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Nordanstig J, Behrendt CA, Baumgartner I, Belch J, Bäck M, Fitridge R, Hinchliffe R, Lejay A, Mills JL, Rother U, Sigvant B, Spanos K, Szeberin Z, van de Water W, Antoniou GA, Björck M, Gonçalves FB, Coscas R, Dias NV, Van Herzeele I, Lepidi S, Mees BME, Resch TA, Ricco JB, Trimarchi S, Twine CP, Tulamo R, Wanhainen A, Boyle JR, Brodmann M, Dardik A, Dick F, Goëffic Y, Holden A, Kakkos SK, Kolh P, McDermott MM. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Asymptomatic Lower Limb Peripheral Arterial Disease and Intermittent Claudication. Eur J Vasc Endovasc Surg 2024; 67:9-96. [PMID: 37949800 DOI: 10.1016/j.ejvs.2023.08.067] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 08/14/2023] [Indexed: 11/12/2023]
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Patel RJ, Zarrintan S, Jagadeesh V, Vootukuru NR, Gaffey A, Malas MB. Long-term outcomes after lower extremity bypass in the actively smoking claudicant. J Vasc Surg 2023; 78:1003-1011. [PMID: 37327952 PMCID: PMC10528269 DOI: 10.1016/j.jvs.2023.05.047] [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: 04/26/2023] [Revised: 05/26/2023] [Accepted: 05/26/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE Smoking is known to increase complications, including poor wound healing, coagulation abnormalities, and cardiac and pulmonary ramifications. Across specialties, elective surgical procedures are commonly denied to active smokers. Given the base population of active smokers with vascular disease, smoking cessation is encouraged but is not required the way it is for elective general surgery procedures. We aim to study the outcomes of elective lower extremity bypass (LEB) in actively smoking claudicants. METHODS We queried the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network LEB database from 2003 to 2019. In this database we found 609 (10.0%) never smokers (NS), 3388 (55.3%) former smokers (FS), and 2123 (34.7%) current smokers (CS) who underwent LEB for claudication. We performed two separate propensity score matches without replacement on 36 clinical variables (age, gender, race, ethnicity, obesity, insurance, hypertension, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, previous coronary artery bypass graft, carotid endarterectomy, major amputation, inflow treatment, preoperative medications and treatment type), one of FS to NS and a second analysis of CS to FS. Primary outcomes included 5-year overall survival (OS), limb salvage (LS), freedom from reintervention (FR), and amputation-free survival (AFS). RESULTS Propensity score matches resulted in 497 well-matched pairs of NS and FS. In this analysis we found no difference in terms of OS (HR, 0.93; 95% CI, 0.70-1.24; P = .61), LS (HR, 1.07; 95% CI, 0.63-1.82; P = .80), FR (HR, 0.9; 95% CI,0.71-1.21; P = .59), or AFS (HR, 0.93; 95% CI,0.71-1.22; P = .62). In the second analysis, we had 1451 well-matched pairs of CS and FS. There was no difference in LS (HR, 1.36; 95% CI,0.94-1.97; P = .11) or FR (HR, 1.02; 95% CI,0.88-1.19; P = .76). However, we did find a significant increase in OS (HR, 1.37; 95% CI,1.15-1.64, P <.001) and AFS (HR, 1.38; 95% CI,1.18-1.62; P < .001) in FS compared with CS. CONCLUSIONS Claudicants represent a unique nonemergent vascular patient population that may require LEB. Our study found that FS have better OS and AFS when compared with CS. Additionally, FS mimic nonsmokers at 5-year outcomes for OS, LS, FR, and AFS. Therefore, structured smoking cessation should be a more prominent part of vascular office visits before elective LEB procedures in claudicants.
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Affiliation(s)
- Rohini J Patel
- Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, CA
| | - Sina Zarrintan
- Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, CA
| | - Vasan Jagadeesh
- Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, CA
| | | | - Ann Gaffey
- Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, CA
| | - Mahmoud B Malas
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ.
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Weaver ML, Neal D, Columbo JA, Holscher CM, Sorber RA, Hicks CW, Stone DH, Clouse WD, Scali ST. Market competition influences practice patterns in management of patients with intermittent claudication in the vascular quality initiative. J Vasc Surg 2023; 78:727-736.e3. [PMID: 37141948 PMCID: PMC10699768 DOI: 10.1016/j.jvs.2023.04.032] [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: 02/13/2023] [Revised: 04/06/2023] [Accepted: 04/24/2023] [Indexed: 05/06/2023]
Abstract
OBJECTIVE The Society for Vascular Surgery (SVS) clinical practice guidelines recommend best medical therapy (BMT) as first-line therapy before offering revascularization to patients with intermittent claudication (IC). Notably, atherectomy and tibial-level interventions are generally discouraged for management of IC; however, high regional market competition may incentivize physicians to treat patients outside the scope of guideline-directed therapy. Therefore, we sought to determine the association between regional market competition and endovascular treatment of patients with IC. METHODS We examined patients with IC undergoing index endovascular peripheral vascular interventions (PVI) in the SVS Vascular Quality Initiative from 2010 to 2022. We assigned the Herfindahl-Hirschman Index as a measure of regional market competition and stratified centers into very high competition (VHC), high competition, moderate competition, and low competition cohorts. We defined BMT as preoperative documentation of being on antiplatelet medication, statin, nonsmoking status, and a recorded ankle-brachial index. We used logistic regression to evaluate the association of market competition with patient and procedural characteristics. A sensitivity analysis was performed in patients with isolated femoropopliteal disease matched by the TransAtlantic InterSociety classification of disease severity. RESULTS There were 24,669 PVIs that met the inclusion criteria. Patients with IC undergoing PVI were more likely to be on BMT when treated in higher market competition centers (odds ratio [OR], 1.07 per increase in competition quartile; 95% confidence interval [CI], 1.04-1.11; P < .0001). The probability of undergoing aortoiliac interventions decreased with increasing competition (OR, 0.84; 95% CI, 0.81-0.87; P < .0001), but there were higher odds of receiving tibial (OR, 1.40; 95% CI, 1.30-1.50; P < .0001) and multilevel interventions in VHC vs low competition centers (femoral + tibial OR, 1.10; 95% CI, 1.03-1.14; P = .001). Stenting decreased as competition increased (OR, 0.89; 95% CI, 0.87-0.92; P < .0001), whereas exposure to atherectomy increased with higher market competition (OR, 1.15; 95% CI, 1.11-1.19; P < .0001). When assessing patients undergoing single-artery femoropopliteal intervention for TransAtlantic InterSociety A or B lesions to account for disease severity, the odds of undergoing either balloon angioplasty (OR, 0.72; 95% CI, 0.625-0.840; P < .0001) or stenting only (OR, 0.84; 95% CI, 0.727-0.966; P < .0001) were lower in VHC centers. Similarly, the likelihood of receiving atherectomy remained significantly higher in VHC centers (OR, 1.6; 95% CI, 1.36-1.84; P < .0001). CONCLUSIONS High market competition was associated with more procedures among patients with claudication that are not consistent with guideline-directed therapy per the SVS clinical practice guidelines, including atherectomy and tibial-level interventions. This analysis demonstrates the susceptibility of care delivery to regional market competition and signifies a novel and undefined driver of PVI variation among patients with claudication.
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Affiliation(s)
- M Libby Weaver
- Division of Vascular and Endovascular Surgery, University of Virginia Health System, Charlottesville, VA.
| | - Dan Neal
- Department of Surgery, University of Florida, Gainesville, FL
| | - Jesse A Columbo
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Courtenay M Holscher
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rebecca A Sorber
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD
| | - David H Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia Health System, Charlottesville, VA
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
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Patients undergoing interventions for claudication experience low perioperative morbidity but are at risk for worsening functional status and limb loss. J Vasc Surg 2020; 72:241-249. [DOI: 10.1016/j.jvs.2019.08.278] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/24/2019] [Indexed: 01/17/2023]
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Young JC, Paul NJ, Karatas TB, Kondrasov SA, McGinigle KL, Crowner JR, Pascarella L, Farber MA, Kibbe MR, Marston WA, Kalbaugh CA. Cigarette smoking intensity informs outcomes after open revascularization for peripheral artery disease. J Vasc Surg 2019; 70:1973-1983.e5. [PMID: 31176638 DOI: 10.1016/j.jvs.2019.02.066] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 02/20/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Cigarette smoking is the leading risk factor for peripheral artery disease (PAD). Existing literature often defines smoking history in broad categories of current, former, and never smokers, which may not sufficiently identify patients at the highest risk for poor outcomes. The purpose of this study was to examine the use of more informative categorization of smoking and to determine the association with important revascularization outcomes. METHODS We conducted a retrospective review of all patients undergoing open lower extremity revascularization for symptomatic PAD, defined as claudication (Rutherford 3) or critical limb ischemia (Rutherford 4-6), during a 5-year period (2013-2017). Smoking history, demographics, and comorbidities were abstracted from electronic health records from seven hospitals within our health care system. Smoking history was defined by intensity (packs/day), duration (years), pack-year history, and cessation time. Outcomes included major adverse limb events (MALEs), death, limb loss, and amputation-free survival. Cox proportional hazards models were used to calculate hazard ratios and 95% confidence intervals (CIs) for each parameter adjusted for patients' demographics and comorbidities. Cumulative incidence is reported for outcomes at 30, 180, and 365 days of follow-up. RESULTS We identified 693 patients undergoing open lower extremity revascularization for PAD (66% critical limb ischemia; 46% diabetes). The 1-year cumulative incidence of MALEs was 29.9% (95% CI, 26.4-33.9), whereas the 1-year incidence of death was 9.8% (95% CI, 7.5-12.7). The broad classification of current and former smokers identified no statistically significant differences in any measured outcomes. Patients who smoked more than one pack/day had 1.48 (95% CI, 1.01-2.16) times increase in risk of MALEs at 1 year compared with patients who smoked one or fewer packs/day. Patients who smoked more than one pack/day also had the highest 1-year amputation incidence (12.7%). Each of the four parameters was associated with increased risk of poor outcomes, although small sample size limited the precision of our estimates. CONCLUSIONS We found that smoking intensity is particularly informative of outcomes of patients undergoing open lower extremity revascularization for symptomatic PAD. These findings lay the groundwork for future research on relevant smoking history parameters and benefits of smoking reduction and cessation for clinicians to discuss with patients and to better understand and inform patients of intervention risks and expected outcomes.
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Affiliation(s)
- Jessica C Young
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Nicole Jadue Paul
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Turkan Banu Karatas
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Sasha A Kondrasov
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Katharine L McGinigle
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jason R Crowner
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Luigi Pascarella
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Mark A Farber
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Melina R Kibbe
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - William A Marston
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Corey A Kalbaugh
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC.
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Arinze N, Farber A, Levin SR, Cheng TW, Jones DW, Siracuse CG, Patel VI, Rybin D, Doros G, Siracuse JJ. The effect of the duration of preoperative smoking cessation timing on outcomes after elective open abdominal aortic aneurysm repair and lower extremity bypass. J Vasc Surg 2019; 70:1851-1861. [PMID: 31147124 DOI: 10.1016/j.jvs.2019.02.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 02/09/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Smoking has been associated with poor postoperative outcomes across various surgical procedures. However, the effect of quitting smoking preoperatively for elective operations is unclear. Our goal was to assess the temporal effect of smoking cessation before elective lower extremity bypass (LEB) and open abdominal aortic aneurysm (AAA) repair on perioperative outcomes. METHODS The Vascular Quality Initiative was reviewed for all patients with a documented smoking history and who underwent an elective LEB or open AAA repair from 2010 to 2017. Patients were then categorized into three groups: long-term smoking cessation (LTSC; defined as quitting smoking ≥8 weeks before surgery), short-term smoking cessation (STSC; defined as quitting smoking < 8 weeks before surgery), and current smokers (CS). Patient and procedure details were recorded. Univariate and multivariate analysis for crude and propensity-matched data were used to compare outcomes among groups. RESULTS We identified 15,950 patients with a documented smoking history who underwent an elective LEB (43.3% LTSC, 2.2% STSC, 54.5% CS) and 5215 patients who underwent an elective open AAA repair (42.9% LTSC, 2.4% STSC, 54.7% CS). LTSC patients compared with STSC and CS, respectively, were more often obese, diabetic, on aspirin, on a statin, had coronary artery disease, and had congestive heart failure, but were less likely to have chronic obstructive pulmonary disease (all P < .05). Perioperative outcomes demonstrated significant differences comparing LTSC with STSC and CS for myocardial infarction (3.4% vs 1.4% vs 1.4%), dysrhythmia (4.2% vs 2.5% vs 2.7%), 30-day mortality (1.6% vs .3% vs .9%), in-hospital mortality (1.1% vs 0% vs 0.5%; all P < .001) and congestive heart failure (1.8% vs .8% vs 1.5%; P = .003). There was no difference in outcomes after analysis of propensity-matched data for LTSC or STSC on any postoperative outcomes for LEB. For open AAA repair, LTSC compared with CS patients, respectively, were older, more often male, obese, on a statin, diabetic, and less frequently had chronic obstructive pulmonary disease (P < .05 for all). Perioperative outcomes demonstrated differences in pulmonary complications when comparing LTSC with STSC and CS (9.5% vs 8.0% vs 12.5%; P = .002). Multivariate analysis demonstrated that LTSC patients compared with CS were less likely to experience pulmonary complications (odds ratio, 0.65; 95% confidence interval, 0.53-0.79; P < .001). Propensity-matched multivariate analysis confirmed that LTSC remained significantly less likely to encounter pulmonary complications (odds ratio, 0.49; 95% confidence interval, 0.33-0.74; P = .001). CONCLUSIONS In our propensity-matched, risk-adjusted cohort, LTSC and STSC were not associated with perioperative outcomes after elective LEB. LTSC was associated with a significantly decreased odds of pulmonary complications after elective open AAA repair. STSC was not associated with perioperative outcomes after elective open AAA repair. If time permits, a longer period of smoking cessation should be attempted before elective open AAA repair.
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Affiliation(s)
- Nkiruka Arinze
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Mass
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Mass
| | - Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Mass
| | - Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Mass
| | - Douglas W Jones
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Mass
| | - Carrie G Siracuse
- Division of Pulmonary and Critical Care, Steward Healthcare, Norwood Hospital, Norwood, Mass
| | - Virendra I Patel
- Division of Vascular Surgery and Endovascular Interventions, Columbia University Medical Center, New York, NY
| | - Denis Rybin
- Department of Statistics, Boston University School of Public Health, Boston, Mass
| | - Gheorghe Doros
- Department of Statistics, Boston University School of Public Health, Boston, Mass
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Mass.
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