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Kim TI, DeWan A, Murray M, Wang H, Mani A, Mena-Hurtado C, Guzman RJ, Ochoa Chaar CI. Anticoagulation in Patients with Premature Peripheral Artery Disease Undergoing Lower Extremity Revascularization. Ann Vasc Surg 2024; 105:150-157. [PMID: 38593922 DOI: 10.1016/j.avsg.2024.02.006] [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: 12/16/2023] [Revised: 02/11/2024] [Accepted: 02/13/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Premature peripheral artery disease (PAD), defined by lower extremity revascularization (LER) at age ≤ 50 years, is associated with poor major adverse limb events. The early onset of disease is thought to be influenced by genetic factors that regulate homeostasis of the vascular wall and coagulation. The aim of this study is to investigate the effect of anticoagulation as an adjunct to antiplatelet therapy on the outcomes of LER in patients with premature PAD. METHODS There were 8,804 patients with premature PAD on preoperative and postoperative antiplatelet therapy only and 1,236 patients on preoperative and postoperative anticoagulation plus antiplatelet therapy in the Vascular Quality Initiative peripheral vascular intervention, infrainguinal, and suprainguinal files. Propensity score matching (2:1) was performed between patients with premature PAD who were on antiplatelet therapy and those on anticoagulation plus antiplatelet therapy. Perioperative and 1-year outcomes were analyzed including reintervention, major amputation, and mortality. RESULTS Patients on anticoagulation were more likely to have coronary artery disease (48.7% vs. 41.2%, P < 0.001), congestive heart failure (20.2% vs. 13.1%, P < 0.001), and have undergone prior LER (73.9% vs. 49.2%, P < 0.001) compared to patients on antiplatelet therapy only. They were also less likely to be independently ambulatory (74.2% vs. 81.8%, P < 0.001) and be on a statin medication (66.8% vs. 74.3%, P < 0.001) compared to patients on antiplatelet therapy only. Patients on anticoagulation were also less likely to be treated for claudication (38.1% vs. 48.6%, P < 0.001), and less likely to be treated with an endovascular procedure (64.8% vs. 73.8%, P < 0.001). After matching for baseline characteristics, there were 1,256 patients on antiplatelet therapy only and 628 patients on anticoagulation. Patients on anticoagulation were more likely to require a return to the operating room (3.7% vs. 1.6%, P < 0.001) and had higher perioperative mortality (1.1% vs. 0.3%, P = 0.032), but major amputation was not significantly different (1.8% vs. 1.6%, P = 0.798) compared to patients on antiplatelet therapy alone. At 1 year, amputation-free survival was higher in patients on antiplatelets only compared to patients on anticoagulation and antiplatelet medications (87.5% vs. 80.9%, log-rank P = 0.001). CONCLUSIONS Anticoagulation in addition to antiplatelet therapy in patients with premature PAD undergoing LER is associated with increased reintervention and mortality at 1 year.
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Affiliation(s)
- Tanner I Kim
- Queen's Health System, Honolulu, HI; Department of Surgery, John A Burns School of Medicine, University of Hawaii, Honolulu, HI.
| | | | - Michael Murray
- Department of Genetics, Yale School of Medicine, New Haven, CT
| | - He Wang
- Department of Pathology, Yale University School of Medicine, New Haven, CT
| | - Arya Mani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Carlos Mena-Hurtado
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Raul J Guzman
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
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Dun C, Stonko DP, Bose S, Keegan AC, McDermott KM, Rumalla KC, Black JH, Kalbaugh CA, Makary MA, Hicks CW. Trends and Factors Associated With Peripheral Vascular Interventions for the Treatment of Claudication From 2011 to 2022: A National Medicare Cohort Study. J Am Heart Assoc 2024:e033463. [PMID: 38958132 DOI: 10.1161/jaha.123.033463] [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: 02/06/2024] [Accepted: 05/03/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Previous cross-sectional studies have identified wide practice pattern variations in the use of peripheral vascular interventions (PVIs) for the treatment of claudication. However, there are limited data on longitudinal practice patterns. We aimed to describe the temporal trends and charges associated with PVI use for claudication over the past 12 years in the United States. METHODS AND RESULTS We conducted a retrospective analysis using 100% Medicare fee-for-service claims data to identify all patients who underwent a PVI for claudication between January 2011 and December 2022. We evaluated the trends in utilization and Medicare-allowed charges of PVI according to anatomic level, procedure type, and intervention settings using generalized linear models. Multinomial logistic regressions were used to evaluate factors associated with different levels and types of PVI. We identified 599 197 PVIs performed for claudication. The proportional use of tibial PVI increased 1.0% per year, and atherectomy increased by 1.6% per year over the study period. The proportion of PVIs performed in ambulatory surgical centers/office-based laboratories grew at 4% per year from 12.4% in 2011 to 55.7% in 2022. Total Medicare-allowed charges increased by $11 980 035 USD/year. Multinomial logistic regression identified significant associations between race and ethnicity and treatment setting with use of both atherectomy and tibial PVI. CONCLUSIONS The use of tibial PVI and atherectomy for the treatment of claudication has increased dramatically in in ambulatory surgical center/office-based laboratory settings, non-White patients, and resulting in a significant increase in health care charges. There is a critical need to improve the delivery of value-based care for the treatment of claudication.
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Affiliation(s)
- Chen Dun
- Biomedical Informatics and Data Science Johns Hopkins University School of Medicine Baltimore MD
- Department of Surgery Johns Hopkins University School of Medicine Baltimore MD
| | - David P Stonko
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery Johns Hopkins University School of Medicine Baltimore MD
| | - Sanuja Bose
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery Johns Hopkins University School of Medicine Baltimore MD
| | - Alana C Keegan
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery Johns Hopkins University School of Medicine Baltimore MD
- Department of Surgery Sinai Hospital of Baltimore Baltimore MD USA
| | - Katherine M McDermott
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery Johns Hopkins University School of Medicine Baltimore MD
| | - Kranti C Rumalla
- Department of Surgery Johns Hopkins University School of Medicine Baltimore MD
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery Johns Hopkins University School of Medicine Baltimore MD
| | - Corey A Kalbaugh
- Department of Epidemiology and Biostatistics Indiana University School of Public Health- Bloomington Bloomington IN USA
| | - Martin A Makary
- Department of Surgery Johns Hopkins University School of Medicine Baltimore MD
- Johns Hopkins Carey Business School Baltimore MD USA
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery Johns Hopkins University School of Medicine Baltimore MD
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Wegerif ECJ, Ünlü Ç, Generaal MI, van den Bor RM, van de Ven PM, Bots ML, de Borst GJ. Rationale and design for the randomized placebo-controlled double-blind trial studying the effect of single antiplatelet therapy (clopidogrel) versus dual antiplatelet therapy (clopidogrel/acetylsalicylic acid) on the occurrence of atherothrombotic events following lower extremity peripheral transluminal angioplasty (CLEAR-PATH). Am Heart J 2024; 273:121-129. [PMID: 38608997 DOI: 10.1016/j.ahj.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 04/02/2024] [Accepted: 04/02/2024] [Indexed: 04/14/2024]
Abstract
RATIONALE Antiplatelet therapy (APT) is the standard of care after endovascular revascularization (EVR) in patients with peripheral artery disease (PAD). APT aims to prevent both major adverse cardiovascular events (MACE) and major adverse limb events (MALE). Nonetheless, the rates of MACE and MALE after EVR remain high. In coronary artery and cerebrovascular disease, dual APT (DAPT)compared to acetylsalicylic acid alone has been proven to reduce MACE without increasing the risk of major bleeding when applied for a restricted number of weeks. However, within the PAD population, insufficient data are available to understand the potential attributable effect of DAPT over single APT (SAPT). Therefore, prospective randomized studies in targeted study populations are warranted. TRIAL DESIGN CLEAR-PATH is a Dutch multicenter, double-blind, placebo-controlled, randomized trial comparing SAPT (clopidogrel 75 mg plus placebo) with DAPT (clopidogrel 75 mg plus acetylsalicylic acid 80 mg) in patients with PAD undergoing EVR. CLEAR-PATH includes a time-to-event analysis with a follow-up of one year. The primary composite efficacy endpoint consists of all-cause mortality, nonfatal stroke, nonfatal myocardial infarction, severe limb ischemia, (indication for) re-intervention due to any symptomatic restenosis, re-occlusion, or due to acute limb ischemia, and major amputation. The primary safety endpoint contains major bleeding following the Thrombolysis in Myocardial Infarction classification. The enrolment started in August 2022. In total 450 primary efficacy outcome events are required which expectedly amounts to 1696 subjects. Recruitment will take approximately 36 months. CONCLUSION CLEAR-PATH will assess the efficacy and safety of DAPT compared to SAPT following EVR in PAD patients. TRIAL REGISTRATION NUMBER NL80009.041.21.
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Affiliation(s)
- Emilien C J Wegerif
- Division of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Çağdaş Ünlü
- Division of Vascular Surgery, Northwest Hospital Group, Alkmaar, The Netherlands
| | - Manon I Generaal
- Division of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Rutger M van den Bor
- Department of Data Science and Biostatistics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Peter M van de Ven
- Department of Data Science and Biostatistics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Gert J de Borst
- Division of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
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Alzahrani A, Sultan SR, Aslam M. Tomographic 3D ultrasound for grading stenosis of superficial femoral artery. Perfusion 2024; 39:943-947. [PMID: 37068210 DOI: 10.1177/02676591231169852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
INTRODUCTION Treatment decision of lower extremity peripheral arterial disease (PAD) is governed by the severity of stenosis. Tomographic 3D ultrasound (t3DUS) is a reliable imaging technique for measuring vessel stenosis. In this study we attempted to provide a precise measurement of superficial femoral artery (SFA) stenosis using t3DUS in patients with PAD. METHODS t3DUS was used to measure maximum stenosis percentage in SFA from 50 patients with lower extremity PAD. The maximum stenosed segment in SFA was defined using Duplex 2DUS aliasing was noted. The peak systolic velocity (PSV) was measured at the maximum stenotic site and proximal to aliasing for calculating the velocity ratio. The association between blood flow velocity ratio and the degree of stenosis measured using Duplex 2DUS and t3DUS, respectively, was assessed using Spearman rank correlation. RESULTS There was a strong positive correlation between velocity ratio and degree of stenosis in SFA measured using t3DUS (correlation value (r) = 0.99, p < 0.001). The correlation between Stenosis percentage and velocity ratio in SFA are as followed: <50:<2; 50-54:2-2.4; 55-59:2.5-2.9; 60-64:3-3.4; 65-69:3.5-3.9; 70-74:4-4.4; 75-79:4.5-4.9; >80:>5. t3DUS can be used to provide precise measurement of the severity of SFA stenosis in patients with lower extremities arterial disease. The established criteria for grading SFA stenosis in this study can be applied to the current practice alongside Duplex 2DUS as it showed a strong positive correlation with velocity ratio. Further studies investigating the sensitivity and specificity of t3DUS in the assessment of stenosis in lower limbs arteries are required.
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Affiliation(s)
- Adel Alzahrani
- Diagnostic Radiology, King Abdullah Medical City, Makkah, Saudi Arabia
- Vascular Laboratory, Hammersmith Hospital, Imperial College NHS Healthcare Trust, London, UK
| | - Salahaden R Sultan
- Radiologic Sciences, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohammed Aslam
- Vascular Laboratory, Hammersmith Hospital, Imperial College NHS Healthcare Trust, London, UK
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McBane RD, Murphree DH, Liedl D, Lopez-Jimenez F, Arruda-Olson A, Scott CG, Prodduturi N, Nowakowski SE, Rooke TW, Casanegra AI, Wysokinski WE, Houghton DE, Muthusamy K, Wennberg PW. Artificial intelligence of arterial Doppler waveforms to predict major adverse outcomes among patients with diabetes mellitus. J Vasc Surg 2024; 80:251-259.e3. [PMID: 38417709 DOI: 10.1016/j.jvs.2024.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/12/2024] [Accepted: 02/19/2024] [Indexed: 03/01/2024]
Abstract
OBJECTIVE Patients with diabetes mellitus (DM) are at increased risk for peripheral artery disease (PAD) and its complications. Arterial calcification and non-compressibility may limit test interpretation in this population. Developing tools capable of identifying PAD and predicting major adverse cardiac event (MACE) and limb event (MALE) outcomes among patients with DM would be clinically useful. Deep neural network analysis of resting Doppler arterial waveforms was used to detect PAD among patients with DM and to identify those at greatest risk for major adverse outcome events. METHODS Consecutive patients with DM undergoing lower limb arterial testing (April 1, 2015-December 30, 2020) were randomly allocated to training, validation, and testing subsets (60%, 20%, and 20%). Deep neural networks were trained on resting posterior tibial arterial Doppler waveforms to predict all-cause mortality, MACE, and MALE at 5 years using quartiles based on the distribution of the prediction score. RESULTS Among 11,384 total patients, 4211 patients with DM met study criteria (mean age, 68.6 ± 11.9 years; 32.0% female). After allocating the training and validation subsets, the final test subset included 856 patients. During follow-up, there were 262 deaths, 319 MACE, and 99 MALE. Patients in the upper quartile of prediction based on deep neural network analysis of the posterior tibial artery waveform provided independent prediction of death (hazard ratio [HR], 3.58; 95% confidence interval [CI], 2.31-5.56), MACE (HR, 2.06; 95% CI, 1.49-2.91), and MALE (HR, 13.50; 95% CI, 5.83-31.27). CONCLUSIONS An artificial intelligence enabled analysis of a resting Doppler arterial waveform permits identification of major adverse outcomes including all-cause mortality, MACE, and MALE among patients with DM.
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Affiliation(s)
- Robert D McBane
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN.
| | - Dennis H Murphree
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, MN
| | - David Liedl
- Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - Francisco Lopez-Jimenez
- Cardiovascular Department, Mayo Clinic, Rochester, MN; Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, MN
| | | | | | - Naresh Prodduturi
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | | | - Thom W Rooke
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN
| | - Ana I Casanegra
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN
| | - Waldemar E Wysokinski
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN
| | - Damon E Houghton
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN
| | | | - Paul W Wennberg
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN
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Komai H, Ogura M, Sakashita H, Miyama N, Yamamoto N, Takai K, Hatada A, Tanimura N, Nakamura T, Yoshida M, Kawaura T, Kitawaki T. The real-world data of lipid-lowering treatment in patients with peripheral artery disease and its association with severity of disease. J Cardiol 2024; 84:36-40. [PMID: 37816481 DOI: 10.1016/j.jjcc.2023.10.002] [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: 07/13/2023] [Revised: 09/07/2023] [Accepted: 09/28/2023] [Indexed: 10/12/2023]
Abstract
BACKGROUND The risk of coronary artery disease in peripheral arterial disease (PAD) is high, life prognosis is poor, and lipid-lowering treatment with statins has been reported to improve prognosis. In clinical practice, however, hypolipidemia is more common in patients with severe PAD and statin prescription rates appear to be low, but specific data are scarce in Japan. Therefore, we conducted this cross-sectional study in collaboration with other centers of vascular surgery to determine the rate of statin prescriptions for PAD patients in real-world practice, the rate of achievement of low-density lipoprotein (LDL) cholesterol control targets, and whether statin non-use is a determinant factor of critical limb ischemia (CLI). METHODS A total of 246 PAD patients (97 with CLI) from 5 sites were included in this study. Medical history and blood test data were obtained from medical records and interviews with patients, and were compared between CLI and non-CLI patients. RESULTS Statin prescription rate was only 34 %. The overall LDL cholesterol control target rate was 46 % of CLI cases and 51 % of non-CLI cases, according to the lipid management criteria of the Japanese Society for Atherosclerosis 2022 guidelines. Patients in the CLI group had a lower mean body mass index and lower LDL cholesterol levels than those in the non-CLI group, suggesting that these factors were responsible for the lower statin prescription rate. However, multivariate analysis revealed that statin non-use was one of the determinants of CLI. CONCLUSIONS Statin prescription rates for PAD patients were low in real-world practice settings in the field of vascular surgery. Since statin non-use is a determinant of CLI, there is a need to educate physicians engaged in treatment regarding lipid-lowering treatment with statins.
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Affiliation(s)
- Hiroyoshi Komai
- Department of Vascular Surgery, Kansai Medical University Medical Center, Moriguchi, Osaka, Japan.
| | - Masatsune Ogura
- Department of Clinical Laboratory Technology, Faculty of Medical Science, Juntendo University, Urayasu, Chiba, Japan
| | - Hideki Sakashita
- Department of Vascular Surgery, Kansai Medical University Medical Center, Moriguchi, Osaka, Japan
| | - Noriyuki Miyama
- Department of Vascular Surgery, Kansai Medical University Medical Center, Moriguchi, Osaka, Japan
| | - Nobuko Yamamoto
- Department of Vascular Surgery, Kansai Medical University Medical Center, Moriguchi, Osaka, Japan
| | - Kanako Takai
- Department of Vascular Surgery, Kansai Medical University Medical Center, Moriguchi, Osaka, Japan
| | - Atsutoshi Hatada
- Department of Cardiovascular Surgery, Saiseikai Wakayama Hospital, Wakayama, Japan
| | - Nobuhiro Tanimura
- Department of Vascular Surgery, Aijinkai Inoue Hospital, Suita, Osaka, Japan
| | - Takashi Nakamura
- Department of Vascular Surgery, Osaka Rosai Hospital, Sakai, Japan
| | - Masato Yoshida
- Department of Cardiovascular Surgery, Hyogo Brain and Heart Center, Himeji, Japan
| | - Takayuki Kawaura
- Department of Mathematics, Kansai Medical University, Hirakata, Osaka, Japan
| | - Tomomi Kitawaki
- Department of Mathematics, Kansai Medical University, Hirakata, Osaka, Japan
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Aulivola B. A critical look at our role in smoking cessation in the patient with claudication. J Vasc Surg 2024; 80:175-176. [PMID: 38906661 DOI: 10.1016/j.jvs.2024.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 02/26/2024] [Indexed: 06/23/2024]
Affiliation(s)
- Bernadette Aulivola
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Loyola University Medical Center, Maywood, IL
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Cho S, Kim SJ, Joh JH. Single Tract Aortic Revascularization Technique in the Treatment of Aortoiliac Occlusive Disease. Vasc Specialist Int 2024; 40:24. [PMID: 38937896 PMCID: PMC11211738 DOI: 10.5758/vsi.240033] [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: 03/18/2024] [Revised: 05/30/2024] [Accepted: 06/11/2024] [Indexed: 06/29/2024] Open
Abstract
Endovascular treatment is an acceptable option for patients with aortoiliac occlusive disease. However, bilateral passage of guidewires through the aortoiliac occlusion can be a challenging step in achieving successful revascularization. The aim of this article is to present a novel strategy for successfully passing bilateral guidewires through long aortoiliac occlusive lesions. After one guidewire is passed through the aortic and iliac lesions via one side of the femoral artery, the other guidewire is passed using the up-and-over technique and pulled out from the ipsilateral side of the body. This contralateral guidewire is then inserted into the ipsilateral angiographic catheter along with the ipsilateral guidewire. Subsequently, the angiographic catheter is removed in a manner similar to a peel-away sheath. Eventually, bilateral guidewires can be passed through the lesion via a single aortic tract.
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Affiliation(s)
- Sungsin Cho
- Division of Vascular Surgery, Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Se Jun Kim
- Division of Vascular Surgery, Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jin Hyun Joh
- Division of Vascular Surgery, Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
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Bellomo TR, Liu Y, Gilliland TC, Miksenas H, Haidermota S, Wong M, Hu X, Cristino JR, Browne A, Plutzky J, Tsimikas S, Januzzi JL, Natarajan P. Associations between lipoprotein(a), oxidized phospholipids, and extra-coronary vascular disease. J Lipid Res 2024:100585. [PMID: 38942114 DOI: 10.1016/j.jlr.2024.100585] [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: 03/04/2024] [Revised: 06/20/2024] [Accepted: 06/21/2024] [Indexed: 06/30/2024] Open
Abstract
The roles of lipoprotein(a) [Lp(a)] and related oxidized phospholipids (OxPL) in the development and progression of coronary disease is known, but their influence on extra-coronary vascular disease is not well-established. We sought to evaluate associations between Lp(a), OxPL apolipoprotein B (OxPL-apoB), and apolipoprotein(a) (OxPL-apo(a)) with angiographic extra-coronary vascular disease and incident major adverse limb events (MALE). 446 participants who underwent coronary and/or peripheral angiography were followed up for a median of 3.7 years. Lp(a) and OxPLs were measured before angiography. Elevated Lp(a) was defined as ≥150 nmol/L. Elevated OxPL-apoB and OxPL-apo(a) were defined as greater than or equal to the 75th percentile (OxPL-apoB ≥8.2 nmol/L and OxPL-apo(a) ≥35.8 nmol/L, respectively). Elevated Lp(a) had a stronger association with the presence of extra-coronary vascular disease compared to OxPLs and was minimally improved with the addition of OxPLs in multivariable models. Compared to participants with normal Lp(a) and OxPL concentrations, participants with elevated Lp(a) levels were twice as likely to experience a MALE (OR 2.14 95% CI: 1.03, 4.44) and the strength of the association as well as the C statistic of 0.82 was largely unchanged with the addition of OxPL-apoB and OxPL-apo(a). Elevated Lp(a) and OxPLs are risk factors for progression and complications of extra-coronary vascular disease. However, the addition of OxPLs to Lp(a) does not provide additional information about risk of extra-coronary vascular disease. Therefore, Lp(a) alone captures the risk profile of Lp(a), OxPL-apoB, and OxPL-apo(a) in the development and progression of atherosclerotic plaque in peripheral arteries. These results lay a foundation in support of studying Lp(a) lowering medications and their effect on limb-related complications.
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Affiliation(s)
- Tiffany R Bellomo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Yuxi Liu
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Thomas C Gilliland
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, MA
| | - Hannah Miksenas
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Sara Haidermota
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Megan Wong
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Xingdi Hu
- Novartis Pharmaceuticals Corporation
| | | | | | - Jorge Plutzky
- Division of Cardiology, Brigham and Women's Hospital, Boston, Harvard Medical School, Boston, MA
| | - Sotirios Tsimikas
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, CA
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Baim Institute for Clinical Research, Boston, MA
| | - Pradeep Natarajan
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, MA.
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10
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Li X, Zhang L, Li Q, Zhang J, Qin X. Construction of prediction models for novel subtypes in patients with arteriosclerosis obliterans undergoing endovascular therapy: an unsupervised machine learning study. J Cardiothorac Surg 2024; 19:370. [PMID: 38918804 PMCID: PMC11197167 DOI: 10.1186/s13019-024-02913-6] [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: 01/09/2024] [Accepted: 06/15/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND Arteriosclerosis obliterans (ASO) is a chronic arterial disease that can lead to critical limb ischemia. Endovascular therapy is increasingly used for limb salvage in ASO patients, but the outcomes vary. The development of prediction models using unsupervised machine learning may lead to the identification of novel subtypes to guide patient prognosis and treatment. METHODS This retrospective study analyzed clinical data from 448 patients with ASOs who underwent endovascular therapy. Unsupervised machine learning algorithms were employed to identify subgroups. To validate the precision of the clustering outcomes, an analysis of the postoperative results of the clusters was conducted. A prediction model was constructed using binary logistic regression. RESULTS Two distinct subgroups were identified by unsupervised machine learning and characterized by differing patterns of clinical features. Patients in Cluster 2 had significantly worse conditions and prognoses than those in Cluster 1. For the novel ASO subtypes, a nomogram was developed using six predictive factors, namely, platelet count, ankle brachial index, Rutherford category, operation method, hypertension, and diabetes status. The nomogram achieved excellent discrimination for predicting membership in the two identified clusters, with an area under the curve of 0.96 and 0.95 in training cohort and internal test cohort. CONCLUSION This study demonstrated that unsupervised machine learning can reveal novel phenotypic subgroups of patients with varying prognostic risk who underwent endovascular therapy. The prediction model developed could support clinical decision-making and risk counseling for this complex patient population. Further external validation is warranted to assess the generalizability of the findings.
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Affiliation(s)
- Xiaocheng Li
- Department of Vascular Surgery Ward, The First Affiliated Hospital of Guangxi Medical University, No.6 of Shuangyong Road, Nanning, Guangxi, 530021, P. R. China
| | - Lin Zhang
- Department of Vascular Surgery Ward, The First Affiliated Hospital of Guangxi Medical University, No.6 of Shuangyong Road, Nanning, Guangxi, 530021, P. R. China
| | - Que Li
- Department of Vascular Surgery Ward, The First Affiliated Hospital of Guangxi Medical University, No.6 of Shuangyong Road, Nanning, Guangxi, 530021, P. R. China
| | - Jiangfeng Zhang
- Department of Vascular Surgery Ward, The First Affiliated Hospital of Guangxi Medical University, No.6 of Shuangyong Road, Nanning, Guangxi, 530021, P. R. China
| | - Xiao Qin
- Department of Vascular Surgery Ward, The First Affiliated Hospital of Guangxi Medical University, No.6 of Shuangyong Road, Nanning, Guangxi, 530021, P. R. China.
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Tsou TC, Dun C, Bose S, McDermott KM, White M, Siracuse JJ, Weaver ML, Black JH, Makary MA, Hicks CW. Practice Patterns of Peripheral Vascular Interventions for Peripheral Artery Disease in the Office-Based Laboratory Setting versus Outpatient Hospital. J Vasc Surg 2024:S0741-5214(24)01250-3. [PMID: 38908807 DOI: 10.1016/j.jvs.2024.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 06/03/2024] [Accepted: 06/05/2024] [Indexed: 06/24/2024]
Abstract
OBJECTIVE Controversy exists regarding the value and limitations of different sites of service for peripheral artery disease (PAD) treatment. We aimed to examine practice patterns associated with peripheral vascular interventions (PVI) performed in the office-based laboratory (OBL) vs. outpatient hospital site of service using a nationally representative database. METHODS Using 100% Medicare fee-for-service claims data, we identified all patients undergoing PVI for claudication or chronic limb-threatening ischemia (CLTI) between 01/2017 and 12/2022. We evaluated the associations of patient and procedure characteristics with site of service using multivariable hierarchical logistic regression. We used multinomial regression models to estimate the relative risk ratios (RRR) of site of service and intervention type (angioplasty, stent, atherectomy) and intervention level (iliac, femoropopliteal, tibial) after adjusting for baseline patient characteristics and clustering by physician. RESULTS Of 848,526 PVI, 485,942 (57.3%) were performed in an OBL. OBL use increased significantly over time from 48.3% in 2017 to 65.5% in 2022 (P<0.001). Patients treated in OBLs were more likely to be Black (aOR 1.14, 95%CI 1.11-1.18) or other non-white race (aOR 1.13, 95%CI 1.08-1.18), have fewer comorbidities, and receive treatment for claudication vs. CLTI (aOR 1.30, 95%CI 1.26-1.33) compared to patients treated in outpatient hospital settings. Physicians with majority practice (>50% procedures) in an OBL were more likely to practice in urban settings (aOR 21.58, 95%CI 9.31-50.02), specialize in radiology (aOR 18.15, 95%CI 8.92- 36.92), and have high-volume PVI practices (aOR 2.15, 95%CI 2.10-2.29). The median time from diagnosis to treatment was shorter in OBLs, particularly for patients with CLTI (29 vs. 39 days, P<0.001). The OBL setting was the strongest predictor of patients receiving an atherectomy alone (aRRR 6.67, 95%CI 6.59-6.76) or atherectomy+stent (aRRR 10.84, 95%CI 10.64-11.05), and these findings were consistent in subgroup analyses stratified by PVI indication. OBL setting was also associated with higher risk of tibial interventions for both claudication (aRRR 3.18, 95%CI 3.11-3.25) and CLTI (aRRR 1.89, 95%CI 1.86-1.92). Average reimbursement (including procedure and facility fees) was slightly higher for OBLs compared to the hospital ($8,742/case vs. $8,459/case; P<0.001). However, in a simulated cohort resetting the OBL's intervention type distribution to that of the hospital, OBLs were associated with a hypothetical cost savings of $221,219,803 overall and $2,602 per case. CONCLUSION The OBL site of service was associated with greater access to care for non-white patients and shorter time from diagnosis to treatment, but more frequently performed high-cost interventions compared to the outpatient hospital setting. The benefit to patients from improved access to PAD care in OBL settings must be balanced with the potential limitations of receiving differential care.
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Affiliation(s)
- Terrence C Tsou
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD.
| | - Chen Dun
- Department of Biomedical Informatics and Data Science, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sanuja Bose
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Katherine M McDermott
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Midori White
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - M Libby Weaver
- Division of Vascular and Endovascular Surgery, University of Virginia School of Medicine, Charlottesville, VA
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Martin A Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins Carey Business School, Baltimore, MD
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD.
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12
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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:2497-2604. [PMID: 38752899 DOI: 10.1016/j.jacc.2024.02.013] [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] [Indexed: 05/23/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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13
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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1313-e1410. [PMID: 38743805 DOI: 10.1161/cir.0000000000001251] [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] [Indexed: 05/16/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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14
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Ciuti G, Monami M, Ragghianti B, Fabbri A, Bandini G, Mercatelli P, Edoardo M, Pignone AM. The resistive and pulsatility indices of the dorsal metatarsal artery for the screening of peripheral lower artery disease in patients with and without diabetes. Diabetes Res Clin Pract 2024; 213:111732. [PMID: 38838944 DOI: 10.1016/j.diabres.2024.111732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 05/22/2024] [Accepted: 06/02/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND In lower extremity peripheral artery disease (PAD), the ankle-brachial index (ABI) is an easily reproducible diagnostic tool for PAD, but it loses reliability when > 1.4 due to calcification of the vessel wall. Patients with diabetes are at higher risk for wall calcification. In order to overcome the limitation and reliability of ABI, particularly in patients with diabetes, we decided to assess resistive (RI) and pulsatility index (PI) by ultrasound doppler of the dorsal metatarsal artery (DMA). RESULTS We therefore analyzed 51 legs (32 patients), evaluating the correlation between PI, RI, and ABI. Patients with diabetes were 21 (65.6 %), accounting for 33 legs (64.7 %). Out of 51 legs assessed, 37 (72.5 %) cases had compressible arteries, whereas in 14 legs (27.5 %) ABI was not calculable due to wall calcification. PAD was significantly associated with lower both RI and PI of the DMA (both p < 0.000). RI, but not PI, showed a significant correlation (r = 0.535) with ABI, when ABI was less than 1.4, but not when ABI > 1.4. When analyzed separately, patients with diabetes showed a similar figure in comparison with those without diabetes (r = 0.600), RI, but not PI, showed a significant correlation with ABI. CONCLUSION Dorsal metatarsal artery resistive index (MARI) showed a significant inverse correlation with PAD, similarly to ABI, irrespective of the presence of diabetes. MARI seems to be an effective screening tool for PAD even in patients with wall calcification. Further studies are needed for confirming the results of the present pilot study.
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Affiliation(s)
- Gabriele Ciuti
- Medicina Interna 4 Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy.
| | - Matteo Monami
- Diabetic Foot Unit, Diabetology, Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | - Benedetta Ragghianti
- Diabetic Foot Unit, Diabetology, Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | - Alessia Fabbri
- Medicina Interna 4 Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | - Giulia Bandini
- Medicina Interna 4 Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | - Paolo Mercatelli
- Medicina Interna 4 Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | - Mannucci Edoardo
- Diabetic Foot Unit, Diabetology, Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | - Alberto Moggi Pignone
- Medicina Interna 4 Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
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Feliz JD, Heindel P, Fitzgibbon JJ, Ozaki CK, Gravereaux E, Nguyen LL, Menard M, Belkin M, Hussain MA. Descriptive Analysis of Amputation-Free Survival After First Time Infra-Inguinal Bypass Occlusion. J Surg Res 2024; 300:263-271. [PMID: 38824856 DOI: 10.1016/j.jss.2024.05.010] [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: 02/23/2023] [Revised: 05/05/2024] [Accepted: 05/08/2024] [Indexed: 06/04/2024]
Abstract
INTRODUCTION Occlusion after infra-inguinal bypass surgery for peripheral artery disease is a major complication with potentially devastating consequences. In this descriptive analysis, we sought to describe the natural history and explore factors associated with long-term major amputation-free survival following occlusion of a first-time infra-inguinal bypass. METHODS Using a prospective database from a tertiary care vascular center, we conducted a retrospective cohort study of all patients with peripheral artery disease who underwent a first-time infra-inguinal bypass and subsequently suffered a graft occlusion (1997-2021). The primary outcome was longitudinal rate of major amputation-free survival after bypass occlusion. Cox proportional hazard models were used to generate hazard ratios (HRs) and 95% confidence intervals (CIs) to explore predictors of outcomes. RESULTS Of the 1318 first-time infra-inguinal bypass surgeries performed over the study period, 255 bypasses occluded and were included in our analysis. Mean age was 66.7 (12.6) years, 40.4% were female, and indication for index bypass was chronic limb threatening ischemia (CLTI) in 89.8% (n = 229). 48.2% (n = 123) of index bypass conduits used great saphenous vein, 29.0% (n = 74) prosthetic graft, and 22.8% (n = 58) an alternative conduit. Median (interquartile range) time to bypass occlusion was 6.8 (2.3-19.0) months, and patients were followed for median of 4.3 (1.7-8.1) years after bypass occlusion. Following occlusion, 38.04% underwent no revascularization, 32.94% graft salvage procedure, 25.1% new bypass, and 3.92% native artery recanalization. Major amputation-free survival following occlusion was 56.9% (50.6%-62.8%) at 1 y, 37.1% (31%-43.3%) at 5 y, and 17.2% (11.9%-23.2%) at 10 y. In multivariable analysis, factors associated with lower amputation-free survival were older age, female sex, advanced cardiorenal comorbidities, CLTI at index procedure, CLTI at time of occlusion, and distal index bypass outflow. Initial treatment after occlusion with both a new surgical bypass (HR 0.44, CI: 0.29-0.67) or a graft salvage procedure (HR 0.56, CI: 0.38-0.82) showed improved amputation-free survival. One-year rate of major amputation or death were 59.8% (50.0%-69.6%) for those who underwent no revascularization, 37.9% (28.7%-49.0%) for graft salvage, and 26.7% (17.6%-39.5%) for new bypass. CONCLUSIONS Long-term major amputation-free survival is low after occlusion of a first-time infra-inguinal bypass. While several nonmodifiable risk factors were associated with lower amputation-free survival, treatment after graft occlusion with either a new bypass or a graft salvage procedure may improve longitudinal outcomes.
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Affiliation(s)
- Jessica Dominique Feliz
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Patrick Heindel
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts; Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - James J Fitzgibbon
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts; Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - C Keith Ozaki
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Edwin Gravereaux
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Louis L Nguyen
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts; Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Matthew Menard
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Michael Belkin
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Mohamad A Hussain
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts; Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts.
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16
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Hoitz N, Kraima A, Fioole B, Mees B, de Borst GJ, Ünlü Ç. Surveillance After Surgical and Endovascular Treatment for Peripheral Artery Disease: a Dutch Survey. Eur J Vasc Endovasc Surg 2024; 67:980-986. [PMID: 38159674 DOI: 10.1016/j.ejvs.2023.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 10/18/2023] [Accepted: 12/27/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE At present, there is no clear, optimal approach to surveillance after invasive treatment of peripheral artery disease (PAD) in terms of modality, duration, clinical benefit, and cost effectiveness. The ongoing debate on the clinical benefit and cost effectiveness of standard surveillance creates a clear knowledge gap and may result in overtreatment or undertreatment. In this study, a survey was conducted among vascular surgeons in the Netherlands to assess the currently applied surveillance programmes. METHODS All vascular surgeons from the Dutch Society for Vascular Surgery received an online survey on follow up after open and endovascular revascularisation in patients with PAD. Surveillance was defined as at least one follow up visit after intervention with or without additional imaging or ankle brachial index (ABI) measurement. Ten types of PAD intervention were surveyed. RESULTS Surveys were returned by 97 (46.2%) of 210 vascular surgeons, and 76% reported using a routine follow up protocol after an invasive intervention. Clinical follow up only is most commonly performed after femoral endarterectomy (53%). After peripheral bypass surgery, clinical follow up only is applied rarely (4 - 8%). In six of the 10 interventions surveyed, duplex ultrasound (DUS) was the most used imaging modality for follow up. After bypass surgery, 76 - 86% of vascular surgeons perform DUS with or without ABI measurement. After endovascular interventions, 21 - 60% performed DUS surveillance. Lifelong surveillance is most often applied after aortobifemoral bypass (57%). Surveillance frequency and duration vary greatly within the same intervention. Frequencies range from every three or six months to annually. Duration ranges from one time surveillance to lifelong follow up. CONCLUSION There is significant practice variation in surveillance after surgical and endovascular treatment of patients with PAD in the Netherlands. Prospective studies to evaluate treatment outcomes and to define the clinical need and cost effectiveness of standardised surveillance programmes for patients with PAD are recommended.
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Affiliation(s)
- Nathalie Hoitz
- Department of Vascular Surgery, Northwest Clinics, Alkmaar, the Netherlands.
| | - Annelot Kraima
- Department of Vascular Surgery, Northwest Clinics, Alkmaar, the Netherlands
| | - Bram Fioole
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - Barend Mees
- Department of Vascular Surgery, MUMC+, Maastricht, the Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, UMCU, Utrecht, the Netherlands
| | - Çağdaş Ünlü
- Department of Vascular Surgery, Northwest Clinics, Alkmaar, the Netherlands
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Gray WA, Soga Y, Fujihara M, Iida O, Babaev A, Kawasaki D, Zeller T, O'Connor D, Jaff MR, Chavez AM, Müller-Hülsbeck S. Polymer-based drug-eluting stent treatment extends the time to reintervention for patients with symptomatic femoropopliteal artery disease: clinical evidence and potential economic value. J Comp Eff Res 2024; 13:e240025. [PMID: 38606556 PMCID: PMC11145520 DOI: 10.57264/cer-2024-0025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 03/26/2024] [Indexed: 04/13/2024] Open
Abstract
Aim: Use long-term follow-up data from the IMPERIAL study to determine whether drug-eluting polymer-based nitinol stent treatment can delay the time to repeat intervention for femoropopliteal artery disease and how such a delay may result in cost savings in a value-based episode of care. Patients & methods: The IMPERIAL randomized controlled trial was an international study of a paclitaxel-eluting polymer-coated stent (Eluvia, Boston Scientific, MA, USA) versus a polymer-free paclitaxel-coated stent (Zilver PTX, Cook Corporation, IN, USA) for treating lesions of the femoropopliteal arterial segment. Study patients (n = 465) had symptomatic lower limb ischemia. Safety and efficacy assessments were performed through 5 years. Mean time to first reintervention was calculated in post-hoc analysis for patients who underwent a clinically driven target lesion revascularization (CD-TLR) through 3 or 5 years following the index procedure. To simulate potential cost savings associated with differential CD-TLR burden over time, a cost-avoidance analysis using input parameters from IMPERIAL and US 100% Medicare standard analytical files was developed. Results: Among patients with a first CD-TLR through 3 years of follow-up, mean time to reintervention was 5.5 months longer (difference 166 days, 95% CI: 51, 282 days; p = 0.0058) for patients treated with Eluvia (n = 56) than for those treated with Zilver PTX (n = 30). Through the 5-year study follow-up period, CD-TLR rates were 29.3% (68/232) for Eluvia and 34.2% (39/114) for Zilver PTX (p = 0.3540) and mean time to first reintervention exceeded 2 years for patients treated with Eluvia at 737 days versus 645 days for the Zilver PTX group (difference 92 days, 95% CI: -85, 269 days; p = 0.3099). Simulated savings considering reinterventions occurring over 1 and 5 years following initial use of Eluvia over Zilver PTX were US $1,395,635 and US $1,531,795, respectively, when IMPERIAL CD-TLR rates were extrapolated to 1000 patients. Conclusion: IMPERIAL data suggest initial treatment with Eluvia extends the time patients spend without undergoing reintervention. This extension may be associated with cost savings in relevant time frames.
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Affiliation(s)
- William A Gray
- Department of Medicine, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA
- Division of Cardiology, Main Line Health, Wynnewood, PA, USA & Lankenau Heart Institute, Wynnewood, PA 19096, USA
| | - Yoshimitsu Soga
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Masahiko Fujihara
- Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan
| | - Osamu Iida
- Kansai Rosai Hospital, Cardiovascular Center, Amagasaki, Japan
| | - Anvar Babaev
- New York University Medical Center, New York, NY 10016, USA
| | - Daizo Kawasaki
- Department of Cardiology, Morinomiya Hospital, Osaka, Japan
| | - Thomas Zeller
- Department of Angiology, Universitäts-Herzzentrum Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - David O'Connor
- Hackensack University Medical Center, Hackensack, NJ 07061, USA
| | - Michael R Jaff
- Peripheral Interventions, Boston Scientific, Marlborough, MA 01752, USA
| | - Anna M Chavez
- Peripheral Interventions, Boston Scientific, Marlborough, MA 01752, USA
| | - Stefan Müller-Hülsbeck
- Institut Für Diagnostische und Interventionelle Radiologie und Neuroradiologie, Diako Hospital gGmbH, Flensburg, Germany
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18
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Francisco-Brandão J, Costa-Pereira T, Pereira-Neves A, Romana-Dias L, Marques-Vieira M, Vidoedo J, Andrade JP, Rocha-Neves J. Gupta Perioperative Risk for Myocardial Infarction or Cardiac Arrest score is a long-term cardiovascular risk predictor after aortoiliac revascularization. Ann Vasc Surg 2024:S0890-5096(24)00214-0. [PMID: 38825068 DOI: 10.1016/j.avsg.2024.02.027] [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: 12/21/2023] [Revised: 02/21/2024] [Accepted: 02/24/2024] [Indexed: 06/04/2024]
Abstract
INTRODUCTION Gupta Perioperative Risk for Myocardial Infarction or Cardiac Arrest (MICA) is a validated self-explanatory score applied in cardiac or non-cardiac surgeries. This study aims to assess the predictive value of the MICA score for cardiovascular events after aortoiliac revascularization. METHODS This prospective cohort underwent elective aortoiliac revascularization between 2013 and 2021. Patients' demographic, clinical characteristics and outcomes were registered. The patients were divided into two groups according to the MICA score using optimal binning. Survival analysis to test for time-dependent variables and multivariate Cox regression analysis for independent predictors were performed. RESULTS This study included 130 patients with a median follow-up of 55 months. Preoperative MICA score was ≥ 6.5 in 41 patients. MICA ≥ 6.5 presented a statistically significant association with long-term occurrence of acute heart failure (HR=1.695, 95% CI 1.208-2.379, p=0.002), major adverse cardiovascular events (HR=1.222, 95% CI 1.086-1.376, p<0.001) and all-cause mortality (HR=1.256, 95% CI 1.107-1.425, p<0.001). Multivariable Cox regression confirmed MICA as a significant independent predictor of long-term major adverse cardiovascular events (aHR=1.145 95%CI 1.010-1.298, p=0.034) and all-cause mortality (aHR=1.172 95%CI 1.026-1.339, p=0.020). CONCLUSION The MICA score is a quick, easy-to-obtain, predictive tool in identifying patients with a higher risk of post-aortoiliac revascularization cardiovascular events, such as acute heart failure, major adverse cardiovascular events and all-cause mortality. Additional research for validation of the MICA score in the context of aortoiliac revascularization and specific interventions are necessary.
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Affiliation(s)
| | - Tiago Costa-Pereira
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal
| | - António Pereira-Neves
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal; Department of Biomedicine - Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Portugal
| | - Lara Romana-Dias
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal
| | | | - José Vidoedo
- Department of Angiology and Vascular Surgery, Hospital de Braga, EPE
| | - José P Andrade
- Department of Biomedicine - Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Portugal; Department of Angiology and Vascular Surgery, Centro Hospitalar entre o Tâmega e o Sousa, Penafiel, Portugal
| | - João 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, Portugal; Department of Angiology and Vascular Surgery, Centro Hospitalar entre o Tâmega e o Sousa, Penafiel, Portugal
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Shimizu H, Kobayashi T, Okazaki T, Mochizuki S, Maeda K, Sato T, Emura S, Arai Y, Kato Y, Takahashi S. Clinical impact of fluoropolymer-based drug-eluting stent thrombosis in femoropopliteal artery occlusive lesions. Vascular 2024:17085381241258553. [PMID: 38811860 DOI: 10.1177/17085381241258553] [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: 05/31/2024]
Abstract
BACKGROUND Endovascular treatment (EVT) is recommended for superficial femoral artery (SFA) lesions, and good results have been reported after implantation of drug-eluting stents (DES) for SFA. However, the major concern after implantation is acute thrombosis during the follow-up period, resulting in major amputation and major adverse limb events. In this study, we examined the incidence and outcome of acute thrombosis after DES implantation in the SFA. OBJECTIVES AND METHODS DES implantation for a femoropopliteal lesion was performed in 288 patients at multiple centers in Japan from 2019 to 2021. A total of 25 patients (8.6%) with DES acute occlusion were analyzed retrospectively. The primary endpoint was amputation-free survival (AFS) after acute occlusion. RESULTS The median patient age was 77 years, with 48% having diabetes, 40% undergoing maintenance dialysis, and 66% having chronic limb-threatening ischemia (CLTI). The mean time from initial DES implantation to acute occlusion was 153.5 ± 177.6 days, with a median of 104 days. EVT was performed in 18 patients (72%), surgical revascularization in 3 (12%), and conservative treatment in 4 (16%). Two deaths within 30 days were both due to sepsis. No major amputation or major adverse cardiovascular events occurred within 30 days. The 1-year rates of patency and freedom from target lesion revascularization after DES thrombosis were 22.9% and 48.8%, respectively. AFS at 1 year was 55.1%. CONCLUSION Acute DES occlusion is relatively frequent, and the outcome is poor. Therefore, the indication of DES implantation for a complex SFA lesion may require careful consideration. Further investigation may be needed in DES implantation for a complex SFA lesion.
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Affiliation(s)
- Haruna Shimizu
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Taira Kobayashi
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Japan
| | - Takanobu Okazaki
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Japan
| | - Shingo Mochizuki
- Department of Cardiovascular Surgery, Akane-Foundation Tsuchiya General Hospital, Hiroshima, Japan
| | - Kazuki Maeda
- Department of Cardiovascular Surgery, Akane-Foundation Tsuchiya General Hospital, Hiroshima, Japan
| | - Tomoyasu Sato
- Department of Radiology, Akane-Foundation Tsuchiya General Hospital, Hiroshima, Japan
| | - Shogo Emura
- Department of Cardiovascular Surgery, National Hospital Organization Higashihiroshima Medical Center, Higashihiroshima-shi, Japan
| | - Yasunori Arai
- Department of Cardiology, Fukuyama City Hospital, Fukuyama-shi, Japan
| | - Yuichi Kato
- Department of Cardiology, Fukuyama City Hospital, Fukuyama-shi, Japan
| | - Shinya Takahashi
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Japan
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20
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Portela FSO, Rossetti CA, de Souza TF, Magnani AS, da Silva MFA, Portugal MFC, Teivelis MP, Wolosker N, Mendes CDA. Retrospective analysis of 1,203 cases of referral to a quaternary vascular surgery outpatient clinic within the Unified Health System, São Paulo, Brazil. EINSTEIN-SAO PAULO 2024; 22:eAO0676. [PMID: 38808797 PMCID: PMC11155721 DOI: 10.31744/einstein_journal/2024ao0676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 11/27/2023] [Indexed: 05/30/2024] Open
Abstract
OBJECTIVE Through a retrospective analysis of 1,203 cases of referral from primary healthcare units to a specialized quaternary vascular surgical service, the findings of this study revealed a high proportion of inappropriate referrals, which may represent a substantial subutilization of this highly complex service. Consequently, in this study, we aimed to evaluate 1,203 cases of referral to a quaternary vascular surgical service, in São Paulo, Brazil, over a 6-year period, to assess the appropriate need for referral; in addition to the prevalence of surgical indications. METHODS In this retrospective analysis, we reviewed the institutional records of participants referred from Basic Healthcare Units to a vascular surgical service inside the Brazilian Unified Health System, between May 2015 and December 2020. Demographic and clinical data were collected. The participants were stratified, as per the reason for referral to the vascular surgical service, previous imaging studies, and surgical treatment indications. Referral appropriateness and complementary examinations were evaluated for each disease cohort. Finally, the prevalence of cases requiring surgical treatment was defined as the outcome measure. RESULTS Of the 1,203 referrals evaluated, venous disease was the main reason for referral (53%), followed by peripheral arterial disease (19.4%). A considerable proportion of participants had been referred without complementary imaging or after a long duration of undergoing an examination. Referrals were regarded as inappropriate in 517 (43%) cases. Of these, 32 cases (6.2%) had been referred to the vascular surgical service, as the incorrect specialty. The percentage of referred participants who ultimately underwent surgical treatment was 39.92%. Carotid (18%) and peripheral arterial diseases (18.4%) were correlated with a lower prevalence of surgical treatments. CONCLUSION The rate of referral appropriateness to specialized vascular care from primary care settings was low. This may represent a subutilization of quaternary surgical services, with low rates of surgical treatment.
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Affiliation(s)
| | - Carlos Augusto Rossetti
- Faculdade Israelita de Ciências da Saúde Albert EinsteinHospital Israelita Albert EinsteinSão PauloSPBrazil Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Thulio Fernandes de Souza
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Arthur Souza Magnani
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | | | | | - Marcelo Passos Teivelis
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
- Faculdade Israelita de Ciências da Saúde Albert EinsteinHospital Israelita Albert EinsteinSão PauloSPBrazil Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Nelson Wolosker
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
- Faculdade Israelita de Ciências da Saúde Albert EinsteinHospital Israelita Albert EinsteinSão PauloSPBrazil Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Cynthia de Almeida Mendes
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
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21
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Fan EY, Schanzer A, Beck AW, Eagleton MJ, Farber MA, Gasper WJ, Lee WA, Oderich GS, Parodi FE, Schneider DB, Sweet MP, Timaran CH, Simons JP. Practice patterns of antiplatelet and anticoagulant therapy after fenestrated/branched endovascular aortic repair. J Vasc Surg 2024:S0741-5214(24)01220-5. [PMID: 38796031 DOI: 10.1016/j.jvs.2024.05.041] [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: 12/27/2023] [Revised: 04/02/2024] [Accepted: 05/20/2024] [Indexed: 05/28/2024]
Abstract
OBJECTIVE Antiplatelet and/or anticoagulant therapy are commonly prescribed after fenestrated/branched endovascular aortic repair (F/BEVAR). However, the optimal regimen remains unknown. We sought to characterize practice patterns and outcomes of antiplatelet and anticoagulant use in patients who underwent F/BEVAR. METHODS Consecutive patients enrolled (2012-2023) as part of the United States Aortic Research Consortium (US-ARC) from 10 independent physician-sponsored investigational device exemption studies were evaluated. The cohort was characterized by medication regimen on discharge from index F/BEVAR: (1) Aspirin alone OR P2Y12 alone (single-antiplatelet therapy [SAPT]); (2) Anticoagulant alone; (3) Aspirin + P2Y12 (dual-antiplatelet therapy [DAPT]); (4) Aspirin + anticoagulant OR P2Y12 + anticoagulant (SAPT + anticoagulant); (5) Aspirin + P2Y12 + anticoagulant (triple therapy [TT]); and (6) No therapy. Kaplan-Meier analysis and Cox proportional hazards modeling were used to compare 1-year outcomes including survival, target artery patency, freedom from bleeding complication, freedom from all reinterventions, and freedom from stent-specific reintervention. RESULTS Of the 1525 patients with complete exposure and outcome data, 49.6% were discharged on DAPT, 28.8% on SAPT, 13.6% on SAPT + anticoagulant, 3.2% on TT, 2.6% on anticoagulant alone, and 2.2% on no therapy. Discharge medication regimen was not associated with differences in 1-year survival, bleeding complications, composite reintervention rate, or stent-specific reintervention rate. However, there was a significant difference in 1-year target artery patency. On multivariable analysis comparing with SAPT, DAPT conferred a lower hazard of loss of target artery patency (hazard ratio [HR], 0.48; 95% confidence interval [CI], 0.27-0.84; P = .01). On sub-analyses of renal stents alone or visceral stents alone, DAPT no longer had a significantly lower hazard of loss of target artery patency (renal: HR, 0.66; 95% CI, 0.35-1.27; P = .22; visceral: HR, 0.31; 95% CI, 0.05-1.9; P = .21). Lastly, duration of DAPT therapy (1 month, 6 months, or 1 year) did not significantly affect target artery patency. CONCLUSIONS Practice patterns for antiplatelet and anticoagulant regimens after F/BEVAR vary widely across the US-ARC. There were no differences in bleeding complications, survival or reintervention rates among different regimens, but higher branch vessel patency was noted in the DAPT cohort. These data suggest there is a benefit in DAPT therapy. However, the generalizability of this finding is limited by the retrospective nature of this data, and the clinical significance of this finding is unclear, as there is no difference in survival, bleeding, or reintervention rates amongst the different regimens. Hence, an "optimal" regimen, including the duration of such regimen, could not be clearly discerned. This suggests equipoise for a randomized trial, nested within this cohort, to identify the most effective antiplatelet/anticoagulant regimen for the growing number of patients being treated globally with F/BEVAR.
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22
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Cleary CM, Adajian A, Gifford ED, Orosco E, Li YH, Healy L, Dawiczyk S, Bozeman P, Guerin E, Farrell H, Shah P. Incentives and individualized coaching improves completion rates of supervised exercise therapy for claudication. J Vasc Surg 2024:S0741-5214(24)01081-4. [PMID: 38912995 DOI: 10.1016/j.jvs.2024.04.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 04/22/2024] [Accepted: 04/24/2024] [Indexed: 06/25/2024]
Abstract
OBJECTIVE Supervised exercise therapy (SET) provides clinical benefit for patients suffering from intermittent claudication and has been widely recommended as first-line therapy before endovascular or surgical intervention. However, published rates of SET program completion range from 5% to 55%, with historic completion of 54% at our own institution. As such, we sought to identify if targeted patient-supportive interventions improve SET completion rates while still maintaining efficacious SET programming. METHODS Patients who were diagnosed with intermittent claudication, as defined by ankle-brachial index (ABI) <0.9 without rest pain, were offered enrollment in a prospective quality improvement protocol for our 12-week SET for peripheral artery disease program. Program completion was defined as ≥24 of 36 offered sessions over 12 weeks. A three-pronged approach was utilized to improve completion during the study, including financial incentives up to $180, scheduled coaching with our advanced practitioner staff, and informational materials on the importance of SET programming and lifestyle modification. Patient-reported improvements in walking symptoms were tracked via regularly administered questionnaires. Functional measures of SET programming including total walking duration and distance, metabolic equivalent of task, and ABIs; vascular intervention within 12-months after enrollment was also collected and compared using univariate paired analysis. RESULTS In total, seventy-three patients were enrolled in SET for peripheral artery disease programming over the study period. Utilizing our three-pronged coaching approach, 56 patients completed SET programming, increasing our SET completion rate to 76.7% over a 2-year study period. Compared with pre-SET baseline, patients who completed SET noted less pain, aching, cramps in calves when walking (P = .004), and less difficulty walking 1 block (P = .038). Additionally, patients significantly increased their metabolic equivalent of task (3.1 vs 2.6; P < .001), total walking duration (30 mins vs 13.5 mins; P < .001), and total walking distance (0.7 vs 0.3 miles; P < .001) from their pre-SET baseline. There were no changes in participant ABIs from enrollment to completion in participants. Patients who completed SET programming also delayed vascular intervention compared with those who did not complete SET or declined participation (213.5 vs 122.5 days from enrollment; P = .041). CONCLUSIONS Targeted incentives, including cost-coverage vouchers and personalized coaching with instructional materials, successfully improved patient completion of a prescribed SET program. Patients who completed SET programming reported subjective improvement in walking symptoms and objective walking benefits. In addition, these patients had delayed time to vascular intervention, supporting current vascular guidelines advocating for effective SET therapy prior to offering vascular intervention for intermittent claudication.
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Affiliation(s)
- Colin M Cleary
- University of Connecticut School of Medicine, Farmington, CT
| | - Allison Adajian
- Hartford Hospital Division of Vascular and Endovascular Surgery, Hartford, CT
| | - Edward D Gifford
- Hartford Hospital Division of Vascular and Endovascular Surgery, Hartford, CT
| | - Emily Orosco
- University of Connecticut School of Medicine, Farmington, CT
| | - Ya-Huei Li
- Hartford HealthCare Research Administration, Hartford, CT
| | - Laura Healy
- Hartford Hospital Division of Vascular and Endovascular Surgery, Hartford, CT
| | - Stephania Dawiczyk
- Hartford Hospital Division of Vascular and Endovascular Surgery, Hartford, CT
| | - Patricia Bozeman
- Hartford Hospital Division of Vascular and Endovascular Surgery, Hartford, CT
| | - Elizabeth Guerin
- Hartford Hospital Division of Vascular and Endovascular Surgery, Hartford, CT
| | - Hannah Farrell
- Hartford Hospital Division of Vascular and Endovascular Surgery, Hartford, CT
| | - Parth Shah
- Hartford Hospital Division of Vascular and Endovascular Surgery, Hartford, CT.
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23
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Radomski SN, Sorber R, Canner JK, Holscher CM, Weaver ML, Hicks CW, Reifsnyder T. Clinical factors associated with ultrashort length of stay in patients undergoing lower extremity bypass for peripheral arterial disease. J Vasc Surg 2024:S0741-5214(24)01106-6. [PMID: 38768833 DOI: 10.1016/j.jvs.2024.04.073] [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: 02/22/2024] [Revised: 04/11/2024] [Accepted: 04/12/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Length of stay (LOS) is a major driver of cost and resource utilization following lower extremity bypass (LEB). However, the variable comorbidity burden and mobility status of LEB patients makes implementing enhanced recovery after surgery pathways challenging. The aim of this study was to use a large national database to identify patient factors associated with ultrashort LOS among patients undergoing LEB for peripheral artery disease. METHODS All patients undergoing LEB for peripheral artery disease in the National Surgical Quality Improvement Project database from 2011 to 2018 were included. Patients were divided into two groups based on the postoperative length of stay : ultrashort (≤2 days) and standard (>2 days). Thirty-day outcomes were compared using descriptive statistics, and multivariable logistic regression was used to identify patient factors associated with ultrashort LOS. RESULTS Overall, 17,510 patients were identified who underwent LEB, of which 2678 patients (15.3%) had an ultrashort postoperative LOS (mean, 1.8 days) and 14,832 (84.7%) patients had a standard LOS (mean, 7.1 days). When compared to patients with a standard LOS, patients with an ultrashort LOS were more likely to be admitted from home (95.9% vs 88.0%; P < .001), undergo elective surgery (86.1% vs 59.1%; P < .001), and be active smokers (52.1% vs 40.4%; P < .001). Patients with an ultrashort LOS were also more likely to have claudication as the indication for LEB (53.1% vs 22.5%; P < .001), have a popliteal revascularization target rather than a tibial/pedal target (76.7% vs 55.3%; P < .001), and have a prosthetic conduit (40.0% vs 29.9%; P < .001). There was no significant difference in mortality between the two groups (1.4% vs 1.8%; P = .21); however, patients with an ultrashort LOS had a lower frequency of unplanned readmission (10.7% vs 18.8%; P < .001) and need for major reintervention (1.9% vs 5.6%; P < .001). On multivariable analysis, elective status (odds ratio , 2.66; 95% confidence interval [CI], 2.33-3.04), active smoking (OR, 1.18; 95% CI, 1.07-1.30), and lack of vein harvest (OR, 1.55; 95% CI, 1.41-1.70) were associated with ultrashort LOS. Presence of rest pain (OR, 0.57; 95% CI, 0.51-0.63), tissue loss (OR, 0.30; 95% CI, 0.27-0.34), and totally dependent functional status (OR, 0.54; 95% CI, 0.35-0.84) were associated negatively with an ultrashort LOS. When examining the subgroup of patients who underwent vein harvest, totally dependent (OR, 0.38; 95% CI, 0.19-0.75) and partially dependent (OR, 0.53; 95% CI, 0.32-0.88) functional status were persistently negatively associated with ultrashort LOS. CONCLUSIONS Ultrashort LOS (≤2 days) after LEB is uncommon but feasible in select patients. Preoperative functional status and mobility are important factors to consider when identifying LEB patients who may be candidates for early discharge.
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Affiliation(s)
- Shannon N Radomski
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD.
| | - Rebecca Sorber
- Division of Vascular Surgery, University of Washington, Seattle, WA
| | - Joseph K Canner
- Johns Hopkins Surgery Center for Outcomes Research (JSCOR), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Courtenay M Holscher
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD
| | - M Libby Weaver
- Division of Vascular Surgery, University of Virginia, Charlottesville, VA
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD; Johns Hopkins Surgery Center for Outcomes Research (JSCOR), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Thomas Reifsnyder
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD
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24
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Wang H, Zuo H, Pan D, Cao Y, Zhang Y, Liu D, Guo L, Guo J. An in vitro feasibility study of 355 nm laser atherectomy for the treatment of peripheral atherosclerotic lesions. JOURNAL OF BIOPHOTONICS 2024:e202400110. [PMID: 38740541 DOI: 10.1002/jbio.202400110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 03/28/2024] [Accepted: 04/19/2024] [Indexed: 05/16/2024]
Abstract
In this study, we utilized a novel 355 nm laser to ablate porcine aortas in the presence of physiological saline and contrast agent. Subsequently, we investigated the shape and depth of the resulting injuries. After ablating bovine tendons and aortas with the laser, we analyzed the size and quantity of particles postablation. Finally, we conducted ablation experiments using human ex vivo plaques. The analysis revealed minimal damage to porcine aortas within 2 s of exposure to the 355 nm laser. The degree of injury in the presence of contrast agent was higher than that in the presence of physiological saline but significantly lower than the damage caused by 308 nm laser. Regardless of whether it was bovine tendon or porcine aorta tissue, the proportion of particles <25 μm postlaser ablation exceeded 99%. Lastly, the 355 nm laser successfully opened three types of plaques: chronically occluded, stent restenosis, and stale thrombosis.
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Affiliation(s)
- Hui Wang
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hui Zuo
- Shenzhen Vivolight Medical Device & Technology Co. Ltd, Shenzhen, Guangdong Province, China
| | - Dikang Pan
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yihui Cao
- Shenzhen Vivolight Medical Device & Technology Co. Ltd, Shenzhen, Guangdong Province, China
| | - Yiqun Zhang
- Shenzhen Vivolight Medical Device & Technology Co. Ltd, Shenzhen, Guangdong Province, China
| | - Duan Liu
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Lianrui Guo
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jianming Guo
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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25
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Li B, Aljabri B, Verma R, Beaton D, Hussain MA, Lee DS, Wijeysundera DN, de Mestral C, Mamdani M, Al‐Omran M. Predicting Outcomes Following Lower Extremity Endovascular Revascularization Using Machine Learning. J Am Heart Assoc 2024; 13:e033194. [PMID: 38639373 PMCID: PMC11179886 DOI: 10.1161/jaha.123.033194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 03/01/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Lower extremity endovascular revascularization for peripheral artery disease carries nonnegligible perioperative risks; however, outcome prediction tools remain limited. Using machine learning, we developed automated algorithms that predict 30-day outcomes following lower extremity endovascular revascularization. METHODS AND RESULTS The National Surgical Quality Improvement Program targeted vascular database was used to identify patients who underwent lower extremity endovascular revascularization (angioplasty, stent, or atherectomy) for peripheral artery disease between 2011 and 2021. Input features included 38 preoperative demographic/clinical variables. The primary outcome was 30-day postprocedural major adverse limb event (composite of major reintervention, untreated loss of patency, or major amputation) or death. Data were split into training (70%) and test (30%) sets. Using 10-fold cross-validation, 6 machine learning models were trained using preoperative features. The primary model evaluation metric was area under the receiver operating characteristic curve. Overall, 21 886 patients were included, and 30-day major adverse limb event/death occurred in 1964 (9.0%) individuals. The best performing model for predicting 30-day major adverse limb event/death was extreme gradient boosting, achieving an area under the receiver operating characteristic curve of 0.93 (95% CI, 0.92-0.94). In comparison, logistic regression had an area under the receiver operating characteristic curve of 0.72 (95% CI, 0.70-0.74). The calibration plot showed good agreement between predicted and observed event probabilities with a Brier score of 0.09. The top 3 predictive features in our algorithm were (1) chronic limb-threatening ischemia, (2) tibial intervention, and (3) congestive heart failure. CONCLUSIONS Our machine learning models accurately predict 30-day outcomes following lower extremity endovascular revascularization using preoperative data with good discrimination and calibration. Prospective validation is warranted to assess for generalizability and external validity.
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Affiliation(s)
- Ben Li
- Department of SurgeryUniversity of TorontoCanada
- Division of Vascular SurgerySt. Michael’s Hospital, Unity Health Toronto, University of TorontoTorontoCanada
- Institute of Medical Science, University of TorontoTorontoCanada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine (T‐CAIREM)University of TorontoTorontoCanada
| | - Badr Aljabri
- Department of SurgeryKing Saud UniversityRiyadhSaudi Arabia
| | - Raj Verma
- School of Medicine, Royal College of Surgeons in IrelandUniversity of Medicine and Health SciencesDublinIreland
| | - Derek Beaton
- Data Science & Advanced Analytics, Unity Health TorontoUniversity of TorontoTorontoCanada
| | - Mohamad A. Hussain
- Division of Vascular and Endovascular Surgery and the Center for Surgery and Public Health, Brigham and Women’s HospitalHarvard Medical SchoolBostonMAUSA
| | - Douglas S. Lee
- Division of Cardiology, Peter Munk Cardiac CentreUniversity Health NetworkTorontoCanada
- Institute of Health Policy, Management and Evaluation, University of TorontoTorontoCanada
- ICES, University of TorontoTorontoCanada
| | - Duminda N. Wijeysundera
- Institute of Health Policy, Management and Evaluation, University of TorontoTorontoCanada
- ICES, University of TorontoTorontoCanada
- Department of AnesthesiaSt. Michael’s Hospital, Unity Health TorontoTorontoCanada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health TorontoTorontoCanada
| | - Charles de Mestral
- Department of SurgeryUniversity of TorontoCanada
- Division of Vascular SurgerySt. Michael’s Hospital, Unity Health Toronto, University of TorontoTorontoCanada
- Institute of Health Policy, Management and Evaluation, University of TorontoTorontoCanada
- ICES, University of TorontoTorontoCanada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health TorontoTorontoCanada
| | - Muhammad Mamdani
- Institute of Medical Science, University of TorontoTorontoCanada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine (T‐CAIREM)University of TorontoTorontoCanada
- Data Science & Advanced Analytics, Unity Health TorontoUniversity of TorontoTorontoCanada
- Institute of Health Policy, Management and Evaluation, University of TorontoTorontoCanada
- ICES, University of TorontoTorontoCanada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health TorontoTorontoCanada
- Leslie Dan Faculty of PharmacyUniversity of TorontoTorontoCanada
| | - Mohammed Al‐Omran
- Department of SurgeryUniversity of TorontoCanada
- Division of Vascular SurgerySt. Michael’s Hospital, Unity Health Toronto, University of TorontoTorontoCanada
- Institute of Medical Science, University of TorontoTorontoCanada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine (T‐CAIREM)University of TorontoTorontoCanada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health TorontoTorontoCanada
- Department of SurgeryKing Faisal Specialist Hospital and Research CenterRiyadhSaudi Arabia
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26
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Cucato G, Longano PP, Perren D, Ritti-Dias RM, Saxton JM. Effects of additional exercise therapy after a successful vascular intervention for people with symptomatic peripheral arterial disease. Cochrane Database Syst Rev 2024; 5:CD014736. [PMID: 38695785 PMCID: PMC11064885 DOI: 10.1002/14651858.cd014736.pub2] [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] [Indexed: 05/04/2024]
Abstract
BACKGROUND Peripheral arterial disease (PAD) is characterised by obstruction or narrowing of the large arteries of the lower limbs, usually caused by atheromatous plaques. Most people with PAD who experience intermittent leg pain (intermittent claudication) are typically treated with secondary prevention strategies, including medical management and exercise therapy. Lower limb revascularisation may be suitable for people with significant disability and those who do not show satisfactory improvement after conservative treatment. Some studies have suggested that lower limb revascularisation for PAD may not confer significantly more benefits than supervised exercise alone for improved physical function and quality of life. It is proposed that supervised exercise therapy as adjunctive treatment after successful lower limb revascularisation may confer additional benefits, surpassing the effects conferred by either treatment alone. OBJECTIVES To assess the effects of a supervised exercise programme versus standard care following successful lower limb revascularisation in people with PAD. SEARCH METHODS We searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, two other databases, and two trial registers, most recently on 14 March 2023. SELECTION CRITERIA We included randomised controlled trials which compared supervised exercise training following lower limb revascularisation with standard care following lower limb revascularisation in adults (18 years and older) with PAD. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were maximum walking distance or time (MWD/T) on the treadmill, six-minute walk test (6MWT) total distance, and pain-free walking distance or time (PFWD/T) on the treadmill. Our secondary outcomes were changes in the ankle-brachial index, all-cause mortality, changes in health-related quality-of-life scores, reintervention rates, and changes in subjective measures of physical function. We analysed continuous data by determining the mean difference (MD) and 95% confidence interval (CI), and dichotomous data by determining the odds ratio (OR) with corresponding 95% CI. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We identified seven studies involving 376 participants. All studies involved participants who received either additional supervised exercise or standard care after lower limb revascularisation. The studies' exercise programmes varied, and included supervised treadmill walking, combined exercise, and circuit training. The duration of exercise therapy ranged from six weeks to six months; follow-up time ranged from six weeks to five years. Standard care also varied between studies, including no treatment or advice to stop smoking, lifestyle modifications, or best medical treatment. We classified all studies as having some risk of bias concerns. The certainty of the evidence was very low due to the risk of bias, inconsistency, and imprecision. The meta-analysis included only a subset of studies due to concerns regarding data reporting, heterogeneity, and bias in most published research. The evidence was of very low certainty for all the review outcomes. Meta-analysis comparing changes in maximum walking distance from baseline to end of follow-up showed no improvement (MD 159.47 m, 95% CI -36.43 to 355.38; I2 = 0 %; 2 studies, 89 participants). In contrast, exercise may improve the absolute maximum walking distance at the end of follow-up compared to standard care (MD 301.89 m, 95% CI 138.13 to 465.65; I2 = 0 %; 2 studies, 108 participants). Moreover, we are very uncertain if there are differences in the changes in the six-minute walk test total distance from baseline to treatment end between exercise and standard care (MD 32.6 m, 95% CI -17.7 to 82.3; 1 study, 49 participants), and in the absolute values at the end of follow-up (MD 55.6 m, 95% CI -2.6 to 113.8; 1 study, 49 participants). Regarding pain-free walking distance, we are also very uncertain if there are differences in the mean changes in PFWD from baseline to treatment end between exercise and standard care (MD 167.41 m, 95% CI -11 to 345.83; I2 = 0%; 2 studies, 87 participants). We are very uncertain if there are differences in the absolute values of ankle-brachial index at the end of follow-up between the intervention and standard care (MD 0.01, 95% CI -0.11 to 0.12; I2 = 62%; 2 studies, 110 participants), in mortality rates at the end of follow-up (OR 0.92, 95% CI 0.42 to 2.00; I2 = 0%; 6 studies, 346 participants), health-related quality of life at the end of follow-up for the physical (MD 0.73, 95% CI -5.87 to 7.33; I2 = 64%; 2 studies, 105 participants) and mental component (MD 1.04, 95% CI -6.88 to 8.95; I2 = 70%; 2 studies, 105 participants) of the 36-item Short Form Health Survey. Finally, there may be little to no difference in reintervention rates at the end of follow-up between the intervention and standard care (OR 0.91, 95% CI 0.23 to 3.65; I2 = 65%; 5 studies, 252 participants). AUTHORS' CONCLUSIONS There is very uncertain evidence that additional exercise therapy after successful lower limb revascularisation may improve absolute maximal walking distance at the end of follow-up compared to standard care. Evidence is also very uncertain about the effects of exercise on pain-free walking distance, six-minute walk test distance, quality of life, ankle-brachial index, mortality, and reintervention rates. Although it is not possible to confirm the effectiveness of supervised exercise compared to standard care for all outcomes, studies did not report any harm to participants from this intervention after lower limb revascularisation. Overall, the evidence incorporated into this review was very uncertain, and additional evidence is needed from large, well-designed, randomised controlled studies to more conclusively demonstrate the role additional exercise therapy has after lower limb revascularisation in people with PAD.
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Affiliation(s)
- Gabriel Cucato
- Department of Sport, Exercise, and Rehabilitation, Northumbria University, Newcastle-upon-Tyne, UK
| | - Paulo Pl Longano
- Ciências da Reabilitação, Universidade Nove de Julho, São Paulo, Brazil
| | - Daniel Perren
- Department of Vascular Surgery, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | | | - John M Saxton
- Department of Sport, Health & Exercise Science, University of Hull, Hull, UK
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Thangada ND, McDermott MM. Exercise Therapy for Peripheral Artery Disease. Curr Cardiol Rep 2024; 26:405-412. [PMID: 38722492 DOI: 10.1007/s11886-024-02043-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE OF REVIEW To summarize evidence regarding exercise treatments for lower extremity peripheral artery disease (PAD). RECENT FINDINGS Supervised walking exercise is recommended by practice guidelines for PAD. Supervised treadmill exercise improves treadmill walking distance by approximately 180 m and 6-min walk distance by 30-35 m, compared to control. The Centers for Medicaid and Medicare Services covers 12 weeks of supervised exercise, but most people with PAD do not participate. Home-based walking exercise may be more convenient and accessible than supervised exercise. In randomized clinical trials, home-based walking exercise interventions incorporating behavioral methods, such as accountability to a coach, goal-setting, and self-monitoring, improved 6-min walk distance by 40-54 m, compared to control. Arm and leg ergometry also improved walking endurance for people with PAD, but efficacy compared to walking exercise remains unclear. Walking exercise is first-line therapy for PAD-related walking impairment and can be effective in either a supervised or a structured home-based setting.
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Affiliation(s)
- Neela D Thangada
- Feinberg School of Medicine, Northwestern University, 750 N Lake Shore Dr, 10th floor, Chicago, IL, 60611, USA
| | - Mary M McDermott
- Feinberg School of Medicine, Northwestern University, 750 N Lake Shore Dr, 10th floor, Chicago, IL, 60611, USA.
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Pyun AJ, Goodney PP, Eldrup-Jorgensen J, Wadzinski J, Secemsky EA, Cigarroa JE. Device regulation and surveillance in vascular care: Challenges and opportunities. Catheter Cardiovasc Interv 2024. [PMID: 38639136 DOI: 10.1002/ccd.31053] [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: 03/31/2024] [Accepted: 04/02/2024] [Indexed: 04/20/2024]
Abstract
Cardiovascular devices are essential for the treatment of cardiovascular diseases including cerebrovascular, coronary, valvular, congenital, peripheral vascular and arrhythmic diseases. The regulation and surveillance of vascular devices in real-world practice, however, presents challenges during each individual product's life cycle. Four examples illustrate recent challenges and questions regarding safety, appropriate use and efficacy arising from FDA approved devices used in real-world practice. We outline potential pathways wherein providers, regulators and payors could potentially provide high-quality cardiovascular care, identify safety signals, ensure equitable device access, and study potential issues with devices in real-world practice.
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Affiliation(s)
- Alyssa J Pyun
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, California, USA
| | - Philip P Goodney
- Heart and Vascular Center, Dartmouth Health, Lebanon, New Hampshire, USA
- The Society for Vascular Surgery's Patient Safety Organization (SVS-PSO) and Vascular Quality Initiative (VQI), Chicago, Illinois, USA
| | - Jens Eldrup-Jorgensen
- The Society for Vascular Surgery's Patient Safety Organization (SVS-PSO) and Vascular Quality Initiative (VQI), Chicago, Illinois, USA
| | - James Wadzinski
- The Society for Vascular Surgery's Patient Safety Organization (SVS-PSO) and Vascular Quality Initiative (VQI), Chicago, Illinois, USA
| | - Eric A Secemsky
- Division of Vascular Interventions, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Joaquin E Cigarroa
- Division of Cardiovascular Medicine, Department of Medicine, Oregon Health Sciences University (OHSU), Portland, Oregon, USA
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Fujimura N, Obara H, Matsubara K, Toya N, Isogai N, Ogino H, Fujii T, Kudo T, Kanaoka Y, Harada H, Uchiyama H, Guntani A, Shimogawara T, Watada S, Shibutani S, Ohki T. Long-Term Outcomes of a Japanese Prospective Multicenter Registry Using a Heparin-Bonded Expanded Polytetrafluoroethylene Graft for Above-the-Knee Femoropopliteal Bypasses. Circ J 2024:CJ-24-0135. [PMID: 38616124 DOI: 10.1253/circj.cj-24-0135] [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] [Indexed: 04/16/2024]
Abstract
BACKGROUND Despite the widespread use of PROPATEN®, a bioactive heparin-bonded expanded polytetrafluoroethylene graft, in bypass surgery, there are only a few reports of long-term results. We evaluated the long-term results of PROPATEN®use for above-knee femoropopliteal bypass (AKFPB).Methods and Results: After PROPATEN®-based AKFPB, patients were prospectively registered at 20 Japanese institutions between July 2014 and October 2017 to evaluate long-term results. During the median follow-up of 76 months (interquartile range 36-88 months) for 120 limbs (in 113 patients; mean [±SD] age 72.7±8.1 years; 66.7% male; ankle-brachial index [ABI] 0.45±0.27; lesion length 26.2±5.7 cm; chronic limb-threatening ischemia in 45 limbs), there were 8 major amputations; however, clinical improvement was sustained (mean [±SD] ABI 0.87±0.23) and the Rutherford classification grade improved in 105 (87.5%) limbs at the latest follow-up. At 8 years, the primary patency, freedom from target-lesion revascularization, secondary patency, survival, and amputation-free survival, as estimated by the Kaplan-Meier method, were 66.3±4.8%, 71.5±4.4%, 86.5±3.4%, 53.1±5.0%, and 47.4±5.3%, respectively. CONCLUSIONS This multicenter prospective registry-based analysis showed sustained excellent clinical improvement and secondary patency for up to 8 years following PROPATEN®-based AKFPB. PROPATEN®constitutes a durable and good revascularization option for complex superficial femoral artery lesions, especially when endovascular treatment is inappropriate or an adequate venous conduit is unavailable.
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Affiliation(s)
- Naoki Fujimura
- Department of Vascular Surgery, Saiseikai Central Hospital
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine
| | | | - Naoki Toya
- Department of Surgery, The Jikei University Kashiwa Hospital
| | - Naoko Isogai
- Department of Surgery, Shonan Kamakura General Hospital
| | | | - Taku Fujii
- Department of Surgery, Saitama Municipal Hospital
| | - Toshifumi Kudo
- Department of Surgery, Tokyo Medical and Dental University
| | - Yuji Kanaoka
- Department of Cardiovascular Surgery, Kawasaki Medical School
| | | | | | - Atsushi Guntani
- Department of Vascular Surgery, Saiseikai Yahata General Hospital
| | | | | | | | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
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30
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Holeman TA, Chester C, Hales JB, Zhang Y, Johnson CE, Brooke BS. Long-term patient-reported outcomes among patients undergoing revascularization vs medical therapy for intermittent claudication. J Vasc Surg 2024:S0741-5214(24)00981-9. [PMID: 38608965 DOI: 10.1016/j.jvs.2024.03.455] [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: 11/09/2023] [Revised: 02/29/2024] [Accepted: 03/16/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVE Society for Vascular Surgery guidelines recommend revascularization for patients with intermittent claudication (IC) if it can improve patient function and quality of life. However, it is still unclear if patients with IC achieve a significant functional benefit from surgery compared with medical management alone. This study examines the relationship between IC treatment modality (operative vs nonoperative optimal medical management) and patient-reported outcomes for physical function (PROMIS-PF) and satisfaction in social roles and activities (PROMIS-SA). METHODS We identified patients with IC who presented for index evaluation in a vascular surgery clinic at an academic medical center between 2016 and 2021. Patients were stratified based on whether they underwent a revascularization procedure during follow-up vs continued nonoperative management with medication and recommended exercise therapy. We used linear mixed-effect models to assess the relationship between treatment modality and PROMIS-PF, PROMIS-SA, and ankle-brachial index (ABI) over time, clustering among repeat patient observations. Models were adjusted for age, sex, diabetes, Charlson Comorbidity Index, Clinical Frailty Score, tobacco use, and index ABI. RESULTS A total of 225 patients with IC were identified, of which 40% (n = 89) underwent revascularization procedures (42% bypass; 58% peripheral vascular intervention) and 60% (n = 136) continued nonoperative management. Patients were followed up to 6.9 years, with an average follow-up of 5.2 ± 1.6 years. Patients who underwent revascularization were more likely to be clinically frail (P = .03), have a lower index ABI (0.55 ± 0.24 vs 0.72 ± 0.28; P < .001), and lower baseline PROMIS-PF score (36.72 ± 8.2 vs 40.40 ± 6.73; P = .01). There were no differences in patient demographics or medications between treatment groups. Examining patient-reported outcome trends over time; there were no significant differences in PROMIS-PF between groups, trends over time, or group differences over time after adjusting for covariates (P = .07, P = .13, and P =.08, respectively). However, all patients with IC significantly increased their PROMIS-SA over time (adjusted P = .019), with patients managed nonoperatively more likely to have an improvement in PROMIS-SA over time than those who underwent revascularization (adjusted P = .045). CONCLUSIONS Patient-reported outcomes associated with functional status and satisfaction in activities are similar for patients with IC for up to 7 years, irrespective of whether they undergo treatment with revascularization or continue nonoperative management. These findings support conservative long-term management for patients with IC.
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Affiliation(s)
- Teryn A Holeman
- Division of Vascular Surgery, University of Utah, School of Medicine, Salt Lake City, UT; Department of Population Health Science, University of Utah, School of Medicine, Salt Lake City, UT.
| | - Cassidy Chester
- Division of Vascular Surgery, University of Utah, School of Medicine, Salt Lake City, UT
| | - Julie B Hales
- Division of Vascular Surgery, University of Utah, School of Medicine, Salt Lake City, UT
| | - Yue Zhang
- Department of Population Health Science, University of Utah, School of Medicine, Salt Lake City, UT
| | - Cali E Johnson
- Division of Vascular Surgery, University of Utah, School of Medicine, Salt Lake City, UT
| | - Benjamin S Brooke
- Division of Vascular Surgery, University of Utah, School of Medicine, Salt Lake City, UT; Department of Population Health Science, University of Utah, School of Medicine, Salt Lake City, UT
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Li B, Nassereldine R, Zamzam A, Syed MH, Mamdani M, Al-Omran M, Abdin R, Qadura M. Development and evaluation of a prediction model for peripheral artery disease-related major adverse limb events using novel biomarker data. J Vasc Surg 2024:S0741-5214(24)00951-0. [PMID: 38599293 DOI: 10.1016/j.jvs.2024.03.450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/26/2024] [Accepted: 03/31/2024] [Indexed: 04/12/2024]
Abstract
OBJECTIVE Prognostic tools for individuals with peripheral artery disease (PAD) remain limited. We developed prediction models for 3-year PAD-related major adverse limb events (MALE) using demographic, clinical, and biomarker data previously validated by our group. METHODS We performed a prognostic study using a prospectively recruited cohort of patients with PAD (n = 569). Demographic/clinical data were recorded including sex, age, comorbidities, previous procedures, and medications. Plasma concentrations of three biomarkers (N-terminal pro-B-type natriuretic peptide [NT-proBNP], fatty acid binding protein 3 [FABP3], and FABP4) were measured at baseline. The cohort was followed for 3 years. MALE was the primary outcome (composite of open/endovascular vascular intervention or major amputation). We trained three machine learning models with 10-fold cross-validation using demographic, clinical, and biomarker data (random forest, decision trees, and Extreme Gradient Boosting [XGBoost]) to predict 3-year MALE in patients. Area under the receiver operating characteristic curve (AUROC) was the primary model evaluation metric. RESULTS Three-year MALE was observed in 162 patients (29%). XGBoost was the top-performing predictive model for 3-year MALE, achieving the following performance metrics: AUROC = 0.88 (95% confidence interval [CI], 0.84-0.94); sensitivity, 88%; specificity, 84%; positive predictive value, 83%; and negative predictive value, 91% on test set data. On an independent validation cohort of patients with PAD, XGBoost attained an AUROC of 0.87 (95% CI, 0.82-0.90). The 10 most important predictors of 3-year MALE consisted of: (1) FABP3; (2) FABP4; (3) age; (4) NT-proBNP; (5) active smoking; (6) diabetes; (7) hypertension; (8) dyslipidemia; (9) coronary artery disease; and (10) sex. CONCLUSIONS We built robust machine learning algorithms that accurately predict 3-year MALE in patients with PAD using demographic, clinical, and novel biomarker data. Our algorithms can support risk stratification of patients with PAD for additional vascular evaluation and early aggressive medical management, thereby improving outcomes. Further validation of our models for clinical implementation is warranted.
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Affiliation(s)
- Ben Li
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Temerty Centre for Artificial Intelligence Research and Education in Medicine (T-CAIREM), University of Toronto, Toronto, Ontario, Canada
| | - Rakan Nassereldine
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada; Division of Vascular Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Abdelrahman Zamzam
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Muzammil H Syed
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Muhammad Mamdani
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Temerty Centre for Artificial Intelligence Research and Education in Medicine (T-CAIREM), University of Toronto, Toronto, Ontario, Canada; Data Science & Advanced Analytics, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, University of Toronto, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed Al-Omran
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Temerty Centre for Artificial Intelligence Research and Education in Medicine (T-CAIREM), University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada; Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Rawand Abdin
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mohammad Qadura
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada.
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Bromenshenkel D, Quint C. Management of claudicants with low toe-brachial index in a Veteran population. Vascular 2024:17085381241246309. [PMID: 38588174 DOI: 10.1177/17085381241246309] [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: 04/10/2024]
Abstract
INTRODUCTION Intermittent claudication includes a wide spectrum of peripheral artery disease ranging from asymptomatic with reduced perfusion to lifestyle-limiting atherosclerotic disease. The purpose of this study was to evaluate the management of claudicants with a low toe-brachial index (TBI). METHODS This study was a retrospective review of consecutive patients that presented in 2015 with claudication and a low TBI (<0.6) monitored over 5 years. The patient demographics, co-morbidities, and vascular-related characteristics (ankle-brachial index, TBI, calcified vessels, and wounds) were collected. The patients were separated into two cohorts: diabetics and non-diabetics. The outcomes included progression to chronic limb threatening ischemia (CLTI), interventions (endovascular or open), minor amputations, major amputations, and mortality. RESULTS A total of 184 patients with 356 limbs were identified as claudicants with a low TBI, and there were 103 diabetics with 81 non-diabetics. The ABI and TBI were similar between the diabetics and non-diabetics, but the diabetics had a significantly higher number of calcified vessels (p < .001) and progression to CLTI (p < .001). The time to revascularization and number of patients that had a revascularization procedure were similar between the two groups, and nearly half of the revascularization procedures were performed within the first 6 months. The major amputation rate trended higher in the diabetic population, and there was a statistically significantly higher rate of minor amputations in the diabetics over the 5 years (Log-rank, p < .001). There was no difference in 5-year survival between diabetics and non-diabetics, and the overall 5-year mortality was 34%. CONCLUSION Patients presenting with claudication and low TBI, especially with diabetes, are at a higher risk to develop chronic limb threatening ischemia. Claudicants with a low TBI should have closer follow-up and more aggressive risk factor modification to reduce long-term mortality.
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Affiliation(s)
- Drew Bromenshenkel
- Department of Surgery, South Texas Veterans Healthcare System, San Antonio, TX, USA
| | - Clay Quint
- Department of Surgery, South Texas Veterans Healthcare System, San Antonio, TX, USA
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Pinto P, Ochoa Chaar CI. Atherectomy - The Options, the Evidence, and When Should It Be Used. Ann Vasc Surg 2024:S0890-5096(24)00153-5. [PMID: 38583766 DOI: 10.1016/j.avsg.2023.12.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/18/2023] [Accepted: 12/25/2023] [Indexed: 04/09/2024]
Abstract
The use of atherectomy for peripheral vascular interventions (PVIs) has increased exponentially and reached 18% of all PVI in the United States. The theoretical benefit on extensive arterial calcification relies on the concept of plaque modification and removal instead of displacement, as with other endovascular techniques. To date, there are no prospective studies comparing the different atherectomy technologies (directional, rotational, orbital, and laser). Moreover, most related prospective comparative studies have a small number of patients, and larger studies are single arm in patients with relatively mild to moderate disease burden. While available literature shows lower dissection risk and reduced bailout stenting, the superiority of this technology compared to other endovascular techniques has yet to be proven. Despite the lack of level 1 evidence to support its superiority, the lucrative reimbursement fueled the overuse of this technology as first-line therapy, particularly in office-based laboratories and ambulatory surgery centers. The use of atherectomy ought to be selective and complementary to other endovascular technologies, and individualized patient-level decision-making based on the practitioner's preference and expertise is essential to selectively incorporate atherectomy in managing complex atherosclerotic lesions.
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Affiliation(s)
- Paula Pinto
- Division of Vascular Surgery and Endovascular Therapy, Yale School of Medicine, New Haven, CT, USA.
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Yale School of Medicine, New Haven, CT, USA
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Abumoawad A, Okazaki RA, Behrooz L, Eberhardt RT. Medical Optimization of Patients with Symptomatic Peripheral Arterial Disease. Ann Vasc Surg 2024:S0890-5096(24)00160-2. [PMID: 38582206 DOI: 10.1016/j.avsg.2024.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 01/03/2024] [Indexed: 04/08/2024]
Abstract
Peripheral artery disease (PAD) is a progressive disease associated with the occurrence of major adverse cardiovascular and limb events and elevated mortality rates. Symptoms of PAD, including claudication and chronic limb-threatening ischemia, impair functional capacity and lead to lower quality of life. The focus of current therapies is to minimize symptoms, improve quality of life, and reduce adverse cardiovascular and limb events. Among the medical therapies are antiplatelets, anticoagulants, antihypertensives, lipid lowering therapies, cilostazol and pentoxifylline, and novel blood sugar-lowering therapies, plus exercise therapy and smoking cessation. In this review, we discuss these evidence-based medical therapies that are available for patients with symptomatic PAD.
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Affiliation(s)
| | - Ross A Okazaki
- Evans Department of Medicine/Section of Cardiovascular Medicine and Whitaker Cardiovascular Institute, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Leili Behrooz
- Department of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Robert T Eberhardt
- Evans Department of Medicine/Section of Cardiovascular Medicine and Whitaker Cardiovascular Institute, Boston University Chobanian & Avedisian School of Medicine, Boston, MA.
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Cheng TW, Doros G, Jones DW, Vazirani A, Malikova MA. Evaluation of Computerized Tomography Utilization in Comparison to Digital Subtraction Angiography in Patients with Peripheral Arterial Disease. Ann Vasc Surg 2024:S0890-5096(24)00165-1. [PMID: 38582215 DOI: 10.1016/j.avsg.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 02/28/2024] [Accepted: 03/28/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Perform literature review to analyze current practices in imaging patient with peripheral arterial disease (PAD) and examine patterns in our practice in order to assess whether a lower extremity computed tomography angiography (CTA) in addition to digital subtraction angiography enhanced the assessment of vessel calcification, percentage of stenosis, and affected outcomes in patients with PAD. METHODS The study included patients who underwent lower extremity imaging and were followed up to 12 months. This population was divided into cases who had both an angiogram and CTA performed within 30 days (n = 20), and controls who underwent angiography only (n = 19). Baseline characteristics, imaging results, and clinical outcomes were analyzed. RESULTS Thirty-nine patients met study criteria (mean age was 58.4 years, 69.2% were males, and 33.3% had diabetes). Patients mostly presented with tissue loss/rest pain (10.3%), claudication (15.4%), acute limb (10.3%), and trauma (15.4%). We have not observed any statistically significant differences in various examined blood vessels when their features (e.g., vessel diameter, stenosis, calcifications) were assessed by CTA combined with angiography versus angiography alone. The exceptions were external iliac artery, superficial femoral artery and dorsalis pedis vessels. In external iliac artery percentage of stenosis was 1.11% as determined by computed tomography (CT) scan versus 30% by angiography (P = 0.009). For superficial femoral artery stenosis, the percentage determined by CT was 48.68% vs. 81.41% by angiography, and observed difference between 2 modalities was statistically significant (P = 0.025). For dorsalis pedis percentage of stenosis detected by CT scan was 60.63% vs. 22.73% by angiography, and the differences in findings by these modalities were statistically significant (P = 0.039). The most frequent perioperative complication was cardiac-related (35.5%). Nineteen patients were readmitted and 8 had reinterventions within 12 months. CONCLUSIONS Both imaging modalities yielded similar results for assessing vessel calcification and percentage of stenosis regardless of anatomic vessel location. Overall, utilization of CTA in addition to angiography for large vessels above the knee (e.g., iliac artery, superficial femoral artery) and below the knee for dorsalis pedis provided more detailed information on the properties of these vessels. Therefore, during preoperative assessments, CTA may be helpful in addition to angiography for planning surgical and endovascular interventions for symptomatic PAD treatment in larger vessels.
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Affiliation(s)
- Thomas Wei Cheng
- Vascular Surgery Residency Program, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Gheorghe Doros
- Department of Biostatistics, Boston University, Boston, MA
| | | | - Aniket Vazirani
- General Surgery Residency Program, Jefferson Abington Hospital, Philadelphia, PA
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Hicks CW, Conte MS, Dun C, Makary MA. Appropriateness of Care Measures: A Novel Approach to Quality. Ann Vasc Surg 2024:S0890-5096(24)00162-6. [PMID: 38582205 DOI: 10.1016/j.avsg.2024.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/18/2024] [Indexed: 04/08/2024]
Abstract
The clinical judgment of a physician is one of the most important aspects of medical quality, yet it is rarely captured with quality measures in use today. We propose a novel approach using individualized physician benchmarking that measures the appropriateness of care that a physician delivers by looking at their practice pattern in a specific clinical situation. A prime application of our novel approach to appropriateness measures is the surgical management of peripheral artery disease and claudication. We discuss 4 potential consensus metrics for the treatment of claudication that explore appropriateness of care of claudication management and are meaningful, actionable, and quantifiable. Given the multitude of medical specialties involved in the care of patients with peripheral artery disease and the consequences of both preemptive and delayed care, it is in all of our interests to promote data transparency with confidential communications to outlier physicians while advocating for evidence-based management.
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Affiliation(s)
- Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Chen Dun
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Martin A Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Ørskov M, Skjøth F, Behrendt CA, Nicolajsen CW, Eldrup N, Søgaard M. External Validation of the OAC 3-PAD Bleeding Score in a Nationwide Population of Patients Undergoing Invasive Treatment for Peripheral Arterial Disease. Eur J Vasc Endovasc Surg 2024; 67:621-629. [PMID: 38056523 DOI: 10.1016/j.ejvs.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 10/30/2023] [Accepted: 12/01/2023] [Indexed: 12/08/2023]
Abstract
OBJECTIVE The OAC3-PAD score was developed to predict bleeding risk in patients with lower extremity peripheral arterial disease (PAD), but its performance in concomitant international cohorts is largely unknown. This study aimed to validate the OAC3-PAD score in an unselected nationwide population of patients undergoing invasive treatment for symptomatic PAD. METHODS This was a nationwide cohort study including all patients who underwent a first revascularisation procedure or major amputation for symptomatic PAD in Denmark from 2000 - 2021. The study population was stratified based on OAC3-PAD score, and the one year risk of major bleeding was assessed, accounting for the competing risk of death. The score performance was evaluated using calibration plots, C statistic, Brier score, and the index of prediction accuracy (IPA). RESULTS A total of 52 016 patients were included (mean age 71 years, 43.8% female). The one year risk of major bleeding increased with higher OAC3-PAD score, ranging from 1.6% (95% confidence interval [CI] 1.4 - 1.8%) to 2.3% (95% CI 2.0 - 2.5%), 3.5% (95% CI 3.2 - 3.8%), and 5.2% (95% CI 4.8 - 5.6%) for patients with low, low moderate, moderate high, and high score, respectively. Using patients with low risk as reference, the OAC3-PAD score effectively categorised patients, demonstrating statistically significant differences in bleeding risk across strata. However, the score showed modest discriminative performance, with a C statistic of 65% (95% CI 63 - 66%) and a Brier score of 2.6% (95% CI 2.5 - 2.7%). Nevertheless, it performed significantly better than the null model, as indicated by an IPA of 3.1%. CONCLUSION Among patients who underwent invasive treatment for symptomatic PAD in routine care, the OAC3-PAD score was associated with greater risk of major bleeding with increasing score level. However, its discriminatory ability was modest, and the clinical utility remains to be determined.
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Affiliation(s)
- Marie Ørskov
- Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark; Department of Ophthalmology, Aalborg University Hospital, Aalborg, Denmark.
| | - Flemming Skjøth
- Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark; Research Data and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany; Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
| | - Chalotte W Nicolajsen
- Department of Surgery, Unit of Vascular Surgery, Regional Hospital Viborg, Viborg, Denmark
| | - Nikolaj Eldrup
- Department of Vascular Surgery, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Mette Søgaard
- Danish Centre for Health Services Research, Department of Clinical Medicine, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
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Fanaroff AC, Coratti S, Farraday D, Norton L, Rareshide C, Zhu J, Levin MG, Damrauer SM, Giri JS, Chokshi NP, Jackson BM, Patel MS. Gamification-augmented home-based exercise for peripheral artery disease: Rationale and design of the GAMEPAD Study. Am Heart J 2024; 270:95-102. [PMID: 38354997 PMCID: PMC10947804 DOI: 10.1016/j.ahj.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 02/07/2024] [Accepted: 02/07/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND Supervised exercise therapy improves walking performance, functional capacity, and quality of life in patients with peripheral artery disease (PAD). However, few patients with PAD are enrolled in supervised exercise programs, and there are a number of logistical and financial barriers to their participation. A home-based walking intervention is likely to be more accessible to patients with PAD, but no fully home-based walking program has demonstrated efficacy. Concepts from behavioral economics have been used to design scalable interventions that increase daily physical activity in patients with atherosclerotic vascular disease, but whether a similar program would be effective in patients with PAD is uncertain. STUDY DESIGN AND OBJECTIVES GAMEPAD (NCT04536012) is a pragmatic, virtual, randomized controlled trial designed to evaluate the effectiveness of a gamification strategy informed by concepts from behavioral economics to increase daily physical activity in patients with PAD who are seen in cardiology and vascular surgery clinics affiliated with the University of Pennsylvania Health System. Patients are contacted by email or text message, and complete enrollment and informed consent on the Penn Way to Health online platform. A GAMEPAD substudy will evaluate the effectiveness of opt-in versus opt-out framing when approaching patients for study participation. Patients are then provided with a wearable fitness tracker, establish a baseline daily step count, set a goal to increase daily step count by 33%-50%, and are randomized 1:1 to the gamification or control arms. Interventions continue for 16 weeks, including a 4-week period during which goal step count is gradually increased in the gamification arm, with follow-up for an additional 8 weeks to evaluate the durability of behavior change. The trial has met its enrollment goal of 102 participants, with a primary endpoint of change from baseline in daily steps over the 16-week intervention period. Key secondary endpoints include change from baseline in daily steps over the 8-week postintervention follow-up period and changes in patient-reported measures of PAD symptoms and quality of life over the intervention and follow-up periods. CONCLUSIONS GAMEPAD is a virtual, pragmatic randomized clinical trial of a novel, fully home-based walking intervention informed by concepts from behavioral economics to increase physical activity and PAD-specific quality of life in patients with PAD. Its results will have important implications for the application of behavioral economic concepts to scalable home-based strategies to promote physical activity in patients with PAD and other disease processes where physical activity is limited by exertional symptoms. CLINICAL TRIAL REGISTRATION clinicaltrials.gov; NCT04536012.
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Affiliation(s)
- Alexander C Fanaroff
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA; Penn Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Penn Center for Digital Cardiology, University of Pennsylvania, Philadelphia, PA.
| | - Samantha Coratti
- Penn Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
| | - David Farraday
- Penn Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
| | - Laurie Norton
- Penn Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA; Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA
| | - Charles Rareshide
- Penn Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
| | - Jingsan Zhu
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Penn Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA; Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA
| | - Michael G Levin
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Scott M Damrauer
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania; Division of Vascular Surgery, University of Pennsylvania, Philadelphia, PA
| | - Jay S Giri
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Penn Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Neel P Chokshi
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Penn Center for Digital Cardiology, University of Pennsylvania, Philadelphia, PA
| | - Benjamin M Jackson
- Division of Vascular Surgery, Lehigh Valley Heart and Vascular Institute, Allentown, PA
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Yuan F, Tracci MC, Clouse WD, Robinson WP. Outcomes of open and endovascular infra-inguinal revascularization are poor in young patients with atherosclerotic peripheral artery disease but do not differ between genders. Vascular 2024; 32:337-346. [PMID: 36377515 DOI: 10.1177/17085381221140160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
OBJECTIVES The effect of gender on the outcomes of revascularization procedures in young patients with premature atherosclerotic peripheral arterial disease (PAD) is not known. The objective of this study was to compare short-term and long-term outcomes between young males and females undergoing infra-inguinal revascularization procedures. METHODS We examined postoperative outcomes of male and female PAD patients under the age of 55 who underwent infra-inguinal revascularization procedures at a single tertiary institution from 2011 to 2019. Primary outcomes included 30-day morbidity, patency of the revascularization procedures, and major adverse limb events (MALE). Secondary outcomes included survival, amputation rate, reintervention rate, improvement of ankle-brachial index (ABI), and number of reinterventions. RESULTS Eighty-one infra-inguinal revascularization procedures (46 endovascular and 35 open procedures) were reviewed including 45 procedures in 37 males and 36 procedures in 31 females. Fifty-three (65.4%) of the procedures were performed in patients with chronic limb-threatening ischemia symptoms. The rest were treated for life-disabling claudication. The female patients were younger, had higher body mass index, and were more likely to have diabetes, hyperlipidemia, or chronic obstructive pulmonary disease in comparison to males. Thirty-day major adverse cardiovascular event was 0.0% and MALE was 16.0%. Mean follow-up was 806.2 days. At 1 year, primary patency was 34.4 ± 6.2%, primary assisted patency was 52.7 ± 6.5%, secondary patency was 61.8 ± 6.3%, and MALE-free rate was 47.0 ± 6.4%. For secondary outcomes at 1 year, amputation-free rate was 92.5 ± 3.2%, reintervention-free rate was 50.2 ± 6.4%, and survival was 96.2 ± 2.6%. By the end of the study, overall mortality rate was 14.8% and major amputation rate was 13.6%. No major differences were observed between males and females among these outcomes. A smaller improvement in ABI after revascularization was noted in females compared to males (female 0.2 ± 0.2 vs male 0.4 ± 0.2, p = .04). Among patients who required reintervention, females required a higher number of reinterventions than males (female 1.7 ± 2.5 vs male 0.8 ± 1.1, p = .03). CONCLUSIONS There were no significant differences in short-term and long-term outcomes between males and females under the age of 55 after infra-inguinal revascularization. Poor patency, high MALE rate, and high mid-term mortality, and amputation rates after revascularization in young PAD patients highlight the need for improved strategies to treat premature PAD.
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Affiliation(s)
- Fang Yuan
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Margaret C Tracci
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - William P Robinson
- Division of Vascular Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
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Chu D, Zheng X, Mao J, Ramsey L, Mukherjee D. Comparison of endovascular therapies for chronic limb-threatening ischemia and claudication. J Vasc Surg 2024; 79:875-886.e8. [PMID: 38070783 PMCID: PMC11144288 DOI: 10.1016/j.jvs.2023.12.001] [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: 09/22/2023] [Revised: 11/30/2023] [Accepted: 12/01/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVE Analysis of regional data from the Vascular Quality Initiative (VQI) suggested improved survival for patients undergoing stent placement compared with balloon angioplasty and atherectomy. Using national data from the VQI linked to Medicare claims data through the Vascular Implant Surveillance and Interventional Outcomes Network program, this study aimed to compare the rates of mortality, reintervention, and amputation after endovascular interventions (atherectomy, stenting, and balloon angioplasty) for two separate cohorts: patients with chronic limb-threatening ischemia (CLTI) and patients with claudication. METHODS This was a secondary data analysis of Society for Vascular Surgery National VQI data linked to Medicare claims, between October 2016 and December 2019. Patients aged ≥65 years with symptoms of claudication or CLTI and a diagnosis of occlusive disease were included. Urgent or emergent interventions or those with concurrent procedures (endarterectomy, bypass, or bilateral intervention) were excluded. Interventions were grouped into (1) balloon angioplasty only; (2) stent (with or without balloon angioplasty); or (3) atherectomy (alone, with or without stent, with or without balloon angioplasty). Propensity score-matched cohorts were constructed to conduct pairwise intervention comparisons of mortality, reintervention, and amputation rates. Multivariable logistic regression was used to derive propensity scores for each patient. Kaplan-Meier estimates and Cox proportional hazards ratios (HRs) (95% confidence interval [CI]) analyses were performed. RESULTS A total of 9785 (2665 claudication, 7120 CLTI) eligible patients were identified. After propensity score matching for the CLTI group, 2826, 3608, and 2796 pairs of cases were used to compare balloon angioplasty vs atherectomy, balloon angioplasty vs stent, and stent vs atherectomy, respectively. No statistically significant difference in mortality was observed among all interventions. However, atherectomy was associated with a significant increase in reintervention rate compared with balloon angioplasty (HR, 1.22; 95% CI, 1.06-1.39; P = .01) and compared with stenting (HR, 1.27; 95% CI, 1.10-1.46; P < .01) within the first year after the index procedure. Of note, both atherectomy (HR, 0.82; 95% CI, 0.68-0.98; P < .05) and stenting (HR, 0.76; 95% CI, 0.64-0.90; P < .01) showed lower rates of major amputation when compared with balloon angioplasty within 1 year after the index procedure. In the claudication group, there were no significant differences observed among interventions for peripheral arterial disease for mortality, reintervention, or amputation rates. CONCLUSIONS Further studies are needed to identify appropriate indications for atherectomy, because there may be a subset of patients with CLTI who benefit from this therapy with respect to amputation rates. Until then, caution should be exercised when using atherectomy because it is also associated with higher reintervention rates.
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Affiliation(s)
- David Chu
- Department of Surgery, Inova Fairfax Medical Campus, Falls Church, VA
| | - Xinyan Zheng
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Jialin Mao
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Lolita Ramsey
- Department of Surgery, Inova Fairfax Medical Campus, Falls Church, VA
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Li M, Jin M, Yang H. Remodelers of the vascular microenvironment: The effect of biopolymeric hydrogels on vascular diseases. Int J Biol Macromol 2024; 264:130764. [PMID: 38462100 DOI: 10.1016/j.ijbiomac.2024.130764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/31/2024] [Accepted: 03/07/2024] [Indexed: 03/12/2024]
Abstract
Vascular disease is the leading health problem worldwide. Vascular microenvironment encompasses diverse cell types, including those within the vascular wall, blood cells, stromal cells, and immune cells. Initiation of the inflammatory state of the vascular microenvironment and changes in its mechanics can profoundly affect vascular homeostasis. Biomedical materials play a crucial role in modern medicine, hydrogels, characterized by their high-water content, have been increasingly utilized as a three-dimensional interaction network. In recent times, the remarkable progress in utilizing hydrogels and understanding vascular microenvironment have enabled the treatment of vascular diseases. In this review, we give an emphasis on the utilization of hydrogels and their advantages in the various vascular diseases including atherosclerosis, aneurysm, vascular ulcers of the lower limbs and myocardial infarction. Further, we highlight the importance and advantages of hydrogels as artificial microenvironments.
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Affiliation(s)
- Minhao Li
- School of Intelligent Medicine, China Medical University, No.77, Puhe Road, Shenyang 110122, Liaoning Province, China
| | - Meiqi Jin
- School of Intelligent Medicine, China Medical University, No.77, Puhe Road, Shenyang 110122, Liaoning Province, China
| | - Huazhe Yang
- School of Intelligent Medicine, China Medical University, No.77, Puhe Road, Shenyang 110122, Liaoning Province, China.
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Horie K. Ankle Brachial Index: An Easy and First-Choice Screening Marker of Peripheral Artery Disease and Physical Function. J Atheroscler Thromb 2024; 31:353-354. [PMID: 38233205 PMCID: PMC10999712 DOI: 10.5551/jat.ed252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 12/12/2023] [Indexed: 01/19/2024] Open
Affiliation(s)
- Kazunori Horie
- The Department of Cardiovascular Medicine, Sendai Kousei Hospital, Miyagi, Japan
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Uchida S, Kamiya K, Hamazaki N, Nozaki K, Ichikawa T, Yamashita M, Noda T, Ueno K, Hotta K, Maekawa E, Yamaoka-Tojo M, Matsunaga A, Ako J. The Association between the Level of Ankle-Brachial Index and the Risk of Poor Physical Function in Patients with Cardiovascular Disease. J Atheroscler Thromb 2024; 31:419-428. [PMID: 38044086 PMCID: PMC10999722 DOI: 10.5551/jat.64531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 09/26/2023] [Indexed: 12/05/2023] Open
Abstract
AIMS The progression of atherosclerosis and decline in physical function are poor prognostic factors in patients with cardiovascular disease (CVD). The ankle-brachial index (ABI) is a widely used indicator of the degree of progression of atherosclerosis, which may be used to identify patients with CVD who are at risk of poor physical function. This study examined the association between ABI and poor physical function in patients with CVD. METHODS We reviewed the data of patients with CVD who completed the ABI assessment and physical function tests (6-min walking distance, gait speed, quadriceps isometric strength, and short physical performance battery). Patients were divided into five categories according to the level of ABI, and the association between ABI and poor physical function was examined using multiple logistic regression analysis. Additionally, restricted cubic splines were used to examine the nonlinear association between ABI and physical function. RESULTS A total of 2982 patients (median [interquartile range] age: 71[62-78] years, 65.8% males) were included in this study. Using an ABI range of 1.11-1.20 as a reference, logistic regression analysis showed that ABI ≤ 1.10 was associated with poor physical function. The restricted cubic spline analysis showed that all physical functions increased with an increase in ABI level. The increase in physical function plateaued at an ABI level of approximately 1.1. CONCLUSIONS ABI may be used to identify patients with poor physical function. ABI levels below 1.1 are potentially associated with poor physical function in patients with CVD.
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Affiliation(s)
- Shota Uchida
- Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, Sagamihara, Japan
- Research Fellow of Japan Society for the Promotion of Science, Tokyo, Japan
| | - Kentaro Kamiya
- Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, Sagamihara, Japan
- Department of Rehabilitation, Kitasato University School of Allied Health Sciences, Sagamihara, Japan
| | - Nobuaki Hamazaki
- Department of Rehabilitation, Kitasato University Hospital, Sagamihara, Japan
| | - Kohei Nozaki
- Department of Rehabilitation, Kitasato University Hospital, Sagamihara, Japan
| | - Takafumi Ichikawa
- Department of Rehabilitation, Kitasato University Hospital, Sagamihara, Japan
| | - Masashi Yamashita
- Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, Sagamihara, Japan
- Division of Research, ARCE Inc., Sagamihara, Japan
| | - Takumi Noda
- Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, Sagamihara, Japan
- Exercise Physiology and Cardiovascular Health Lab, Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Canada
| | - Kensuke Ueno
- Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, Sagamihara, Japan
| | - Kazuki Hotta
- Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, Sagamihara, Japan
- Department of Rehabilitation, Kitasato University School of Allied Health Sciences, Sagamihara, Japan
| | - Emi Maekawa
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Minako Yamaoka-Tojo
- Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, Sagamihara, Japan
- Department of Rehabilitation, Kitasato University School of Allied Health Sciences, Sagamihara, Japan
| | - Atsuhiko Matsunaga
- Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, Sagamihara, Japan
- Department of Rehabilitation, Kitasato University School of Allied Health Sciences, Sagamihara, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan
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White M, McDermott KM, Bose S, Wang C, Srinivas T, Kalbaugh C, Hicks CW. Risks and Benefits of the Proposed Amputation Reduction and Compassion Act for Disadvantaged Patients. Ann Vasc Surg 2024; 101:179-185. [PMID: 38142961 PMCID: PMC10957305 DOI: 10.1016/j.avsg.2023.12.003] [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: 12/06/2023] [Accepted: 12/06/2023] [Indexed: 12/26/2023]
Abstract
Racial, ethnic, and socioeconomic disparities in the major risk factors for vascular disease and access to vascular specialist care are well-documented.1-3 The higher incidence of diabetes, peripheral artery disease (PAD), and related nontraumatic lower extremity amputation among racial and ethnic minority groups, those of low socioeconomic status, and those with poor access to care based on geography (together, referred to below as disadvantaged groups) are particularly pervasive.1,4-9 Practitioners of vascular surgery and endovascular therapy are uniquely positioned to address health inequities in lower extremity screening, medical management, intervention, and limb preservation among the population of adults at the highest risk for limb loss.
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Affiliation(s)
- Midori White
- Department of Surgery, Johns Hopkins University, Baltimore, MD
| | | | - Sanuja Bose
- Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Caroline Wang
- Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Tara Srinivas
- Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Corey Kalbaugh
- Department of Epidemiology and Biostatistics, School of Public Health-Bloomington, Indiana University, Bloomington, IN
| | - Caitlin W Hicks
- Department of Surgery, Johns Hopkins University, Baltimore, MD.
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Nwachuku EC, Farber A. Open Surgical Therapy for Peripheral Artery Disease. Curr Cardiol Rep 2024; 26:211-220. [PMID: 38342801 DOI: 10.1007/s11886-024-02027-4] [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] [Accepted: 01/25/2024] [Indexed: 02/13/2024]
Abstract
PURPOSE OF REVIEW The surgical management of symptomatic peripheral artery disease (PAD) has changed in the last few decades. Improvement in endovascular technology has resulted in more complex lesion once reserved for open surgery being addressed in an endovascular fashion. Even with these advances, there are lesions and patients that are better managed with an open surgical procedure. The aim of this review is to describe the most commonly performed open surgical procedures for PAD. RECENT FINDINGS The recently published Best Endovascular versus Best Surgical Therapy (BEST-CLI) trial was an international, prospective, randomized controlled trial that aimed to investigate which revascularization (endovascular vs. surgical bypass) approach was superior for limb salvage. The evidence supports an open surgical bypass as an initial approach. The advancements made in the surgical management of PAD have provided options for patients who were once deemed poor surgical candidates. The goal continues to be utilization of the best available tools to address patient disease. In this current era, it is important to be familiar with the open surgical therapies.
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Affiliation(s)
- Emmanuel C Nwachuku
- Department of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Alik Farber
- Department of Surgery, Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
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Koeckerling D, Zielasek C, Stähli P, Wohlfarth B, Rosenov A, Helfenstein F, Behrendt CA, Baumgartner I. Patient-specific risk factors for reintervention following primary endovascular treatment of iliac artery disease. J Vasc Surg 2024; 79:847-855.e5. [PMID: 38103806 DOI: 10.1016/j.jvs.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 12/03/2023] [Accepted: 12/09/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVE Predictive models for reintervention may guide clinicians to optimize selection, education, and follow-up of patients undergoing endovascular iliac revascularization. Although the impact of lesion- and device-related characteristics on iliac restenosis and reintervention risk is well-defined, data on patient-specific risk factors are scarce and conflicting. This study aimed to explore the value of patient-related factors in predicting the need for clinically driven target-vessel revascularization (CD-TVR) in patients undergoing primary endovascular treatment of iliac artery disease. METHODS Consecutively enrolled patients undergoing endovascular revascularization for symptomatic iliac artery disease at a tertiary vascular referral center between January 2008 and June 2020 were retrospectively analyzed. Primary and secondary outcomes were CD-TVR occurrence within 24 months and time to CD-TVR, respectively. Patients who died or did not require CD-TVR within 24 months were censored at the date of death or at 730 days, respectively. Multiple imputation was used to account for missing data in primary analyses. RESULTS A total of 1538 iliac interventions were performed in 1113 patients (26% females; 68 years). CD-TVR occurred in 108 limbs (74 patients; 7.0%) with a median time to CD-TVR of 246 days. On multivariable analysis, increasing age was associated with lower likelihood of CD-TVR (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.50-0.83; P = .001) and decreased risk of CD-TVR at any given time (hazard ratio [HR], 0.66; 95% CI, 0.52-0.84; P = .001). Similarly, a lower likelihood of CD-TVR (OR, 0.75; 95% CI, 0.59-0.95; P = .017) and decreased risk of CD-TVR at any given time (HR, 0.73; 95% CI, 0.58-0.93; P = .009) were observed with higher glomerular filtration rates. Lastly, revascularization of common vs external iliac artery disease was associated with lower likelihood of CD-TVR (OR, 0.48; 95% CI, 0.24-0.93; P = .030) and decreased risk of CD-TVR at any given time (HR, 0.48; 95% CI, 0.25-0.92; P = .027). No associations were observed between traditional cardiovascular risk factors (sex, hypertension, higher low-density lipoprotein cholesterol, higher hemoglobin A1c, smoking) and CD-TVR. CONCLUSIONS In this retrospective cohort study, younger age, impaired kidney function, and external iliac artery disease were associated with CD-TVR. Traditional markers of cardiovascular risk were not seen to predict reintervention.
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Affiliation(s)
- David Koeckerling
- Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Christian Zielasek
- Department of Vascular Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Patrick Stähli
- Insel Data Science Center, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Benny Wohlfarth
- Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alexander Rosenov
- Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | - Iris Baumgartner
- Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Pedras S, Oliveira R, Veiga C, Silva I. Illness beliefs relation to physical activity and quality of life in patients with peripheral arterial disease. PSYCHOL HEALTH MED 2024:1-18. [PMID: 38477257 DOI: 10.1080/13548506.2024.2325378] [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: 11/29/2022] [Accepted: 02/26/2024] [Indexed: 03/14/2024]
Abstract
Intermittent claudication is the most common symptom of Peripheral Arterial Disease (PAD) and is associated with decreased quality of life (QoL) due to walking impairment. The level of threat attributed to the disease affects QoL and physical activity. This study explores beliefs and illness drawings, and their relationship with quality of life and physical activity in patients undergoing conservative treatment for PAD. A cross-sectional study was carried out including 119 patients with PAD and Intermittent Claudication, in which patients were asked to freely draw their disease and 33 agreed to participate. The profile of beliefs about PAD is characterized by a low level of threat. Belief in the emotional impact of the disease, representations about the consequences and concern about the disease were associated with worse quality of life; the belief of having a high personal control over the disease was associated with more physical activity. The analysis of the disease drawings revealed three categories: extension of the disease (category 1), location and representations of the disease (category 2), and level of detail and complexity of the drawings (category 3). Greater disease extent was associated with more disease symptoms (IPQ 6) (rs = 0.399, p = .021). It is necessary to address beliefs and representations about the disease in consultations with patients with PAD. Patient drawings are a useful, practical, and free tool that does not require a lot of time and can facilitate the approach of health professionals to patient training and education.
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Affiliation(s)
- Susana Pedras
- Angiology & Vascular Surgery Department, Centro Hospitalar Universitário Porto (CHUP), Porto, Portugal
| | - Rafaela Oliveira
- Bachelor of Science degree in Clinical Physiology, Angiology & Vascular Surgery Department, Centro Hospitalar Universitário Porto (CHUP), Porto, Portugal
| | - Carlos Veiga
- Master in Medicine, Angiology & Vascular Surgery Department, Centro Hospitalar Universitário Porto (CHUP), Porto, Portugal
| | - Ivone Silva
- Angiology & Vascular Surgery Department, Centro Hospitalar Universitário Porto (CHUP), Porto, Portugal
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Antonello M, Piazza M, Menara S, Colacchio EC, Grego F, Menegolo M, Squizzato F. Role of intravascular ultrasound for the technical assessment of endovascular reconstruction of the aortic bifurcation. J Vasc Surg 2024:S0741-5214(24)00432-4. [PMID: 38485070 DOI: 10.1016/j.jvs.2024.03.014] [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: 02/02/2024] [Revised: 02/28/2024] [Accepted: 03/05/2024] [Indexed: 04/09/2024]
Abstract
OBJECTIVE The aim of this study was to evaluate the role of intravascular ultrasound (IVUS) for the technical assessment of kissing stents (KSs) and covered endovascular reconstruction of the aortic bifurcation (CERAB) in the treatment of aortoiliac obstructive disease involving the aortic bifurcation. METHODS We conducted a single-center retrospective review of patients undergoing endovascular treatment of severe aorto-iliac obstructive disease (2019-2023). IVUS was performed in patients treated by KSs or CERAB according to preoperative indications, in cases of moderate/severe calcifications, mural thrombus, total occlusions, and lesion extension towards the proximity of renal or hypogastric arteries. Indications for IVUS-guided intraoperative revisions were residual stenosis or compression >30%, incomplete stent-to-wall apposition, or flow-limiting dissection at the landing site. Follow-up assessment was performed at 6 and 12 months, and then yearly. Thirty-day outcomes and 2-year patency rates were evaluated. Logistic regression was used to identify factors associated with significant technical defects detected by IVUS needing intraoperative revision. RESULTS IVUS was used for the technical assessment of 102 patients treated by KSs (n = 57; 56%) or CERAB (n = 45; 44%) presenting with severe intermittent claudication (39%), rest pain (39%), or ischemic tissue loss (25%). Twenty-nine significant technical defects were identified by IVUS in 25 patients (25%) who then had successful intraoperative correction by additional ballooning (n = 23; 80%) or stenting (n = 6; 20%). Patients with a severely calcified chronic total occlusion (odds ratio, 1.85; 95% confidence interval, 1.01-5.27; P = .044) or severely calcified narrow aortic bifurcation with <12 mm diameter (odds ratio, 2.34; 95% confidence interval, 1.10-8.64; P = .032) were at increased risk for IVUS-guided intraoperative revision. There were no postoperative deaths and no major adverse events. Two-year primary patency was 100%. CONCLUSIONS IVUS was used for the technical assessment of KSs/CERAB in a selected cohort of patients with severe aorto-iliac obstructive disease. This allowed the identification and intraoperative correction of a significant technical defect not detected by completion angiogram in one-quarter of patients, achieving optimal 2-year results. IVUS assessment of KSs/CERAB may be considered especially in patients with a calcified total occlusion or narrow aortic bifurcation.
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Affiliation(s)
- Michele Antonello
- Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University, Padua, Italy
| | - Michele Piazza
- Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University, Padua, Italy
| | - Sabrina Menara
- Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University, Padua, Italy
| | - Elda Chiara Colacchio
- Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University, Padua, Italy
| | - Franco Grego
- Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University, Padua, Italy
| | - Mirko Menegolo
- Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University, Padua, Italy
| | - Francesco Squizzato
- Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University, Padua, Italy.
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Xiao YC, Li WY, Zhang L, Fan JF, Wang WZ, Wang YK. Effect of supervised exercise training on cardiovascular function in patients with intermittent claudication: a systematic review and meta-analysis of randomized controlled trials. Clin Res Cardiol 2024:10.1007/s00392-024-02423-4. [PMID: 38451260 DOI: 10.1007/s00392-024-02423-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 02/22/2024] [Indexed: 03/08/2024]
Abstract
This study aimed to determine the effect of supervised exercise training (SET) on cardiovascular function in patients with intermittent claudication (IC). A systematic search in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases was conducted. Primary outcomes were systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), rate pressure product (RPP), cardiac output (CO), peak oxygen consumption (VO2peak), and heart rate variability (HRV). Secondary outcomes were maximum walking distance (MWD) and pain-free walking distance (PFWD). Outcomes were reported as weighted mean difference (WMD) between the SET group and the control group and synthesized by using the random-effects model. Seventeen RCTs with a total of 936 patients were included in this review. SET resulted in significant improvements of SBP (WMD = - 7.40, 95% CI - 10.69 ~ - 4.11, p < 0.001, I2 = 15.2%), DBP (WMD = - 1.92, 95% CI - 3.82 ~ - 0.02, p = 0.048, I2 = 0.0%), HR (WMD = - 3.38, 95% CI - 6.30 ~ - 0.46, p = 0.023, I2 = 0.0%), RPP (WMD = - 1072.82, 95% CI - 1977.05 ~ - 168.59, p = 0.020, I2 = 42.7%), and VO2peak with plantar flexion ergometer exercise (WMD = 5.57, 95% CI 1.66 ~ 9.49, p = 0.005, I2 = 62.4%), whereas CO and HRV remained statistically unaltered. SET also improved MWD (WMD = 139.04, 95% CI 48.64 ~ 229.44, p = 0.003, I2 = 79.3%) and PFWD (WMD = 40.02, 95% CI 23.85 ~ 56.18, p < 0.001, I2 = 0.0%). In conclusion, SET is effective in improving cardiovascular function in patients with IC, which was confirmed on outcomes of cardiovascular function associated with exercise ability. The findings hold out that the standard therapy of SET can improve not only walking distance but also cardiovascular function in patients with IC.
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Affiliation(s)
- Yu-Chen Xiao
- Naval Medical Center of PLA, 880 Xiangyin Road, Shanghai, 200433, China
| | - Wan-Yang Li
- School of Basic Medical Sciences, Naval Medical University (Second Military Medical University), Shanghai, China
| | - Lei Zhang
- Department of Vascular Surgery, Changhai Hospital, Naval Medical University (Second Military Medical University), Shanghai, China
| | - Jie-Fu Fan
- Department of Vascular Surgery, Changhai Hospital, Naval Medical University (Second Military Medical University), Shanghai, China
| | - Wei-Zhong Wang
- Naval Medical Center of PLA, 880 Xiangyin Road, Shanghai, 200433, China.
| | - Yang-Kai Wang
- Naval Medical Center of PLA, 880 Xiangyin Road, Shanghai, 200433, China.
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50
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Li B, Warren BE, Eisenberg N, Beaton D, Lee DS, Aljabri B, Verma R, Wijeysundera DN, Rotstein OD, de Mestral C, Mamdani M, Roche-Nagle G, Al-Omran M. Machine Learning to Predict Outcomes of Endovascular Intervention for Patients With PAD. JAMA Netw Open 2024; 7:e242350. [PMID: 38483388 PMCID: PMC10940965 DOI: 10.1001/jamanetworkopen.2024.2350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/19/2024] [Indexed: 03/17/2024] Open
Abstract
Importance Endovascular intervention for peripheral artery disease (PAD) carries nonnegligible perioperative risks; however, outcome prediction tools are limited. Objective To develop machine learning (ML) algorithms that can predict outcomes following endovascular intervention for PAD. Design, Setting, and Participants This prognostic study included patients who underwent endovascular intervention for PAD between January 1, 2004, and July 5, 2023, with 1 year of follow-up. Data were obtained from the Vascular Quality Initiative (VQI), a multicenter registry containing data from vascular surgeons and interventionalists at more than 1000 academic and community hospitals. From an initial cohort of 262 242 patients, 26 565 were excluded due to treatment for acute limb ischemia (n = 14 642) or aneurysmal disease (n = 3456), unreported symptom status (n = 4401) or procedure type (n = 2319), or concurrent bypass (n = 1747). Data were split into training (70%) and test (30%) sets. Exposures A total of 112 predictive features (75 preoperative [demographic and clinical], 24 intraoperative [procedural], and 13 postoperative [in-hospital course and complications]) from the index hospitalization were identified. Main Outcomes and Measures Using 10-fold cross-validation, 6 ML models were trained using preoperative features to predict 1-year major adverse limb event (MALE; composite of thrombectomy or thrombolysis, surgical reintervention, or major amputation) or death. The primary model evaluation metric was area under the receiver operating characteristic curve (AUROC). After selecting the best performing algorithm, additional models were built using intraoperative and postoperative data. Results Overall, 235 677 patients who underwent endovascular intervention for PAD were included (mean [SD] age, 68.4 [11.1] years; 94 979 [40.3%] female) and 71 683 (30.4%) developed 1-year MALE or death. The best preoperative prediction model was extreme gradient boosting (XGBoost), achieving the following performance metrics: AUROC, 0.94 (95% CI, 0.93-0.95); accuracy, 0.86 (95% CI, 0.85-0.87); sensitivity, 0.87; specificity, 0.85; positive predictive value, 0.85; and negative predictive value, 0.87. In comparison, logistic regression had an AUROC of 0.67 (95% CI, 0.65-0.69). The XGBoost model maintained excellent performance at the intraoperative and postoperative stages, with AUROCs of 0.94 (95% CI, 0.93-0.95) and 0.98 (95% CI, 0.97-0.99), respectively. Conclusions and Relevance In this prognostic study, ML models were developed that accurately predicted outcomes following endovascular intervention for PAD, which performed better than logistic regression. These algorithms have potential for important utility in guiding perioperative risk-mitigation strategies to prevent adverse outcomes following endovascular intervention for PAD.
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Affiliation(s)
- Ben Li
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Vascular Surgery, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine (T-CAIREM), University of Toronto, Toronto, Ontario, Canada
| | - Blair E. Warren
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Naomi Eisenberg
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Derek Beaton
- Data Science & Advanced Analytics, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Douglas S. Lee
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, University of Toronto, Toronto, Ontario, Canada
| | - Badr Aljabri
- Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Raj Verma
- School of Medicine, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | - Duminda N. Wijeysundera
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Ori D. Rotstein
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Division of General Surgery, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Charles de Mestral
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Vascular Surgery, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Muhammad Mamdani
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine (T-CAIREM), University of Toronto, Toronto, Ontario, Canada
- Data Science & Advanced Analytics, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Graham Roche-Nagle
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Mohammed Al-Omran
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Vascular Surgery, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine (T-CAIREM), University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
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