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Yu J, Khamzina Y, Kennedy J, Liang NL, Hall DE, Arya S, Tzeng E, Reitz KM. The association between frailty and outcomes following ruptured abdominal aortic aneurysm repair. J Vasc Surg 2024; 80:379-388.e3. [PMID: 38614142 DOI: 10.1016/j.jvs.2024.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/28/2024] [Accepted: 04/07/2024] [Indexed: 04/15/2024]
Abstract
OBJECTIVE 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 aneurysms (AAAs). 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 AAAs (rAAAs). METHODS 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 (aHRs) with 95% confidence intervals (CIs). Interaction terms evaluated the association's moderation. RESULTS We identified 5806 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 with 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. CONCLUSIONS 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 with 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.
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Affiliation(s)
- Jia Yu
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Jason Kennedy
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Nathan L Liang
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Vascular Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA; Surgery Service, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA; Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, PA
| | - Edith Tzeng
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Vascular Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Katherine M Reitz
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Vascular Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA.
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Sharath SE, Chin-Bong Choi J, Ollison J, Kougias P. Association Between Pack-Years and Smoking Cessation on Outcomes After Vascular Interventions. J Surg Res 2024; 300:534-541. [PMID: 38878328 DOI: 10.1016/j.jss.2024.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 11/08/2023] [Accepted: 05/21/2024] [Indexed: 07/16/2024]
Abstract
INTRODUCTION The influence of pack-year history and smoking cessation timing on postoperative morbidity and mortality in a highly comorbid cohort is uncertain. We examined whether the association between smoking and adverse postoperative events is modified by pack-year history and smoking cessation timing. METHODS We collected single-institution, retrospective data from consecutive patients undergoing open operations for carotid, aortic, and infrainguinal arterial disease. Active smoking was defined as smoking on the day of the index surgical intervention. Duration of smoking cessation was calculated as the time between smoking cessation and index surgery. The primary outcome was a composite of 30-day mortality and morbidity. Logistic and time-to-event Cox regressions estimated associations with interactions between cessation duration and pack-year history for nonactive smokers. RESULTS Between 2010 and 2019, 1087 patients underwent 1640 high-risk vascular interventions. Median pack-year history was 40.0 pack-years (interquartile range [IQR]: 20.0-60.0) among nonactive smokers and 46.0 pack-years (IQR: 31.0-61.0) among active smokers (P < 0.001). The median smoking cessation time was 15.5 y (IQR: 4.4-30.9). Smoking status did not independently predict an increased risk of postoperative mortality or morbidity (odds ratio [OR] = 0.99, P = 0.96). Among nonactive smokers, neither smoking cessation duration (OR = 0.99, P = 0.16) nor pack-year history (OR = 1.00, P = 0.88) were significantly associated with adverse events (interaction P = 0.11). CONCLUSIONS After high-risk vascular interventions in a single institution, active smoking, cessation period, and pack-year history are not associated with an increased risk of postoperative morbidity or mortality-highlighting the benefit of cessation as independent of frequency or intensity.
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Affiliation(s)
- Sherene E Sharath
- Operative Care Line/Research Service Line VA New York, Harbor Healthcare System, Brooklyn, New York; Department of Surgery, State University of New York Downstate Health Sciences University, Brooklyn, New York.
| | - Justin Chin-Bong Choi
- Department of Surgery, State University of New York Downstate Health Sciences University, Brooklyn, New York
| | - Jade Ollison
- Operative Care Line/Research Service Line VA New York, Harbor Healthcare System, Brooklyn, New York
| | - Panos Kougias
- Operative Care Line/Research Service Line VA New York, Harbor Healthcare System, Brooklyn, New York; Department of Surgery, State University of New York Downstate Health Sciences University, Brooklyn, New York
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Aulivola B. A critical look at our role in smoking cessation in the patient with claudication. J Vasc Surg 2024; 80:175-176. [PMID: 38906661 DOI: 10.1016/j.jvs.2024.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 02/26/2024] [Indexed: 06/23/2024]
Affiliation(s)
- Bernadette Aulivola
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Loyola University Medical Center, Maywood, IL
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Patel RJ, Zarrintan S, Vootukuru NR, Allah SH, Gaffey A, Malas MB. Long-term outcomes in the smoking claudicant after peripheral vascular interventions. J Vasc Surg 2024; 80:165-174. [PMID: 38432487 DOI: 10.1016/j.jvs.2024.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 01/28/2024] [Accepted: 02/07/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE Emphasis on tobacco cessation, given the urgent and emergent nature of vascular surgery, is less prevalent than standard elective cases such as hernia repairs, cosmetic surgery, and bariatric procedures. The goal of this study is to determine the effect of active smoking on claudicating individuals undergoing peripheral vascular interventions (PVIs). Our goal is to determine if a greater emphasis on education should be placed on smoking cessation in nonurgent cases scheduled through clinic visits and not the Emergency Department. METHODS This study was performed using the multi-institution de-identified Vascular Quality Initiative/Medicare-linked database (Vascular Implant Surveillance and Interventional Outcomes Network [VISION]). Claudicants who underwent PVI for peripheral arterial occlusive disease between 2004 and 2019 were included in our study. Our final sample consisted of a total of 18,726 patients: 3617 nonsmokers (19.3%) (NSs), 9975 former smokers (53.3%) (FSs), and 5134 current smokers (27.4%) (CSs). We performed propensity score matching on 29 variables (age, gender, race, ethnicity, treatment setting [outpatient or inpatient], obesity, insurance, hypertension, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, previous coronary artery bypass graft, carotid endarterectomy, major amputation, inflow treatment, prior bypass or PVI, preoperative medications, level of treatment, concomitant endarterectomy, and treatment type [atherectomy, angioplasty, stent]) between NS vs FS and FS vs CS. Outcomes were long-term (5-year) overall survival (OS), limb salvage (LS), freedom from reintervention (FR), and amputation-free survival (AFS). RESULTS Propensity score matching resulted in 3160 well-matched pairs of NS and FS and 3750 well-matched pairs of FS and CS. There was no difference between FS and NS in terms of OS (hazard ratio [HR], 0.94; 95% confidence interval [CI], 0.82-1.09; P = .43), FR (HR, 0.96; 95% CI, 0.89-1.04; P = .35), or AFS (HR, 0.90; 95% CI, 0.79-1.03; P = .12). However, when compared with CS, we found FS to have a higher OS (HR, 1.18; 95% CI, 1.04-1.33; P = .01), less FR (HR, 0.89; 95% CI, 0.83-0.96; P = .003), and greater AFS (HR, 1.16; 95% CI, 1.03-1.31; P = .01). CONCLUSIONS This multi-institutional Medicare-linked study looking at elective PVI cases in patients with peripheral artery disease presenting with claudication found that FSs have similar 5-year outcomes in comparison to NSs in terms of OS, FR, and AFS. Additionally, CSs have lower OS and AFS when compared with FSs. Overall, this suggests that smoking claudicants should be highly encouraged and referred to structured smoking cessation programs or even required to stop smoking prior to elective PVI due to the perceived 5-year benefit.
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Affiliation(s)
- Rohini J Patel
- Division of Vascular and Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), University of California San Diego, San Diego, CA
| | - Sina Zarrintan
- Division of Vascular and Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), University of California San Diego, San Diego, CA
| | | | - Shatha H Allah
- Division of Vascular and Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), University of California San Diego, San Diego, CA
| | - Ann Gaffey
- Division of Vascular and Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), University of California San Diego, San Diego, CA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), University of California San Diego, San Diego, CA.
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Rao P, O'Meara R, Kang I, Cichocki MN, Kittrell Z, Weise LB, Babrowski T, Blecha M. Risk score for one-year mortality following emergent infra-inguinal bypass. J Vasc Surg 2024:S0741-5214(24)01218-7. [PMID: 38782215 DOI: 10.1016/j.jvs.2024.05.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE The purpose of this study is to identify variables that place patients at higher risk for mortality following emergent infra-inguinal bypass. Further, this study will create a risk score for mortality following emergent infra-inguinal bypass to help tailor postoperative and long-term patient management. METHODS In the Vascular Quality Initiative, we identified 2126 patients who underwent emergent infra-inguinal artery bypass. Two primary outcomes were investigated: 30 day mortality following emergent infra-inguinal bypass; and 1-year mortality following emergent infra-inguinal bypass. The first step in analysis was univariable analysis for each outcome with χ2 analysis for categorical variables and Student t-test for comparison of means of ordinal variables. Next, binary logistic regression analysis was performed for each outcome utilizing variables that achieved a univariable P value ≤ .10. Factors with a multivariable P value ≤ .05 were included in the risk score, and points were weighted and assigned based on the respective regression beta-coefficient in the multivariable regression. RESULTS Variables with a significant multivariable association (P < .05) with 1-year mortality were: increasing age; body mass index less than 20 kg/m2; coronary artery disease; active hemodialysis at time of presentation; anemia at admission; prosthetic conduit for emergent bypass; postoperative myocardial infarction; postoperative acute renal insufficiency; perioperative stroke; baseline non-ambulatory status; new onset hemodialysis requirement perioperatively; need for bypass revision or thrombectomy during index admission; lack of statin prescription at discharge; lack of antiplatelet medication at discharge; and, lack of anticoagulation at time of hospital discharge. Pertinent negatives included all sociodemographic variables including rural living status, insurance status, and Area Deprivation Index home area. The risk score achieved an area under the curve of 0.820, and regression analysis of the risk score achieved an overall accuracy of 87.9% with 97.7% accuracy in predicting survival, indicating the model performs better in determining which patients will survive rather than precisely determining who will experience 1-year mortality. CONCLUSIONS Discharge medications are the primary modifiable variable impacting survival after emergent infra-inguinal bypass surgery. In the absence of contraindication, all these patients should be discharged on antiplatelet, statin, and anticoagulant medications after emergent infra-inguinal bypass as they significantly enhance survival. Social determinants of health do not impact survival among patients treated with emergent infra-inguinal bypass at Vascular Quality Initiative centers. A risk score for mortality at 1 year after emergent infra-inguinal bypass has been created that has excellent accuracy.
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Affiliation(s)
- Priya Rao
- Division of Vascular Surgery and Endovascular Therapy, Stritch School of Medicine, Loyola University Chicago, Loyola University Health System, Maywood, IL
| | - Rylie O'Meara
- Division of Vascular Surgery and Endovascular Therapy, Stritch School of Medicine, Loyola University Chicago, Loyola University Health System, Maywood, IL
| | - Ian Kang
- Division of Vascular Surgery and Endovascular Therapy, Stritch School of Medicine, Loyola University Chicago, Loyola University Health System, Maywood, IL
| | - Meghan N Cichocki
- Division of Vascular Surgery and Endovascular Therapy, Stritch School of Medicine, Loyola University Chicago, Loyola University Health System, Maywood, IL
| | - Zach Kittrell
- Division of Vascular Surgery and Endovascular Therapy, Stritch School of Medicine, Loyola University Chicago, Loyola University Health System, Maywood, IL
| | - Lorela B Weise
- Division of Vascular Surgery and Endovascular Therapy, Stritch School of Medicine, Loyola University Chicago, Loyola University Health System, Maywood, IL
| | - Trissa Babrowski
- Division of Vascular Surgery and Endovascular Therapy, University of Chicago Medical Center, Chicago, IL
| | - Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, Stritch School of Medicine, Loyola University Chicago, Loyola University Health System, Maywood, IL.
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Abumoawad A, Okazaki RA, Behrooz L, Eberhardt RT. Medical Optimization of Patients with Symptomatic Peripheral Arterial Disease. Ann Vasc Surg 2024:S0890-5096(24)00160-2. [PMID: 38582206 DOI: 10.1016/j.avsg.2024.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 01/03/2024] [Indexed: 04/08/2024]
Abstract
Peripheral artery disease (PAD) is a progressive disease associated with the occurrence of major adverse cardiovascular and limb events and elevated mortality rates. Symptoms of PAD, including claudication and chronic limb-threatening ischemia, impair functional capacity and lead to lower quality of life. The focus of current therapies is to minimize symptoms, improve quality of life, and reduce adverse cardiovascular and limb events. Among the medical therapies are antiplatelets, anticoagulants, antihypertensives, lipid lowering therapies, cilostazol and pentoxifylline, and novel blood sugar-lowering therapies, plus exercise therapy and smoking cessation. In this review, we discuss these evidence-based medical therapies that are available for patients with symptomatic PAD.
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Affiliation(s)
| | - Ross A Okazaki
- Evans Department of Medicine/Section of Cardiovascular Medicine and Whitaker Cardiovascular Institute, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Leili Behrooz
- Department of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Robert T Eberhardt
- Evans Department of Medicine/Section of Cardiovascular Medicine and Whitaker Cardiovascular Institute, Boston University Chobanian & Avedisian School of Medicine, Boston, MA.
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Bischoff M, Meisenbacher K, Rother U, Cotta L, Böhner H, Storck M, Behrendt CA. Awareness of smoking cessation amongst German vascular surgeons. VASA 2024; 53:129-134. [PMID: 38319124 DOI: 10.1024/0301-1526/a001113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Background: Smoking represents the well-known enemy of vascular well-being. Numerous previous studies emphasised the important role of smoking on the development and progression of atherosclerotic cardiovascular disease. The current study aimed to identify hurdles and barriers for an insufficient implementation of secondary prevention in the treatment of lower extremity peripheral arterial disease (PAD). Methods: All members of the German Society for Vascular Surgery and Vascular Medicine (DGG) with valid email addresses were invited to participate in an electronic survey on smoking. Results are descriptively presented. Results: Amongst 2716 invited participants, 327 (12%) submitted complete responses, thereof 33% women and 80% between 30 and 59 years old (87% board certified specialists). 83% were employed by hospitals (56% teaching hospital, 14% university, 13% non-academic) and 16% by outpatient facilities. 6% are active smokers (63% never) while a mean of five medical education activities on smoking cessation were completed during the past five years of practice. Only 27% of the institutions offered smoking cessation programs and 28% of the respondents were aware of local programs while a mean of 46% of their patients were deemed eligible for participation. 63% of the respondents deemed outpatient physicians primarily responsible for smoking cessation, followed by medical insurance (26%). Conclusions: The current nationwide survey of one scientific medical society involved in the care of patients with vascular disease revealed that smoking cessation, although being commonly accepted as important pillar of comprehensive holistic care, is not sufficiently implemented in everyday clinical practice.
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Affiliation(s)
- Moritz Bischoff
- Department of Vascular and Endovascular Surgery, University Medical Centre Heidelberg, Germany
| | - Katrin Meisenbacher
- Department of Vascular and Endovascular Surgery, University Medical Centre Heidelberg, Germany
| | - Ulrich Rother
- Department of Vascular Surgery, Friedrich Alexander Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- German Institute for Vascular Research, Berlin, Germany
| | - Livia Cotta
- German Institute for Vascular Research, Berlin, Germany
| | - Hinrich Böhner
- Department of Vascular Surgery, St. Rochus-Hospital Castrop-Rauxel, Dortmund, Germany
| | - Martin Storck
- Department of Vascular and Thoracic Surgery, Klinikum Karlsruhe, Academic Teaching Hospital, Germany
| | - Christian-Alexander Behrendt
- German Institute for Vascular Research, Berlin, Germany
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
- Medical School Brandenburg Theodor-Fontane, Neuruppin, Germany
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Moras E, Khan MI, Song DD, Syed M, Prabhakaran SY, Gandhi KD, Lavie CJ, Alam M, Sharma R, Krittanawong C. Pharmacotherapy and revascularization strategies of peripheral artery disease. Curr Probl Cardiol 2024; 49:102430. [PMID: 38309544 DOI: 10.1016/j.cpcardiol.2024.102430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 01/29/2024] [Indexed: 02/05/2024]
Abstract
The global epidemiological transition of atherosclerotic vascular diseases is witnessing a rapid redistribution of its burden, shifting from high-income to low- and middle-income countries. With a wide clinical spectrum, spanning from intermittent claudication to more complex critical limb threatening ischemia, nonhealing ulcers, gangrene as well as acute limb ischemia, peripheral artery disease is often faced with the challenges of under-diagnosis and under-treatment despite its high prevalence. The management of peripheral arterial disease in patients with multiple comorbidities presents a formidable challenge and remains a pressing global health concern. In this review, we aim to provide an in-depth overview of the pathophysiology of peripheral artery disease and explore evidence-based management strategies encompassing pharmacological, lifestyle, interventional, and surgical approaches. By addressing these challenges, the review contributes to a better understanding of the evolving landscape of peripheral artery disease, offering insights into effective and holistic management strategies.
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Affiliation(s)
- Errol Moras
- Department of Medicine, Mount Sinai Morningside- West, Mount Sinai Health System, New York, USA
| | - Mohammad Ishrak Khan
- Department of Medicine, Mount Sinai Morningside- West, Mount Sinai Health System, New York, USA
| | - David D Song
- Department of Medicine/Cardiology, Icahn School of Medicine at Mount Sinai, The Zena and Michael A. Wiener Cardiovascular Institute and the Marie-Josée Henry R. Kravis Cardiovascular Health Center, Icahn School of Medicine at the Mount Sinai Hospital, Mount Sinai Heart, New York, NY, USA
| | - Moinuddin Syed
- Department of Medicine/Cardiology, Icahn School of Medicine at Mount Sinai, The Zena and Michael A. Wiener Cardiovascular Institute and the Marie-Josée Henry R. Kravis Cardiovascular Health Center, Icahn School of Medicine at the Mount Sinai Hospital, Mount Sinai Heart, New York, NY, USA
| | | | - Kruti D Gandhi
- Department of Medicine, Mount Sinai Morningside- West, Mount Sinai Health System, New York, USA
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, USA
| | - Mahboob Alam
- The Texas Heart Institute, Baylor College of Medicine, Houston, TX
| | - Raman Sharma
- Department of Medicine/Cardiology, Icahn School of Medicine at Mount Sinai, The Zena and Michael A. Wiener Cardiovascular Institute and the Marie-Josée Henry R. Kravis Cardiovascular Health Center, Icahn School of Medicine at the Mount Sinai Hospital, Mount Sinai Heart, New York, NY, USA
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Arena G, Cumming C, Lizama N, Mace H, Preen DB. Hospital length of stay and readmission after elective surgery: a comparison of current and former smokers with non-smokers. BMC Health Serv Res 2024; 24:85. [PMID: 38233897 PMCID: PMC10792937 DOI: 10.1186/s12913-024-10566-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 01/05/2024] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND The purpose of this study was to investigate differences between non-smokers, ex-smokers and current smokers in hospital length of stay (LOS), readmission (seven and 28 days) and cost of readmission for patients admitted for elective surgery. METHODS A retrospective cohort study of administrative inpatient data from 24, 818 patients admitted to seven metropolitan hospitals in Western Australia between 1 July 2016 and 30 June 2019 for multiday elective surgery was conducted. Data included smoking status, LOS, procedure type, age, sex and Indigenous status. LOS for smoking status was compared using multivariable negative binomial regression. Odds of readmission were compared for non-smokers and both ex-smokers and current smokers using separate multivariable logistic regression models. RESULTS Mean LOS for non-smokers (4.7 days, SD=5.7) was significantly lower than both ex-smokers (6.2 days SD 7.9) and current smokers (6.1 days, SD=8.2). Compared to non-smokers, current smokers and ex-smokers had significantly higher odds of readmission within seven (OR=1.29; 95% CI: 1.13, 1.47, and OR=1.37; 95% CI: 1.19, 1.59, respectively) and 28 days (OR=1.35; 95% CI: 1.23, 1.49, and OR=1.53; 95% CI: 1.39, 1.69, respectively) of discharge. The cost of readmission for seven and 28-day readmission was significantly higher for current smokers compared to non-smokers (RR=1.52; 95% CI: 1.1.6, 2.0; RR=1.39; 95% CI: 1.18, 1.65, respectively). CONCLUSION Among patients admitted for elective surgery, hospital LOS, readmission risk and readmission costs were all higher for smokers compared with non-smokers. The findings indicate that provision of smoking cessation treatment for adults undergoing elective surgery is likely to produce multiple benefits.
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Affiliation(s)
- Gina Arena
- School of Population and Global Health M431, The University of Western Australia, 35 Stirling Highway, Crawley, Western Australia, 6009, Australia.
| | - Craig Cumming
- School of Population and Global Health M431, The University of Western Australia, 35 Stirling Highway, Crawley, Western Australia, 6009, Australia
| | - Natalia Lizama
- Cancer Council Western Australia, Subiaco, Western Australia, Australia
- Curtin University, Bentley, Western Australia, Australia
| | - Hamish Mace
- Division of Emergency Medicine, The University of Western Australia, Perth, Western Australia, Australia
- Department of Anaesthesia and Pain Medicine, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - David B Preen
- School of Population and Global Health M431, The University of Western Australia, 35 Stirling Highway, Crawley, Western Australia, 6009, Australia
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Nordanstig J, Behrendt CA, Baumgartner I, Belch J, Bäck M, Fitridge R, Hinchliffe R, Lejay A, Mills JL, Rother U, Sigvant B, Spanos K, Szeberin Z, van de Water W, Antoniou GA, Björck M, Gonçalves FB, Coscas R, Dias NV, Van Herzeele I, Lepidi S, Mees BME, Resch TA, Ricco JB, Trimarchi S, Twine CP, Tulamo R, Wanhainen A, Boyle JR, Brodmann M, Dardik A, Dick F, Goëffic Y, Holden A, Kakkos SK, Kolh P, McDermott MM. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Asymptomatic Lower Limb Peripheral Arterial Disease and Intermittent Claudication. Eur J Vasc Endovasc Surg 2024; 67:9-96. [PMID: 37949800 DOI: 10.1016/j.ejvs.2023.08.067] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 08/14/2023] [Indexed: 11/12/2023]
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Cole MW, Collins LK, Waters TL, Salas Z, Sherman WF, Cyriac M. Put Down the Tin: Chewing Tobacco Use Is Associated With Worse Outcomes After Primary Lumbar Fusion. Clin Spine Surg 2023; 36:E332-E338. [PMID: 37053116 DOI: 10.1097/bsd.0000000000001457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 03/09/2023] [Indexed: 04/14/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE This study evaluated the impact of chewing tobacco on both medical and spine-related complication rates after spinal lumbar fusions in comparison to both a control cohort and a smoking cohort. SUMMARY OF BACKGROUND DATA Smoking is a prevalent modifiable risk factor that has been demonstrated to be associated with increased complications after lumbar fusion. Although smoking rates have decreased in the United States, chewing tobacco use has not similarly reduced. Despite chewing tobacco delivering up to 4 times the dose of smoking, the impact of chewing tobacco is incompletely understood. METHODS A retrospective cohort study was conducted using the PearlDiver database. Patients who underwent lumbar spine fusion and used chewing tobacco were matched with a control cohort and a smoking cohort. Medical complications within 90 days after primary lumbar fusion were evaluated, including deep venous thrombosis, acute kidney injury, pulmonary embolism, transfusion, acute myocardial infarction, and inpatient readmission. Spine-related complications were evaluated at 2 years postoperatively, including pseudoarthrosis, incision and drainage (I&D), instrument failure, revision, and infection. RESULTS After primary lumbar fusion, the chewing tobacco cohort demonstrated significantly higher rates of pseudoarthrosis [odds ratio (OR): 1.41], revision (OR: 1.57), and any spine-related complication (OR: 1.32) compared with controls. The smoking cohort demonstrated significantly higher rates of pseudoarthrosis (OR: 1.88), I&D (OR: 1.27), instrument failure (OR: 1.39), revision (OR: 1.54), infection (OR: 1.34), and any spine-related complication (OR: 1.77) compared with controls. The chewing tobacco cohort demonstrated significantly lower rates of pseudoarthrosis (OR: 0.84), I&D (OR: 0.49), infection (OR: 0.70), and any spine-related complication (OR: 0.81) compared with the smoking cohort. CONCLUSIONS This study demonstrated that chewing tobacco is associated with higher rates of both spine-related and medical complications after primary lumbar fusion. However, chewing tobacco use is associated with less risk of complications compared with smoking. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Matthew W Cole
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA
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Behrooz L, Abumoawad A, Rizvi SHM, Hamburg NM. A modern day perspective on smoking in peripheral artery disease. Front Cardiovasc Med 2023; 10:1154708. [PMID: 37187787 PMCID: PMC10175606 DOI: 10.3389/fcvm.2023.1154708] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 04/10/2023] [Indexed: 05/17/2023] Open
Abstract
Peripheral artery disease (PAD) is associated with increased risk of cardiovascular morbidity and mortality, poor functional status, and lower quality of life. Cigarette smoking is a major preventable risk factor for PAD and is strongly associated with a higher risk of disease progression, worse post-procedural outcomes, and increased healthcare utilization. The arterial narrowing due to atherosclerotic lesions in PAD leads to decreased perfusion to the limbs and can ultimately cause arterial obstruction and limb ischemia. Endothelial cell dysfunction, oxidative stress, inflammation, and arterial stiffness are among the key events during the development of atherogenesis. In this review, we discuss the benefits of smoking cessation among patients with PAD and the use of smoking cessation methods including pharmacological treatment. Given that smoking cessation interventions remain underutilized, we highlight the importance of incorporating smoking cessation treatments as part of the medical management of patients with PAD. Regulatory approaches to reduce the uptake of tobacco product use and support smoking cessation have the potential to reduce the burden of PAD.
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Affiliation(s)
- Leili Behrooz
- Whitaker Cardiovascular Institute, Boston University Chobanian and Avedisian School of Medicine, Section of Vascular Biology, Boston Medical Center, Boston, MA, United States
- Evans Department of Medicine and Whitaker Cardiovascular Institute, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
| | - Abdelrhman Abumoawad
- Whitaker Cardiovascular Institute, Boston University Chobanian and Avedisian School of Medicine, Section of Vascular Biology, Boston Medical Center, Boston, MA, United States
- Evans Department of Medicine and Whitaker Cardiovascular Institute, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
| | - Syed Husain M. Rizvi
- Whitaker Cardiovascular Institute, Boston University Chobanian and Avedisian School of Medicine, Section of Vascular Biology, Boston Medical Center, Boston, MA, United States
- Evans Department of Medicine and Whitaker Cardiovascular Institute, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
| | - Naomi M. Hamburg
- Whitaker Cardiovascular Institute, Boston University Chobanian and Avedisian School of Medicine, Section of Vascular Biology, Boston Medical Center, Boston, MA, United States
- Evans Department of Medicine and Whitaker Cardiovascular Institute, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
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Smolderen KG, Romain G, Provance JB, Scierka LE, Mao J, Goodney PP, Henke PK, Sedrakyan A, Mena-Hurtado C. Guideline-Directed Medical Therapy and Long-Term Mortality and Amputation Outcomes in Patients Undergoing Peripheral Vascular Interventions. JACC Cardiovasc Interv 2023; 16:332-343. [PMID: 36792257 PMCID: PMC10359106 DOI: 10.1016/j.jcin.2022.09.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/29/2022] [Accepted: 09/13/2022] [Indexed: 02/15/2023]
Abstract
BACKGROUND Lack of guideline-directed medical therapy (GDMT) in patients undergoing peripheral vascular interventions (PVIs) may increase mortality and amputation risk. OBJECTIVES The authors sought to study the association between GDMT and mortality/amputation and to examine GDMT variability among providers and health systems. METHODS We performed an observational study using patients in the Vascular Quality Initiative registry undergoing PVI between 2017 and 2018. Two-year all-cause mortality and major amputation data were derived from Medicare claims data. Compliance with GDMT was defined as receiving a statin, antiplatelet therapy, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker if hypertensive. Propensity 1:1 matching was applied for GDMT vs no GDMT and survival analyses were performed to compare outcomes between groups. RESULTS Of 15,891 patients undergoing PVIs, 48.8% received GDMT and 6,120 patients in each group were matched. Median follow-up was 9.6 (IQR: 4.5-16.2) months for mortality and 8.4 (IQR: 3.5-15.4) for amputation. Mean age was 72.0 ± 9.9 years. Mortality risk was higher among patients who did not receive GDMT versus those on GDMT (31.2% vs 24.5%; HR: 1.37, 95% CI: 1.25-1.50; P < 0.001), as well as, risk of amputation (16.0% vs 13.2%; HR: 1.20; 95% CI: 1.08-1.35; P < 0.001). GDMT rates across sites and providers ranging from 0% to 100%, with lower performance translating into higher risk. CONCLUSIONS Almost one-half of the patients receiving PVI in this national quality registry were not on GDMT, and this was associated with increased risk of mortality and major amputation. Quality improvement efforts in vascular care should focus on GDMT in patients undergoing PVI.
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Affiliation(s)
- Kim G Smolderen
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Psychology Section, Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA.
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jeremy B Provance
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Lindsey E Scierka
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jialin Mao
- Population Health Sciences, Weill Cornell Medicine, Cornell University, New York, New York, USA
| | - Phillip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Dartmouth College, Lebanon, New Hampshire, USA
| | - Peter K Henke
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Art Sedrakyan
- Population Health Sciences, Weill Cornell Medicine, Cornell University, New York, New York, USA
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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Wang X, Yang Y, Zhang J, Zang S. Development and validation of a prediction model for the prolonged length of stay in Chinese patients with lower extremity atherosclerotic disease: a retrospective study. BMJ Open 2023; 13:e069437. [PMID: 36759024 PMCID: PMC9923290 DOI: 10.1136/bmjopen-2022-069437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
OBJECTIVES This study aims to develop and internally validate a prediction model, which takes account of multivariable and comprehensive factors to predict the prolonged length of stay (LOS) in patients with lower extremity atherosclerotic disease (LEAD). DESIGN This is a retrospective study. SETTING China. PARTICIPANTS, PRIMARY AND SECONDARY OUTCOMES Data of 1694 patients with LEAD from a retrospective cohort study between January 2014 and November 2021 were analysed. We selected nine variables and created the prediction model using the least absolute shrinkage and selection operator (LASSO) regression model after dividing the dataset into training and test sets in a 7:3 ratio. Prediction model performance was evaluated by calibration, discrimination and Hosmer-Lemeshow test. The effectiveness of clinical utility was estimated using decision curve analysis. RESULTS LASSO regression analysis identified age, gender, systolic blood pressure, Fontaine classification, lesion site, surgery, C reactive protein, prothrombin time international normalised ratio and fibrinogen as significant predictors for predicting prolonged LOS in patients with LEAD. In the training set, the prediction model showed good discrimination using a 500-bootstrap analysis and good calibration with an area under the receiver operating characteristic of 0.750. The Hosmer-Lemeshow goodness of fit test for the training set had a p value of 0.354. The decision curve analysis showed that using the prediction model both in training and tests contributes to clinical value. CONCLUSION Our prediction model is a valuable tool using easily and routinely obtained clinical variables that could be used to predict prolonged LOS in patients with LEAD and help to better manage these patients in routine clinical practice.
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Affiliation(s)
- Xue Wang
- Department of Community Nursing, School of Nursing, China Medical University, Shenyang, Liaoning, China
| | - Yu Yang
- Department of Vascular Surgery, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Jian Zhang
- Department of Vascular Surgery, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Shuang Zang
- Department of Community Nursing, School of Nursing, China Medical University, Shenyang, Liaoning, China
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Ofori SN, Marcucci M, Mbuagbaw L, Conen D, Borges FK, Chow CK, Sessler DI, Chan MTV, Hillis GS, Pettit S, Heels-Ansdell D, Devereaux PJ. Determinants of tobacco smoking abstinence 1 year after major noncardiac surgery: a secondary analysis of the VISION study. Br J Anaesth 2022; 129:497-505. [PMID: 35987704 DOI: 10.1016/j.bja.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/07/2022] [Accepted: 07/11/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Tobacco smoking is a leading preventable cause of death and increases perioperative risk. Determinants of smoking abstinence after noncardiac surgery and the association between smoking and 1-yr vascular outcomes are not fully elucidated. METHODS We did a prospective cohort study of 40 004 patients, aged ≥45 yr, enrolled between August 2007 and November 2013, and followed for 1 yr after surgery. Patients were categorised as never smokers, ex-smokers (quit >4 weeks preoperatively), and current smokers (smoking ≤4 weeks preoperatively). Primary outcome was abstinence at 1 yr. Secondary outcome was a composite of all-cause death, non-fatal myocardial infarction, and non-fatal stroke at 1 yr. RESULTS Of 4658 current smokers, 1838 (39.5%) were abstinent 1 yr after surgery. Median (inter-quartile range) time to resumption was 7 (3-23) days post-surgery. Perioperatively, 7.2% of current smokers obtained smoking cessation pharmacotherapy. Older age (adjusted risk ratio [aRR] 1.21; 95% confidence interval [CI]: 1.12-1.32); having recent coronary artery disease (aRR 1.41; 95% CI: 1.29-1.55); cancer (aRR 1.37; 95% CI: 1.18-1.59); and undergoing major vascular (aRR 1.20; 95% CI: 1.02-1.41), urgent/emergent (aRR 1.14; 95% CI: 1.05-1.23), or thoracic (aRR 1.41; 95% CI: 1.26-1.56) surgeries increased abstinence. One-year abstinence was less likely when patients stopped smoking 0-1 day (aRR 0.53; 95% CI: 0.43-0.66) and 2-14 days (aRR 0.76; 95% CI: 0.71-0.82) before surgery compared with >14 days before surgery. Current smokers (adjusted hazard ratio [aHR] 1.14; 95% CI: 1.01-1.29) and ex-smokers (aHR 1.11; 95% CI: 1.03-1.21) had higher risk of the 1-yr vascular outcome compared with never smokers. CONCLUSIONS Long-term tobacco abstinence is more likely after major surgery in those with serious medical comorbidities. Interventions to prevent smoking resumption after surgery remain a priority. Clinical trial registration NCT00512109.
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Affiliation(s)
- Sandra N Ofori
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada.
| | - Maura Marcucci
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Biostatistics Unit, St Joseph's Healthcare, Hamilton, ON, Canada
| | - David Conen
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Flavia K Borges
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Clara K Chow
- Westmead Applied Research Centre, University of Sydney, Sydney, Australia; Westmead Hospital, Sydney, Australia
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew T V Chan
- Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Graham S Hillis
- George Institute for Global Health, University of Sydney, Sydney, Australia; Royal Perth Hospital, Perth, Australia; University of Western Australia, Perth, Australia
| | - Shirley Pettit
- Population Health Research Institute, Hamilton, ON, Canada
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Philip J Devereaux
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
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Kim Y, Thangappan K, DeCarlo CS, Jessula S, Majumdar M, Patel SS, Zacharias N, Mohapatra A, Dua A. Outcomes of Femoropopliteal Bypass for Lifestyle-Limiting Claudication in the Endovascular Era. J Surg Res 2022; 279:323-329. [PMID: 35809357 DOI: 10.1016/j.jss.2022.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 05/23/2022] [Accepted: 06/09/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Outcomes after femoropopliteal bypass for intermittent claudication (IC) remain unclear in the endovascular era. METHODS A multi-institutional database was retrospectively queried for all femoropopliteal bypass procedures performed between 1995 and 2020. Demographics, operative details, and outcomes were documented. A statistical analysis included Kaplan-Meier curves and Cox proportional hazards ratios (HR). RESULTS A total of 282 patients underwent femoropopliteal bypass surgery for IC. Median age was 68 y (interquartile range, 61-73 y). Bypass conduits included great saphenous vein (GSV) (48.2%), prosthetic grafts (48.9%), and non-GSV autogenous grafts (2.8%). Distal bypass target was above-knee in 62.1% and below-knee in 37.9% of patients. The most common postoperative complications were wound infections (14.2%) followed by unplanned 30-d hospital readmissions (12.4%). Mortality rates were low at 0.4% (30 d) and 3.2% (1 y). Five-year primary patency rates trended highest for claudicants undergoing above-knee bypass with GSV conduit (log-rank P = 0.065). Five-year amputation-free survival rates were highest using GSV conduit regardless of distal bypass target (log-rank P = 0.017). On a multivariable analysis, age (HR 1.02 [1.00-1.04], P = 0.023) and active smoking (HR 1.48 [1.06-2.06], P = 0.021) were identified as risk factors for diminished primary graft patency. Risk factors for amputation-free survival included age (HR 1.03 [1.01-1.05], P < 0.001) and GSV conduit type (HR 0.65 [0.46-0.90], P = 0.011). CONCLUSIONS Femoropopliteal bypass among claudicants is associated with high rates of wound infection and hospital readmission. Active smoking portends worse outcomes in this population. These data may inform clinical decision-making regarding surgical intervention for claudication in the endovascular era.
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Affiliation(s)
- Young Kim
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Karthik Thangappan
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Charles S DeCarlo
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Samuel Jessula
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Monica Majumdar
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Shiv S Patel
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Nikolaos Zacharias
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Abhisekh Mohapatra
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts.
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