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Körner L, Riddersholm S, Torp-Pedersen C, Houlind K, Bisgaard J. Is General Anesthesia for Peripheral Vascular Surgery Correlated with Impaired Outcome in Patients with Cardiac Comorbidity? A Closer Look into the Nationwide Danish Cohort. J Cardiothorac Vasc Anesth 2024; 38:1707-1715. [PMID: 38789284 DOI: 10.1053/j.jvca.2024.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/27/2024] [Accepted: 03/20/2024] [Indexed: 05/26/2024]
Abstract
OBJECTIVE General anesthesia (GA) may impair outcome after vascular surgery. The use of anticoagulant medication is often used in patients with cardiac comorbidity. Regional anesthesia (RA) requires planning of discontinuation before neuraxial blockade(s) in this subgroup. This study aimed to describe the effect of anesthesia choice on outcome after vascular surgery in patients with known cardiac comorbidity. DESIGN Retrospective cohort study. SETTING Danish hospitals. PARTICIPANTS 6302 patients with known cardiac comorbidity, defined as ischemic heart disease, valve disease, pulmonary vascular disease, heart failure, and cardiac arrhythmias, undergoing lower extremity vascular surgery between 2005 and 2017. INTERVENTIONS GA versus RA. MEASUREMENTS AND MAIN RESULTS Data were extracted from national registries. GA was defined as anesthesia with mechanical ventilation. Multivariable regression models were used to describe the incidence of postoperative complications as well as 30-day mortality, hypothesizing that better outcomes would be seen after RA. The rate of RA decreased from 48% in 2005 to 20% in 2017. The number of patients with 1 or more complications was 9.7% vs 6.2% (p < 0.001), and 30-day mortality was 6.0% vs 3.4% (p < 0.001) after GA. After adjusting for baseline differences, the odds ratio (OR) was significantly lower for medical complications (cardiac, pulmonary, renal, new dialysis, intensive care unit and other medical complications; OR, 0.97; 95% confidence interval [CI], 0.95-0.98) and 30-day mortality (OR 0.98; 95% CI, 0.97-0.99) after RA. CONCLUSIONS RA may be associated with a better outcome than GA after lower extremity vascular surgery in patients with a cardiac comorbidity. Prioritizing RA, despite the inconvenience of discontinuing anticoagulants, may be recommended.
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Affiliation(s)
- Luisa Körner
- Department of Anesthesiology, Aalborg University Hospital, Aalborg, Denmark.
| | - Signe Riddersholm
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Kim Houlind
- Department of Vascular Surgery, Lillebælt Hospital, Kolding, Denmark
| | - Jannie Bisgaard
- Department of Anesthesiology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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McElroy IE, Pillado EB, Greene AJ, Majumdar M, Kirshkaln A, Nuzzolo K, Malek J, Dua A. Impact of socioeconomic disparities on major lower extremity revascularization complications. Vascular 2024; 32:361-365. [PMID: 36384373 DOI: 10.1177/17085381221140165] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
INTRODUCTION Low socioeconomic status (SES), distance lived from hospital, and insurance status are well documented in the literature to increase the risk of post-operative morbidity and mortality for some disease processes however there is a paucity of data regarding how this association impacts patients with peripheral artery disease (PAD). This study aimed to evaluate if SES, distance lived from hospital, and insurance status increased the risk of developing major graft failure in patients undergoing revascularization procedures for symptomatic PAD in a prospective, observation study. METHODS In this prospective, observational study, all patients undergoing lower extremity revascularization (endovascular or open) were included from December 2020 to February 2022. Demographic factors, insurance status, operative details, and median income and distance from hospital were documented through chart review. Complications were defined as thrombosis/occlusion of the revascularized vessel or bypass graft or infection of the distal wound or surgical incision wound. Univariate and multivariate analysis were performed comparing patients that developed complications and those that did not. This project was undertaken at the Massachusetts General Hospital and was governed by the Institutional Review Board (IRB: 2020P000263) all patients agreed to participation via informed written consent prior to enrollment in the study. RESULTS A total of 108 patients were enrolled in the study of which 94 underwent successful revascularization procedures. Of those 94 patients, 38 (40.4%) underwent open bypass, 39 (41.5%) underwent endovascular revascularization, and 17 (18.1%) underwent a hybrid approach. There were no significant differences in post-operative outcomes between operative approaches. Twenty-five patients (28.7%) experienced major revascularization complications as defined as re-occlusion of the treated vessel/thrombosis of the bypass graft (n = 13) or development of post-operative infection (n = 12). There was no significant difference in median income ($75,295 vs $87,757, p = NS), distance lived from hospital, (27.4 miles vs. 29.7 miles, p = NS), or type of insurance (private 24% vs 26%, government 76% vs 73%, p = NS between patients that experienced complications versus those that did not have complications. These findings suggest the risk of major graft failure is independent of a patient's socioeconomic status, distance lived from hospital, or insurance type in patients undergoing revascularization procedures for PAD. CONCLUSION While socioeconomic factors impact access to and have a known association with negative outcomes, complications in patients with PAD appear to be independent of these factors. To mitigate the negative outcomes in patients with peripheral artery disease, a focus should be on patient risk factors and modifiable medical factors that contribute to adverse outcomes.
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Affiliation(s)
- Imani E McElroy
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Eric B Pillado
- Division of Vascular Surgery, McGaw Medical Center of Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Adrienne J Greene
- Weill Cornell Medicine, Department of Surgery, New York Presbyterian-Queens Hospital, USA
| | - Monica Majumdar
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Amanda Kirshkaln
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Kate Nuzzolo
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Junaid Malek
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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Jin S, Choi EJ, Choi YJ, Min WK, Park JY, Yoon SZ. Relationship between Arachidonate 5-Lipoxygenase-Activating Protein Gene and Peripheral Arterial Disease in Elderly Patients Undergoing General Surgery: A Retrospective Observational Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1027. [PMID: 36673783 PMCID: PMC9858772 DOI: 10.3390/ijerph20021027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 01/01/2023] [Accepted: 01/04/2023] [Indexed: 06/17/2023]
Abstract
Patients with peripheral arterial disease (PAD) are at a higher risk of developing postoperative complications. Arachidonate 5-lipoxygenase-activating protein (ALOX5AP) plays an important role in atherosclerosis pathogenesis. In this study, the relationship between PAD and several single nucleotide polymorphisms (SNPs) of ALOX5AP (rs17216473, rs10507391, rs4769874, rs9551963, rs17222814, and rs7222842) was investigated in elderly patients undergoing general surgery. The medical records of 129 patients aged > 55 years who underwent elective general surgery between May 2018 and August 2019 were retrospectively reviewed. The A/A in rs17216473, A/A in rs10507391, G/G in rs4769874, and A/A in rs9551963 were calculated as 0 points and the rest as 1 point to define the genetic risk score. The prevalence of PAD tended to increase with higher genetic risk scores (patients had less ALOX5AP gene polymorphism of A/A in rs17216473, A/A in rs10507391, G/G in rs4769874, or A/A in rs9551963) (p = 0.005). Multivariate logistic regression analysis revealed that the genetic risk score (p = 0.009) and age (p = 0.007) were positively correlated with the prevalence of PAD. Genetic polymorphisms of ALOX5AP and age were associated with the prevalence of PAD in this study.
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Affiliation(s)
- Sejong Jin
- Department of Neuroscience, Korea University College of Medicine, Seoul 02841, Republic of Korea
| | - Eun-Ji Choi
- Department of Dental Anesthesia and Pain Medicine, School of Dentistry, Pusan National University, Dental Research Institute, Yangsan 50612, Republic of Korea
| | - Yoon Ji Choi
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea
| | - Won Kee Min
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea
| | - Ju Yeon Park
- Department of Anesthesiology and Pain Medicine, Daedong Hospital, Busan 47737, Republic of Korea
| | - Seung Zhoo Yoon
- Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea
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Tavares CAM, Gualandro DM, Cardozo FAM, Filho MO, Mello Ando S, Calderaro D, Caramelli B. Psoas muscle area and one‐year mortality in a cohort of patients undergoing vascular surgery. J Am Geriatr Soc 2022; 70:2150-2153. [DOI: 10.1111/jgs.17743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 01/28/2022] [Accepted: 02/20/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Caio Assis Moura Tavares
- Unidade de Cardiogeriatria, Instituto do Coração (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina Universidade de Sao Paulo Sao Paulo Brazil
- Academic Research Organization (ARO) Hospital Israelita Albert Einstein Sao Paulo Brazil
| | - Danielle Menosi Gualandro
- Unidade de Medicina Interdisciplinar em Cardiologia, Instituto do Coração (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina Universidade de Sao Paulo Sao Paulo Brazil
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel University of Basel Basel Switzerland
| | - Francisco Akira Malta Cardozo
- Unidade de Medicina Interdisciplinar em Cardiologia, Instituto do Coração (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina Universidade de Sao Paulo Sao Paulo Brazil
| | - Marcelo Oranges Filho
- Instituto de Radiologia (InRad), Hospital das Clinicas HCFMUSP, Faculdade de Medicina Universidade de Sao Paulo Sao Paulo Brazil
| | - Sabrina Mello Ando
- Instituto de Radiologia (InRad), Hospital das Clinicas HCFMUSP, Faculdade de Medicina Universidade de Sao Paulo Sao Paulo Brazil
| | - Daniela Calderaro
- Unidade de Medicina Interdisciplinar em Cardiologia, Instituto do Coração (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina Universidade de Sao Paulo Sao Paulo Brazil
| | - Bruno Caramelli
- Unidade de Medicina Interdisciplinar em Cardiologia, Instituto do Coração (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina Universidade de Sao Paulo Sao Paulo Brazil
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Two-year outcomes in patients undergoing rotational atherectomy and drug coated balloon therapy for chronic total occluded peripheral arterial diseases: A retrospective cohort study. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.980212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Bisgaard J, Torp-Pedersen C, Rasmussen BS, Houlind KC, Riddersholm SJ. Editor's Choice - Regional Versus General Anaesthesia in Peripheral Vascular Surgery: a Propensity Score Matched Nationwide Cohort Study of 17 359 Procedures in Denmark. Eur J Vasc Endovasc Surg 2021; 61:430-438. [PMID: 33358100 DOI: 10.1016/j.ejvs.2020.11.025] [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: 04/13/2020] [Revised: 11/03/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Cardiopulmonary comorbidity is common in vascular surgery. General anaesthesia (GA) may impair perfusion and induce respiratory depression. Regional anaesthesia (RA), including neuraxial or peripheral nerve blocks, may therefore be associated with a better outcome. METHODS This was a nationwide retrospective cohort study. All open inguinal and infra-inguinal arterial surgical reconstructions from 2005 to 2017 were included. Data were extracted from national registries. Multivariable linear and logistic regression models and propensity score matching were used. The propensity score was derived by developing a model that predicted the probability that a given patient would receive GA based on age, comorbidity, anticoagulant medication, procedure type, and the urgency of surgery. Matching was performed in four groups based on American Society of Anesthesiologists' score I - II, score III - V, and gender. Outcome parameters included surgical and general complications (bleeding, thrombosis/embolus, cardiac, pulmonary, renal, cerebral, and >3 days intensive care therapy), length of stay, and 30 day mortality, hypothesising a better outcome after RA. RESULTS There were 10 509 procedures in the GA group and 6 850 in the RA group. After propensity score matching, 6 267 procedures were included in each group. Surgical and general complications were significantly more common after GA in both matched (3.8 vs. 2.5%, p < .001 and 6.5 vs. 4.2%, p < .001) and unmatched analyses (3.8 vs. 2.5%, p < .001 and 6.5 vs. 4.2%, p < .001). The 30 day mortality rate was significantly higher after GA, in matched and un matched analyses (3.1 vs. 2.4%, p = .019 and 4.1 vs. 2.4%, p < .001). There was no difference in length of stay. CONCLUSION RA may be associated with a better outcome, compared with GA, after open inguinal and infra-inguinal peripheral vascular surgery. In the clinical context when RA is not feasible, GA can still be considered safe.
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Affiliation(s)
- Jannie Bisgaard
- Department of Anaesthesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | | | - Bodil S Rasmussen
- Department of Anaesthesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Kim C Houlind
- Department of Vascular Surgery, Lillebælt Hospital, Kolding, Denmark; Department of Regional Health Research, University of Southern Denmark, Kolding, Denmark
| | - Signe J Riddersholm
- Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark
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Adult spinal deformity surgery: the effect of surgical start time on patient outcomes and cost of care. Spine Deform 2020; 8:1017-1023. [PMID: 32356281 DOI: 10.1007/s43390-020-00129-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 04/20/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE There are reports investigating the effect of surgical start time (SST) on outcomes, length of stay (LOS) and cost in various surgical disciplines. However, this has not been studied in spine deformity surgery to date. This study compares outcomes for patients undergoing spinal deformity surgery based on SST. METHODS Patients at a single academic institution from 2008 to 2016 undergoing elective spinal deformity surgery (defined as fusing ≥ 7 segments) were divided by SST before or after 2 PM. Co-primary outcomes were LOS and direct costs. Secondary outcomes included delayed extubation, ICU stay, complications, reoperation, non-home discharge, and readmission rates. RESULTS There were 373 surgeries starting before 2 PM and 79 after 2 PM. The cohorts had similar demographics including age, sex, comorbidity burden, and levels fused. The late SST cohort had shorter operation durations (p = 0.0007). Multivariable linear regression showed no differences in LOS (estimate 0.4 days, CI - 1.2 to 2.0, p = 0.64) or direct cost (estimate $3652, 95% CI - $1449 to $8755, p = 0.16). Multivariable logistic regression revealed the late SST cohort was more likely to have delayed extubation (OR 2.6, 95% CI 1.4-4.9, p = 0.004) and non-home discharge (OR 2.2, 95% CI 1.1-4.2, p = 0.03). All other secondary outcomes were non-significant. CONCLUSION Patients undergoing spinal deformity surgery before and after 2 PM have similar LOS and cost of care. However, the late SST cohort had increased likelihood of delayed extubation and non-home discharges, which increase cost in bundled payment models. These findings can be utilized in OR scheduling to optimize outcomes and minimize cost.
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Palmer J, Pymer S, Smith GE, Harwood AE, Ingle L, Huang C, Chetter IC. Presurgery exercise-based conditioning interventions (prehabilitation) in adults undergoing lower limb surgery for peripheral arterial disease. Cochrane Database Syst Rev 2020; 9:CD013407. [PMID: 32964423 PMCID: PMC8078675 DOI: 10.1002/14651858.cd013407.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Lower limb peripheral arterial disease (PAD) is a type of cardiovascular disease where the blood vessels that carry the blood to the legs are hardened and narrowed. The most severe manifestation of PAD is critical limb ischaemia (CLI). This condition results in symptoms of intractable rest pain, non-healing wounds and ulceration, gangrene or both. PAD affects more than 200 million people worldwide and approximately 3% to 5% of people aged over 40 have PAD, rising to 18% in people over 70 years of age. Between 5% to 10% of symptomatic PAD patients will progress to CLI over a five-year period and the five year cumulative incidence rate for asymptomatic patients with PAD deteriorating to intermittent claudication is 7%, with 21% of these progressing to CLI. Treatment options include angioplasty, bypass or amputation of the limb, when life or limb is threatened. People with CLI have a high risk of mortality and morbidity. The mortality rates during a surgical admission are approximately 5%. Within one year of surgery, the mortality rate rises to 22%. Postoperative complications are as high as 30% and readmission rates vary between 7% to 18% in people with CLI. Despite recent advances in surgical technology, anaesthesia and perioperative care, a proportion of surgical patients have a suboptimal recovery. Presurgery conditioning (prehabilitation) is a multimodal conditioning intervention carried out prior to surgery using a combination of exercise, with or without nutritional or psychological interventions, or both. The use of prehabilitation is gaining momentum, particularly in elderly patients undergoing surgery and patients undergoing colorectal cancer surgery, as a means of optimising fitness to improve the prognosis for people undergoing the physiological stress of surgery. People with PAD are characterised by poor mobility and physical function and have a lower level of fitness as a result of disease progression. Therefore, prehabilitation may be an opportunity to improve their recovery following surgery. However, as multimodal prehabilitation requires considerable resources, it is important to assess whether it is superior to usual care. This review aimed to compare prehabilitation with usual care (defined as a preoperative assessment, including blood and urine tests). The key outcomes were postoperative complications, mortality and readmissions within 30 days of the surgical procedure, and one-year survival rates. OBJECTIVES To assess the effectiveness of prehabilitation (preoperative exercise, either alone or in combination with nutritional or psychological interventions, or both) on postoperative outcomes in adults with PAD undergoing open lower limb surgery. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials register to 25 September 2019. SELECTION CRITERIA We considered all published and unpublished randomised controlled trials (RCTs) comparing presurgery interventions and usual care. Primary outcomes were postoperative complications, mortality and readmission to hospital within 30 days of the surgical procedure. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed all records identified by the searches conducted by the Cochrane Vascular Information Specialist. We planned to undertake data collection and analysis in accordance with recommendations described in the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS We found no RCTs that met the inclusion criteria for this review. AUTHORS' CONCLUSIONS We found no RCTs conducted to determine the effects of prehabilitation on mortality or other postoperative outcomes when compared to usual care for patients with PAD. As a consequence, we were unable to provide any evidence to guide the treatment of patients with PAD undergoing surgery. To perform a randomised controlled trial of presurgery conditioning would be challenging but trials are warranted to provide solid evidence on this topic.
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Affiliation(s)
- Joanne Palmer
- Academic Vascular Surgical Unit, Hull York Medical School, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Sean Pymer
- Academic Vascular Surgical Unit, Hull York Medical School, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - George E Smith
- Academic Vascular Surgical Unit, Hull York Medical School, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Amy Elizabeth Harwood
- Centre for Sport, Exercise and Life Sciences, Faculty of Health and Life Sciences, Science and Health Building, Coventry University, Coventry, UK
| | - Lee Ingle
- School of Life Sciences, University of Hull, Hull, UK
| | - Chao Huang
- Hull York Medical School, University of Hull, Hull, UK
| | - Ian C Chetter
- Academic Vascular Surgical Unit, Hull York Medical School, Hull University Teaching Hospitals NHS Trust, Hull, UK
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Laukkavirta M, Nikulainen V, Blomgren K, Helmiö P. Patient Injuries in Treatment of Peripheral Arterial Disease in Finland: Review of National Patient Insurance Charts. Ann Vasc Surg 2020; 66:225-232. [DOI: 10.1016/j.avsg.2019.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/04/2019] [Accepted: 12/06/2019] [Indexed: 10/25/2022]
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Palmer J, Pymer S, Smith GE, Harwood AE, Ingle L, Huang C, Chetter IC. Presurgery conditioning interventions (prehabilitation) in adults undergoing lower limb surgery for peripheral arterial disease. Hippokratia 2019. [DOI: 10.1002/14651858.cd013407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Joanne Palmer
- Hull University Teaching Hospitals NHS Trust; Academic Vascular Surgical Unit, Hull York Medical School; Hull UK HU3 2JZ
| | - Sean Pymer
- Hull University Teaching Hospitals NHS Trust; Academic Vascular Surgical Unit, Hull York Medical School; Hull UK HU3 2JZ
| | - George E Smith
- Hull University Teaching Hospitals NHS Trust; Academic Vascular Surgical Unit, Hull York Medical School; Hull UK HU3 2JZ
| | - Amy Elizabeth Harwood
- Hull University Teaching Hospitals NHS Trust; Academic Vascular Surgical Unit, Hull York Medical School; Hull UK HU3 2JZ
- University of Sydney; Thermal Ergonomics Laboratory, Exercise and Sport Science; 75 East Street Sydney NSW Australia 2141
| | - Lee Ingle
- University of Hull; School of Life Sciences; Cottingham Road Hull UK HU6 7RX
| | - Chao Huang
- University of Hull; Hull York Medical School; Rm 347, 3rd Floor Allam Medical Building Hull UK HU6 7RX
| | - Ian C Chetter
- Hull University Teaching Hospitals NHS Trust; Academic Vascular Surgical Unit, Hull York Medical School; Hull UK HU3 2JZ
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Das Gupta J, Marek J, Rana MA, Guliani S. Same-Day ICU Discharge in Selected Patients With Severe Submassive Pulmonary Embolism Treated With Catheter-Directed Thrombolysis. Vasc Endovascular Surg 2019; 54:58-64. [DOI: 10.1177/1538574419872047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A retrospective review from July 2016 to April 2018 was performed of 23 patients with submassive pulmonary embolism (PE) who received catheter-directed thrombolysis (CDT). Five (22%) of the 23 patients were discharged the same day from the intensive care unit (ICU) following thrombolysis completion. Their presentation, hospital courses, complications, and follow-up are reviewed. All 5 patients were diagnosed using chest computed tomography (CT) demonstrating a clot in the pulmonary vasculature and right ventricle dysfunction based on abnormal right ventricle to left ventricle (RV/LV) ratio. Patients with severe right heart dysfunction (RV/LV ratio ≥1.4) were protocolized to receive CDT via EkoSonic catheters (EKOS Corporation). Postoperatively, patients were admitted to the ICU with continuous alteplase at 1 mg/h. Echocardiography was then performed after 24 hours of therapy to assess right ventricle function and removal of EkoSonic catheters. Patients with reversal of right heart dysfunction and symptomatic improvement received bedside removal of catheters. The mean patient age was 50.6 years and body mass index was 33.6. Mean RV/LV ratio on admission via CT imaging was 1.56, with a mean troponin of 0.44. Interval mean RV/LV ratio on echocardiography after thrombolysis therapy was 0.91. There was a 0% incidence of periprocedural complications. One (20%) patient out of 5 had an emergency department visit 10 days postdischarge for acute shortness of breath, with workup revealing no evidence of recurrent PE. No patient required hospital readmission within 30 days. At the 6-week follow-up, all patients had continued normal right ventricular function noted on echocardiography. This case series demonstrates that for a select population of patients with severe submassive PE, the use of CDT and echocardiography monitoring can facilitate same-day discharge from the ICU.
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Affiliation(s)
- Jaideep Das Gupta
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - John Marek
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM, USA
- Division of Vascular Surgery, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Muhammad Ali Rana
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM, USA
- Division of Vascular Surgery, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Sundeep Guliani
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM, USA
- Division of Vascular Surgery, University of New Mexico School of Medicine, Albuquerque, NM, USA
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Effectiveness and Safety of Ultrasound Guided Lower Extremity Nerve Blockade in Infragenicular Bypass Grafting for High Risk Patients With Chronic Limb Threatening Ischaemia. Eur J Vasc Endovasc Surg 2019; 58:206-213. [DOI: 10.1016/j.ejvs.2019.03.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 03/09/2019] [Accepted: 03/16/2019] [Indexed: 11/18/2022]
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Yeung K, Eiberg JP, Kehlet H, Aasvang EK. Acute complications in the post-anaesthesia care unit after infrainguinal surgery for lower limb ischaemia - a prospective observational cohort study. VASA 2018; 48:89-97. [PMID: 30355274 DOI: 10.1024/0301-1526/a000745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Arterial surgery for lower limb ischaemia is a frequently performed procedure in patients with severe cardio-pulmonary comorbidities, making them high-risk patients for acute postoperative complications with a need for prolonged stay in the post-anaesthesia care unit (PACU). However, detailed information on complications during the PACU stay is limited, hindering mechanism-based interventions for early enhanced recovery. Thus, we aimed to systematically describe acute complications and related risk factors in the immediate postoperative phase after infrainguinal arterial surgery. PATIENTS AND METHODS Patients transferred to the PACU after infrainguinal arterial surgery due to chronic or acute lower limb ischaemia were consecutively included in a six-month observational cohort study. Pre- and intraoperative data included comorbidities as well as surgical and anaesthetic technique. Data on complications and treatments in the PACU were collected every 15 minutes using a standardised assessment tool. The primary endpoint was occurrence of predefined moderate or severe complications occurring during PACU stay. RESULTS In total, 155 patients were included for analysis. Eighty (52 %) patients experienced episodes with oxygen desaturation (< 85 %) and moderate or severe pain occurred in 72 patients (47 %); however, circulatory complications (hypotension, tachycardia) were rare. Preoperative opioid use was a significant risk factor for moderate or severe pain in PACU (59 vs. 38 % chronic vs. opioid naïve patients (P = 0.01). CONCLUSIONS Complications in the PACU after infrainguinal arterial surgery relates to saturation and pain, suggesting that future efforts should focus on anaesthesia and analgesic techniques including opioid sparing regimes to enhance early postoperative recovery.
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Affiliation(s)
- Karin Yeung
- 1 Department of Anaesthesiology and Surgery, Rigshospitalet, University of Copenhagen, Denmark.,2 Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Denmark
| | - Jonas Peter Eiberg
- 2 Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Denmark.,3 Copenhagen Academy for Medical Education and Simulation (CAMES), Rigshospitalet, Copenhagen Denmark
| | - Henrik Kehlet
- 4 Section for Surgical Pathophysiology, Rigshospitalet, University of Copgenhagen, Denmark
| | - Eske Kvanner Aasvang
- 1 Department of Anaesthesiology and Surgery, Rigshospitalet, University of Copenhagen, Denmark
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von Meijenfeldt GCI, van der Laan MJ, Zeebregts CJAM, Christopher KB. Red cell distribution width at hospital discharge and out-of hospital outcomes in critically ill non-cardiac vascular surgery patients. PLoS One 2018; 13:e0199654. [PMID: 30183701 PMCID: PMC6124728 DOI: 10.1371/journal.pone.0199654] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 06/12/2018] [Indexed: 11/19/2022] Open
Abstract
Objective Red cell distribution width (RDW) is associated with mortality and bloodstream infection risk in the critically ill. In vascular surgery patients surviving critical care it is not known if RDW can predict subsequent risk of all-cause mortality following hospital discharge. We hypothesized that an increase in RDW at hospital discharge in vascular surgery patients who received critical care would be associated with increased mortality following hospital discharge. Design, setting, and participants We performed a two-center observational cohort study of critically ill non-cardiac vascular surgery patients surviving admission 18 years or older treated between November, 1997, and December 2012 in Boston, Massachusetts. Exposures RDW measured within 24 hours of hospital discharge and categorized a priori as ≤13.3%, 13.3–14.0%, 14.0–14.7%, 14.7–15.8%, >15.8%. Main outcomes and measures The primary outcome was all cause mortality in the 90 days following hospital discharge. Results The cohort included 4,715 patients (male 58%; white 83%; mean age 62.9 years). 90 and 365-day post discharge mortality was 7.5% and 14.4% respectively. In the cohort, 47.3% were discharged to a care facility and 14.8% of patients were readmitted within 30 days. After adjustment for age, gender, race, Deyo-Charlson comorbidity Index, patient type, acute organ failures, prior vascular surgery and vascular surgery category, patients with a discharge RDW 14.7–15.8% or >15.8% have an adjusted OR of 90-day post discharge mortality of 2.52 (95%CI, 1.29–4.90; P = 0.007) or 5.13 (95%CI, 2.70–9.75; P <0.001) relative to patients with a discharge RDW ≤13.3%. The adjusted odds of 30-day readmission in the RDW >15.8% group was 1.52 (95%CI, 1.12–2.07; P = 0.007) relative to patients with a discharge RDW ≤13.3%. Similar adjusted discharge RDW-outcome associations are present at 365 days following hospital discharge and for discharge to a care facility. Conclusions In critically ill vascular surgery patients who survive hospitalization, an elevated RDW at hospital discharge is a strong predictor of subsequent mortality, hospital readmission and placement in a care facility. Patients with elevated RDW are at high risk for adverse out of hospital outcomes and may benefit from closer post discharge follow-up and higher intensity rehabilitation.
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Affiliation(s)
- Gerdine C. I. von Meijenfeldt
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Surgery, Deventer Ziekenhuis, Deventer, The Netherlands
| | - Maarten J. van der Laan
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Clark J. A. M. Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Kenneth B. Christopher
- Renal Division, Brigham and Women’s Hospital, The Nathan E. Hellman Memorial Laboratory, Renal Division, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- * E-mail:
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Routine use of PICO dressings may reduce overall groin wound complication rates following peripheral vascular surgery. J Hosp Infect 2018; 99:75-80. [DOI: 10.1016/j.jhin.2017.10.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 10/27/2017] [Indexed: 11/23/2022]
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Modified Frailty Index Can Be Used to Predict Adverse Outcomes and Mortality after Lower Extremity Bypass Surgery. Ann Vasc Surg 2018; 46:168-177. [DOI: 10.1016/j.avsg.2017.07.007] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 07/10/2017] [Accepted: 07/11/2017] [Indexed: 12/21/2022]
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