reitz, K. M., Althouse, A. D., Meyer, J., Arya, S., Goodney, P. P., Shireman, P. K., Hall, D. E., Tzeng, E. 2021


    Importance: Smoking is a key modifiable risk factor in the development and progression of peripheral artery disease, which often manifests as intermittent claudication (IC). Smoking cessation is a first-line therapy for IC, yet a minority of patients quit smoking prior to elective revascularization.Objective: To assess if preprocedural smoking is associated with an increased risk of early postprocedural complications following elective open and endovascular revascularization.Design, Setting, and Participants: This retrospective cohort study used nearest-neighbor (1:1) propensity score matching of 2011 to 2019 data from the Veterans Affairs Surgical Quality Improvement Program, including all cases with a primary diagnosis of IC and excluding emergent cases, primary procedures that were not lower extremity revascularization, and patients with chronic limb-threatening ischemia within 30 days of the intervention. All data were abstracted June 18, 2020, and analyzed from July 26, 2020, to June 30, 2021.Exposures: Preprocedural cigarette smoking.Main Outcomes and Measures: Any and organ system-specific (ie, wound, respiratory, thrombosis, kidney, cardiac, sepsis, and neurological) 30-day complications and mortality, overall and in prespecified subgroups.Results: Of 14 350 included cases of revascularization, 14 090 patients (98.2%) were male, and the mean (SD) age was 65.7 (7.0) years. A total of 7820 patients (54.5%) were smoking within the preprocedural year. There were a total of 4417 endovascular revascularizations (30.8%), 4319 hybrid revascularizations (30.1%), and 5614 open revascularizations (39.1%). A total of 1594 patients (11.1%) had complications, and 57 (0.4%) died. Among 7710 propensity score-matched cases (including 3855 smokers and 3855 nonsmokers), 484 smokers (12.6%) and 34 nonsmokers (8.9%) experienced complications, an absolute risk difference (ARD) of 3.68% (95% CI, 2.31-5.06; P<.001). Compared with nonsmokers, any complication was higher for smokers following endovascular revascularization (26 [4.3%] vs 52 [2.1%]; ARD, 2.19%; 95% CI, 0.77-3.60; P=.003), hybrid revascularization (204 [17.3%] vs 163 [14.1%]; ARD, 3.18%; 95% CI, 0.23-6.13; P=.04), and open revascularization (228 [15.4%] vs 153 [10.3%]; ARD, 5.18%; 95% CI, 2.78-7.58; P<.001). Compared with nonsmokers, respiratory complications were higher for smokers following endovascular revascularization (20 [1.7%] vs 6 [0.5%]; ARD, 1.17%; 95% CI, 0.35-2.00; P=.009), hybrid revascularization (33 [2.8%] vs 10 [0.9%]; ARD, 1.93%; 95% CI, 0.85-3.02; P=.001), and open revascularization (32 [2.2%] vs 19 [1.3%]; ARD, 0.89%; 95% CI, 0-1.80; P=.06). Wound complications and graft failure were higher for smokers compared with nonsmokers following open interventions (wound complications: 146 [9.9%] vs 87 [5.8%]; ARD, 4.05%; 95% CI, 2.12-5.99; P<.001; graft failure: 33 [2.2%] vs 11 [0.7%]; ARD, 1.50%; 95% CI, 0.63-2.37; P=.001). In a sensitivity analysis, compared with active smokers (n=5173; smoking within 2 weeks before the procedure), the risk of any complication was decreased by 65% for never smokers (n=1197; adjusted odds ratio, 0.45; 95% CI, 0.34-0.59) and 29% for former smokers (n=4755; cessation more than 1 year before the procedure; adjusted odds ratio, 0.71; 95% CI, 0.61-0.83; P=.001 for interaction).Conclusions and Relevance: In this cohort study, more than half of patients with IC were smoking prior to elective revascularization, and complication risks were higher across all modalities of revascularization. These findings stress the importance of smoking cessation to optimize revascularization outcomes.

    View details for DOI 10.1001/jamacardio.2021.3979

    View details for PubMedID 34613348

  • An analysis of gender disparities amongst United States medical students, general surgery residents, vascular surgery trainees and the vascular surgery workforce. Journal of vascular surgery Arya, S., Franco-Mesa, C., Erben, Y. 2021


    Gender diversity in medicine continues to be a critical topic and gender diversity within surgical fields remains an overarching challenge. In the following review, we objectively address the data available in terms of training slots for women in general and vascular surgery and within the vascular surgery workforce. Overall women comprise 36% of active physicians in the 2019 Association of American Medical Colleges' (AAMC) data. The number of women in surgical fields is lower representing 22% in general surgery, 9% in neurosurgery, 6% in orthopedic surgery, 17% in plastic surgery, 8% in thoracic surgery and 15% in vascular surgery. Also notable is the lower academic ranks held by women in surgery. The proportion of women instructors in surgery in 2020 were 61%, assistant professors 30%, associate professors 23% and full-time professors only 13.5%. There are multiple opportunities across the division/institutional/societal in which mentorship and sponsorship can promote gender equity and inclusion. Recruitment and retention of women and minorities into the vascular academic and private practices is essential to ensure best patient outcomes and quality of are for our patients. We hope that by shedding light on this topic, there will be greater awareness and improved strategies to address the disparities within institutions.

    View details for DOI 10.1016/j.jvs.2021.09.029

    View details for PubMedID 34619315

  • Open Abdominal Aortic Surgery in the Endovascular Era-Will we have Enough Volume for Vascular Trainees? George, E. L., Arya, S., Anand, A., Ho, V., Stern, J. R., Chandra, V., Lee, J. T. MOSBY-ELSEVIER. 2021: E418
  • The Correlation Between Case Total Work Relative Value Unit, Operative Stress, and Patient Frailty: Retrospective Cohort Study. Annals of surgery Reitz, K. M., Varley, P. R., Liang, N. L., Youk, A., George, E. L., Shinall, M. C., Shireman, P. K., Arya, S., Tzeng, E., Hall, D. E. 2021; 274 (4): 637-645


    OBJECTIVE: Assess the relationships between case total work relative value units (wRVU), patient frailty, and the physiologic stress of surgical interventions.SUMMARY OF BACKGROUND DATA: Surgeon reimbursement is frequently apportioned by wRVU. These subjective, procedure-specific valuations generated by physician survey estimate the intensity and time for typical patient care services. We hypothesized wRVU would not adequately account for patient-specific factors, such as frailty, that modify the required physician work, regardless of procedural complexity.METHODS: Using National and Veterans Affairs Surgical Quality Improvement Programs (2015-2018), we evaluated the correlation between case total wRVU, patient frailty (risk analysis index) and physiologic surgical stress (operative stress score).RESULTS: Of 4,111,371 (86%) cases, the correlation between total wRVU and operative stress was moderate [rhos = 0.587 (95% confidence interval, 0.586-0.587)], but negligible with frailty rho = 0.177 (95% confidence interval, 0.176-0.178)]. Very high operative stress procedures [n = 34,047 (1%)] generated a mean total wRVU of 55.1 (standard deviation, 12.9), comprising 7%, 2%, and 1% of thoracic, vascular, and general surgical cases, respectively. Very frail patients [n = 152,535 (4%)] accounted for 9% of thoracic, 9% of vascular, 4% of general, 5% of urologic, and 4% of neurologic surgical cases, generating 21.0 (standard deviation, 12.4) mean total wRVU. Some nonfrail patients undergoing low operative stress procedures [n = 60,128 (2%)] nonetheless generated the highest quintile wRVU; these comprised >15% of plastic, gynecologic, and urologic surgical cases.CONCLUSIONS: Surgeon reimbursement correlates with operative stress but not patient frailty. The total wRVU does not adequately reflect patient-specific factors that increase the physician workload required to render optimal care to complex patients.

    View details for DOI 10.1097/SLA.0000000000005068

    View details for PubMedID 34506319

  • Open Abdominal Aortic Surgery in the Endovascular Era - Will We Have Enough Volume for Vascular Trainees? George, E. L., Arya, S., Anand, A., Ho, V. T., Stern, J. R., Chandra, V., Lee, J. T. MOSBY-ELSEVIER. 2021: E259-E260
  • Institutionalization Rates in First Year After Abdominal Aortic Aneurysm Repair in Older Adults Arya, S., Kashikar, A., Gladders, B., Mao, J., Langston, A. H., Sedrakyan, A., Goodney, P. MOSBY-ELSEVIER. 2021: E306-E307
  • Recruitment and Outcome Reporting for Women and Minorities in Stent Device Development Trials for Endovascular Abdominal Aortic Aneurysm Repair Patel, J., Pallapothu, S., Trickey, A., Langston, A., Goodney, P., Arya, S. MOSBY-ELSEVIER. 2021: E54
  • Revascularization for Intermittent Claudication Significantly Increases the 5-year Risk of Major Amputation in the Veterans Health Administration George, E. L., Chen, R., Barreto, N., Langston, A. H., Trickey, A., Arya, S. MOSBY-ELSEVIER. 2021: E309
  • To Perform or Not to Perform Surgery for Frail Patients?-Reply. JAMA surgery Arya, S., George, E. L., Hall, D. E. 2021

    View details for DOI 10.1001/jamasurg.2021.1531

    View details for PubMedID 34009294

  • Gender Disparity in Surgical Society Leadership and Annual Meeting Programs. The Journal of surgical research Tirumalai, A. A., George, E. L., Kashikar, A., Langston, A. H., Rothenberg, K. A., Barreto, N. B., Trickey, A. W., Arya, S. 2021; 266: 69-76


    INTRODUCTION: Prior work suggests women surgical role models attract more female medical students into surgical training. We investigate recent trends of women in surgical society leadership and national conference moderator and plenary speaker roles.METHODS: Gender distribution was surveyed at 15 major surgical societies and 14 conferences from 2014 to 2018 using publicly reported data. Roles were categorized as leadership (executive council), moderator, or plenary speaker. Data were cross-checked from online profiles and by contacting societies. Logistic regression with Huber-White clustering by society was utilized to evaluate proportions of women in each role over time and determine associations between the proportion of women in executive leadership, and scientific session moderators and plenary speakers.RESULTS: The proportion of leadership positions held by women increased slightly from 2014 to 2018 (20.6%-26.6%, P = 0.23), as did the proportion of moderators (26.2%-30.6%, P = 0.027) and plenary speakers (26.2%-30.9%, P = 0.058). The proportion of women in each role varied significantly across societies (all P < 0.001): leaders (range 0.0%-52.0%), moderators (12.5%-58.8%), and plenary speakers (11.3%-60.0%). Three patterns of change were observed: eight societies (53.3%) demonstrated increases in representation of women over time, four societies (26.6%) showed stable moderate-to-good gender balance, and three societies (20.0%) had consistent underrepresentation of women.CONCLUSION: There is significant variability in the representation of women at the leadership level of national surgical societies and participating at national surgical conferences as moderators and plenary speakers. Over the past 5 years some societies have achieved advances in gender equity, but many societies still have substantial room for improvement.

    View details for DOI 10.1016/j.jss.2021.02.023

    View details for PubMedID 33984733

  • Reducing Nontraumatic Lower-Extremity Amputations by 20% by 2030: Time to Get to Our Feet: A Policy Statement From the American Heart Association CIRCULATION Creager, M. A., Matsushita, K., Arya, S., Beckman, J. A., Duval, S., Goodney, P. P., Gutierrez, J. T., Kaufman, J. A., Maddox, K., Pollak, A. W., Pradhan, A. D., Whitsel, L. P., Amer Heart Assoc Advocacy Coordina 2021; 143 (17): E875–E891


    Nontraumatic lower-extremity amputation is a devastating complication of peripheral artery disease (PAD) with a high mortality and medical expenditure. There are ≈150 000 nontraumatic leg amputations every year in the United States, and most cases occur in patients with diabetes. Among patients with diabetes, after an ≈40% decline between 2000 and 2009, the amputation rate increased by 50% from 2009 to 2015. A number of evidence-based diagnostic and therapeutic approaches for PAD can reduce amputation risk. However, their implementation and adherence are suboptimal. Some racial/ethnic groups have an elevated risk of PAD but less access to high-quality vascular care, leading to increased rates of amputation. To stop, and indeed reverse, the increasing trends of amputation, actionable policies that will reduce the incidence of critical limb ischemia and enhance delivery of optimal care are needed. This statement describes the impact of amputation on patients and society, summarizes medical approaches to identify PAD and prevent its progression, and proposes policy solutions to prevent limb amputation. Among the actions recommended are improving public awareness of PAD and greater use of effective PAD management strategies (eg, smoking cessation, use of statins, and foot monitoring/care in patients with diabetes). To facilitate the implementation of these recommendations, we propose several regulatory/legislative and organizational/institutional policies such as adoption of quality measures for PAD care; affordable prevention, diagnosis, and management; regulation of tobacco products; clinical decision support for PAD care; professional education; and dedicated funding opportunities to support PAD research. If these recommendations and proposed policies are implemented, we should be able to achieve the goal of reducing the rate of nontraumatic lower-extremity amputations by 20% by 2030.

    View details for DOI 10.1161/CIR.0000000000000967

    View details for Web of Science ID 000644635000003

    View details for PubMedID 33761757

  • US National Trends in Vascular Surgical Practice During the COVID-19 Pandemic. JAMA surgery Ho, V. T., Eberhard, A. V., Asch, S. M., Leeper, N. J., Fukaya, E., Arya, S., Ross, E. G. 2021

    View details for DOI 10.1001/jamasurg.2021.1708

    View details for PubMedID 33856428

  • PRISMA Reporting Guidelines for Meta-analyses and Systematic Reviews. JAMA surgery Arya, S., Kaji, A. H., Boermeester, M. A. 2021

    View details for DOI 10.1001/jamasurg.2021.0546

    View details for PubMedID 33825806

  • Epidemiology of atherosclerotic carotid artery disease. Seminars in vascular surgery Dossabhoy, S., Arya, S. 2021; 34 (1): 3–9


    Atherosclerotic carotid artery disease is a significant cause of stroke in the United States and globally. Its prevalence increases with age and it is more prevalent in men and White and Native-American populations. However, the outcomes related to carotid disease are worse in women and Black patients. Research suggests the disparities exist due to a multitude of factors, including disease pathophysiology, access to care, provider bias, and socioeconomic status. The prevalence of carotid stenosis in the general population is low (3%), and routine screening for carotid stenosis is not recommended in adults. Randomized clinical trials have shown benefits of stroke risk reduction with surgery (carotid endarterectomy or stenting) for symptomatic patients. Management is controversial in asymptomatic patients, as modern medical management has results equivalent to those of surgery and ongoing randomized clinical trials will address this important question. Carotid surgery is not appropriate in asymptomatic patients with limited life expectancy. Future work should explore comprehensive care models for care of patients with carotid disease and assessment of patient-reported outcomes to measure quality of care.

    View details for DOI 10.1053/j.semvascsurg.2021.02.013

    View details for PubMedID 33757633

  • Applications of Mobile Health Technology in Surgical Innovation. JAMA surgery Aalami, O., Ingraham, A., Arya, S. 2021

    View details for DOI 10.1001/jamasurg.2020.6251

    View details for PubMedID 33533899

  • Of Life and Limb: Addition of Low-Dose Rivaroxaban for Secondary Prevention After Peripheral Artery Disease Surgery. Circulation George, E. L., Arya, S. 2021; 144 (14): 1117-1119

    View details for DOI 10.1161/CIRCULATIONAHA.121.056291

    View details for PubMedID 34606303

  • Recalibration and External Validation of the Risk Analysis Index A Surgical Frailty Assessment Tool ANNALS OF SURGERY Arya, S., Varley, P., Youk, A., Borrebach, J. D., Perez, S., Massarweh, N. N., Johanning, J. M., Hall, D. E. 2020; 272 (6): 996–1005
  • A Novel Preoperative Risk Score for Non-Home Discharge After Elective Thoracic Endovascular Aortic Repair. Journal of vascular surgery Ramirez, J. L., Zarkowsky, D. S., Boitano, L. T., Conrad, M. F., Arya, S., Gasper, W. J., Conte, M. S., Iannuzzi, J. C. 2020


    INTRODUCTION: Non-home discharge (NHD) to a rehabilitation or skilled nursing facility after vascular surgery is poorly described despite its large impact on patients. Understanding post-surgical NHD risk is essential to providing adequate preoperative counseling and shared decision making, particularly for elective surgeries. We aimed to identify independent predictors of NHD following elective thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysms (TAA) and to create a clinically useful preoperative risk score.METHODS: Elective TEVAR cases for descending TAA were queried from the SVS Vascular Quality Initiative 2014-2018. A risk score was created by splitting the data set into two-thirds for model development and one-third for validation. A parsimonious stepwise hierarchical multivariable logistic regression controlling for hospital level variation was performed in the development dataset, and the beta-coefficients were used to assign points for a risk score. This score was then cross-validated and model performance assessed.RESULTS: Overall, 1,469 patients were included and 213 (14.5%) required NHD. At baseline, patients who required NHD were more likely to be ≥ 80 years old (35.2% vs. 19.4%), female (58.7% vs. 40.6%), functionally dependent (42.3% vs. 24.0%), anemic (46.5% vs. 27.8%), and have chronic obstructive pulmonary disease (41.3% vs. 33.4%), congestive heart failure (18.8% vs. 11.1%), and American Society of Anesthesiologists class ≥ 4 (51.6% vs. 39.8%; all P<0.05). Multivariable analysis in the development group identified independent predictors of NHD, which were used to create an 18-point risk score. Patients were stratified into three groups based upon their risk score: low risk (0-7 points; n=563) with an NHD rate of 4.3%, moderate risk (8-11 points; n=701) with an NHD rate of 17.0%, and high risk (≥ 12 points; n=205) with an NHD rate of 34.2%. The risk score had good predictive ability with c-statistic=0.75 for model development and c-statistic=0.72 in the validation dataset.CONCLUSIONS: This novel risk score can predict NHD following TEVAR for TAA using characteristics that can be identified preoperatively. Utilization of this score may allow for improved risk assessment, preoperative counseling, and shared decision making.

    View details for DOI 10.1016/j.jvs.2020.10.005

    View details for PubMedID 33065243

  • Incidence and Management of Arterial Vascular Trauma in the US Kashikar, A., Choi, J., Tennakoon, L., Spain, D., Arya, S. ELSEVIER SCIENCE INC. 2020: E263–E264
  • Factors Associated with Preference of Choice of Aortic Aneurysm Repair Eid, M. A., Barnes, J., Scali, S., Arya, S., Stone, D. ELSEVIER SCIENCE INC. 2020: S344
  • Postoperative Function as a Measure of Quality in Geriatric Surgical Care-Can We Do Better? JAMA surgery Seib, C. D., Arya, S. 2020

    View details for DOI 10.1001/jamasurg.2020.2863

    View details for PubMedID 32822480

  • Managing Central Venous Access during a Healthcare Crisis. Journal of vascular surgery Chun, T. T., Judelson, D. R., Rigberg, D., Lawrence, P. F., Cuff, R., Shalhub, S., Wohlauer, M., Abularrage, C. J., Anastasios, P., Arya, S., Aulivola, B., Baldwin, M., Baril, D., Bechara, C. F., Beckerman, W. E., Behrendt, C., Benedetto, F., Bennett, L. F., Charlton-Ouw, K. M., Chawla, A., Chia, M. C., Cho, S., Choong, A. M., Chou, E. L., Christiana, A., Coscas, R., De Caridi, G., Ellozy, S., Etkin, Y., Faries, P., Fung, A. T., Gonzalez, A., Griffin, C. L., Guidry, L., Gunawansa, N., Gwertzman, G., Han, D. K., Hicks, C. W., Hinojosa, C. A., Hsiang, Y., Ilonzo, N., Jayakumar, L., Joh, J. H., Johnson, A. P., Kabbani, L. S., Keller, M. R., Khashram, M., Koleilat, I., Krueger, B., Kumar, A., Lee, C. J., Lee, A., Levy, M. M., Lewis, C. T., Lind, B., Lopez-Pena, G., Mohebali, J., Molnar, R. G., Morrissey, N. J., Motaganahalli, R. L., Mouawad, N. J., Newton, D. H., Ng, J. J., O'Banion, L. A., Phair, J., Rancic, Z., Rao, A., Ray, H. M., Rivera, A. G., Rodriguez, L., Sales, C. M., Salzman, G., Sarfati, M., Savlania, A., Schanzer, A., Sharafuddin, M. J., Sheahan, M., Siada, S., Siracuse, J. J., Smith, B. K., Smith, M., Soh, I., Sorber, R., Sundaram, V., Sundick, S., Tomita, T. M., Trinidad, B., Tsai, S., Vouyouka, A. G., Westin, G. G., Williams, M. S., Wren, S. M., Yang, J. K., Yi, J., Zhou, W., Zia, S., Woo, K. 2020


    INTRODUCTION: During the COVID-19 pandemic, central venous access line teams were implemented at many hospitals throughout the world to provide access for critically ill patients. The objective of this study was to describe the structure, practice patterns and outcomes of these vascular access teams during the COVID-19 pandemic.METHODS: We conducted a cross sectional, self-reported study of central venous access line teams in hospitals afflicted with the COVID-19 pandemic. In order to participate in the study, hospitals were required to meet one of the following criteria: a) development of a formal plan for a central venous access line team during the pandemic, b) implementation of a central venous access line team during the pandemic, c) placement of central venous access by a designated practice group during the pandemic as part of routine clinical practice, or d) management of an iatrogenic complication related to central venous access in a patient with COVID-19.RESULTS: Participants from 60 hospitals in 13 countries contributed data to the study. Central venous line teams were most commonly composed of vascular surgery and general surgery attending physicians and trainees. Twenty sites had 2,657 lines placed by their central venous access line team or designated practice group. During that time, there were 11 (0.4%) iatrogenic complications associated with central venous access procedures performed by the line team or group at those 20 sites. Triple lumen catheters, Cordis catheters and non-tunneled hemodialysis catheters were the most common types of central venous lines placed by the teams. Eight (14%) sites reported experience placing central venous lines in prone, ventilated patients with COVID-19. A dedicated line cart was used by 35 (59%) of hospitals. Less than 50% (24, 41%) of the participating sites reported managing thrombosed central lines in COVID-patients. Twenty-three of the sites managed 48 iatrogenic complications in patients with COVID-19 (including complications caused by providers outside of the line team or designated practice group).CONCLUSIONS: Implementation of a dedicated central venous access line team during a pandemic or other healthcare crisis is a way by which physicians trained in central venous access can contribute their expertise to a stressed healthcare system. A line team composed of physicians with vascular skill sets provides relief to resource-constrained ICU, ward, and emergency medicine teams with a low rate of iatrogenic complications relative to historical reports. We recommend that a plan for central venous access line team implementation be in place for future healthcare crises.

    View details for DOI 10.1016/j.jvs.2020.06.112

    View details for PubMedID 32682063

  • Association of Preoperative Frailty and Operative Stress With Mortality After Elective vs Emergency Surgery. JAMA network open Shinall, M. C., Youk, A., Massarweh, N. N., Shireman, P. K., Arya, S., George, E. L., Hall, D. E. 2020; 3 (7): e2010358

    View details for DOI 10.1001/jamanetworkopen.2020.10358

    View details for PubMedID 32658284

  • The Affordable Care Act Is Associated With Increased Coverage and Decreased Charges, but Limited Improvement in Access to Vascular Surgery for Medicaid Patients George, E. L., Kashikar, A., Barreto, N. B., Chen, R., Trickey, A. W., Arya, S. MOSBY-ELSEVIER. 2020: E247–E248
  • Frailty Increases Reinterventions for Surgical Site Infections After Infrainguinal Bypass Procedures Kashikar, A., Barreto, N. B., George, E. L., Chen, R., Trickey, A. W., Arya, S. MOSBY-ELSEVIER. 2020: E152
  • The Role Of Multidisciplinary Team Comanagement of the Surgical Patient-It Takes A Village. JAMA network open Kashikar, A., Arya, S. 2020; 3 (5): e204354

    View details for DOI 10.1001/jamanetworkopen.2020.4354

    View details for PubMedID 32369176

  • Frailty as measured by the Risk Analysis Index is associated with long-term death after carotid endarterectomy. Journal of vascular surgery Rothenberg, K. A., George, E. L., Barreto, N., Chen, R., Samson, K., Johanning, J. M., Trickey, A. W., Arya, S. 2020


    OBJECTIVE: The role of carotid endarterectomy (CEA) continues to be debated in the age of optimal medical therapy, particularly for patients with limited life expectancy. The Risk Analysis Index (RAI) measures frailty, a syndrome of decreased physiologic reserve, which increases vulnerability to adverse outcomes. The RAI better predicts surgical complications, nonhome discharge, and death than age or comorbidities alone. We sought to measure the association of frailty, as measured by the RAI, with postoperative in-hospital stroke, long-term stroke, and long-term survival after CEA. We also sought to determine how postoperative stroke interacts with frailty to alter survival trajectory after CEA.METHODS: We queried the Vascular Quality Initiative CEA procedure and long-term data sets (2003-2017) for elective CEAs with complete RAI case information. For all analyses, the cohort was divided into asymptomatic and symptomatic carotid stenosis. Scoring was defined as not frail (RAI<30), frail (RAI 30-34), and very frail (RAI ≥35). Mortality information through December 2017 was obtained from the Social Security Death Index. Multivariable models (logistic and Cox proportional hazards regressions) were used to study the association of frail and very frail patients with the outcomes of interest. In a post hoc analysis, we created Kaplan-Meier curves to analyze patient mortality after CEA as well as after postoperative stroke.RESULTS: Of the 42,869 included patients, 17,092 (39.9%) were female, and 38,395 (89.6%) were white. There were 25,673 (59.9%) patients assigned to the asymptomatic stenosis group and 17,196 (40.1%) patients in the symptomatic stenosis group. Frailty was not associated with perioperative or long-term postoperative stroke. The risk of long-term mortality was significantly higher for frail (hazard ratio, 1.9 [1.7-2.3]) and very frail (hazard ratio, 3.1 [2.6-3.7]) asymptomatic patients; symptomatic frail and very frail patients also had a two to three times increased risk of long-term mortality. Frail and very frail patients had two to three times the risk for long-term mortality compared with patients who were not frail. Postoperative stroke negatively affected the mortality trajectory for all patients in the cohort, regardless of frailty status.CONCLUSIONS: RAI score is not associated with postoperative stroke; however, frail and very frail status is associated with decreased long-term survival in an incremental fashion based on increasing RAI. RAI assessment should be considered in the preoperative decision-making for patients undergoing CEA to ensure long-term survival and optimal surgical outcomes vs medical management.

    View details for DOI 10.1016/j.jvs.2020.01.043

    View details for PubMedID 32169359

  • Clinical Utility of the Risk Analysis Index as a Prospective Frailty Screening Tool within a Multi-practice, Multi-hospital Integrated Healthcare System. Annals of surgery Varley, P. R., Borrebach, J. D., Arya, S., Massarweh, N. N., Bilderback, A. L., Wisniewski, M. K., Nelson, J. B., Johnson, J. T., Johanning, J. M., Hall, D. E. 2020


    OBJECTIVE:: The goal of this project was to first address barriers to implementation of the Risk Analysis Index (RAI) within a large, multi-hospital, integrated healthcare delivery system, and to subsequently demonstrate its utility for identifying at-risk surgical patients.BACKGROUND: Prior studies demonstrate the validity of the RAI for evaluating preoperative frailty, but they have not demonstrated the feasibility of its implementation within routine clinical practice.METHODS: Implementation of the RAI as a frailty screening instrument began as a quality improvement initiative at the University of Pittsburgh Medical Center in July 2016. RAI scores were collected within a REDCap survey instrument integrated into the outpatient electronic health record and then linked to information from additional clinical datasets. NSQIP-eligible procedures were queried within 90 days following the RAI, and the association between RAI and postoperative mortality was evaluated using logistic regression and Cox proportional hazards models. Secondary outcomes such as inpatient length of stay and readmissions were also assessed.RESULTS: RAI assessments were completed on 36,261 unique patients presenting to surgical clinics across five hospitals from July 1 to December 31, 2016, and 8,172 of these underwent NSQIP-eligible surgical procedures. The mean RAI score was 23.6 (SD 11.2), the overall 30-day and 180-day mortality after surgery was 0.7% and 2.6%, respectively, and the median time required to collect the RAI was 33 [IQR 23-53] seconds. Overall clinic compliance with the recommendation for RAI assessment increased from 58% in the first month of the study period to 84% in the sixth and final month. RAI score was significantly associated with risk of death (HR=1.099 [95% C.I.: 1.091 - 1.106], p < 0.001). At an RAI cutoff of ≥37, the positive predictive values for 30- and 90-day readmission were 14.8% and 26.2%, respectively, and negative predictive values were 91.6% and 86.4%, respectively.CONCLUSIONS: The RAI frailty screening tool can be efficiently implemented within multi-specialty, multi-hospital healthcare systems. In the context of our findings and given the value of the RAI in predicting adverse postoperative outcomes, health systems should consider implementing frailty screening within surgical clinics.

    View details for DOI 10.1097/SLA.0000000000003808

    View details for PubMedID 32118596

  • Association of peripheral artery disease with life-space mobility restriction and mortality incommunity-dwelling older adults. Journal of vascular surgery Arya, S., Khakharia, A., Rothenberg, K. A., Johnson, T. M., Sawyer, P., Kennedy, R. E., Brown, C. J., Bowling, C. B. 2020


    OBJECTIVE: Symptomatic peripheral artery disease (PAD) impairs walking, but data on the impact of PAD on community mobility is limited. Life-space mobility measures the distance, frequency, and assistance needed as older adults move through geographic areas extending from their bedroom (life-space mobility score: 0) to beyond their town (life-space mobility score: 120). We evaluated the association of PAD with longitudinal life-space mobility trajectory.METHODS: Participants were part of the University of Alabama at Birmingham Study of Aging, a longitudinal study of community-dwelling older adults who were observed from 2001 to 2009. We limited our analysis to those who survived at least 6months (N= 981). PAD was based on self-report with verification by physician report and hospital records. Our primary outcome was life-space mobility score assessed every 6months. A multilevel change model (mixed model) was used to determine the association between PAD and life-space mobility trajectory during a median 7.9years of follow-up.RESULTS: Participants had a mean age of 75.7 (standard deviation, 6.7) years; 50.5% were female, and 50.4% were African American. PAD prevalence was 10.1%, and 57.1% of participants with PAD died. In participants with both PAD and life-space restriction, defined as life-space mobility score<60, we observed the highest mortality (73.1%). In a multivariable adjusted mixed effects model, participants with PAD had a more rapid decline in life-space mobility by-1.1 (95% confidence interval [CI],-1.9 to-0.24) points per year compared with those without PAD. At 5-year follow-up, model-adjusted mean life-space mobility was 48.1 (95% CI, 43.5-52.7) and 52.4 (95% CI, 50.9-53.8) among those with and without PAD, respectively, corresponding to a restriction in independent life-space mobility at the level of one's neighborhood.CONCLUSIONS: Life-space mobility is a novel patient-centered measure of community mobility, and PAD is associated with significant life-space mobility decline among community-dwelling older adults. Further study is needed to mechanistically confirm these findings and to determine whether better recognition and treatment of PAD alter the trajectory of life-space mobility.

    View details for DOI 10.1016/j.jvs.2019.08.276

    View details for PubMedID 32081483

  • Association of Sex With Repair Type and Long-term Mortality in Adults With Abdominal Aortic Aneurysm. JAMA network open Ramkumar, N., Suckow, B. D., Arya, S., Sedrakyan, A., Mackenzie, T. A., Goodney, P. P., Brown, J. R. 2020; 3 (2): e1921240


    Importance: Sex-based differences exist in the prevalence and clinical presentation of abdominal aortic aneurysm (AAA). However, it is unclear if sex is associated with AAA repair type and long-term mortality.Objective: To investigate whether a sex-related difference exists in mortality risk after AAA repair owing to differences in repair type.Design, Setting, and Participants: This cohort study uses data from the Vascular Quality Initiative, a national clinical registry, and Medicare claims to investigate endovascular and surgical repair procedures performed between January 1, 2003, and September 30, 2015, in patients aged 65 years or older with AAA. The data were analyzed from October 1, 2018, to November 19, 2019.Exposure: Sex of the patient.Main Outcomes and Measures: Endovascular (EVR) or open surgical AAA repair type and subsequent long-term, all-cause mortality.Results: In this cohort study of 16 386 patients, 12 757 (77.9%) were men and 3629 (22.1%) were women. Women were more likely than men to be older (mean [SD] age, 77 [6.5] years vs 75 [6.6] years; P<.001), active smokers (33% vs 28%; P<.001), and to have smaller aneurysms (mean [SD] diameter, 57 [11.7] mm vs 59 [17.7] mm; P<.001). Surgical AAA repair was performed in 27% (983 of 3629) of women compared with 18% (2328 of 12 757) of men (P<.001). After inverse probability weighting for risk adjustment, women were more likely to receive open surgical repair than EVR repair (risk ratio, 1.65; 95% CI, 1.51-1.80). The 10-year unadjusted survival rate after EVR repair was 14% lower in women than in men (23% vs 37%; log-rank P<.001), but the rates were comparable after open surgical repair (36% in men vs 32% in women; log-rank P=.22). Risk-adjusted analysis showed that women were associated with higher mortality rates after EVR repair (hazard ratio, 1.13; 95% CI, 1.03-1.24), whereas both men and women had a similar risk of death after open surgical repair (hazard ratio, 0.94; 95% CI, 0.84-1.06). After further stratification by symptom severity, higher risk of mortality among women was limited to elective EVR and open surgical repair for ruptured AAA.Conclusions and Relevance: In this study, women were 65% more likely than men to undergo open surgical repair. After EVR repair, women were 13% more likely to die than men, although no sex-based difference in mortality was found after open surgical repair. The differential treatment benefit of EVR repair in women is concerning given the shift toward an EVR-first approach to AAA repair.

    View details for DOI 10.1001/jamanetworkopen.2019.21240

    View details for PubMedID 32058556

  • Practical Guide to Meta-analysis. JAMA surgery Arya, S., Schwartz, T. A., Ghaferi, A. A. 2020

    View details for DOI 10.1001/jamasurg.2019.4523

    View details for PubMedID 31995161

  • Assessment of Risk Analysis Index for Prediction of Mortality, Major Complications and Length of Stay in Vascular Surgery Patients. Annals of vascular surgery Rothenberg, K. A., George, E. L., Trickey, A. W., Barreto, N. B., Johnson, T. M., Hall, D. E., Johanning, J. M., Arya, S. 2020


    INTRODUCTION: Frailty is a risk factor for adverse postoperative outcomes. We aimed to test the performance of a prospectively-validated frailty measure, the Risk Analysis Index (RAI) in vascular surgery patients and delineate the additive impact of procedure complexity on surgical outcomes.METHODS: We queried the 2007-2013 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify six major elective vascular procedure categories (carotid revascularization, abdominal aortic aneurysm [AAA] repair, suprainguinal revascularization, infrainguinal revascularization, thoracic aortic aneurysm [TAA] repair, and thoracoabdominal aortic aneurysm [TAAA] repair). We trained and tested logistic regression models for 30-day mortality, major complications and prolonged length of stay (LOS). The first model, "RAI", used the RAI alone; "RAI-Procedure (RAI-P)" included procedure category (e.g., AAA repair) and procedure approach (e.g., endovascular); "RAI-Procedure Complexity (RAI-PC)" added outpatient versus inpatient surgery, general anesthesia use, work relative value units (RVUs), and operative time.RESULTS: The RAI model was a good predictor of mortality for vascular procedures overall (C-statistic 0.72). The C-statistic increased with the RAI-P (0.78), which further improved minimally, with the RAI-PC (0.79). When stratified by procedure category, the RAI predicted mortality well for infrainguinal (0.79) and suprainguinal (0.74) procedures, moderately well for AAA repairs (0.69) and carotid revascularizations (0.70), and poorly for TAAs (0.62) and TAAAs (0.54). For carotid, infrainguinal, and suprainguinal procedures, procedure complexity (RAI-PC) had little impact on model discrimination for mortality, did improve discrimination for AAAs (0.84), TAAs (0.73), and TAAAs (0.80). While the RAI model was not a good predictor for major complications or LOS, discrimination improved for both with the RAI-PC model.CONCLUSIONS: Frailty as measured by the RAI was a good predictor of mortality overall after vascular surgery procedures. While the RAI was not a strong predictor of major complications or prolonged LOS, the models improved with the addition of procedure characteristics like procedure category and approach.

    View details for DOI 10.1016/j.avsg.2020.01.015

    View details for PubMedID 31935435

  • Contemporary Practices and Complications of Surgery for Thoracic Outlet Syndrome in the United States. Annals of vascular surgery George, E. L., Arya, S. n., Rothenberg, K. A., Hernandez-Broussard, T. n., Ho, V. T., Stern, J. R., Gelabert, H. A., Lee, J. T. 2020


    Thoracic outlet syndrome (TOS) surgery is relatively rare and controversial given the challenges in diagnosis as well as wide variation in symptomatic and functional recovery. Our aims were to measure trends in utilization of TOS surgery, complications, and mortality rates in a nationally representative cohort and compare higher- versus lower-volume centers.The National Inpatient Sample was queried using ICD-9 codes for rib resection and scalenectomy paired with axillo-subclavian aneurysm [arterial (aTOS)], subclavian DVT [venous (vTOS)], or brachial plexus lesions [neurogenic (nTOS)]. Basic descriptive statistics, non-parametric tests for trend, and multivariable hierarchical regression models with random intercept for center were used to compare outcomes for TOS types, trends over time, and higher- and lower-volume hospitals, respectively.There were 3,547 TOS operations (for an estimated 18,210 TOS operations nationally) performed between 2010-2015 (89.2% nTOS, 9.9% vTOS, 0.9% aTOS) with annual case volume increasing significantly over time (p=0.03). Higher-volume centers (≥10 cases/year) represented 5.2% of hospitals and 37.0% of cases, and these centers achieved significantly lower overall major complication (defined as neurologic injury, arterial or venous injury, vascular graft complication, pneumothorax, hemorrhage/hematoma or lymphatic leak) rates [adjusted Odds Ratio (OR) 0.71 (95% confidence interval 0.52-0.98); p=0.04], but no difference in neurologic complications such as brachial plexus injury (aOR 0.69 (0.20-2.43); p=0.56) or vascular injuries/graft complications [aOR 0.71 (0.0.33=1.54); p=0.39]. Overall mortality was 0.6%, neurologic injury was rare (0.3%), and the proportion of patients experiencing complications decreased over time (p=0.03). However, vTOS & aTOS had >2.5 times the odds of major complication compared to nTOS [OR 2.68 (1.88-3.82) & aOR 4.26 (1.78-10.17); p<0.001], and ∼10 times the odds of a vascular complication [aOR 10.37 (5.33-20.19) & aOR 12.93 (3.54-47.37); p<0.001], respectively. As the number of complications decreased, average hospital charges also significantly decreased over time (p<0.001). Total hospital charges were on average higher when surgery was performed in lower-volume centers (< 10 cases/year) compared to higher-volume centers [mean $65,634 (standard deviation 98,796) vs. $45,850 (59,285), p<0.001].The annual number of TOS operations have increased in the United States from 2010-2015, while complications and average hospital charges have decreased. Mortality and neurologic injury remain rare. Higher-volume centers delivered higher-value care: less or similar operative morbidity with lower total hospital charges.

    View details for DOI 10.1016/j.avsg.2020.10.046

    View details for PubMedID 33340669

  • Poor glycemic control is associated with significant increase in major limb amputation and adverse events in the 30-day postoperative period after infrainguinal bypass. Journal of vascular surgery McGinigle, K. L., Kindell, D. G., Strassle, P. D., Crowner, J. R., Pascarella, L. n., Farber, M. A., Marston, W. A., Arya, S. n., Kalbaugh, C. A. 2020


    Understanding modifiable risk factors to improve surgical outcomes is increasingly important in value-based health care. There is an established association between peripheral artery disease (PAD), diabetes, and limb loss, but less is known about expected outcomes after revascularization relative to the degree of glycemic control. The purpose of this study was to determine the association between hemoglobin A1c (HbA1c) management in diabetics and surgical outcomes after open infrainguinal bypass.The Vascular Quality Initiative infrainguinal bypass module was used to identify adult patients (≥18 years) with a history of diabetes who underwent bypass for PAD between 2011 and 2018. Exclusion criteria included missing or illogical HbA1c values and if the indication for the limb treated was not PAD. Patients were categorized by preoperative HbA1c levels as low severity/controlled (<7.0%), high severity (7.0%-10.0%), and very high severity (>10.0%). Primary outcomes were 30-day incidence of major adverse cardiac events (MACEs), major adverse limb events (MALEs), ipsilateral amputation, and 1-year all-cause mortality. Thirty-day outcomes were calculated using multivariable regression to compute odds ratios; hazard ratios were calculated for all-cause mortality. All analyses were adjusted for demographics, comorbidities, and clinical characteristics.The final sample included 30,813 operations (27,988 unique patients): 17,517 (57%) nondiabetic patients, 5194 patients with low-severity/controlled diabetes, and 8102 (26%) patients with poorly controlled diabetes, including 5531 (70%) treated with insulin. There were 6439 (21%) patients with high-severity HbA1c values and 1663 (5%) patients with very-high-severity HbA1c values. Those with a very high HbA1c level were more likely to be nonwhite, insulin dependent, and active smokers. Compared with nondiabetics, patients with very-high-severity HbA1c had an 81% increase in MACEs and 31% increase in MALEs, whereas patients with high-severity HbA1c only had a 49% increase in MACEs and a 12% increase in MALEs. Each one-step increase in severity category (eg, low to high to very high) was associated with an average 29% increase in the odds of MACEs and an 8% increase in the odds of MALEs.Uncontrolled diabetes with an HbA1c value >10.0% was associated with significantly worse 30-day surgical outcomes. Patients with incrementally better glycemic control (HbA1c level of 7.0%-10.0%) did not suffer the same rate of complications, suggesting that preoperative attempts at improving diabetes management even slightly could lead to improved surgical outcomes in open infrainguinal bypass patients.

    View details for DOI 10.1016/j.jvs.2019.11.048

    View details for PubMedID 32139308

  • Validation of the Risk Analysis Index for Evaluating Frailty in Ambulatory Patients. Journal of the American Geriatrics Society Shah, R. n., Borrebach, J. D., Hodges, J. C., Varley, P. R., Wisniewski, M. K., Shinall, M. C., Arya, S. n., Johnson, J. n., Nelson, J. B., Youk, A. n., Massarweh, N. N., Johanning, J. M., Hall, D. E. 2020


    Frailty is a marker of dependency, disability, hospitalization, and mortality in community-dwelling older adults. However, existing tools for measuring frailty are too cumbersome for rapid point-of-care assessment. The Risk Analysis Index (RAI) of frailty is validated in surgical populations, but its performance outside surgical populations is unknown.Validate the RAI in ambulatory patients.Observational cohort study of outpatient surgical clinics within the University of Pittsburgh Medical Center Healthcare System between July 1, 2016, and December 31, 2016. Frailty was assessed using the RAI. Current Procedural Terminology codes following RAI assessment identified patients with and without minor office-based procedures (eg, joint injection, laryngoscopy).All-cause 1-year mortality, assessed by stratified Cox proportional hazard models.Of 28,059 patients, 13,861 were matched to a minor, office-based procedure and 14,198 did not undergo any procedure. The mean (SD) age was 56.7 (17.2) years; women constituted 15,797 (56.3%) of the cohort. Median time (interquartile range 25th-75th percentile) to measure RAI was 30 (22-47) seconds. Mortality among the frail was two to five times that of patients with normal RAI scores. For example, the hazard ratio for frail ambulatory patients without a minor procedure was 3.69 (95% confidence interval [CI] = 2.51-5.41), corresponding to 30-, 180-, and 365-day mortality rates of 2.9%, 11.2%, and 17.4%, respectively, compared to 0.3%, 2.3%, and 4.0% among patients with normal RAI scores. Discrimination of mortality (overall, and censored at 30, 180, and 365 days) was excellent, ranging from c = 0.838 (95% CI = 0.773-0.902) for 30-day mortality after minor procedures to c = 0.909 (95% CI = 0.855-0.964) without a procedure.RAI is a valid, easily administered tool for point-of-care frailty assessment in ambulatory populations that may help clinicians and patients make better informed decisions about care choices-especially among patients considered high risk with a potentially limited life span.

    View details for DOI 10.1111/jgs.16453

    View details for PubMedID 32310317

  • Patients with Depression Are Less Likely to Go Home After Critical Limb Revascularization. Journal of vascular surgery Ramirez, J. L., Zahner, G. J., Arya, S. n., Grenon, S. M., Gasper, W. J., Sosa, J. A., Conte, M. S., Iannuzzi, J. C. 2020


    While often overlooked during preoperative evaluation, recent evidence suggests that depression in patients with peripheral arterial disease (PAD) is associated with increased postoperative complications including decreased primary and secondary patency after revascularization and increased risk of major amputation and mortality. Post-operative non-home discharge (NHD) is an important outcome for patients and has also been associated with other adverse outcomes, but the impact that depression has on NHD after vascular surgery remains unexplored. We hypothesized that depression would be associated with an increased risk for NHD following revascularization for chronic limb threatening ischemia (CLTI).Endovascular, open, and hybrid (combined open and endovascular) cases of revascularization for CLTI were identified from the 2012-2014 National (Nationwide) Inpatient Sample. CLTI, diagnoses of depression, and medical comorbidities were defined using corresponding ICD-9 codes. A hierarchical multivariable binary logistic regression controlling for hospital level variation examined the association between depression and NHD and controlled for confounders meeting P<0.01 on bivariate analysis. A sensitivity analysis after coarsened exact matching (CEM) for baseline characteristics that differed between the two groups was done to reduce imbalance.There were 64,817 cases identified, of which 5,472 (8.4%) were diagnosed with depression, and 16,524 (25.5%) required NHD. Patients with depression were younger, more likely to be women, white, have multiple comorbidities, a non-elective admission, and experience a postoperative complication (P<0.05). On unadjusted analyses, patients with depression had an 8% absolute increased risk of requiring NHD (32.1% vs 24.9%, P<0.001). On multivariable analysis, patients with depression had an increased odds for NHD (OR=1.50; 95% CI=1.40-1.61, c-statistic=0.81) compared to those without depression. After stratification by operative approach, depression had a larger effect estimate in endovascular revascularization (OR=1.57; 95% CI=1.42-1.74) compared to open (OR=1.45; 95% CI=1.30-1.62). A test for interaction between depression and gender identified that men with depression had higher odds of NHD compared to women with depression (OR=1.68, 95% CI=1.51-1.88 vs OR=1.37, 95% CI=1.25-1.51; interaction P<0.01). A sensitivity analysis after CEM confirmed these findings.To our knowledge, this is the first study to identify an association between depression and NHD after revascularization for CLTI. These results provide further evidence of the negative impact that comorbid depression has on patients undergoing revascularization for CLTI. Future study should examine whether treating depression can improve outcomes in this patient population.

    View details for DOI 10.1016/j.jvs.2020.12.079

    View details for PubMedID 33383108

  • Racial and Sex Disparities in Catheter Use and Dialysis Access in the United States Medicare Population. Journal of the American Society of Nephrology : JASN Arya, S. n., Melanson, T. A., George, E. L., Rothenberg, K. A., Kurella Tamura, M. n., Patzer, R. E., Hockenberry, J. M. 2020


    Despite efforts to increase arteriovenous fistula and graft use, 80% of patients in the United States start hemodialysis on a central venous catheter (CVC).To better understand in incident hemodialysis patients how sex and race/ethnicity are associated with time on a central venous catheter and transition to an arteriovenous fistula and graft, our observational cohort study analyzed US Renal Data System data for patients with incident ESKD aged ≥66 years who started hemodialysis on a CVC in July 2010 through 2013.At 1 year, 32.7% of 74,194 patients transitioned to an arteriovenous fistula, 10.8% transitioned to an arteriovenous graft, 32.1% stayed on a CVC, and 24.5% died. Women spent a significantly longer time on a CVC than men. Compared with white patients, patients who were black, Hispanic, or of another racial/ethnicity minority spent significantly more days on a CVC. In competing risk regression, women were significantly less likely than men to transition to a fistula and more likely to transition to a graft. Compared with white patients, blacks were significantly less likely to transition to a fistula but more likely to transition to a graft, Hispanics were significantly more likely to transition to a fistula, and other races/ethnicities were significantly more likely to transition to either a fistula or a graft.Female patients spend a longer time on a CVC and are less likely to transition to permanent access. Compared with white patients, minorities also spend longer time on a CVC, but are more likely to eventually transition to permanent access. Strategies to speed transition to permanent access should target groups that currently lag in this area.

    View details for DOI 10.1681/ASN.2019030274

    View details for PubMedID 31941721

  • Association of comorbid depression with inpatient outcomes in critical limb ischemia. Vascular medicine (London, England) Zahner, G. J., Cortez, A., Duralde, E., Ramirez, J. L., Wang, S., Hiramoto, J., Cohen, B. E., Wolkowitz, O. M., Arya, S., Hills, N. K., Grenon, S. M. 2019: 1358863X19880277


    There is a growing body of evidence that peripheral artery disease (PAD) may be impacted by depression. The objective of this study is to determine whether outcomes, primarily major amputation, differ between patients with depression and those without who presented to hospitals with critical limb ischemia (CLI), the end-stage of PAD. A retrospective cohort of patients hospitalized for CLI during 2012 and 2013 was identified from the National Inpatient Sample (NIS) using ICD-9 codes. The primary outcome was major amputation and secondary outcomes were length of stay and other complications. The sample included 116,008 patients hospitalized for CLI, of whom 10,512 (9.1%) had comorbid depression. Patients with depression were younger (64 ± 14 vs 67 ± 14 years, p < 0.001) and more likely to be female (55% vs 41%, p < 0.001), white (73% vs 66%, p < 0.001), and tobacco users (46% vs 41%, p < 0.001). They were also more likely to have prior amputations (9.8% vs 7.9%, p < 0.001). During the hospitalization, the rate of major amputation was higher in patients with comorbid depression (11.5% vs 9.1%, p < 0.001). In multivariable analysis, excluding patients who died prior to/without receiving an amputation (n = 2621), comorbid depression was associated with a 39% increased odds of major amputation (adjusted OR 1.39, 95% CI 1.30, 1.49; p < 0.001). Across the entire sample, comorbid depression was also independently associated with a slightly longer length of stay (beta = 0.199, 95% CI 0.155, 0.244; p < 0.001). These results provide further evidence that depression is a variable of interest in PAD and surgical quality databases should include mental health variables to enable further study.

    View details for DOI 10.1177/1358863X19880277

    View details for PubMedID 31713461

  • Simplifying Hospital Quality Comparisons for Vascular Surgery Using Center-Level Frailty Burden Rather than Comorbidities George, E. L., Rothenberg, K., Barreto, N. L., Chen, R., Trickey, A. W., Arya, S. ELSEVIER SCIENCE INC. 2019: S163–S164
  • Novel Preoperative Risk Score to Identify Patients at High Risk for Non-Home Discharge after Elective Thoracic Endovascular Aortic Aneurysm Repair Ramirez, J. L., Zarkowsky, D. S., Boitano, L. T., Conrad, M. F., Arya, S., Gasper, W. J., Conte, M. S., Iannuzzi, J. C. ELSEVIER SCIENCE INC. 2019: S332
  • Patients with Depression Are Less Likely to Go Home after Critical Limb Revascularization Ramirez, J. L., Zahner, G. J., Arya, S., Grenon, S., Gasper, W. J., Sosa, J. A., Conte, M. S., Iannuzzi, J. C. ELSEVIER SCIENCE INC. 2019: S332–S333
  • Genome-wide association study of peripheral artery disease in the Million Veteran Program. Nature medicine Klarin, D., Lynch, J., Aragam, K., Chaffin, M., Assimes, T. L., Huang, J., Lee, K. M., Shao, Q., Huffman, J. E., Natarajan, P., Arya, S., Small, A., Sun, Y. V., Vujkovic, M., Freiberg, M. S., Wang, L., Chen, J., Saleheen, D., Lee, J. S., Miller, D. R., Reaven, P., Alba, P. R., Patterson, O. V., DuVall, S. L., Boden, W. E., Beckman, J. A., Gaziano, J. M., Concato, J., Rader, D. J., Cho, K., Chang, K., Wilson, P. W., O'Donnell, C. J., Kathiresan, S., VA Million Veteran Program, Tsao, P. S., Damrauer, S. M. 2019


    Peripheral artery disease (PAD) is a leading cause of cardiovascular morbidity and mortality; however, the extent to which genetic factors increase risk for PAD is largely unknown. Using electronic health record data, we performed a genome-wide association study in the Million Veteran Program testing ~32 million DNA sequence variants with PAD (31,307 cases and 211,753 controls) across veterans of European, African and Hispanic ancestry. The results were replicated in an independent sample of 5,117 PAD cases and 389,291 controls from the UK Biobank. We identified 19 PAD loci, 18 of which have not been previously reported. Eleven of the 19 loci were associated with disease in three vascular beds (coronary, cerebral, peripheral), including LDLR, LPL and LPA, suggesting that therapeutic modulation of low-density lipoprotein cholesterol, the lipoprotein lipase pathway or circulating lipoprotein(a) may be efficacious for multiple atherosclerotic disease phenotypes. Conversely, four of the variants appeared to be specific for PAD, including F5 p.R506Q, highlighting the pathogenic role of thrombosis in the peripheral vascular bed and providing genetic support for Factor Xa inhibition as a therapeutic strategy for PAD. Our results highlight mechanistic similarities and differences among coronary, cerebral and peripheral atherosclerosis and provide therapeutic insights.

    View details for DOI 10.1038/s41591-019-0492-5

    View details for PubMedID 31285632

  • Frailty as Measured by the Risk Analysis Index Predicts Long-Term Death After Carotid Endarterectomy Rothenberg, K. A., George, E., Barreto, N., Chen, R., Samson, K. K., Johanning, J. M., Trickey, A., Arya, S. MOSBY-ELSEVIER. 2019: E62
  • The Impact of Frailty on Failure to Rescue Following Elective Abdominal Aortic Aneurysm Repair George, E. L., Rothenberg, K. A., Barreto, N., Chen, R., Trickey, A., Johanning, J., Hockenberry, J., Arya, S. MOSBY-ELSEVIER. 2019: E124–E125
  • Association of Frailty and Postoperative Complications With Unplanned Readmissions After Elective Outpatient Surgery. JAMA network open Rothenberg, K. A., Stern, J. R., George, E. L., Trickey, A. W., Morris, A. M., Hall, D. E., Johanning, J. M., Hawn, M. T., Arya, S. 2019; 2 (5): e194330


    Importance: Ambulatory surgery in geriatric populations is increasingly prevalent. Prior studies have demonstrated the association between frailty and readmissions in the inpatient setting. However, few data exist regarding the association between frailty and readmissions after outpatient procedures.Objective: To examine the association between frailty and 30-day unplanned readmissions after elective outpatient surgical procedures as well as the potential mediation of surgical complications.Design, Setting, and Participants: In this retrospective cohort study of elective outpatient procedures from 2012 and 2013 in the National Surgical Quality Improvement Program (NSQIP) database, 417 840 patients who underwent elective outpatient procedures were stratified into cohorts of individuals with a length of stay (LOS) of 0 days (LOS=0) and those with a LOS of 1 or more days (LOS≥1). Statistical analysis was performed from June 1, 2018, to March 31, 2019.Exposure: Frailty, as measured by the Risk Analysis Index.Main Outcomes and Measures: The main outcome was 30-day unplanned readmission.Results: Of the 417 840 patients in this study, 59.2% were women and unplanned readmission occurred in 2.3% of the cohort overall (LOS=0, 2.0%; LOS≥1, 3.4%). Frail patients (mean [SD] age, 64.9 [15.5] years) were more likely than nonfrail patients (mean [SD] age, 35.0 [15.8] years) to have an unplanned readmission in both LOS cohorts (LOS=0, 8.3% vs 1.9%; LOS≥1, 8.5% vs 3.2%; P<.001). Frail patients were also more likely than nonfrail patients to experience complications in both cohorts (LOS=0, 6.9% vs 2.5%; LOS≥1, 9.8% vs 4.6%; P<.001). In multivariate analysis, frailty doubled the risk of unplanned readmission (LOS=0: adjusted relative risk [RR], 2.1; 95% CI, 2.0-2.3; LOS≥1: adjusted RR, 1.8; 95% CI, 1.6-2.1). Complications occurred in 3.1% of the entire cohort, and frailty was associated with increased risk of complications (unadjusted RR, 2.6; 95% CI, 2.4-2.8). Mediation analysis confirmed that complications are a significant mediator in the association between frailty and readmissions; however, it also indicated that the association of frailty with readmission was only partially mediated by complications (LOS=0, 22.8%; LOS≥1, 29.3%).Conclusions and Relevance: These findings suggest that frailty is a significant risk factor for unplanned readmission after elective outpatient surgery both independently and when partially mediated through increased complications. Screening for frailty might inform the development of interventions to decrease unplanned readmissions, including those for outpatient procedures.

    View details for DOI 10.1001/jamanetworkopen.2019.4330

    View details for PubMedID 31125103

  • The Importance of Incorporating Frailty Screening Into Surgical Clinical Workflow JAMA NETWORK OPEN George, E. L., Arya, S. 2019; 2 (5)
  • Appropriateness of Carotid Endarterectomy in Asymptomatic Carotid Disease-Predicting 5-Year Survival JAMA SURGERY Rothenberg, K. A., Arya, S. 2019; 154 (4): 345
  • The Importance of Incorporating Frailty Screening Into Surgical Clinical Workflow. JAMA network open George, E. L., Arya, S. n. 2019; 2 (5): e193538

    View details for PubMedID 31074807

  • Variation in center-level frailty burden and the impact of frailty on long-term survival in patients undergoing elective repair for abdominal aortic aneurysms. Journal of vascular surgery George, E. L., Chen, R. n., Trickey, A. W., Brooke, B. S., Kraiss, L. n., Mell, M. W., Goodney, P. P., Johanning, J. n., Hockenberry, J. n., Arya, S. n. 2019


    Frailty is increasingly recognized as a key determinant in predicting postoperative outcomes. Centers that see more frail patients may not be captured in risk adjustment, potentially accounting for poorer outcomes in hospital comparisons. We aimed to (1) determine the effect of frailty on long-term mortality in patients undergoing elective abdominal aortic aneurysm (AAA) repair and (2) evaluate the variability in frailty burden among centers in the Vascular Quality Initiative (VQI) database.Patients undergoing elective open and endovascular AAA repair (2003-2017) were identified, and those with complete data on component variables of the VQI-derived Risk Analysis Index (VQI-RAI) and centers with ≥10 AAA repairs were included. VQI-RAI characteristics are sex, age, body mass index, renal failure, congestive heart failure, dyspnea, preoperative ambulation, and functional status. Frailty was defined as VQI-RAI ≥35 based on prior work in surgical patients using other quality improvement databases. This corresponds to the top 12% of patients at risk in the VQI. Center-level VQI-RAI differences were assessed by analysis of variance test. Relationships between frailty and survival were compared by Kaplan-Meier analysis and the log-rank test for open and endovascular procedures. Multivariable hierarchical Cox proportional hazards regression models were calculated with random intercepts for center, controlling for frailty, race, insurance, AAA diameter, procedure type, AAA case mix, and year.A total of 15,803 patients from 185 centers were included. Mean VQI-RAI scores were 27.6 (standard deviation, 5.9; range, 4-56) and varied significantly across centers (F = 2.41, P < .001). The percentage of frail patients per center ranged from 0% to 40.0%. In multivariable analysis, frailty was independently associated with long-term mortality (hazard ratio, 2.88; 95% confidence interval, 2.6-3.2) after accounting for covariates and center-level variance. Open AAA repair was not associated with long-term mortality after adjusting for frailty (hazard ratio, 0.98; 95% confidence interval, 0.86-1.13). There was a statistically significant difference in the percentage of frail patients compared with nonfrail patients who were discharged to a rehabilitation facility or nursing home after both open (40.5% vs 17.8%; P < .0001) and endovascular repair (17.7% vs 4.6%; P < .0001).There is considerable variability of preoperative frailty among VQI centers performing elective AAA repair. Adjusting for center-level variation, frailty but not procedure type had a significant association with long-term mortality; however, frailty and procedure type were both associated with nonhome discharge. Routine measurement of frailty preoperatively by centers to identify high-risk patients may help mitigate procedural and long-term outcomes and improve shared decision-making regarding AAA repair.

    View details for DOI 10.1016/j.jvs.2019.01.074

    View details for PubMedID 31147116

  • Outcomes and Durability of Endovascular Aneurysm Repair in Octogenarians Lagergren, E., Chihade, D., Zhan, H., Perez, S., Brewster, L., Arya, S., Jordan, W. D., Duwayri, Y. ELSEVIER SCIENCE INC. 2019: 33–39


    Endovascular aneurysm repair (EVAR) accounts for the majority of all abdominal aortic aneurysm (AAA) repairs in the United States. EVAR utilization in the aging population is increasing due to the minimally invasive nature of the procedure, the low associated perioperative morbidity, and early survival benefit over open repair. The objective of this study is to compare the outcomes of octogenarians after elective EVAR to their younger counterparts, a question that can be answered by a long-term, institutional data set.This was a retrospective series of 255 patients, who underwent elective EVAR within our institution from 2008 to 2015. A comparative analysis of patients aged 80 years and older and less than 80 years was performed. Outcomes measured included perioperative death and myocardial infarction (MI), length of stay, and readmission within 30 days. Aneurysm reintervention, long-term surveillance imaging, and aneurysm-related deaths were also evaluated. In addition, subset analyses of octogenarians were compared for survival at 24 months.Overall, 255 patients were included in our analysis. Fifty-nine patients were octogenarians, and 196 patients were nonoctogenarians. The mean age difference between the two groups was significant (84.5 years [SD, ±3.44] vs. 69.6 years [SD, ±6.13] in the ≥80 and <80 groups, respectively; P < 0.0001). There was no significant difference in the mean aneurysm size (6.03 cm [SD, ±1.12] vs. 5.535 cm [SD, ±0.9]; P < 0.06) between the ≥80 and < 80 groups. Octogenarians had higher rates of perioperative MI (5% vs. 1%, P < 0.04), thirty-day mortality (7% vs. 0%, P < 0.003), a higher number of perioperative complications (0.64 incidence per patient [SD, ±1.11] vs. 0.31 [SD, ±0.69], P < 0.005), and a longer mean hospital stay (5.34 [SD, ±5.75] days vs. 3.16 [SD, ±3.23] days, P < 0.0003), and they were also less likely to be discharged home after surgery (75% vs. 91%, P < 0.002). In the evaluated long-term outcomes, the two groups were similar with regard to aneurysm reintervention (10% vs. 9%, P < 0.06) and the stability of aneurysm sac size on imaging at last follow-up (71% vs. 80%, P < 0.27). The overall aortic related cause of death was different between the groups (8% vs. 1%, P < 0.003); however, the long-term aortic related mortality was not different between the two groups (2% vs. 1%, P < 0.4). Finally, a subset analysis of the octogenarian group was performed comparing patients based on survival status at 24 months. Higher preoperative creatinine (1.73 mg/dL [SD, ±1.54] vs. 1.15 mg/dL [SD, ±0.46]) and lower preoperative hematocrit (33.9% [SD, ±3.43] vs. 37.2% [SD, ±4.9]) along with number of perioperative complications (1.2 incidence per patient [SD, ±1.74] vs. 0.45 [SD, ±0.73]) were associated with death at 24 months after the index operation.Elective endovascular repair of AAA in octogenarians carries a higher risk of perioperative mortality but acceptable long-term outcomes. Appropriateness of elective EVAR in octogenarians should be answered based on this potential short-lived survival benefit, taking into account that advanced age should not be the sole basis of exclusion for otherwise suitable candidates for elective EVAR.

    View details for PubMedID 30244017

  • Appropriateness of Carotid Endarterectomy in Asymptomatic Carotid Disease-Predicting 5-Year Survival. JAMA surgery Rothenberg, K. A., Arya, S. n. 2019

    View details for PubMedID 30624550

  • Comparison of Surgeon Assessment to Frailty Measurement in Abdominal Aortic Aneurysm Repair. The Journal of surgical research George, E. L., Kashikar, A. n., Rothenberg, K. A., Barreto, N. L., Chen, R. n., Trickey, A. W., Arya, S. n. 2019; 248: 38–44


    Endovascular abdominal aortic aneurysm repair (EVAR) allows us to intervene on patients otherwise considered poor candidates for open repair. Despite its importance in determining operative approach, no comparison has been made between the subjective "eyeball test" and an objective measurement of preoperative frailty for EVAR patients.Patients undergoing elective EVAR were identified in the Vascular Quality Initiative (VQI) database (2003-2017). Patients were classified "unfit" based on a surgeon-reported variable. Frailty was defined using the VQI-derived Risk Analysis Index, which includes sex, age, BMI, renal failure, congestive heart failure, dyspnea, preoperative ambulation, and functional status. The association between fitness and/or frailty and adverse outcomes was determined by logistic regression.A total of 11,694 patients undergoing elective EVAR were included of which only 18.1% were "unfit," whereas 34.6% were "frail" and overall 43.6% "unfit or frail." Patients deemed "unfit" or "frail" had significantly increased odds of mortality, complications, and nonhome discharge (P < 0.001), and both frailty and unfitness generated negative predictive values for these outcomes greater than 93%. In adjusted logistic regression, the addition of objective frailty significantly improved model performance in predicting nonhome discharge (C-statistic 0.65 versus 0.71, P < 0.001) and complications (0.59 versus 0.61, P = 0.01), but similarly predicted mortality (0.74 versus 0.73, P = 0.99).Preoperative frailty assessment provides a useful objective measure of risk stratification as an adjunct to a physician's clinical intuition. The addition of frailty expands the pool of high-risk patients who are more likely to experience adverse postoperative events after elective EVAR and may benefit from uniquely tailored perioperative interventions.

    View details for DOI 10.1016/j.jss.2019.11.005

    View details for PubMedID 31841735

  • Poor glycemic control is a strong predictor of postoperative morbidity and mortality in patients undergoing vascular surgery. Journal of vascular surgery Long, C. A., Fang, Z. B., Hu, F. Y., Arya, S., Brewster, L. P., Duggan, E., Duwayri, Y. 2018


    OBJECTIVE: Hyperglycemia is a common occurrence in patients undergoing cardiovascular surgery. It has been identified in several surgical cohorts that improved perioperative glycemic control reduced postoperative morbidity and mortality. A significant portion of the population with peripheral arterial disease suffers from the sequelae of diabetes or metabolic syndrome. A paucity of data exists regarding the relationship between perioperative glycemic control and postoperative outcomes in vascular surgery patients. The objective of this study was to better understand this relationship and to determine which negative perioperative outcomes could be abated with improved glycemic control.METHODS: This is a retrospective review of a vascular patient database at a large academic center from 2009 to 2013. Eligible procedures included carotid endarterectomy and stenting, endovascular and open aortic aneurysm repair, and all open bypass revascularization procedures. Data collected included standard demographics, outcome parameters, and glucose levels in the perioperative period. Perioperative hyperglycemia was defined as at least one glucose value>180mg/dL within 72hours of surgery. The primary outcome was 30-day mortality, with secondary outcomes of complications, need to return to the operating room, and readmission.RESULTS: Of the total 1051 patients reviewed, 366 (34.8%) were found to have perioperative hyperglycemia. Hyperglycemic patients had a higher 30-day mortality (5.7% vs 0.7%; P< .01) and increased rates of acute renal failure (4.9% vs 0.9%; P<.01), postoperative stroke (3.0% vs 0.7%; P< .01), and surgical site infections (5.7% vs 2.6%; P= .01). In addition, these patients were also more likely to undergo readmission (12.3% vs 7.9%; P= .02) and reoperation (6.3% vs 1.8%; P< .01). Furthermore, multivariable logistic regression demonstrated that perioperative hyperglycemia had a strong association with increased 30-day mortality and multiple negative postoperative outcomes, including myocardial infarction, stroke, renal failure, and wound complications.CONCLUSIONS: This study demonstrates a strong association between perioperative glucose control and 30-day mortality in addition to multiple other postoperative outcomes after vascular surgery.

    View details for PubMedID 30459015

  • Long-Term Mortality in Carotid Revascularization Patients. Circulation. Cardiovascular quality and outcomes Arya, S., Girotra, S. 2018; 11 (11): e004875

    View details for DOI 10.1161/CIRCOUTCOMES.118.004875

    View details for PubMedID 30571342

  • Long-Term Mortality in Carotid Revascularization Patients Procedure Risk Versus Patient Risk? CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES Arya, S., Girotra, S. 2018; 11 (11)
  • Interaction of Frailty and Postoperative Complications on Unplanned Readmission after Elective Outpatient Surgery Stern, J. R., Blum, K., Trickey, A. W., Hall, D. E., Johanning, J. M., Morris, A. M., Hawn, M. T., Arya, S. ELSEVIER SCIENCE INC. 2018: E25
  • Evaluation of Peripheral Calcium Score as a Measure of Peripheral Artery Disease Severity Lee, S., Kalra, K., Path, B., Little, B., Bernheim, A., Brewster, L., Shaw, L., Arya, S. MOSBY-ELSEVIER. 2018: E137
  • The association of comorbid depression with mortality and amputation in veterans with peripheral artery disease. Journal of vascular surgery Arya, S., Lee, S., Zahner, G. J., Cohen, B. E., Hiramoto, J., Wolkowitz, O. M., Khakharia, A., Binney, Z. O., Grenon, S. M. 2018


    OBJECTIVE: Peripheral artery disease (PAD) is an increasing health concern with rising incidence globally. Previous studies have shown an association between PAD incidence and depression. The objective of the study was to determine the association of comorbid depression with PAD outcomes (amputation and all-cause mortality rates) in veterans.METHODS: An observational retrospective cohort of 155,647 patients with incident PAD (2003-2014) from nationwide U.S. Veterans Health Administration hospitals was conducted using the national Veterans Affairs Corporate Data Warehouse. Depression was measured using concurrent International Classification of Diseases, Ninth Revision diagnosis codes 6months before or after PAD diagnosis. The main outcomes were incident major amputation and all-cause mortality. Crude associations were assessed with Kaplan-Meier plots. The effects of depression adjusted for covariates were analyzed using Cox proportional hazards models.RESULTS: Depression was present in 16% of the cohort, with the occurrence of 9517 amputations and 63,287 deaths (median follow-up, 5.9years). Unadjusted hazard ratios (HRs) of comorbid depression for amputations and all-cause mortality were 1.32 (95% confidence interval [CI], 1.25-1.39) and 1.02 (95% CI, 0.99-1.04), respectively. After adjustment for covariates in Cox regression models, a diagnosis of comorbid depression at the time of PAD diagnosis was associated with a 13% higher amputation (HR, 1.13; 95% CI, 1.07-1.19) and 17% higher mortality (HR, 1.17; 95% CI, 1.14-1.20) risk compared with patients with no depression. On stratification by use of antidepressants, depressed patients not taking antidepressants had a 42% higher risk of amputation (HR, 1.42; 95% CI, 1.27-1.58) compared with those without depression. Patients taking antidepressants for depression still had increased risk of amputation but only 10% higher compared with those without depression (HR, 1.10; 95% CI, 1.03-1.17). Interestingly, patients taking antidepressants for other indications also had a higher risk of amputation compared with those not having depression or not taking antidepressants (HR, 1.08; 95% CI, 1.03-1.14). Having any diagnosis of depression or the need for antidepressants increased the mortality risk by 18% to 25% in the PAD cohort compared with those without depression and not taking antidepressants for any other indication.CONCLUSIONS: PAD patients with comorbid depression have a significantly higher risk of amputation and mortality than PAD patients without depression. Furthermore, untreated depression was associated with an increased amputation risk in the PAD population, more so than depression or other mental illness being treated by antidepressants. The underlying mechanisms for causality, if any, remain to be determined. The association of antidepressant treatment use with amputation risk should prompt further investigations into possible mechanistic links between untreated depression and vascular dysfunction.

    View details for PubMedID 29588133

  • Race and Socioeconomic Status Independently Affect Risk of Major Amputation in Peripheral Artery Disease. Journal of the American Heart Association Arya, S., Binney, Z., Khakharia, A., Brewster, L. P., Goodney, P., Patzer, R., Hockenberry, J., Wilson, P. W. 2018; 7 (2)


    BACKGROUND: Black race has been shown to be a risk factor for amputation in peripheral artery disease (PAD); however, race has been argued to be a marker for socioeconomic status (SES) rather than true disparity. The aim of this study is to study the impact of race and SES on amputation risk in PAD patients.METHODS AND RESULTS: Patients with incident PAD in the national Veterans Affairs Corporate Data Warehouse were identified from 2003 to 2014 (N=155647). The exposures were race and SES (measured by median income in residential ZIP codes). The outcome was incident major amputation. Black veterans were significantly more likely to live in low-SES neighborhoods and to present with advanced PAD. Black patients had a higher amputation risk in each SES stratum compared with white patients. In Cox models (adjusting for covariates), black race was associated with a 37% higher amputation risk compared with white race (hazard ratio: 1.37; 95% confidence interval, 1.30-1.45), whereas low SES was independently predictive of increased risk of amputation (hazard ratio: 1.12; 95% confidence interval, 1.06-1.17) and showed no evidence of interaction with race. In predicted amputation risk analysis, black race and low SES continued to be significant risk factors for amputation regardless of PAD presentation.CONCLUSIONS: Black race significantly increases the risk of amputation within the same SES stratum compared with white race and has an independent effect on limb loss after controlling for comorbidities, severity of PAD at presentation, and use of medications.

    View details for PubMedID 29330260