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Hawkins A, Jin R, Clouse WD, Tracci M, Weaver ML, Farivar BS. Center-level outcomes following elective fenestrated endovascular aortic aneurysm repair in the Vascular Quality Initiative database. J Vasc Surg 2024; 80:311-322. [PMID: 38604317 DOI: 10.1016/j.jvs.2024.03.453] [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: 12/27/2023] [Revised: 03/25/2024] [Accepted: 03/31/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE Hospital volume is associated with mortality after open aortic aneurysm repair. Fenestrated and branched endovascular aortic repair (B-FEVAR) has been increasingly used for repair of complex thoracoabdominal and juxtarenal aneurysms, but evidence of a center-volume relationship is limited. We aimed to measure the association of center volume with in-hospital mortality, postoperative outcomes, and 1-year survival following B-FEVAR. METHODS Patients undergoing elective endovascular thoracoabdominal and complex abdominal aneurysm repair with branch intervention (2014-2021) listed within the national Vascular Quality Initiative Thoracic Endovascular Aortic Repair/Complex EVAR database were analyzed. Centers were grouped into quartiles by mean annual procedure volume. Multivariable regression was used to evaluate the effect of center volume on in-hospital mortality adjusting for baseline and procedural characteristics. Kaplan-Meier estimation, log rank test, and mixed effects Cox regression were used to evaluate 1-year survival. RESULTS A total of 4302 adult elective F-BEVAR procedures were identified at a total of 163 centers. In-hospital mortality did not differ by hospital volume (quartile [Q]1 = 35/1059 [3.3%]; Q2 = 30/1063 [2.8%]; Q3 = 33/1120 [2.9%]; and Q4 = 44/1060 [4.2%]; P = .308). The high volume group had a higher rate of major complication (Q1 = 14.9%; Q2 = 12.8%; Q3 = 13.3%; and Q4 = 20.1%; adjusted P < .001). Physician-modified grafts were more frequently employed in high-volume centers (Q1 = 4.5%; Q2 = 18.7%; Q3 = 11.3%; and Q4 = 19.2%; P < .001), with a decreased incidence of any endoleak noted at the end of the procedure (Q1 = 34.9%; Q2 = 32.8%; Q3 = 30.0%; and Q4 = 29.0%; P = .003). In the multivariable analysis, in-hospital mortality was not associated with center volume, comparing very low volume to medium- and high-volume centers (odds ratio [95% confidence interval] vs Q4: Q1 = 1.1 [0.6-1.9], Q2 = 0.6 [0.4-1.1], and Q3 = 0.9 [0.5-1.5]; all P > .05). No significant difference was found in 1-year survival between center volume groups. CONCLUSIONS In-hospital mortality is not associated with procedure volume within centers performing complex endovascular aortic repair. However, complication rates and endoleak may be associated with procedure volume. Long-term outcomes by annualized procedure volume, specifically graft durability and sac expansion, should be investigated.
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MESH Headings
- Humans
- Endovascular Procedures/adverse effects
- Endovascular Procedures/mortality
- Female
- Male
- Hospital Mortality
- Aged
- Databases, Factual
- Elective Surgical Procedures
- Blood Vessel Prosthesis Implantation/adverse effects
- Blood Vessel Prosthesis Implantation/mortality
- Hospitals, High-Volume
- Aortic Aneurysm, Abdominal/surgery
- Aortic Aneurysm, Abdominal/mortality
- Aortic Aneurysm, Abdominal/diagnostic imaging
- Risk Factors
- United States
- Hospitals, Low-Volume
- Retrospective Studies
- Time Factors
- Aortic Aneurysm, Thoracic/surgery
- Aortic Aneurysm, Thoracic/mortality
- Aortic Aneurysm, Thoracic/diagnostic imaging
- Treatment Outcome
- Aged, 80 and over
- Postoperative Complications/mortality
- Postoperative Complications/etiology
- Risk Assessment
- Middle Aged
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Affiliation(s)
- Andrew Hawkins
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Ruyun Jin
- Division of Biostatistics, Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Margaret Tracci
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - M Libby Weaver
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Behzad S Farivar
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA.
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2
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Bertges DJ, Eldrup-Jorgensen J, Eskandari MK, Hamdan A, Mena-Hurtado C, Mewissen M, Smith T, Woo E, Cronenwett JL. The Vascular Quality Initiative assessment of the Bard Lifestent for the treatment of popliteal artery occlusive disease. J Vasc Surg 2023; 78:1489-1496.e1. [PMID: 37648091 DOI: 10.1016/j.jvs.2023.08.122] [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: 02/08/2023] [Revised: 08/16/2023] [Accepted: 08/23/2023] [Indexed: 09/01/2023]
Abstract
OBJECTIVE The Bard LifeStent self-expanding stent is approved for the treatment of occlusive disease involving the superficial femoral artery and proximal popliteal artery. We conducted a post-market trial of treatment of the popliteal artery above and below the knee (P1, P2, and P3 segments) within the Society for Vascular Surgery Vascular Quality Initiative (VQI) Peripheral Vascular Intervention registry. METHODS A single-arm, prospective trial was conducted at 29 VQI sites in the United States, enrolling 74 patients from November 2016 to May 2019. The primary safety outcome was freedom from major adverse events including device-/procedure-related mortality and major amputation at 1 year. The primary efficacy outcomes were freedom from target vessel revascularization and freedom from target lesion revascularization at 1 year. Secondary outcomes included lesion success; procedural success; primary, primary-assisted, and secondary patency; and sustained clinical (improvement in Rutherford class) and hemodynamic success (increase in ankle brachial index >0.10). Outcomes were assessed by Kaplan-Meier analysis. Arteriogram of patients undergoing target lesion revascularization were assessed for stent fracture by a core laboratory. RESULTS The mean age was 71 years, with 63.5% male and 55% with diabetes. The indication was claudication 28% and chronic limb-threatening ischemia in 72%. The superficial femoral artery-popliteal artery was stented in 38% and the popliteal artery alone in 62%. The majority of stents were placed in the P1 + P2 (39%) or P1 + P2 + P3 (37%) segments of the popliteal artery. The composite primary endpoint of freedom from major adverse events was 82% and 74% at 1 and 2 years, respectively. Freedom from mortality was 100% and 97%, and freedom from major amputation was 100% and 90% at 1 and 12 months, with all deaths and major amputations occurring in patients with chronic limb-threatening ischemia. freedom from target lesion revascularization was 86%, and freedom from target vessel revascularization was 84% at 12 months. At discharge, lesion treatment success was 99%, and procedural success was 82%. Primary patency was 80% and 72%, primary-assisted patency was 80% and 72%, and secondary patency was 89% and 82% at 12 and 24 months. Sustained clinical success was 98% and 95%, and sustained hemodynamic success was 100% and 79% at 12 and 24 months. CONCLUSIONS In this multi-center, registry-based, single-arm prospective study the Bard LifeStent self-expanding stent demonstrated favorable performance in the challenging anatomy of the P2 and P3 popliteal segment. Post-market studies for label expansion of peripheral vascular intervention devices can be successfully conducted within the Society for Vascular Surgery VQI registry.
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Affiliation(s)
- Daniel J Bertges
- University of Vermont Medical Center, Division of Vascular Surgery, Burlington, VT.
| | | | - Mark K Eskandari
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Allen Hamdan
- Beth Israel Deaconess Medical Center, Boston, MA
| | - Carlos Mena-Hurtado
- Yale University, School of Medicine, Department of Internal Medicine, Vascular Medicine Outcomes Program, New Haven, CT
| | | | | | - Edward Woo
- Washington Hospital Center, Washington, DC
| | - Jack L Cronenwett
- Section of Vascular Surgery and the Dartmouth Institute, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Beck AW, Wang G, Lombardi JV, White R, Fillinger MF, Kern JA, Cronenwett JL, Cambria RP, Azizzadeh A. Impact of TEVAR timing on outcomes after uncomplicated Type B Aortic Dissection in the SVS VQI Post-approval Project for Dissection. J Vasc Surg 2023; 77:1377-1386.e1. [PMID: 36603666 DOI: 10.1016/j.jvs.2022.12.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 12/28/2022] [Accepted: 12/28/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The timing of TEVAR after the onset of uncomplicated acute type B aortic dissection (UATBAD) remains controversial. The objective of this study was to evaluate the SVS VQI post-approval study (VQI PAS) data for the impact of TEVAR timing for UATBAD on early and late outcomes, including mortality, procedural complications and long-term reintervention. METHODS The VQI PAS utilized for this analysis includes a total of 606 patients. Patients with UATBAD (defined as those without rupture or malperfusion) exclusive of cases categorized as emergent (N=206), were divided into groups defined by the SVS/STS reporting guidelines based on timing of treatment after the onset of dissection: within 24 hours (N=8), 1-14 days (N=121), and 15-90 days (N=77). Univariate and multivariable analysis was used to determine differences between timing groups for postoperative mortality, in-hospital complications, and reintervention. RESULTS Demographics and comorbid conditions were very similar across the 3 TEVAR timing groups. Notable differences included a higher prevalence of baseline elevated creatinine (>1.8mg/dL)/chronic ESRD and designation as "urgent" in the <24-hour group, as well as a higher rate of pre-operative beta-blocker therapy in the 1-14 day group. Post-operative stroke, CHF, and renal ischemia were more common in the <24-hour group, without an increase in mortality. Unadjusted 30-day mortality across groups was lowest in the early TEVAR group (0%, 3.3%, 5.2% P=0.68), as was 1-year mortality (0%, 8.3%, 18.2%; P=0.06), although not statistically different at any time point. Reintervention out to three years was not different between the groups. Multivariable analysis demonstrated the need for a postoperative therapeutic lumbar drain to be the only a predictive risk factor for mortality (HR=7.595, 95% CI 1.730-33.337, P=0.007). When further subdivided into patients treated 1-7 days or 8-14 days after dissection, findings were similar. CONCLUSIONS UATBAD patients treated within 24 hours were unusual (N=8), too small for valid statistical comparison, and likely represent a high-risk subgroup, which is manifested in a higher risk of complications. Although there was a trend towards improved survival in the acute (1-14 day phase), outcomes did not differ compared to the subacute (15-90 days) phase with relation to early mortality, post-operative complications or one-year survival. These data suggest that proper selection of patients for early TEVAR can result in equivalent survival and early outcomes.
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Affiliation(s)
- Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham (UAB), Birmingham, AL.
| | - Grace Wang
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Joseph V Lombardi
- Division of Vascular and Endovascular Surgery, Cooper University Hospital, Camden, NJ
| | - Rodney White
- Vascular Surgery Services, Long Beach Memorial Heart & Vascular, Long Beach, Calif
| | - Mark F Fillinger
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - John A Kern
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA
| | - Jack L Cronenwett
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Richard P Cambria
- Division of Vascular Surgery, St. Elizabeth's Medical Center, Boston, Mass
| | - Ali Azizzadeh
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif
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Retrograde Type A Dissection in the Vascular Quality Initiative TEVAR for Dissection Post-approval Project. J Vasc Surg 2022; 75:1539-1551. [DOI: 10.1016/j.jvs.2021.11.075] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/27/2021] [Indexed: 11/21/2022]
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5
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Bai H, Fereydooni A, Zhang Y, Tonnessen BH, Guzman RJ, Chaar CIO. Trends in Utilization and Outcomes of Orbital, Laser, and Excisional Atherectomy for Lower Extremity Revascularization. J Endovasc Ther 2021; 29:389-401. [PMID: 34643142 DOI: 10.1177/15266028211050329] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The aim of this study is to analyze the utilization pattern of atherectomy modalities and compare their outcomes. MATERIALS AND METHODS All patients undergoing atherectomy in the 2010-2016 Vascular Quality Initiative Database were identified. Utilization of orbital, laser, or excisional atherectomy was obtained. Characteristics and outcomes of patients treated for isolated femoropopliteal and isolated tibial disease by different modalities were compared. RESULTS Atherectomy use increased from 10.3% to 18.3% of all peripheral interventions (n = 122 938). Orbital atherectomy was most commonly used and increased from 59.4% in 2010 to 63.2% of all atherectomies in 2016, while laser atherectomy decreased from 19.2% to 13.1%. Atherectomy was mostly used for treatment of isolated femoropopliteal disease (51.1%), followed by combined femoropopliteal and tibial disease (25.8%) and isolated tibial disease (11.7%). In isolated femoropopliteal revascularization, excisional atherectomy was associated with higher rate of perforation (1.2%) compared with laser (0.4%) and orbital atherectomy (0.5%). The technical success of orbital atherectomy (96.7%) was lower compared with excisional atherectomy (98.7%). Concomitant stenting was significantly higher with laser atherectomy (43.0%) compared with orbital (27.2%) and excisional (26.1%) atherectomy. Nevertheless, there was no difference in 1-year primary patency, reintervention, major amputation, improvement in ambulatory status, or mortality. Multivariable analysis also demonstrated no difference in 1-year primary patency and major ipsilateral amputation among the modalities. In isolated tibial revascularization, there were no differences in perioperative outcomes among the modalities. Excisional atherectomy was associated with the highest 1-year primary patency (88.1%). After adjusting for confounders, excisional atherectomy remained associated with superior 1-year primary patency compared with orbital atherectomy (odds ratio [OR] = 2.59, 95% confidence interval [CI] = [1.18-5.68]), and excisional atherectomy remained associated with a lower rate of 1-year major ipsilateral amputation compared with laser atherectomy (OR = 0.29, 95% CI = [0.09-0.95]). CONCLUSION Atherectomy use has increased, driven primarily by orbital atherectomy. Despite significant variation in perioperative outcomes, there were no differences in 1-year outcomes among the different modalities when used for treating isolated femoropopliteal disease. In isolated tibial disease treatment, excisional atherectomy was associated with higher 1-year primary patency compared with orbital atherectomy and decreased major ipsilateral amputation rates compared with laser atherectomy. These differences warrant further investigation into the comparative effectiveness of atherectomy modalities in various vascular beds.
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Affiliation(s)
- Halbert Bai
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Arash Fereydooni
- Department of Surgery, Division of Vascular Surgery, Stanford Health Care, Stanford, CA, USA
| | - Yawei Zhang
- Yale School of Public Health, New Haven, CT, USA
| | - Britt H Tonnessen
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Raul J Guzman
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
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Bertges DJ, Eldrup-Jorgensen J, Drozda J, Jones WS, Sedrakyan A, Krucoff MW, Cronenwett JL. Toward a better system for the sustainable development of objective performance goals for peripheral vascular interventions. J Vasc Surg 2021; 74:1013-1014. [PMID: 34425943 DOI: 10.1016/j.jvs.2021.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 06/01/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Daniel J Bertges
- Division of Vascular Surgery, University of Vermont Medical Center, Burlington, Vt
| | - Jens Eldrup-Jorgensen
- Division of Vascular Surgery and Endovascular Therapy, Maine Medical Center, Portland, Me
| | - Joseph Drozda
- Department of Cardiology, Mercy Health, Chesterfield, Mo
| | - W Schuyler Jones
- Department of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Art Sedrakyan
- Department of Population Health Sciences and Department of Cardiothoracic Surgery, Weill Cornell College of Medicine, New York, NY
| | - Mitchell W Krucoff
- Department of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Jack L Cronenwett
- Section of Vascular Surgery and the Dartmouth Institute, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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7
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Aucoin VJ, Bolaji B, Novak Z, Spangler EL, Sutzko DC, McFarland GE, Pearce BJ, Passman MA, Scali ST, Beck AW. Trends in the use of cerebrospinal drains and outcomes related to spinal cord ischemia after thoracic endovascular aortic repair and complex endovascular aortic repair in the Vascular Quality Initiative database. J Vasc Surg 2021; 74:1067-1078. [PMID: 33812035 DOI: 10.1016/j.jvs.2021.01.075] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 01/23/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Spinal cord ischemia (SCI) is a dreaded complication of thoracic and complex endovascular aortic repair (TEVAR/cEVAR). Controversy exists surrounding cerebrospinal fluid drain (CSFD) use, especially preoperative prophylactic placement, owing to concerns regarding catheter-related complications. However, these risks are balanced by the widely accepted benefits of CSFDs during open repair to prevent and/or rescue patients with SCI. The importance of this issue is underscored by the paucity of data on CSFD practice patterns, limiting the development of practice guidelines. Therefore, the purpose of the present analysis was to evaluate the differences between patients who developed SCI despite preoperative CSFD placement and those treated with therapeutic postoperative CSFD placement. METHODS All elective TEVAR/cEVAR procedures for degenerative aneurysm pathology in the Society for Vascular Surgery Vascular Quality Initiative from 2014 to 2019 were analyzed. CSFD use over time, the factors associated with preoperative prophylactic vs postoperative therapeutic CSFD placement in patients with SCI (transient or permanent), and outcomes were evaluated. Survival differences were estimated using the Kaplan-Meier method. RESULTS A total of 3406 TEVAR/cEVAR procedures met the inclusion criteria, with an overall SCI rate of 2.3% (n = 88). The SCI rate decreased from 4.55% in 2014 to 1.43% in 2018. Prophylactic preoperative CSFD use was similar over time (2014, 30%; vs 2018, 27%; P = .8). After further exclusions to evaluate CSFD use in those who had developed SCI, 72 patients were available for analysis, 48 with SCI and prophylactic CSFD placement and 24 with SCI and therapeutic CSFD placement. Specific to SCI, the patient demographics and comorbidities were not significantly different between the prophylactic and therapeutic groups, with the exception of previous aortic surgery, which was more common in the prophylactic CSFD cohort (46% vs 23%; P < .001). The SCI outcome was significantly worse for the therapeutic group because 79% had documented permanent paraplegia at discharge compared with 54% of the prophylactic group (P = .04). SCI patients receiving a postoperative therapeutic CSFD had had worse survival than those with a preoperative prophylactic CSFD (50% ± 10% vs 71% ± 9%; log-rank P = .1; Wilcoxon P = .05). CONCLUSIONS Prophylactic CSFD use with TEVAR/cEVAR remained stable during the study period. Of the SCI patients, postoperative therapeutic CSFD placement was associated with worse sustained neurologic outcomes and overall survival compared with preoperative prophylactic CSFD placement. These findings highlight the need for a randomized clinical trial to examine prophylactic vs therapeutic CSFD placement in association with TEVAR/cEVAR.
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Affiliation(s)
- Victoria J Aucoin
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Bolanle Bolaji
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Zdenek Novak
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Emily L Spangler
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Danielle C Sutzko
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Graeme E McFarland
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Benjamin J Pearce
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Marc A Passman
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala.
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Cronenwett JL, Avila-Tang E, Beck AW, Bertges D, Eldrup-Jorgensen J, Resnic FS, Radoja N, Sedrakyan A, Schick A, Smale J, Bloss RA, Phillips P, Hasenbank M, Wang S, Marinac-Dabic D, Pappas G. Use of data from the Vascular Quality Initiative registry to support regulatory decisions yielded a high return on investment. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2020; 2:e000039. [PMID: 35051256 PMCID: PMC8749325 DOI: 10.1136/bmjsit-2020-000039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/30/2020] [Accepted: 08/06/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Real-world data (RWD) from the Society for Vascular Surgery Vascular Quality Initiative (VQI) registry has been used to support US Food and Drug Administration (FDA) regulatory decisions regarding vascular devices. The variables of cost and time needed for these registry-based studies have not been previously compared to traditional, independent, industry studies that would otherwise have been conducted to support regulatory decisions. OBJECTIVES To determine the potential value (cost and time saving and return on investment) created by device evaluation studies using the VQI registry infrastructure. METHODS We compared studies that used data from the VQI registry with estimated costs of independent industry studies (counterfactual studies) using an established model using design specifications determined by FDA reviewers. RESULTS We analyzed the initial six studies evaluating vascular devices for regulatory decisions using data from the VQI registry that generated evidence for four device manufacturers. Return on investment for these studies was estimated to be 143% and cost saving as 59% based on an actual per patient (with 5-year follow-up) cost of US$11K using VQI data versus US$26K from the counterfactual when averaged across all studies. Significant enrollment time savings (45%-71%) were also realized compared with industry-based estimates. CONCLUSIONS The use of RWD from the VQI registry in this study and the transcatheter valve treatment coordinated registry network in a prior study indicates that substantial value was added to device evaluation projects by the reuse of registry data, with additional potential savings if linked claims data can be used instead of costly long-term in-person follow-up.
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Affiliation(s)
- Jack L Cronenwett
- Department of Surgery, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Erika Avila-Tang
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Adam W Beck
- Department of Surgery, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Daniel Bertges
- Department of Surgery, University of Vermont College of Medicine, Burlington, Vermont, USA
| | | | - Frederic S Resnic
- Department of Cardiology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Nadezda Radoja
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Art Sedrakyan
- Healthcare Polcy and Research, Weill Cornell Medical College, New York, New York, USA
| | - Andreas Schick
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Josh Smale
- B-D Bard, Franklin Lakes, New Jersey, USA
| | - Roberta A Bloss
- W L Gore and Associates Medical Products Division, Flagstaff, Arizona, USA
| | | | | | | | - Danica Marinac-Dabic
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Gregory Pappas
- Center for Biologics Evaluation and Research, Food and Drug Administration Office of the Commissioner, Rockville, Maryland, USA
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9
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Bertges DJ, White R, Cheng YC, Sun T, Ramkumar N, Goodney PP, Wilgus RW, Lottes AE, Smale JA, Drozda J, Raska M, Heise T, Jones WS, Tcheng JE, Eldrup-Jorgensen J, Sedrakyan A, Malone ML, Marinac-Dabic D, Thatcher R, Morales P, Krucoff MW, Cronenwett JL. Registry Assessment of Peripheral Interventional Devices objective performance goals for superficial femoral and popliteal artery peripheral vascular interventions. J Vasc Surg 2020; 73:1702-1714.e11. [PMID: 33080324 DOI: 10.1016/j.jvs.2020.09.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 09/10/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND The Superficial Femoral Artery-Popliteal EvidencE Development Study Group developed contemporary objective performance goals (OPGs) for peripheral vascular interventions (PVI) for superficial femoral artery (SFA)-popliteal artery disease using the Registry Assessment of Peripheral Interventional Devices. METHODS The Society for Vascular Surgery Vascular Quality Initiative PVI registry from January 2010 to October 2016 was used to develop OPGs based on SFA-popliteal procedures (n = 21,377) for intermittent claudication and critical limb ischemia (CLI). OPGs included 1-year rates for target lesion revascularization (TLR), major amputation, and 1 and 4-year survival rates. OPGs were calculated for the SFA and popliteal arteries and stratified by four treatments: angioplasty alone (percutaneous transluminal angioplasty [PTA]), self-expanding stenting, atherectomy, and any treatment type. Outcomes were illustrated by unadjusted Kaplan-Meier analyses. RESULTS Cohorts included PTA (n = 7505), stenting (n = 9217), atherectomy (n = 2510) and any treatment (n = 21,377). The mean age was 69 years, 58% were male, 79% were White, and 52% had CLI. The freedom from TLR OPGs at 1 year in the SFA were 80.3% (PTA), 83.2% (stenting), 83.9% (atherectomy), and 81.9% (any treatments). The freedom from TLR OPGs at 1 year in the popliteal were 81.3% (PTA), 81.3% (stenting), 80.2% (atherectomy), and 81.1% (any treatments). The freedom from major amputation OPGs at 1 year after SFA PVI were 93.4% (PTA), 95.7% (stenting), 95.1% (atherectomy), and 94.8% (any treatments). The freedom from major amputation OPG at 1 year after popliteal PVI were 90.5% (PTA), 93.7% (stenting), 91.8% (atherectomy), and 91.8%, (any treatments). The 4-year survival OPGs after SFA PVI were 76% (PTA), 80% (stenting), 82% (atherectomy), and 79% (any treatments), and for the popliteal artery were 72% (PTA), 77% (stenting), 82% (atherectomy), and 75% (any treatment). On a multivariable analysis, which included patient-level, leg-level, and lesion-level covariates, CLI was the single independent factor associated with increased TLR, amputation, and mortality. CONCLUSIONS The Superficial Femoral Artery-Popliteal EvidencE Development OPGs define a new, contemporary benchmark for SFA-popliteal interventions using a large subset of real-world evidence to inform more efficient peripheral device clinical trial designs to support regulatory and clinical decision-making. It is appropriate to discuss proposals intended for regulatory approval with the US Food and Drug Administration to refine the OPG to match the specific trial population. The OPGs may be updated using coordinated registry networks to assess long-term real-world device performance.
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Affiliation(s)
- Daniel J Bertges
- University of Vermont Medical Center, Division of Vascular Surgery, Burlington, VT.
| | | | | | - Tianyi Sun
- Departments of Cardiothoracic Surgery and Populations Health Sciences, Weill Cornell College of Medicine, New York, NY
| | - Niveditta Ramkumar
- Section of Vascular Surgery and the Dartmouth Institute, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Philip P Goodney
- Section of Vascular Surgery and the Dartmouth Institute, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Rebecca W Wilgus
- Department of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | | | | | | | | | | | - W Schuyler Jones
- Department of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - James E Tcheng
- Department of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | | | - Art Sedrakyan
- Departments of Cardiothoracic Surgery and Populations Health Sciences, Weill Cornell College of Medicine, New York, NY
| | | | | | | | | | - Mitchell W Krucoff
- Department of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Jack L Cronenwett
- Section of Vascular Surgery and the Dartmouth Institute, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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10
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Sutzko DC, Mani K, Behrendt CA, Wanhainen A, Beck AW. Big data in vascular surgery: registries, international collaboration and future directions. J Intern Med 2020; 288:51-61. [PMID: 32303118 DOI: 10.1111/joim.13077] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 02/21/2020] [Accepted: 04/06/2020] [Indexed: 01/09/2023]
Abstract
Given the increasing availability of large data set, small single-institutional series raise decreasing attention. Rapid expansion of technology from electronic medical records to easily accessible internet access, and widespread use and acceptance of registries in the medical world has allowed for research and quality improvement efforts using 'big data'. Big data, although technically not defined, typically refers to large databases that can be used to investigate common or rare disease processes or outcomes, describe variation in clinical practices across and between different specialties at various practice location, whilst allowing important information about trends over time. Big data have allowed investigators to quickly assimilate cohorts of patients and/or procedures to answer current questions, with more complete population representation and improved generalizability whilst decreasing the likelihood of power problems and type II errors. On the other hand, pitfalls still exist with the growing problem of hypothesis fishing, lack of granularity and the fear by many clinicians that registry transparency may have already gone too far, where surgery groups or individual surgeon outcomes are readily available to patients and referring providers. Within vascular surgery specifically, big data have expanded over the last decade and now includes regional, national and global registries that have major benefits of gathering specific clinical and procedural information within vascular surgery. In this review, we highlight the main vascular surgery registries and recap a few success stories of how the registries have been leveraged to benefit discovery, quality improvement and ultimately patient care. Additionally, we outline future directions that will be imperative for continued expansion, acceptance and adoption of 'big data' utilization inpatients with vascular disease.
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Affiliation(s)
- D C Sutzko
- From the, Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AB, USA
| | - K Mani
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - C-A Behrendt
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A Wanhainen
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - A W Beck
- From the, Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AB, USA
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11
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Cronenwett JL. Why should I join the Vascular Quality Initiative? J Vasc Surg 2020; 71:364-373. [DOI: 10.1016/j.jvs.2019.10.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 10/04/2019] [Indexed: 01/12/2023]
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12
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Liao E, Eisenberg N, Kaushal A, Montbriand J, Tan KT, Roche-Nagle G. Utility of the Vascular Quality Initiative in improving quality of care in Canadian patients undergoing vascular surgery. Can J Surg 2019; 62:66-69. [PMID: 30693748 DOI: 10.1503/cjs.002218] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
The Vascular Quality Initiative (VQI) is a national cooperative quality-improvement initiative designed to evaluate processes of care and outcomes in vascular surgery. The purpose of this report is to show the utility of such a database to provide insight into the standard of care provided, to highlight areas of local quality improvement, to benchmark our data against local, regional and national trends, and to ultimately improve safety in Canadian patients undergoing vascular surgery. We present the history of the database, its spread in the Canadian health care system and examples of quality improvements achieved from analyses of data recorded and retrieved from the VQI. Using the VQI, our institution was able to decrease the length of stay after endovascular aneurysm repair, decrease the contrast volume in endovascular aneurysm repair, save on costs, and provide medium-term outcome data on peripheral vascular interventions and smoking cessation strategies. The VQI is a powerful tool to improve patient safety and quality in vascular surgery. Its ability to create local regional improvement groups fosters a quality-focused culture and is important for Canadian patients.
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Affiliation(s)
- Elizabeth Liao
- From the Faculty of Medicine, University of Toronto, Toronto, Ont. (Liao); the Division of Vascular Surgery, University Health Network, Toronto, Ont. (Eisenberg, Roche-Nagle); the Faculty of Medicine, University of Edinburgh, Edinburgh, Scotland (Kaushal); the Pain Research Unit, Department of Anesthesia and Pain Management, University Health Network (Montbriand); and the Division of Vascular and Interventional Radiology, University Health Network, Toronto, Ont. (Tan, Roche-Nagle)
| | - Naomi Eisenberg
- From the Faculty of Medicine, University of Toronto, Toronto, Ont. (Liao); the Division of Vascular Surgery, University Health Network, Toronto, Ont. (Eisenberg, Roche-Nagle); the Faculty of Medicine, University of Edinburgh, Edinburgh, Scotland (Kaushal); the Pain Research Unit, Department of Anesthesia and Pain Management, University Health Network (Montbriand); and the Division of Vascular and Interventional Radiology, University Health Network, Toronto, Ont. (Tan, Roche-Nagle)
| | - Anish Kaushal
- From the Faculty of Medicine, University of Toronto, Toronto, Ont. (Liao); the Division of Vascular Surgery, University Health Network, Toronto, Ont. (Eisenberg, Roche-Nagle); the Faculty of Medicine, University of Edinburgh, Edinburgh, Scotland (Kaushal); the Pain Research Unit, Department of Anesthesia and Pain Management, University Health Network (Montbriand); and the Division of Vascular and Interventional Radiology, University Health Network, Toronto, Ont. (Tan, Roche-Nagle)
| | - Janice Montbriand
- From the Faculty of Medicine, University of Toronto, Toronto, Ont. (Liao); the Division of Vascular Surgery, University Health Network, Toronto, Ont. (Eisenberg, Roche-Nagle); the Faculty of Medicine, University of Edinburgh, Edinburgh, Scotland (Kaushal); the Pain Research Unit, Department of Anesthesia and Pain Management, University Health Network (Montbriand); and the Division of Vascular and Interventional Radiology, University Health Network, Toronto, Ont. (Tan, Roche-Nagle)
| | - Kong-Teng Tan
- From the Faculty of Medicine, University of Toronto, Toronto, Ont. (Liao); the Division of Vascular Surgery, University Health Network, Toronto, Ont. (Eisenberg, Roche-Nagle); the Faculty of Medicine, University of Edinburgh, Edinburgh, Scotland (Kaushal); the Pain Research Unit, Department of Anesthesia and Pain Management, University Health Network (Montbriand); and the Division of Vascular and Interventional Radiology, University Health Network, Toronto, Ont. (Tan, Roche-Nagle)
| | - Graham Roche-Nagle
- From the Faculty of Medicine, University of Toronto, Toronto, Ont. (Liao); the Division of Vascular Surgery, University Health Network, Toronto, Ont. (Eisenberg, Roche-Nagle); the Faculty of Medicine, University of Edinburgh, Edinburgh, Scotland (Kaushal); the Pain Research Unit, Department of Anesthesia and Pain Management, University Health Network (Montbriand); and the Division of Vascular and Interventional Radiology, University Health Network, Toronto, Ont. (Tan, Roche-Nagle)
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Jayaraman R, Salah K, King N. Improving Opportunities in Healthcare Supply Chain Processes via the Internet of Things and Blockchain Technology. INTERNATIONAL JOURNAL OF HEALTHCARE INFORMATION SYSTEMS AND INFORMATICS 2019. [DOI: 10.4018/ijhisi.2019040104] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Despite key advances in healthcare informatics and management, little progress to address supply chain process-related problems has been made to date. Specifically, key healthcare supply chain processes include product recalls, monitoring of product supply shortages, expiration, and counterfeits. Implementing and executing these processes in a trusted, secure, efficient, globally accessible and traceable manner is challenging due to the fragmented nature of the healthcare supply chain, which is prone to systemic errors and redundant efforts that may compromise patient safety and impact health outcomes adversely. Blockchain, combined with the Internet of things (IoT), is an emerging technology that can offer a practical solution to these challenges. Accordingly, IoT blockchain offers a superior way to track and trace products via a peer-to-peer distributed, secure, and shared ledger of the blockchain network. This article highlights key challenges related to healthcare supply chains, and illustrates how IoT blockchain technologies can play a role in overcoming these challenges now and in the near future.
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Affiliation(s)
- Raja Jayaraman
- Khalifa University of Science and Technology, Department of Industrial and Systems Engineering, Abu Dhabi, UAE
| | - Khaled Salah
- Khalifa University of Science and Technology, Department of Electrical and Computer Engineering, Abu Dhabi, UAE
| | - Nelson King
- Khalifa University of Science and Technology, Department of Industrial and Systems Engineering, Abu Dhabi, UAE
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14
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Wang GJ, Cambria RP, Lombardi JV, Azizzadeh A, White RA, Abel DB, Cronenwett JL, Beck AW. Thirty-day outcomes from the Society for Vascular Surgery Vascular Quality Initiative thoracic endovascular aortic repair for type B dissection project. J Vasc Surg 2019; 69:680-691. [DOI: 10.1016/j.jvs.2018.06.203] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 06/01/2018] [Indexed: 11/26/2022]
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15
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O'Donnell TFX, Patel VI, Deery SE, Li C, Swerdlow NJ, Liang P, Beck AW, Schermerhorn ML. The state of complex endovascular abdominal aortic aneurysm repairs in the Vascular Quality Initiative. J Vasc Surg 2019; 70:369-380. [PMID: 30718110 DOI: 10.1016/j.jvs.2018.11.021] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 11/05/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Endovascular repair of complex abdominal aortic aneurysms has become increasingly common, but reports have mostly been limited to single centers and single devices. METHODS We studied all endovascular repairs of complex abdominal aortic aneurysms (zone 6 or caudal) from 2014 to 2018 in the Vascular Quality Initiative. This included all commercially available fenestrated endovascular aneurysm repair (FEVAR), chimney/snorkel repairs, and physician-modified endografts (PMEGs), exclusive of investigational device exemptions and clinical trial devices. We used inverse probability-weighted multilevel logistic regression to compare rates of perioperative outcomes including death, acute kidney injury (AKI), and major adverse cardiac events (MACEs; the composite of death/stroke/myocardial infarction) and Cox regression for long-term mortality. RESULTS During the study period, surgeons performed 1396 complex endovascular repairs: 1308 (94%) elective, 63 (4.5%) for symptomatic aneurysms, and 25 (1.8%) for rupture. The number of centers performing complex endovascular repairs expanded steadily from 39 in 2014 to 81 in 2017. There were 880 FEVAR (63%), 256 PMEG (18%), and 260 chimney/snorkel repairs (19%). In elective cases, 3214 visceral vessels were incorporated and revascularized; 120 repairs (9%) involved one vessel, 481 (38%) repairs involved two vessels, 560 (44%) involved three vessels, and 113 (9%) involved four vessels. The mean number of arteries incorporated was 2.5 ± 0.8, with PMEGs involving the most arteries (3.3 ± 0.8 for PMEG vs 2.5 ± 0.6 for FEVAR and 1.9 ± 0.9 for chimney/snorkel; P < .001). PMEGs were used to treat more extensive aneurysms, and more incorporated the celiac and superior mesenteric arteries. There was no change in aneurysm extent, but the length of proximal seal extended over time. Chimney/snorkel cases employed more arm or neck access, had longer procedure times, and used more contrast material. Rates of perioperative death (3.4% for FEVAR vs 2.7% for PMEG vs 6.1% for chimney/snorkel; P = .13) and AKI (17% vs 18% vs 19%; P = .42) were similar, but chimney/snorkel was associated with higher rates of stroke (0.8% vs 0.9% vs 3.3%; P = .03) and MACEs (6.1% vs 5.4% vs 11.7%; P = .02). After adjustment, rates of perioperative death, AKI, and overall complications remained similar, but chimney/snorkel was associated with significantly higher odds of stroke (odds ratio [OR], 7.3 [1.5-36.4]; P = .015), myocardial infarction (OR, 18.7 [2.6-136.8]; P = .004), and MACEs (OR, 11.1 [2.1-58.9]; P = .005). Overall survival after elective repair was 91% at 1 year and 88% at 3 years, with no difference between repair types in crude or adjusted analysis. CONCLUSIONS The Vascular Quality Initiative provides a unique opportunity to study the real-world application and outcomes of complex endovascular aneurysm repair. Perioperative morbidity appears to be higher after chimney/snorkel repair, but further study is needed to confirm these findings and to establish the durability of these novel technologies.
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Affiliation(s)
- Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Virendra I Patel
- Division of Vascular Surgery and Endovascular Interventions, NewYork-Presbyterian/Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York, NY
| | - Sarah E Deery
- Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Chun Li
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Nicholas J Swerdlow
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Patric Liang
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
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16
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Iannuzzi JC, Stapleton SM, Bababekov YJ, Chang D, Lancaster RT, Conrad MF, Cambria RP, Patel VI. Favorable impact of thoracic endovascular aortic repair on survival of patients with acute uncomplicated type B aortic dissection. J Vasc Surg 2018; 68:1649-1655. [DOI: 10.1016/j.jvs.2018.04.034] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 04/07/2018] [Indexed: 11/28/2022]
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17
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Wang GJ, Jackson BM, Foley PJ, Damrauer SM, Goodney PP, Kelz RR, Wirtalla C, Fairman RM. National trends in admissions, repair, and mortality for thoracic aortic aneurysm and type B dissection in the National Inpatient Sample. J Vasc Surg 2018; 67:1649-1658. [DOI: 10.1016/j.jvs.2017.09.050] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Accepted: 09/28/2017] [Indexed: 10/17/2022]
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18
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Wang GJ, Goodney PP, Sedrakyan A. Conceptualizing treatment of uncomplicated type B dissection using the IDEAL framework. J Vasc Surg 2018; 67:662-668. [PMID: 29389429 DOI: 10.1016/j.jvs.2017.10.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 10/10/2017] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The objective of this study was to introduce a new framework, called IDEAL (idea, development, exploration, assessment, and long-term study), to guide physicians, investigators, and regulatory agencies through the life cycle of device development and procedural refinement. METHODS This review describes the IDEAL framework and illustrates its application for treatment of uncomplicated type B dissection (uTBD) as an example of this process. RESULTS Components of IDEAL are summarized and applied to devices used to treat uTBD. Treatment of uTBD is currently in the exploration phase, with concurrent assessment and long-term study being facilitated by detailed registries. CONCLUSIONS The application of IDEAL to the development and monitoring of technologies standardizes the nomenclature, facilitates evidence-based practice, and enhances the innovation process.
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Affiliation(s)
- Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa.
| | - Philip P Goodney
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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