Explantation of infected thoracic endovascular aortic repair

Prosthetic graft infection is a rare and serious complication of thoracic endovascular aortic repair associated with high mortality and posing unique challenges for treatment. The prosthetic graft infection is often identified late as patients present with mild nonspecific symptoms. We describe the successful medical management and surgical explantation of an infected thoracic endograft with an aorta-bronchial fistula, using an inline reconstruction with an antibiotic-soaked synthetic graft. In this report, we provide an example of a patient with an infected thoracic endograft and how inline reconstruction combined with appropriate medical management is an acceptable treatment strategy.

Peripheral atherectomy practice patterns in the United States from the Vascular Quality Initiative

OBJECTIVE

Peripheral atherectomy has been shown to have technical success in single-arm studies, but clinical advantages over angioplasty and stenting have not been demonstrated, leaving its role unclear. We sought to describe patterns of atherectomy use in a real-world U.S. cohort to understand how it is currently being applied.

METHODS

The Vascular Quality Initiative was queried to identify all patients who underwent peripheral vascular intervention from January 2010 to September 2016. Descriptive statistics were performed to analyze demographics of the patients, comorbidities, indication, treatment modalities, and lesion characteristics. The intermittent claudication (IC) and critical limb ischemia (CLI) cohorts were analyzed separately.

RESULTS

Of 85,605 limbs treated, treatment indication was IC in 51% (n = 43,506) and CLI in 49% (n = 42,099). Atherectomy was used in 15% (n = 13,092) of cases, equivalently for IC (15%; n = 6674) and CLI (15%; n = 6418). There was regional variation in use of atherectomy, ranging from a low of 0% in one region to a high of 32% in another region. During the study period, there was a significant increase in the proportion of cases that used atherectomy (11% in 2010 vs 18% in 2016; P < .0001). Compared with nonatherectomy cases, those with atherectomy use had higher incidence of prior peripheral vascular intervention (IC, 55% vs 43% [P < .0001]; CLI, 47% vs 41% [P < .0001]), greater mean number of arteries treated (IC, 1.8 vs 1.6 [P < .0001]; CLI, 2.1 vs 1.7 [P < .0001]), and lower proportion of prior leg bypass (IC, 10% vs 14% [P < .0001]; CLI, 11% vs 17% [P < .0001]). There was lower incidence of failure to cross the lesion (IC, 1% vs 4% [P < .0001]; CLI, 4% vs 7% [P < .0001]) but higher incidence of distal embolization (IC, 1.9% vs 0.8% [P < .0001]; CLI, 3.0% vs 1.4% [P < .0001]) and, in the CLI cohort, arterial perforation (1.4% vs 1.0%; P = .01).

CONCLUSIONS

Despite a lack of evidence for atherectomy over angioplasty and stenting, its use has increased across the United States from 2010 to 2016. It is applied equally to IC and CLI populations, with no identifiable pattern of comorbidities or lesion characteristics, suggesting that indications are not clearly delineated or agreed on. This study places impetus on further understanding of the optimal role for atherectomy and its long-term clinical benefit in the management of peripheral arterial disease.

Comparison of Point-of-Care Activated Clotting Time Methods in Different Clinical Settings in a Large Academic Medical Center

OBJECTIVES

This study is a comparative analysis of measured activated clotting time (ACT) values by use of 5 different point-of-care (POC) ACT methods spanning the range detected during different clinical procedures at our institution.

METHODS

We determined the correlation, imprecision, and differences in measured ACT values with use of 4 POC ACT methods compared with a reference ACT method in 41 venous whole blood samples collected from 25 adult patients undergoing interventional procedures. The POC ACT methods evaluated included the i-STAT with kaolin activator in prewarm mode, i-STAT with Celite activator in prewarm and nonprewarm modes, ACTPlus, and HMSPlus, which was designated the reference method. Each venous whole blood patient sample was tested in duplicate on each POC ACT test system (total n = 410 ACT measurements). Analyses of imprecision and differences in measured ACT values were stratified by moderate (100-299 s) and high (≥300 s) ACT ranges.

RESULTS

In this study population, measured ACT values ranged from 100-835 s with use of the HMSPlus. All methods demonstrated good correlation (r ≥ 0.95) in ACT values compared to the reference method. Imprecision varied by method with ranges of 1.7%-2.7% CV in the moderate ACT range and 2.5%-4.8% CV in the high ACT range. ACTPlus and i-STAT-Celite-prewarm methods exhibited proportional differences in measured ACT values whereas the i-STAT-Celite-nonprewarm and i-STAT-kaolin-prewarm demonstrated constant differences in measured ACT values compared to HMSPlus.

CONCLUSIONS

ACT values correlate well between POC methods. Imprecision and difference profiles vary by method; notably, imprecision exceeds systematic differences in the high ACT range and contributes to intermethod differences that are limitations worthy of consideration when contemplating a change in ACT methods.

Aneurysm sac expansion is independently associated with late mortality in patients treated with endovascular aneurysm repair

BACKGROUND

Patients undergoing endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms can exhibit variations in sac behavior ranging from complete regression to expansion. We evaluated the impact of sac behavior at 1-year follow-up on late survival.

METHODS

We used the Vascular Study Group of New England (VSGNE) registry from 2003 to 2011 to identify EVAR patients with 1-year computed tomography follow-up. Aneurysm sac enlargement ≥5 mm (sac expansion) and decrease ≥5 mm (sac regression) were defined per Society for Vascular Surgery guidelines. Predictors of change in sac diameter and impact of sac behavior on long-term mortality were assessed by multivariable methods.

RESULTS

Of 2437 patients who underwent EVAR, 1802 (74%) had complete 1-year follow-up data and were included in the study. At 1 year, 162 (9%) experienced sac expansion, 709 (39%) had a stable sac, and 931 (52%) experienced sac regression. Sac expansion was associated with preoperative renal insufficiency (odds ratio [OR], 3.4; 95% confidence interval [CI], 1.5-8.0; P < .01), urgent repair (OR, 2.7; 95% CI, 1.4-5.1; P < .01), hypogastric coverage (OR, 1.7; 95% CI, 1.1-2.7; P = .02), and type I/III (OR, 16.8; 95% CI, 7.3-39.0; P < .001) or type II (OR, 2.9; 95% CI, 2.0-4.3; P < .001) endoleak at follow-up, and sac expansion was inversely associated with smoking (OR, 0.6; 95% CI, 0.4-0.96; P = .03) and baseline aneurysm diameter (OR, 0.7; 95% CI, 0.6-0.9; P < .001). Sac regression (vs expansion or stable sac) was associated with female gender (OR, 1.8; 95% CI, 1.4-2.4; P < .001) and larger baseline aneurysm diameter (OR, 1.4; 95% CI, 1.2-1.5; P < .001) and inversely associated with type I/III (OR, 0.2; 95% CI, 0.1-0.5; P < .01) or type II endoleak at follow-up (OR, 0.2; 95% CI, 0.2-0.3; P < .001). After risk-adjusted Cox regression, sac expansion was independently associated with late mortality (hazard ratio, 1.5; 95% CI, 1.1-2.0; P = .01), even with adjustment for reinterventions and endoleak during follow-up. Sac regression was associated with lower late mortality (hazard ratio, 0.6; 95% CI, 0.5-0.7; P < .001). Long-term survival was lower (log-rank, P < .001) in patients with sac expansion (98% 1-year and 68% 5-year survival) compared with all others (99% 1-year and 83% 5-year survival).

CONCLUSIONS

These data suggest that an abdominal aortic aneurysm sac diameter increase of at least 5 mm at 1 year, although infrequent, is independently associated with late mortality regardless of the presence or absence of endoleak and warrants close observation and perhaps early intervention.

Variation in Transfusion Practices and the Association with Perioperative Adverse Events in Patients Undergoing Open Abdominal Aortic Aneurysm Repair and Lower Extremity Arterial Bypass in the Vascular Quality Initiative

BACKGROUND

Blood transfusions are associated with adverse events. We examined perioperative transfusion practices and associated complications following open vascular procedures nationwide in the Vascular Quality Initiative (VQI).

METHODS

Adults undergoing open abdominal aortic aneurysm repair (OAR) and lower extremity arterial bypass (Bypass) within VQI (2003-2016) were identified. All emergent cases, patients with preoperative hemoglobin <7 g/dL, preoperative hospitalization >1 day, or a return to operating room during the index hospitalization were excluded. Units of red blood cells transfused were the primary outcome. Secondary outcomes were postoperative myocardial infarction (MI) and death. Patient, center, and procedural factors were evaluated. Multivariable mixed effects negative binomial regression and multivariable logistic regression were performed.

RESULTS

We identified 24,131 procedures (OAR 3885, 16.1%; Bypass 20,246, 83.9%) among 22,532 patients (10.1% had >1 procedure). Overall, 37.5% of OAR and 19.5% of Bypass were transfused. Transfusion rates varied across estimated blood loss quartiles and across various preoperative hemoglobin levels. The overall rate of postoperative MI and death was 4.0% and 1.8% for OAR, and 2.2% and 0.7% for Bypass, respectively. In univariate and multivariable analysis, transfusions were associated with an increased risk of postoperative MI and death. A mixed effects negative binomial model demonstrated variation in transfusions across centers (P < 0.001). Female gender and preoperative anemia were significantly associated with transfusions.

CONCLUSIONS

Blood transfusions are variable across centers in VQI. Transfusions are associated with a higher postoperative MI and death after OAR and Bypass. Efforts to reduce transfusion may focus on center variability, gender, and preoperative anemia.

2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. These guidelines, based on systematic methods to evaluate and classify evidence, provide a cornerstone of quality cardiovascular care.

In response to reports from the Institute of Medicine1 ,2 and a mandate to evaluate new knowledge and maintain relevance at the point of care, the ACC/AHA Task Force on Clinical Practice Guidelines (Task Force) modified its methodology.3 –5 The relationships among guidelines, data standards, appropriate use criteria, and performance measures are addressed elsewhere.5

Durable Results with In Situ Graft Repair of Ruptured Salmonella Aneurysm in a Patient with Autoimmune Deficiency Syndrome

We describe a case of a 42-year-old male patient with advanced autoimmune deficiency syndrome (AIDS) (CD4 count of 16 cells/mm3) found to have a ruptured infected infrarenal aortic aneurysm. Emergent in situ repair was performed with a Hemashield Dacron graft (Boston Scientific, Natick, MA). Aortic tissue cultures grew group D Salmonella. Patient was placed initially on intravenous ciprofloxacin followed by lifelong oral levofloxacin and trimethoprim. Over 2 years following repair, he remains asymptomatic, with repair intact and no recurrent infection. This case is the first reported successful long-term repair of a ruptured salmonella infected abdominal aortic aneurysm in the setting of advanced AIDS.

Regional Variation in Postoperative Myocardial Infarction in Patients Undergoing Vascular Surgery in the United States

BACKGROUND

The aim of this study is to assess for regional variation in the incidence of postoperative myocardial infarction (POMI) following nonemergent vascular surgery across the United States to identify potential areas for quality improvement initiatives.

METHODS

We evaluated POMI rates across 17 regional Vascular Quality Initiative (VQI) groups that comprised 243 centers with 1,343 surgeons who performed 75,057 vascular operations from 2010 to 2014. Four procedures were included in the analysis: carotid endarterectomy (CEA, n = 39,118), endovascular abdominal aortic aneurysm (AAA) repair (EVAR, n = 15,106), infrainguinal bypass (INFRA, n = 17,176), and open infrarenal AAA repair (OAAA, n = 3,657). POMI was categorized by the method of diagnosis as troponin-only or clinical/ECG and rates were investigated in regions with ≥100 consecutive cases. Regions with significantly different POMI rates were defined as those >1.5 interquartile lengths beyond the 75th percentile of the distribution. Risk-adjusted rates of POMI were assessed using the VQI Cardiac Risk Index all-procedures prediction model to compare the observed versus expected rates for each region.

RESULTS

Overall rates of POMI varied by procedure type: CEA 0.8%, EVAR 1.1%, INFRA 2.7%, and OAAA 4.2% (P < 0.001). Significant variation in POMI rates was observed between regions, resulting in differing ranges of POMI rates for each procedure: CEA 0.5-2.0% (P = 0.001), EVAR 0.3-3.1% (P < 0.001), INFRA 1.1-4.8% (P < 0.001), and OAAA 2.2-10.0% (P < 0.001). A single region in 3 of the 4 procedure-specific datasets was identified as a statistical outlier with a significantly higher POMI rate after CEA, EVAR, and OAAA; this region was identical for the EVAR and OAAA datasets but was a different region for the CEA dataset. No significant variation in POMI was noted between regions after INFRA. Procedure-specific clinical POMI rates (mean; range) were significantly different between regions for EVAR (0.4%; 0-1.1%, P = 0.01) and INFRA (1.4%; 0.5-2.9%, P = 0.01), but not for CEA (0.4%; 0-0.8%, P = 0.53) or OAAA (1.6%; 0-3.8%, P = 0.23). Procedure-specific troponin-only POMI rates (mean; range) were significantly different between regions for all procedures: CEA (0.4%; 0.1-1.2%, P < 0.001), EVAR (0.7%; 0-2.1%, P < 0.001), INFRA (1.3%; 0.4-2.5%, P = 0.001), and OAAA (2.5%; 0-8.5%, P < 0.001). After risk adjustment, regional variation was again noted with 3 regions having higher and 4 regions having lower than expected rates of POMI.

CONCLUSIONS

Significant variation in POMI rates following major vascular surgery exists across VQI regions even after risk adjustment. These findings may present an opportunity for focused regional quality improvement efforts.

2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. These guidelines, based on systematic methods to evaluate and classify evidence, provide a cornerstone of quality cardiovascular care.

In response to reports from the Institute of Medicine^1,2 and a mandate to evaluate new knowledge and maintain relevance at the point of care, the ACC/AHA Task Force on Clinical Practice Guidelines (Task Force) modified its methodology.^3–5 The relationships among guidelines, data standards, appropriate use criteria, and performance measures are addressed elsewhere.⁵

A multidisciplinary approach to vascular surgery procedure coding improves coding accuracy, work relative value unit assignment, and reimbursement

BACKGROUND

Vascular surgery procedural reimbursement depends on accurate procedural coding and documentation. Despite the critical importance of correct coding, there has been a paucity of research focused on the effect of direct physician involvement. We hypothesize that direct physician involvement in procedural coding will lead to improved coding accuracy, increased work relative value unit (wRVU) assignment, and increased physician reimbursement.

METHODS

This prospective observational cohort study evaluated procedural coding accuracy of fistulograms at an academic medical institution (January-June 2014). All fistulograms were coded by institutional coders (traditional coding) and by a single vascular surgeon whose codes were verified by two institution coders (multidisciplinary coding). The coding methods were compared, and differences were translated into revenue and wRVUs using the Medicare Physician Fee Schedule. Comparison between traditional and multidisciplinary coding was performed for three discrete study periods: baseline (period 1), after a coding education session for physicians and coders (period 2), and after a coding education session with implementation of an operative dictation template (period 3). The accuracy of surgeon operative dictations during each study period was also assessed. An external validation at a second academic institution was performed during period 1 to assess and compare coding accuracy.

RESULTS

During period 1, traditional coding resulted in a 4.4% (P = .004) loss in reimbursement and a 5.4% (P = .01) loss in wRVUs compared with multidisciplinary coding. During period 2, no significant difference was found between traditional and multidisciplinary coding in reimbursement (1.3% loss; P = .24) or wRVUs (1.8% loss; P = .20). During period 3, traditional coding yielded a higher overall reimbursement (1.3% gain; P = .26) than multidisciplinary coding. This increase, however, was due to errors by institution coders, with six inappropriately used codes resulting in a higher overall reimbursement that was subsequently corrected. Assessment of physician documentation showed improvement, with decreased documentation errors at each period (11% vs 3.1% vs 0.6%; P = .02). Overall, between period 1 and period 3, multidisciplinary coding resulted in a significant increase in additional reimbursement ($17.63 per procedure; P = .004) and wRVUs (0.50 per procedure; P = .01). External validation at a second academic institution was performed to assess coding accuracy during period 1. Similar to institution 1, traditional coding revealed an 11% loss in reimbursement ($13,178 vs $14,630; P = .007) and a 12% loss in wRVU (293 vs 329; P = .01) compared with multidisciplinary coding.

CONCLUSIONS

Physician involvement in the coding of endovascular procedures leads to improved procedural coding accuracy, increased wRVU assignments, and increased physician reimbursement.

Complete regression of a symptomatic, mycotic juxtarenal abdominal aortic aneurysm after treatment with fenestrated endovascular aneurysm repair

Mycotic abdominal aortic aneurysms are rare and present unique challenges when potential treatment options are considered. Although aortic resection with in situ grafting techniques or extra-anatomic reconstruction are the treatments of choice, endovascular aortic repair has emerged as a suitable alternative in critically ill patients. We report the successful endovascular repair of a symptomatic, mycotic juxtarenal aortic aneurysm using a physician-modified fenestrated endograft. In this patient, with >6 months of follow-up, the aneurysm has completely regressed, illustrating that in select patients with complex mycotic aneurysms, endovascular repair combined with appropriate medical management is a viable treatment strategy.

Smoking cessation counseling in vascular surgical practice using the results of interviews and focus groups in the Vascular Surgeon offer and report smoking cessation pilot trial

OBJECTIVE

Although smoking cessation is a key priority emphasized by professional societies and multidisciplinary consensus guidelines, significant variation exists in the methods and efficacy of smoking cessation treatment practiced by vascular surgeons. We conducted a series of patient, surgeon, and nonpatient stakeholder focus groups to identify important domains for establishment of a successful smoking cessation program.

METHODS

As part of a planning effort for a randomized clinical trial on usual care vs a standardized, evidence-based smoking cessation intervention, our group performed a series of interviews and focus groups. These were four 1-hour interviews, conducted with stakeholders such as tobacco cessation counselors (n = 2), a Quit Line representative (n = 1), and a Vascular Quality Initiative leader (n = 1), as well as two 90-minute, formal, professionally moderated focus groups, one with vascular surgeons (n = 7), and another with patients (n = 4). Transcripts and audio recordings were qualitatively reviewed for themes to establish the most important domains perceived to be associated with a successful smoking cessation program.

RESULTS

Patients emphasized four domains critical for a successful smoking cessation program: the motivation to quit, an individualized approach, the timing of an intervention, and the tone of the physician who offers counseling. Although surgeons and nonpatient stakeholders also emphasized the importance of a compassionate physician tone, surgeons and nonpatient stakeholders differed from patients in their remaining domains. They emphasized the feasibility of a brief intervention in a busy clinical practice, implementation of the effort, and necessary infrastructure for smoking cessation programs. All focus group participants described a brief, evidence-based smoking cessation intervention as feasible in routine vascular practice.

CONCLUSIONS

Differences in motivation and significance exist for patients, surgeons, and stakeholders when they considered the specific domains most important in building a successful smoking cessation program. Despite these differences, all parties involved agreed that a brief, standardized intervention can be successful delivered in a busy vascular clinic setting.