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Coelho A, Peixoto J, Mansilha A, Naylor AR, de Borst GJ. Timing of Carotid Intervention in Symptomatic Carotid Artery Stenosis: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2021; 63:3-23. [PMID: 34953681 DOI: 10.1016/j.ejvs.2021.08.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 07/05/2021] [Accepted: 08/13/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE This review aimed to analyse the timing of carotid endarterectomy (CEA) and carotid artery stenting (CAS) after the index event as well as 30 day outcomes at varying time periods within 14 days of symptom onset. METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-analysis statement, comprising an online search of the Medline and Cochrane databases. Methodical quality assessment of the included studies was performed. Endpoints included procedural stroke and/or death stratified by delay from the index event and surgical technique (CEA/CAS). RESULTS Seventy-one studies with 232 952 symptomatic patients were included. Overall, 34 retrospective analyses of prospective databases, nine prospective, three RCT, three case control, and 22 retrospective studies were included. Compared with CEA, CAS was associated with higher 30 day stroke (OR 0.70; 95% CI 0.58 - 0.85) and mortality rates (OR 0.41; 95% CI 0.31 - 0.53) when performed ≤ 2 days of symptom onset. Patients undergoing CEA/CAS were analysed in different time frames (≤ 2 vs. 3 - 14 and ≤ 7 vs. 8 - 14 days). Expedited CEA (vs. 3 - 14 days) presented a sampled 30 day stroke rate of 1.4%; 95% CI 0.9 - 1.8 vs. 1.8%; 95% CI 1.8 - 2.0, with no statistically significant difference. Expedited CAS (vs. 3 - 14 days) was associated with no difference in stroke rate but statistically significantly higher mortality rate (OR 2.76; 95% CI 1.39 - 5.50). CONCLUSION At present, CEA is safer than transfemoral CAS within 2/7 days of symptom onset. Also, considering absolute rates, expedited CEA complies with the accepted thresholds in international guidelines. The ideal timing for performing CAS (when indicated against CEA) is not yet defined. Additional granular data and standard reporting of timing of intervention will facilitate future monitoring.
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Affiliation(s)
- Andreia Coelho
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário do Porto, Portugal; Department of Surgery and Physiology, Faculdade Medicina da Universidade do Porto, Portugal
| | - João Peixoto
- Department of Surgery and Physiology, Faculdade Medicina da Universidade do Porto, Portugal; Department of Angiology and Vascular Surgery, Centro Hospitalar Vila Nova de Gaia/Espinho, Portugal
| | - Armando Mansilha
- Department of Surgery and Physiology, Faculdade Medicina da Universidade do Porto, Portugal
| | | | - Gert J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, the Netherlands.
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Zebolsky AL, Chou J, Key P, Knight P, Mahmood G, Jain K, Rummel M. Safety and efficacy of transcarotid artery revascularization in a community hospital. J Vasc Surg 2020; 74:203-208. [PMID: 33348008 DOI: 10.1016/j.jvs.2020.12.066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 12/05/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE We evaluated the outcomes and complications of transcarotid artery revascularization (TCAR) outside of academic vascular surgery programs. METHODS An institutional review board-approved retrospective study was performed. Data from all cases of TCAR performed at a community hospital from May 2017 to February 2020 were collected and analyzed. Seven vascular surgeons performed the procedures after receiving appropriate training. The primary outcomes included technical success, the need for further revascularization, and major adverse events (death, cerebrovascular accident [CVA], myocardial infarction). The secondary outcomes included other adverse events and complications. The outcomes were assessed in the perioperative and 30-day follow-up periods. RESULTS During a 33-month period, TCAR was completed in 147 of 149 attempted cases (98.7%). No patients required further revascularization. The perioperative and 30-day major adverse event rates were 0.7% (n = 1) and 3.4% (n = 5), respectively. One case of a minor perioperative CVA occurred. At 30 days, one patient had died. The 30-day complications included CVA (n = 1) and myocardial infarction (n = 3). The combined perioperative and 30-day minor complication rates were 2.7% and 1.4%, respectively. CONCLUSIONS TCAR is a safe and effective method of carotid artery revascularization in a community hospital setting. This technology might help improve revascularization in patients without access to larger academic centers.
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Affiliation(s)
- Aaron L Zebolsky
- Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Mich
| | - Jesse Chou
- Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Mich
| | - Phillip Key
- Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Mich
| | - Patrick Knight
- Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Mich
| | - Gulrez Mahmood
- Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Mich
| | - Krishna Jain
- Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Mich.
| | - Mark Rummel
- Advanced Vascular Surgery at Kalamazoo, Kalamazoo, Mich
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Aggarwal I, Li J, Trupin L, Gaynon L, Katz PP, Lanata C, Criswell L, Murphy LB, Dall'Era M, Yazdany J. Quality of Care for the Screening, Diagnosis, and Management of Lupus Nephritis Across Multiple Health Care Settings. Arthritis Care Res (Hoboken) 2020; 72:888-896. [PMID: 31058460 DOI: 10.1002/acr.23915] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 04/30/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVE We examined quality measures for screening, diagnosis, and treatment of lupus nephritis (LN) among participants of the California Lupus Epidemiology Study across 25 different clinical sites to identify gaps in quality of care. METHODS Data from 250 participants with lupus were analyzed across 3 sources (medical records, physician examination, and patient interviews). Overall performance on 8 quality measures was calculated separately for participants with and without LN. We used generalized estimating equations in which the outcome was performance on measures, adjusting for participant demographics, lupus disease severity, and practice characteristics. RESULTS Of 148 patients without LN, 42% underwent screening laboratory tests for nephritis, 38% underwent lupus activity serum studies, and 81% had their blood pressure checked every 6 months. Of 102 LN patients, 67% had a timely kidney biopsy, at least 81% had appropriate treatment, and 78% achieved target blood pressure within 1 year of diagnosis. Overall performance in participants across quality measures was 54% (no LN) and 80% (LN). Significantly higher overall performance for screening measures for LN was seen at academic (63.4-73%) versus community clinics (37.9-38.4%). Similarly, among those with LN, higher performance in academic (84.1-85.2%) versus community clinics (54.8-60.2%) was observed for treatment measures. CONCLUSION In this quality-of-care analysis across 25 diverse clinical settings, we found relatively high performance on measures for management of LN. However, future work should focus on bridging the gaps in lupus quality of care for patients without nephritis, particularly in community settings.
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Affiliation(s)
| | - Jing Li
- University of California, San Francisco
| | | | - Lisa Gaynon
- California Pacific Medical Center, San Francisco
| | | | | | | | - Louise B Murphy
- Centers for Disease Control and Prevention, Atlanta, Georgia
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Cheng TW, Farber A, Kalish JA, Jones DW, Castagne M, Rybin D, Raulli SJ, Siracuse JJ. Carotid Endarterectomy Performed before the Weekend is Associated with Increased Length of Stay. Ann Vasc Surg 2018; 48:119-126. [DOI: 10.1016/j.avsg.2017.09.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 09/13/2017] [Accepted: 09/27/2017] [Indexed: 10/18/2022]
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Lieber BA, Appelboom G, Taylor BES, Malone H, Agarwal N, Connolly ES. Assessment of the “July Effect”: outcomes after early resident transition in adult neurosurgery. J Neurosurg 2016; 125:213-21. [DOI: 10.3171/2015.4.jns142149] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Each July, 4th-year medical students become 1st-year resident physicians and have much greater responsibility in making management decisions. In addition, incumbent residents and fellows advance to their next postgraduate year and face greater challenges. It has been suggested that among patients who have resident physicians as members of their neurosurgical team, this transition may be associated with increased rates of morbidity and mortality, a phenomenon known as the “July Effect.” In this study, the authors compared morbidity and mortality rates between the initial and later months of the academic year to determine whether there is truly a July Effect that has an impact on this patient population.
METHODS
The authors compared 30-day postoperative outcomes of neurosurgery performed by surgical teams that included resident physicians in training during the first academic quarter (Q1, July through September) with outcomes of neurosurgery performed with resident participation during the final academic quarter (Q4, April through June), using 2006–2012 data from the prospectively collected American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Regression analyses were performed on outcome data that included mortality, surgical complications, and medical complications, which were graded as mild or severe. To determine whether a July Effect was present in subgroups, secondary analyses were performed to analyze the association of outcomes with each major neurosurgical subspecialty, the postgraduate year of the operating resident, and the academic quarter during which the surgery was performed. To control for possible seasonal trends in certain diseases, the authors compared patient outcomes at academic medical centers to those at community-based hospitals, where procedures were not performed by residents. In addition, the efficiency of academic centers was compared to that of community centers in terms of operative duration and total length of hospital stay.
RESULTS
Overall, there were no statistically significant differences in mortality, morbidity, or efficiency between the earlier and later quarters of the academic year, a finding that also held true among neurosurgical subspecialties and among postgraduate levels of training. There was, however, a slight increase in intraoperative transfusions associated with the transitional period in July (6.41% of procedures in Q4 compared to 7.99% in Q1 of the prior calendar year; p = 0.0005), which primarily occurred in cases involving junior (2nd- to 4th-year) residents. In addition, there was an increased rate of reoperation (1.73% in Q4 to 2.19% in Q1; p < 0.0001) observed mainly among senior (5th- to 7th-year) residents in the early academic months and not paralleled in our community cohort.
CONCLUSIONS
There is minimal evidence for a significant July Effect in adult neurosurgery. Our results suggest that, overall, the current resident training system provides enough guidance and support during this challenging transition period.
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Affiliation(s)
- Bryan A. Lieber
- 1Department of Neurosurgery, New York University, and
- 2Department of Neurosurgery and
| | | | | | | | - Nitin Agarwal
- 4Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - E. Sander Connolly
- 2Department of Neurosurgery and
- 3Neurointensive Care Unit, Columbia University Medical Center, New York, New York; and
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Kayssi A, de Mestral C, Forbes TL, Roche-Nagle G. Predictors of hospital readmissions after lower extremity amputations in Canada. J Vasc Surg 2016; 63:688-95. [DOI: 10.1016/j.jvs.2015.09.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 09/04/2015] [Indexed: 10/22/2022]
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Lobo M, Mourão J, Afonso G. Endarterectomia carotídea: revisão de 10 anos de prática de anestesia geral e locorregional num hospital terciário em Portugal. Braz J Anesthesiol 2015; 65:249-54. [DOI: 10.1016/j.bjan.2014.03.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 03/10/2014] [Indexed: 10/23/2022] Open
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Lobo M, Mourão J, Afonso G. Carotid endarterectomy: review of 10 years of practice of general and locoregional anesthesia in a tertiary care hospital in Portugal. Braz J Anesthesiol 2015; 65:249-54. [PMID: 26123143 DOI: 10.1016/j.bjane.2014.03.011] [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: 01/13/2014] [Accepted: 03/10/2014] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Retrospective and prospective randomized studies have compared general and locoregional anesthesia for carotid endarterectomy, but without definitive results. OBJECTIVES Evaluate the incidence of complications (medical, surgical, neurological, and hospital mortality) in a tertiary center in Portugal and review the literature. METHODS Retrospective analysis of patients undergoing endarterectomy between 2000 and 2011, using a software for hospital consultation. RESULTS A total of 750 patients were identified, and locoregional anesthesia had to be converted to general anesthesia in 13 patients. Thus, a total of 737 patients were included in this analysis: 74% underwent locoregional anesthesia and 26% underwent general anesthesia. There was no statistically significant difference between the two groups regarding per operative variables. The use of shunt was more common in patients undergoing general anesthesia, a statistically significant difference. The difference between groups of strokes and mortality was not statistically significant. The average length of stay was shorter in patients undergoing locoregional anesthesia with a statistically significant difference. CONCLUSIONS We found that our data are overlaid with the literature data. After reviewing the literature, we found that the number of studies comparing locoregional and general anesthesia and its impact on delirium, cognitive impairment, and decreased quality of life after surgery is still very small and can provide important data to compare the two techniques. Thus, some questions remain open, which indicates the need for randomized studies with larger number of patients and in new centers.
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Affiliation(s)
- Mercês Lobo
- Instituto Português de Oncologia do Porto, Hospital Francisco Gentil, Porto, Porto, Portugal.
| | - Joana Mourão
- Instituto Português de Oncologia do Porto, Hospital Francisco Gentil, Porto, Porto, Portugal
| | - Graça Afonso
- Instituto Português de Oncologia do Porto, Hospital Francisco Gentil, Porto, Porto, Portugal
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Patel ST, Patil SV, Chamberlain RS. A United States Population-Based Study on Clinical Outcomes Following Primary Carotid Endarterectomy: Who and When? ACTA ACUST UNITED AC 2012. [DOI: 10.4236/ss.2012.312117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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