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Aridi HD, Leon B, Murphy MP, Malas M, Schermerhorn ML, Kashyap VS, Wang GJ, Eldrup-Jorgensen J, Gonzalez AA, Motaganahalli RL. Predictors of prolonged length of stay after elective carotid revascularization. J Vasc Surg 2024:S0741-5214(24)01201-1. [PMID: 38763455 DOI: 10.1016/j.jvs.2024.05.022] [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: 03/13/2024] [Revised: 05/12/2024] [Accepted: 05/14/2024] [Indexed: 05/21/2024]
Abstract
OBJECTIVE Postoperative day-one discharge is used as a quality-of-care indicator after carotid revascularization. This study identifies predictors of prolonged length of stay (pLOS), defined as a postprocedural LOS of >1 day, after elective carotid revascularization. METHODS Patients undergoing carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TFCAS) in the Vascular Quality Initiative between 2016 and 2022 were included in this analysis. Multivariable logistic regression analysis was used to identify predictors of pLOS, defined as a postprocedural LOS of >1 day, after each procedure. RESULTS A total of 118,625 elective cases were included. pLOS was observed in nearly 23.2% of patients undergoing carotid revascularization. Major adverse events, including neurological, cardiac, infectious, and bleeding complications, occurred in 5.2% of patients and were the most significant contributor to pLOS after the three procedures. Age, female sex, non-White race, insurance status, high comorbidity index, prior ipsilateral CEA, non-ambulatory status, symptomatic presentation, surgeries occurring on Friday, and postoperative hypo- or hypertension were significantly associated with pLOS across all three procedures. For CEA, additional predictors included contralateral carotid artery occlusion, preoperative use of dual antiplatelets and anticoagulation, low physician volume (<11 cases/year), and drain use. For TCAR, preoperative anticoagulation use, low physician case volume (<6 cases/year), no protamine use, and post-stent dilatation intraoperatively were associated with pLOS. One-year analysis showed a significant association between pLOS and increased mortality for all three procedures; CEA (hazard ratio [HR],1.64; 95% confidence interval [CI], 1.49-1.82), TCAR (HR,1.56; 95% CI, 1.35-1.80), and TFCAS (HR, 1.33; 95%CI, 1.08-1.64) (all P < .05). CONCLUSIONS A postoperative LOS of more than 1 day is not uncommon after carotid revascularization. Procedure-related complications are the most common drivers of pLOS. Identifying patients who are risk for pLOS highlights quality improvement strategies that can optimize short and 1-year outcomes of patients undergoing carotid revascularization.
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Affiliation(s)
- Hanaa D Aridi
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Brandon Leon
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Michael P Murphy
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Mahmoud Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Vikram S Kashyap
- Frederik Meijer Heart and Vascular Institute, Corewell Health, Grand Rapids, MI
| | - Grace J Wang
- Division of Vascular and Endovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | - Andrew A Gonzalez
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN.
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Feldman ZM, Lella SK, Lee S, Bellomo T, Bocklett J, Dua A, LaMuraglia GM, Srivastava SD, Eagleton MJ, Zacharias N. Implementation of a Consensus-Driven Quality Improvement Protocol to Decrease Length of Stay after Elective Carotid Endarterectomy. Ann Vasc Surg 2023; 97:97-105. [PMID: 37355013 DOI: 10.1016/j.avsg.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/23/2023] [Accepted: 06/04/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND National guidelines stipulate that postoperative length-of-stay (LOS) after elective carotid endarterectomy (CEA) should not exceed 1 day on average, yet perioperative care coordination gaps may limit the ability for institutions to achieve this goal. Internal review determined that increased LOS after CEA at our institution was frequently attributable to urinary retention or postoperative hypertension. We designed and implemented a quality improvement (QI) protocol aiming to better our institutional performance in postoperative LOS after CEA, consisting of 2 Plan-Do-Study-Act (PDSA) cycles. METHODS In the first PDSA cycle, a division-wide standardized protocol was developed by which antihypertensive medications were managed preoperatively and through postoperative day (POD) 1. This protocol included dedicated patient outreach with instructions for at-home antihypertensive management through the morning of POD 0. Second, alpha-1-blockade was administered to all male patients preoperatively. All patients receiving an elective CEA performed at our institution by vascular surgeons were included in the protocol. The primary outcome measure was defined percent failure of the LOS >1 day metric, with raw LOS as a secondary outcome measure. Process measures included adherence to the antihypertensive medication protocol and adherence to preoperative alpha-1 blockade. Balance measures included documented intraoperative hypotension and 30-day readmission. Fisher's exact test was used to evaluate relationships between preintervention and postintervention cohorts and the outcome measure. Wilcoxon rank-sum tests were used to evaluate relationships between cohorts and total LOS. RESULTS Baseline performance on the LOS >1 day metric after elective CEA was 58.3% in the 8 months prior to intervention, across 48 patients. Both PDSA interventions were implemented simultaneously. In the 12 months after intervention, 64 patients met protocol inclusion criteria, including 19 symptomatic patients (29.7%). Process measure success for preoperative antihypertensive regimen adherence was 89.8%. For males not chronically prescribed alpha-1 blockade preoperatively, process measure success for adherence to preoperative alpha-1 blockade was 78.8%. The intraoperative hypotension balance measure occurred in 1 patient (1.6%). Performance on the LOS >1 day outcome measure was improved to 32.8% (P = 0.01). Performance on the raw LOS outcome measure was similar between the preintervention cohort (median 2 days, interquartile range [IQR] 1-2) and postintervention cohort (median 1 day, IQR 1-2, P = 0.07). Performance on the 30-day readmission balance measure was similar between preintervention (6.3%) and postintervention cohorts (9.4%, P = 0.73). CONCLUSIONS The consensus-driven development and implementation of a QI protocol to reduce postoperative LOS after CEA showed promising results in our institution, with approximately 40% improvement in the primary outcome measure. Wider efforts to improve LOS after CEA should include a focus on minimization of postoperative hypertension and urinary retention.
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Affiliation(s)
- Zach M Feldman
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA.
| | - Srihari K Lella
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Sujin Lee
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Tiffany Bellomo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Jennifer Bocklett
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Glenn M LaMuraglia
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Sunita D Srivastava
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Nikolaos Zacharias
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
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Xiao W, Yang S, Feng S, Wang C, Huang H, Wang C, Zhong C, Zhan S, Yao D, Wang T. Risk factors for postoperative acute ischemic stroke in advanced-aged patients with previous stroke undergoing noncardiac surgery: a retrospective cohort study. BMC Surg 2023; 23:258. [PMID: 37644425 PMCID: PMC10466868 DOI: 10.1186/s12893-023-02162-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/20/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND The current study aimed to investigate the incidence and risk factors for postoperative acute ischemic stroke (PAIS) in advanced-aged patients (≥ 75 years) with previous ischemic stroke undergoing noncardiac surgery. METHODS In this single-center retrospective cohort study, all advanced-aged patients underwent noncardiac surgery from 1 January, 2019, to 30 April, 2022. Data were extracted from hospital electronic medical records. Multivariable logistic regression analysis was performed to determine predictors of PAIS. Multivariable linear or logistic regression analysis was performed to determine predictors of outcomes due to PAIS. RESULTS Twenty-four patients (6.0%) of the 400 patients developed PAIS. Carotid endarterectomy (CEA), length of surgery and preoperative Modified Rankin scale (mRS) ≥ 3 were significant predictors of PAIS. CEA was associated with increased risk of PAIS (OR 4.14; 95%CI, 1.43-11.99). Each additional minute in length of surgery had slightly increased the risk of PAIS (OR, 1.01; 95%CI, 1.00-1.01). Compared with reference (mRS < 3), mRS ≥ 3 increased odds of PAIS (OR, 4.09;95%CI, 1.12-14.93). Surgery type and length of surgery were found to be significant predictors of in-hospital expense (P < 0.001) and hospital stays (P < 0.05). CONCLUSIONS CEA, length of surgery and preoperative mRS ≥ 3 may increase the development of PAIS in advanced-aged patients (≥ 75 years) with previous stroke undergoing noncardiac surgery. PAIS increased in-hospital mortality and prolonged hospital stay.
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Affiliation(s)
- Wei Xiao
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Shuyi Yang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.
| | - Shuai Feng
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Chunxiu Wang
- Department of Evidence-based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hao Huang
- Department of Medical Records and Statistics, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chaodong Wang
- Department of Neurology, Xuanwu Hospital, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing, China
| | - Chonglin Zhong
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Shubin Zhan
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Dongxu Yao
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.
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Duraiswamy S, Cheng TW, Garofalo D, Levin SR, Farber A, King EG, Siracuse JJ. Qualitative Analysis of Length of Stay and Readmission after Carotid Endarterectomy. Ann Vasc Surg 2023; 90:1-6. [PMID: 36442710 DOI: 10.1016/j.avsg.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/23/2022] [Accepted: 10/09/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Length of stay (LOS) and readmissions are common measures to evaluate quality of health care. The objective of this study was to evaluate factors related to hospital LOS and readmission within 90 days following carotid endarterectomy (CEA) in patients who have not had a stroke. METHODS Using a single institution database, patients who underwent CEA for carotid stenosis between 2014 and 2019 were identified. Asymptomatic carotid stenosis (no history of any stroke or transient ischemic attack (TIA) within 6 months prior to CEA), and patients who had a TIA without stroke were included. Demographic and perioperative factors were collected. Primary outcomes analyzed were increased LOS (>1 day) and readmission within 90 days after surgery. RESULTS There were 125 patients identified who underwent CEA for 133 carotid stenosis, and 8 patients had bilateral CEA; of which 36.8% were asymptomatic carotid stenosis with the remaining being operated on for TIA without any stroke. The mean age was 68 years old and 36.1% of cases were female. The median postoperative LOS was 2 days. Increased LOS occurred in 81 cases (60.9%). Increased LOS, compared to no increased LOS, occurred more often in patients with diabetes (48.1% vs. 30.8%, P = 0.047), in those with operations starting after 12:00 pm (45.7% vs. 21.2%, P = 0.004) and those with any minor complications such as neck swelling, neck pain, and urinary retention (30.9% vs. 15.4%, P = 0.044). Readmission within 90 days after CEA occurred in 24 (18%) of cases. Readmission within 90 days, compared to no readmission within 90 days, occurred more often in patients with a history of coronary artery disease (58.3% vs. 27.5%, P = 0.004), congestive heart failure (37.5% vs. 11%, P = 0.001), and atrial fibrillation (29.2% vs. 8.3%, P = 0.004). CONCLUSIONS More than half of patients undergoing CEA for carotid stenosis were discharged after postoperative day 1. Interventions on modifiable clinical risk factors, such as morning CEA scheduling and management of comorbidities, may decrease LOS and 90-day readmission rates.
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Affiliation(s)
- Swetha Duraiswamy
- Division of Vascular and Endovascular Surgery, School of Medicine, Boston Medical Center, Boston University, Boston, MA
| | - Thomas W Cheng
- Division of Vascular and Endovascular Surgery, School of Medicine, Boston Medical Center, Boston University, Boston, MA
| | - Denise Garofalo
- Division of Vascular and Endovascular Surgery, School of Medicine, Boston Medical Center, Boston University, Boston, MA
| | - Scott R Levin
- Division of Vascular and Endovascular Surgery, School of Medicine, Boston Medical Center, Boston University, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, School of Medicine, Boston Medical Center, Boston University, Boston, MA
| | - Elizabeth G King
- Division of Vascular and Endovascular Surgery, School of Medicine, Boston Medical Center, Boston University, Boston, MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, School of Medicine, Boston Medical Center, Boston University, Boston, MA.
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A systematic review and meta-analysis of real-world studies evaluating the association between beta-blocker use and postoperative adverse events of carotid endarterectomy (CEA). J Vasc Surg 2021; 75:1456-1465.e5. [PMID: 34788650 DOI: 10.1016/j.jvs.2021.10.052] [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: 05/16/2021] [Accepted: 10/27/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To estimate the association of beta-blocker use with postoperative adverse events of CEA based on real-world data. METHODS Electronic bibliographic sources (MEDLINE, EMBASE, and CENTRAL) were searched up to Apr. 2021 using a combination of thesaurus and free-text terms to identify the studies about the effect of beta-blockers on outcomes of CEA. The systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. All observational studies and randomized controlled trials investigating the effect of preoperative beta-blockers on the outcomes of CEA were included. Independent extraction of articles by two authors using predefined data fields, including study quality indicators. All pooled analyses were based on a random-effects model. RESULTS A total of seven observational studies (six case-control studies and one cohort study) were included. Of the three case-control studies that examine the association of beta-blockers with composite postoperative adverse events, two studies including three datasets totaled 24161 participants were included in the quantitative synthesis and the overall results showed a statistically significant association between beta-blocker use and composite postoperative adverse events of CEA (OR 1.35, 95%CI 1.15- 1.59, p = .0003; I2 = 13%). Publication bias was not present in the meta-analysis (Egger's test showed non-significant results: p = .453). Two of the included studies utilized indirect measures of cerebral ischemia: intraoperative EEG, intraoperative hemodynamic indicators; and found a significant association between beta-blockers and intraoperative cerebral ischemia. Another two studies were included for meta-analysis on the association between beta-blockers and 30-day strokes or death of CEA (OR 1.61, 95%CI 0.98-2.65, p = .06; I2=0%). Of all included studies, there is only one cohort study that reported the association of beta-blockers with postoperative MI by chi-squared analysis (OR 1.96, 95%CI 1.86-2.07). CONCLUSION This systematic review suggested that there was an increased risk of postoperative adverse outcomes of CEA among beta-blocker users compared to non-users in the real world.
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Kuhrij LS, Karthaus EG, Vahl AC, Willems MCM, Elshof JW, de Borst GJ. A Composite Measure for Quality of Care in Patients with Symptomatic Carotid Stenosis Using Textbook Outcome. Eur J Vasc Endovasc Surg 2020; 60:502-508. [PMID: 32732140 DOI: 10.1016/j.ejvs.2020.06.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 05/14/2020] [Accepted: 06/07/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Composite measures may better objectify hospital performance than individual outcome measures (IOM). Textbook outcome (TO) is an outcome measure achieved for an individual patient when all undesirable outcomes are absent. The aim of this study was to assess TO as an additional outcome measure to evaluate quality of care in symptomatic patients treated by carotid endarterectomy (CEA). METHODS All symptomatic patients treated by CEA in 2018, registered in the Dutch Audit for Carotid Interventions, were included. TO was defined as a composite of the absence of 30 day mortality, neurological events (any stroke or transient ischaemic attack [TIA]), cranial nerve deficit, haemorrhage, 30 day readmission, prolonged length of stay (LOS; > 5 days) and any other surgical complication. Multivariable logistic regression was used to identify covariables associated with achieving TO, which were used for casemix adjustment for hospital comparison. For each hospital, an observed vs. expected number of events ratio (O/E ratio) was calculated and plotted in a funnel plot with 95% control limits. RESULTS In total, 70.7% of patients had a desired outcome within 30 days after CEA and therefore achieved TO. Prolonged LOS was the most common parameter (85%) and mortality the least common (1.1%) for not achieving TO. Covariates associated with achieving TO were younger age, the absence of pulmonary comorbidity, higher haemoglobin levels, and TIA as index event. In the case mix adjusted funnel plot, the O/E ratios between hospitals ranged between 0.63 and 1.27, with two hospitals revealing a statistically significantly lower rate of TO (with O/E ratios of 0.63 and 0.66). CONCLUSION In the Netherlands, most patients treated by CEA achieve TO. Variation between hospitals in achieving TO might imply differences in performance. TO may be used as an additive to the pre-existing IOM, especially in surgical care with low baseline risk such as CEA.
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Affiliation(s)
- Laurien S Kuhrij
- Department of Neurology, Amsterdam University Medical Centre, Academic Medical Centre, Amsterdam, the Netherlands; Dutch Institute for Clinical Auditing, Leiden, the Netherlands
| | - Eleonora G Karthaus
- Dutch Institute for Clinical Auditing, Leiden, the Netherlands; Department of Surgery, OLVG, Amsterdam, the Netherlands
| | - Anco C Vahl
- Department of Surgery, OLVG, Amsterdam, the Netherlands
| | | | - Jan W Elshof
- Department of Surgery, VieCuri Medical Centre, Venlo, the Netherlands
| | - Gert J de Borst
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands.
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Rocha-Neves JM, Pereira-Macedo J, Dias-Neto MF, Andrade JP, Mansilha AA. Benefit of selective shunt use during carotid endarterectomy under regional anesthesia. Vascular 2020; 28:505-512. [DOI: 10.1177/1708538120922098] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives Carotid cross-clamping during endarterectomy exposes the patient to intraoperative neurological deficits due to embolism or cerebral hypoperfusion. To prevent further cerebrovascular incidents, resorting to shunt is frequently recommended. However, since this method is also considered a stroke risk factor, the use is still controversial. This study aims to shed some light on the best approach regarding the use of shunt in symptomatic cerebral malperfusion after carotid artery cross-clamping. Methods From January 2012 to January 2018, 79 patients from a tertiary referral hospital who underwent carotid endarterectomy with regional anesthesia for carotid artery stenosis and manifested post-clamping neurologic deficits were prospectively gathered. Shunt use was left to the decision of the surgeon and performed in 31.6% (25) of the patients. Demographics, comorbidities, imaging tests, and clinical/intraoperative features were evaluated. For data assessment, univariate analysis was performed. Results Regarding 30-day stroke, 30-day postoperative complications (stroke, surgical hematoma, hyperperfusion syndrome), and cranial nerve injury, no significant differences were found ( P = 0.301, P = 0.460, and P = 0.301, respectively) between resource to shunt and non-shunt. Clamping and surgery times were significantly higher in the shunt group ( P < 0.001 and P = 0.0001, respectively). Conclusions Selective-shunting did not demonstrate superiority for patients who developed focal deficits regarding stroke or other postoperative complications. However, due to the limitations of this study, the benefit of shunting cannot be excluded. Further randomized trials are recommended for precise results on this matter with current sparse clinical evidence.
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Affiliation(s)
- João M Rocha-Neves
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Biomedicine – Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Department of Physiology and Surgery, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Juliana Pereira-Macedo
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Marina F Dias-Neto
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Physiology and Surgery, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - José Paulo Andrade
- Department of Biomedicine – Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Armando A Mansilha
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Physiology and Surgery, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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DeMartino RR. Standardized operations lacking standardized recovery. J Vasc Surg 2020; 71:545. [PMID: 32040429 DOI: 10.1016/j.jvs.2019.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 05/18/2019] [Indexed: 11/16/2022]
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Ross EG, Mell MW. Evaluation of regional variations in length of stay after elective, uncomplicated carotid endarterectomy in North America. J Vasc Surg 2020; 71:536-544.e7. [PMID: 31280981 PMCID: PMC8269949 DOI: 10.1016/j.jvs.2019.02.071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 02/25/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate factors affecting regional variation in length of stay (LOS) after elective, uncomplicated carotid endarterectomy (CEA). METHODS Data were obtained from the Vascular Quality Initiative database and included patients with complete data who received elective CEA without complications between 2012 and 2017 across 18 regions in North America and 294 centers. The main outcome measure was LOS >1 day after surgery (LOS >1 postoperative day [POD]). Using least absolute shrinkage and selection operator regression, multivariable modeling, and mixed-effects general linear modeling, we evaluated whether regional variations in LOS were independent of demographic, clinical, or center-related factors and to what extent these factors accounted for postoperative variation in LOS. RESULTS A total of 36,004 patients were included. Mean postprocedure LOS was 1.6 ± 6.6 days. Overall, 24% of patients had an LOS >1 POD. After adjustment for important demographic, clinical, and center-related factors, the region in which a patient was treated independently and significantly affected LOS after elective, uncomplicated CEA. Region and center of treatment accounted for 18% of LOS variation. Demographic, clinical, and surgical factors accounted for another 32% of variation in LOS. Of these factors, postoperative discharge to a facility other than home (odds ratio [OR], 6.3; confidence interval [CI], 5.2-7.6), use of intravenous (IV) vasoactive agents (OR, 3.2; CI, 3-3.4), intraoperative drain placement (OR, 1.4; CI, 1.3-1.55), and female sex (OR, 1.4; CI, 1.3-1.5) were associated with longer LOS. Factors associated with LOS ≤1 POD included preoperative aspirin (OR, 0.88; CI, 0.8-0.96) and statin use (OR, 0.9; CI, 0.83-0.98), high surgeon volume (highest quartile: OR, 0.68; CI, 0.5-0.87), and completion evaluation after CEA (eg, Doppler, ultrasound; OR, 0.87; CI, 0.8-0.95). We also found that use of IV vasoactive medications varied significantly across regions, independent of demographic and clinical factors. CONCLUSIONS Significant regional variation in LOS exists after elective, uncomplicated CEA even after controlling for a wide range of important factors, indicating that there remain unmeasured causes of longer LOS in some regions. Even so, modification of certain clinical practices may reduce overall LOS. Regional differences in use of IV vasoactive medications not driven by clinical factors warrant further analysis, given the strong association with longer LOS.
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Affiliation(s)
- Elsie Gyang Ross
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Matthew W Mell
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, Calif.
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Ngo HTN, Nemeth B, Wever JJ, Veger HTC, Mairuhu ATA, de Laat KF, Statius van Eps RG. Clinical outcomes of postcarotid endarterectomy hypertension. J Vasc Surg 2019; 71:553-559. [PMID: 31280977 DOI: 10.1016/j.jvs.2019.04.477] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 04/11/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of this study was to determine the clinical relevance of postcarotid endarterectomy hypertension (PEH) by investigating the effect of PEH on hospital length of stay (LOS) and by investigating short-term and long-term complications of PEH. In addition, risk factors for PEH were determined. METHODS A single-center retrospective cohort study was performed. Demographic, preoperative, intraoperative, and postoperative outcomes of 192 patients undergoing carotid endarterectomy were evaluated. Outcomes were compared between patients with PEH and patients without PEH. PEH was defined as an acute systolic blood pressure (SBP) rise >170 mm Hg or persistent SBP >150 mm Hg on the ward and leading to the consultation of an internist. The overall survival and event-free survival were compared using a Kaplan-Meier analysis and a Cox regression analysis. A multivariate logistic regression analysis was performed to determine risk factors for PEH. RESULTS PEH developed in 44 of 192 patients (25%). Preoperative hypertension (SBP >150 mm Hg) was determined to be a risk factor for PEH (odds ratio, 3.3; 95% confidence interval [CI], 1.6-6.9). Hospital LOS was prolonged in patients with PEH compared with patients without PEH (median LOS of 5 days vs 3 days, respectively; P < .001). No difference in the occurrence of ischemic neurologic events or rebleeding during hospitalization was observed (P = .58 and P = .72, respectively). Cardiovascular and ischemic neurologic events during follow-up did not occur more often in patients with PEH than in patients without PEH (P = .46). There was no difference in mortality between the PEH and non-PEH groups (hazard ratio, 1.6; 95% CI, 0.6-4.3). The same applies to the event-free survival (hazard ratio, 0.77; 95% CI, 0.4-1.7). Combined event-free survival for stroke and myocardial infarction was 92% (95% CI, 87%-97%) at 2 years for patients without PEH and 86% (95% CI, 74%-98%) at 2 years for patients with PEH (P = .25). Event-free survival for mortality was 90% (95% CI, 85%-96%) at 2 years for patients without PEH and 94% (95% CI, 86%-100%) at 2 years for patients with PEH (P = .36). CONCLUSIONS Patients with PEH had a significant increase in hospital LOS. However, adverse short-term and long-term events did not occur more often in patients with PEH. High preoperative SBP was identified as a risk factor for PEH; no other demographic and clinical variables were associated with PEH.
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Affiliation(s)
- Hà T N Ngo
- HAGA Heart and Vascular Center, Haga Teaching Hospital, The Hague, The Netherlands; Department of Vascular Surgery, Haga Teaching Hospital, The Hague, The Netherlands
| | - Banne Nemeth
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan J Wever
- HAGA Heart and Vascular Center, Haga Teaching Hospital, The Hague, The Netherlands; Department of Vascular Surgery, Haga Teaching Hospital, The Hague, The Netherlands
| | - Hugo T C Veger
- HAGA Heart and Vascular Center, Haga Teaching Hospital, The Hague, The Netherlands; Department of Vascular Surgery, Haga Teaching Hospital, The Hague, The Netherlands
| | - Albert T A Mairuhu
- HAGA Heart and Vascular Center, Haga Teaching Hospital, The Hague, The Netherlands; Department of Vascular Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Karlijn F de Laat
- HAGA Heart and Vascular Center, Haga Teaching Hospital, The Hague, The Netherlands; Department of Vascular Neurology, Haga Teaching Hospital, The Hague, The Netherlands
| | - Randolph G Statius van Eps
- HAGA Heart and Vascular Center, Haga Teaching Hospital, The Hague, The Netherlands; Department of Vascular Surgery, Haga Teaching Hospital, The Hague, The Netherlands.
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11
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Saraçoğlu A, Ezelsoy M, Saraçoğlu KT. Does Transfusion of Blood and Blood Products Increase the Length of Stay in Hospital? Indian J Hematol Blood Transfus 2019; 35:313-320. [PMID: 30988569 DOI: 10.1007/s12288-018-1039-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 10/31/2018] [Indexed: 11/30/2022] Open
Abstract
We aimed to analyze the use of blood products in cardiac surgery and to investigate its effect on clinical outcomes. Perioperative transfusion requirement, survival and complication rates and the duration of hospitalization were noted. Patients were divided into two groups considering the duration of hospital and intensive care unit (ICU) stay. The cardiopulmonary bypass time and the cross clamp time, and the amount of used cryoprecipitate, fresh frozen plasma, platelet, red blood cell and the bleeding amount were significantly higher in groups that stayed at the hospital for > 7 days and at the ICU for > 2 days (p > 0.05). In the univariate model, to predict the patients who might stay at the hospital for more than 1 week and who might stay at the ICU for more than 3 days, we considered the significant efficacy of postoperative blood transfusion, bleeding amount, and the cardiopulmonary bypass time (p < 0.05). In the reduced multivariate model, however, we analyzed the significant-independent efficacy of the postoperative fresh frozen plasma use to determine the patients who would stay at the hospital for more than 1 week and who would stay at the ICU for more than 3 days (p < 0.05). We have concluded that increased use of blood products was associated with the cross clamp and cardiopulmonary bypass time and prolonged duration of hospital and ICU stays. In open cardiac surgeries, the use of blood products due to bleeding was identified as a predictor for staying longer than 3 days at the ICU and longer than 7 days at the hospital.
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Affiliation(s)
- Ayten Saraçoğlu
- 1Department of Anesthesiology and Intensive Care, Marmara University Medical School, Istanbul, Turkey
| | - Mehmet Ezelsoy
- 2Department of Cardiovascular Surgery, Istanbul Bilim University Medical School, Istanbul, Turkey
| | - Kemal Tolga Saraçoğlu
- 3Department of Anesthesiology and Intensive Care, Health Sciences University Medical School, Derince Training and Research Hospital, Ibnisina Mh. Lojman Sk. No: 1, 41900 Derince Kocaeli, Turkey
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12
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Minc SD, Misra R, Holmes SD, Ren Y, Marone L. Impact of rural versus urban geographic location on length of stay after carotid endarterectomy. Vascular 2019; 27:390-396. [PMID: 30845899 DOI: 10.1177/1708538119835402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Reducing the incidence of extended length of stay (ELOS) after carotid endarterectomy (CEA), defined as LOS > 1 day, is an important quality improvement focus of the Vascular Quality Initiative (VQI). Rural patients with geographic barriers pose a particular challenge for discharge and may have higher incidences of ELOS as a result. The purpose of this study was to examine the impact of patients’ home geographic location on ELOS after CEA. Methods The VQI national database for CEA comprised the sample for analyses ( N = 66,900). Rural-Urban Commuting Area (RUCA) codes, a validated system used to classify the nation’s census tracts according to rural and urban status, was applied to the VQI database and used to indicate patients’ home geographic location. LOS was categorized into two groups: LOS ≤ 1 day (66%) and LOS > 1 day (ELOS) (34%). Multivariable logistic regression was conducted to examine the effect of geographic location on ELOS after adjustment for age, gender, race, and comorbid conditions. Results A total of 66,900 patients were analyzed and the mean age of the sample was 70.5 ± 9.3 years (40% female). After adjustment for covariates, the urban group had increased risk for ELOS (OR = 1.20, p < 0.001). Other factors that significantly increased risk for ELOS were non-White race/Latinx/Hispanic ethnicity (OR = 1.44, p < 0.001) and nonelective status (OR = 3.31, p < 0.001). In addition, patients treated at centers with a greater percentage of urban patients had greater risk for ELOS (OR = 1.008, p < 0.001). Conclusions These analyses found that geographic location did impact LOS, but not in the hypothesized direction. Even with adjustment for comorbidities and other factors, patients from urban areas and centers with more urban patients were more likely to have ELOS after CEA. These findings suggest that other mechanisms, such as racial disparities, barriers in access to care, and disparities in support after discharge for urban patients may have a significant impact on LOS.
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Affiliation(s)
| | - Ranjita Misra
- 2 School of Public Health, West Virginia University, Morgantown, WV, USA
| | - Sari D Holmes
- 1 WVU Heart and Vascular Institute, Morgantown, WV, USA
| | - Yue Ren
- 1 WVU Heart and Vascular Institute, Morgantown, WV, USA
| | - Luke Marone
- 1 WVU Heart and Vascular Institute, Morgantown, WV, USA
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13
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Mehaffey JH, Hawkins RB, Tracci MC, Robinson WP, Cherry KJ, Kern JA, Upchurch GR. Preoperative dementia is associated with increased cost and complications after vascular surgery. J Vasc Surg 2018; 68:1203-1208. [PMID: 29606569 DOI: 10.1016/j.jvs.2018.01.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 01/09/2018] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Dementia represents a major risk factor for medical complications and has been linked to higher rates of complication after surgery. Given the systemic nature of vascular disease, medical comorbidities significantly increase cost and complications after vascular surgery. We hypothesize that the presence of dementia is an independent predictor of increased postoperative complications and higher health care costs after vascular surgery. METHODS The Vascular Quality Initiative database was queried for all patients undergoing vascular surgery at a single academic medical center from 2012 to 2017. All modules were included (open abdominal aortic aneurysm, suprainguinal bypass, lower extremity bypass, amputation, carotid endarterectomy, endovascular aortic aneurysm repair, thoracic endovascular aortic aneurysm repair, and peripheral endovascular intervention). An institutional clinical data repository was queried to identify patients with International Classification of Diseases, Ninth Revision diagnosis codes for dementia as well as total hospital cost and long-term survival using Social Security records from the Virginia Department of Health. Hierarchical logistic and linear regression models were fit to assess risk-adjusted predictors of any complication and inflation-adjusted cost. Kaplan-Meier and Cox proportional hazards models were used for survival analysis. RESULTS A total of 2318 patients underwent vascular surgery and were captured by the Vascular Quality Initiative during the past 5 years, with 88 (3.8%) having a diagnosis of dementia. Patients with dementia were older and had higher rates of medical comorbidities, and the most common procedure was major amputation. In addition, dementia patients had a significantly higher rate of any complication (52% vs 16%; P < .0001) and increased 90-day mortality (14% vs 4.8%; P = .0002). Furthermore, dementia was associated with significant resource utilization, including preoperative length of stay (LOS), postoperative LOS, intensive care unit LOS, and inflation-adjusted total hospital cost (all P < .0001). Hierarchical modeling demonstrated that dementia was the strongest preoperative predictor for any complication (odds ratio, 8.64; P < .0001) and had the largest risk-adjusted impact on total hospital cost ($22,069; P < .0001). Finally, survival analysis demonstrated that dementia is independently associated with reduced survival after vascular surgery (hazard ratio, 1.37; P = .018). CONCLUSIONS This study demonstrated that dementia is one of the strongest predictors of any complication and increased hospital cost after vascular surgery. Given the high risk of clinical and financial maladies, patients with dementia should be carefully considered and counseled before undergoing vascular surgery.
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Affiliation(s)
- J Hunter Mehaffey
- Division of Vascular and Endovascular Surgery and Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Robert B Hawkins
- Division of Vascular and Endovascular Surgery and Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Margaret C Tracci
- Division of Vascular and Endovascular Surgery and Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - William P Robinson
- Division of Vascular and Endovascular Surgery and Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Kenneth J Cherry
- Division of Vascular and Endovascular Surgery and Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - John A Kern
- Division of Vascular and Endovascular Surgery and Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Gilbert R Upchurch
- Division of Vascular and Endovascular Surgery and Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Va.
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14
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Shean KE, O'Donnell TFX, Deery SE, Pothof AB, Schneider JR, Rockman CB, Nolan BW, Schermerhorn ML. Regional variation in patient outcomes in carotid artery disease treatment in the Vascular Quality Initiative. J Vasc Surg 2018; 68:749-759. [PMID: 29571620 DOI: 10.1016/j.jvs.2017.11.080] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 11/20/2017] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Quality metrics were developed to improve outcomes after carotid artery revascularization; however, few studies have evaluated regional differences in perioperative outcomes. This study aimed to evaluate regional variation in mortality and perioperative outcomes after carotid endarterectomy (CEA) and carotid artery stenting (CAS). METHODS We identified all patients who underwent CEA or CAS from 2009 to 2016 in the Vascular Quality Initiative. Patients were analyzed on the basis of their symptom status. We assessed variation in perioperative outcomes using χ2 analysis, Fisher exact test, and t-test, where appropriate. RESULTS A total of 78,467 carotid interventions were identified; 85% were CEAs, with 69% of those asymptomatic. Within CAS, 39% were asymptomatic. Perioperative stroke/death varied across regions within both CAS groups (asymptomatic, 0%-5.8% [P = .03]; symptomatic, 2.4%-8.1% [P = .1]), and several regions did not meet the American Heart Association (AHA) guidelines of 3% for asymptomatic patients and 6% for symptomatic patients, which persisted after risk adjustment. For CEA, the stroke/death rates fell within the standards set by the AHA guidelines in all regions for both the unadjusted and risk-adjusted models; however, there was significant regional variation in the cohorts (asymptomatic, 0.9%-3.1% [P < .01]; symptomatic, 1.3%-4.9% [P < .01]). Variation in 30-day mortality was significant in symptomatic patients (asymptomatic: CEA, 0%-1.3% [P = .2], CAS, 0%-2.4% [P = .2]; symptomatic: CEA, 0%-1.8% [P < .01], CAS, 0%-4.6% [P = .01]). Rates of in-hospital stroke, postoperative myocardial infarction, prolonged length of stay (>2 days), and use of intravenous blood pressure medications all varied significantly across the regions. After CEA, there was significant variation in the rates of cranial nerve injuries (asymptomatic, 0.9%-4.9% [P < .01]; symptomatic, 1.5%-7.7% [P < .01]), return to the operating room (asymptomatic, 0.9%-3.4% [P < .01]; symptomatic, 0.6%-3.4% [P = .02]), and discharge on antiplatelet and statin (asymptomatic, 75%-87% [P < .01]; symptomatic, 78%-91% [P < .01]). After CAS, significant variation was found in the rates of access site complications (asymptomatic, 2.3%-18.2% [P < .01]; symptomatic, 1.4%-16.9% [P < .01]) and discharge on dual antiplatelet therapy (asymptomatic, 79%-94% [P < .01]; symptomatic, 83%-93% [P < .01]). CONCLUSIONS Unwarranted regional variation exists in outcomes after carotid artery revascularization across the regions of the VQI. Significant variation was seen in a number of outcomes for which quality metrics currently exist, such as length of stay and discharge medications. In addition, after CAS, several regions failed to meet the AHA guidelines for stroke and death. Given these results, quality improvement projects should be targeted to improve adherence to current guidelines to promote best practices.
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Affiliation(s)
- Katie E Shean
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, St. Elizabeth's Medical Center, Boston, Mass
| | - Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Sarah E Deery
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Alexander B Pothof
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
| | - Joseph R Schneider
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Caron B Rockman
- Division of Vascular and Endovascular Surgery, NYU Langone Medical Center, New York, NY
| | - Brian W Nolan
- Division of Vascular and Endovascular Surgery, Maine Medical Center, Portland, Me
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
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15
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Pei KY, Zhang Y, Sarac T, Davis KA. Comparison of Outcomes in Below-Knee Amputation between Vascular and General Surgeons. Ann Vasc Surg 2018; 50:259-268. [PMID: 29501591 DOI: 10.1016/j.avsg.2017.11.073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 11/28/2017] [Accepted: 11/30/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is evidence to suggest outcomes may be related to surgeon experience or skill level. Lower extremity amputations are performed by both general surgeons (GSs) and vascular surgeons (VSs); however, the effect of specialty on postoperative outcome in below-knee amputation is not known. This retrospective study compares outcomes in below-knee amputations (BKA) between VS and GS. METHODS Patients who underwent below-knee amputations between 2005 and 2014 were identified from the American College of Surgeons National Surgical Quality Improvement Project database. Data collected included patient demographics, comorbid conditions, and indication for procedures. Univariate and multivariate unconditional logistic regression models and linear regression models were employed to evaluate the associations between various outcomes and indications for surgery, emergency and teaching status, and surgical specialty. RESULTS Amputations performed by GSs experienced an increased risk of developing pneumonia (odds ratio [OR] = 1.49, 95% confidence interval [CI]: 1.19-1.86), pulmonary embolism (OR = 2.10, 95% CI: 1.10-4.01), and sepsis (OR = 1.29, 95% CI: 1.05-1.59). When stratified by indications for BKA, similar outcomes were noted between GS and VS if indication for surgery was diabetes or peripheral vascular disease; however, there was increased risk of pneumonia (OR = 1.86, 95% CI: 1.26-2.74), sepsis (OR = 1.96, 95% CI: 1.39-2.75), and death (OR = 1.47, 95% CI: 1.04-2.07, P = 0.027) when GS performed BKA for infectious indications. Overall complications were higher when GS performed BKA emergently (OR = 1.17, 95% CI: 1.01-1.36). CONCLUSION There are less postoperative complications when VSs performed BKA for infectious indications, during emergencies, and at nonteaching hospitals. Clinicians should consider vascular consultation for these specific scenarios.
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Affiliation(s)
- Kevin Y Pei
- Section of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, CT.
| | - Yawei Zhang
- Section of Surgical Outcomes and Epidemiology, Department of Surgery, Yale School of Medicine, New Haven, CT; Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT
| | - Timur Sarac
- Section of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Kimberly A Davis
- Section of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, CT
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Krafcik BM, Cheng TW, Farber A, Kalish JA, Rybin D, Doros G, Siracuse JJ. Perioperative outcomes after reoperative carotid endarterectomy are worse than expected. J Vasc Surg 2017; 67:793-798. [PMID: 29042076 DOI: 10.1016/j.jvs.2017.08.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 08/17/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Reoperative carotid endarterectomy (CEA) can be technically challenging because of significant scarring as a consequence of the initial CEA procedure. There are limited data that describe outcomes after reoperative CEA, and as such, our goal was to determine the effect of reoperative CEA on perioperative outcomes. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients undergoing index and reoperative CEA between 2005 and 2014. Multivariate analysis was performed to assess the effect of reoperative CEA on outcomes including stroke, major adverse cardiovascular event, and procedure time. RESULTS There were 75,943 index and 140 reoperative CEAs identified. No differences were found in baseline demographics or comorbidities except that the reoperative group had a higher incidence of patients with end-stage renal disease (3.6% vs 1.1%; P = .004). Prior stroke with deficit (20.8% vs 15.4%; P = .137) and without deficit (11.5% vs 9.1%; P = .43) were similar between reoperative and index CEA groups. Both the reoperative and index initial CEA cohorts had comparable rates of surgical site infection (0.7% vs 0.3%; P = .462), return to the operating room (3.6% vs 4%; P = .816), readmission with 30 days (2.1% vs 6.9%; P = .810), myocardial infarction (2.1% vs 0.9%; P = .125), and perioperative death (0.7% vs 0.9%; P = .853). The reoperative cohort had a significantly higher rate of perioperative stroke (5.0% vs 1.6%; P = .002) and a longer operative duration (137 ± 54 vs 116 ± 49 minutes; P < .001). Multivariate analysis revealed that reoperative CEA was an independent factor for postoperative stroke (odds ratio, 3.71; 95% confidence interval [CI], 1.61-8.57; P = .002), major adverse cardiovascular event (odds ratio, 2.76; 95% CI, 1.32-5.78; P = .007), and longer procedure time (means ratio, 1.21; 95% CI, 1.12-1.30; P < .001). CONCLUSIONS Reoperative carotid surgery is associated with a longer operative time and higher risk for perioperative stroke compared with index CEA. This information informs the risk-benefit analysis for reoperation.
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Affiliation(s)
- Brianna M Krafcik
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, Mass
| | - Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, Mass
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, Mass
| | - Jeffrey A Kalish
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, Mass
| | - Denis Rybin
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, Mass
| | - Gheorghe Doros
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, Mass
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, Mass.
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