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Hanna L, Rodway AD, Garcha P, Maynard L, Sivayogi J, Schlager O, Madaric J, Boc V, Busch L, Whyte MB, Skene SS, Harris J, Heiss C. Safety and procedural success of daycase-based endovascular procedures in lower extremity arteries of patients with peripheral artery disease: a systematic review and meta-analysis. EClinicalMedicine 2024; 75:102788. [PMID: 39290906 PMCID: PMC11406065 DOI: 10.1016/j.eclinm.2024.102788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 07/23/2024] [Accepted: 07/29/2024] [Indexed: 09/19/2024] Open
Abstract
Background Timely and economic provision of revascularisation procedures is a major healthcare need. We aimed to examine the safety and efficacy of daycase-based lower extremity endovascular revascularisation procedures in patients with peripheral artery disease. Methods In this systematic review and meta-analysis, we searched MEDLINE and Embase for studies from Jan 01, 2000 through Apr 01, 2024 reporting complications of lower limb endovascular revascularisation procedures with same-day discharge. Eligibility-criteria, complications, and patient characteristics were extracted, methodological quality assessed (adapted Newcastle-Ottawa Scale), and meta-analyses of complications and technical success performed to provide pooled estimates. This study is registered with PROSPERO, CRD42022316466. Findings Thirty observational studies (17 retrospective, 13 prospective) and 1 RCT reported 2427 minor and 653 major complications after 99,600 daycase procedures (93,344 patients). Eighteen studies reported daycase eligibility-criteria including 'responsible adult companion' (78%), 'proximity to hospital', and 'telephone availability' and excluding unstable and severe co-morbidities, offset coagulation, and severe chronic kidney disease. Pooled incidences of minor (4.7% [95% CI 3.8-5.6%], I 2 = 96%) and major (0.64% [95% CI 0.48-0.79%], I 2 = 46%) complications were low and technical success high (93% [95% CI 91-96%], I 2 = 97%). Most complications were related to the puncture site. Pooled conversion-to-hospitalisation rates and re-admission after discharge were 1.6% (95% CI 1.1-2.2%, I 2 = 82%) and 0.11% (95% CI 0.095-0.23%, I 2 = 97%), respectively. Meta-regression identified that minor complications decreased since 2000. Male sex and coronary artery disease were associated with more frequent, and higher age and closure device use with less minor complications. Diabetes mellitus and chronic kidney disease were associated with less major complications. Six studies reported complication rates both in daycases and inpatients and there was no significant difference (-0.8% [95% CI -1.9 to 0.3%]). Interpretation After careful evaluation of eligibility, lower limb angioplasty can be performed safely with high technical success in a daycase setting. Most complications arise from the puncture site and not the procedure itself highlighting the importance of optimal access site management. The heterogeneity between studies warrants standardised monitoring of complications and outcomes. Funding European Partnership on Metrology, co-financed from European Union's Horizon Europe Research and Innovation Programme and UK Research and Innovation, and Medical Research Council.
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Affiliation(s)
- Lydia Hanna
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Alexander D Rodway
- Vascular Medicine Department, Surrey and Sussex Healthcare NHS Trust, Redhill, UK
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Puneet Garcha
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Luci Maynard
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Janane Sivayogi
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Oliver Schlager
- Division of Angiology, Department of Medicine II, Medical University of Vienna, Austria
| | - Juraj Madaric
- Department of Angiology, Comenius University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia
| | - Vinko Boc
- Clinical Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Lucas Busch
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Martin B Whyte
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Simon S Skene
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Jenny Harris
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Christian Heiss
- Vascular Medicine Department, Surrey and Sussex Healthcare NHS Trust, Redhill, UK
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
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Cook R, Robbins J, Truax L, Hingorani A. Patient selection for arterial procedures in office-based laboratories: A systematic review. Semin Vasc Surg 2024; 37:118-132. [PMID: 39151992 DOI: 10.1053/j.semvascsurg.2024.05.003] [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: 02/14/2024] [Revised: 05/04/2024] [Accepted: 05/16/2024] [Indexed: 08/19/2024]
Abstract
A dramatic increase in the number of vascular procedures performed in the office-based laboratory setting has been observed since 2008, when the Centers for Medicare and Medicaid Services increased reimbursement for procedures performed in the ambulatory setting. We sought to evaluate the appropriateness of arterial intervention in the office-based laboratory and patient selection. This systematic review was conducted with a search of Google Scholar and PubMed using the following search terms: office-based lab, outpatient, angioplasty, patient selection, arterial, and appropriateness. More than 500 publications were screened and 14 publications related to the topic were selected. The existing literature that examined patient selection for intervention in the outpatient setting, rates of complications after outpatient procedures, and short-term data on the safety and efficacy of these procedures is discussed. Gaps were identified in current knowledge about the long-term outcomes of peripheral arterial interventions performed in the office-based laboratory setting, as well as existing guidelines for the management of patients with peripheral arterial disease.
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Affiliation(s)
- Rebekah Cook
- Department of Surgery, HCA Florida Westside Hospital, 8201 W. Broward Boulevard, Plantation, FL, 33324.
| | - Justin Robbins
- Department of Surgery, Wright State University, Dayton, OH
| | - Lauren Truax
- Department of Surgery, Wright State University, Dayton, OH
| | - Anil Hingorani
- New York University Langone, 960 50th Street, Brooklyn, NY
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Krishnaswamy A, Isogai T, Brilakis ES, Nanjundappa A, Ziada KM, Parikh SA, Rodés-Cabau J, Windecker S, Kapadia SR. Same-Day Discharge After Elective Percutaneous Transcatheter Cardiovascular Interventions. JACC Cardiovasc Interv 2023; 16:1561-1578. [PMID: 37438024 DOI: 10.1016/j.jcin.2023.05.015] [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: 11/16/2022] [Revised: 04/23/2023] [Accepted: 05/08/2023] [Indexed: 07/14/2023]
Abstract
Percutaneous transcatheter interventions have evolved as standard therapies for a variety of cardiovascular diseases, from revascularization for atherosclerotic vascular lesions to the treatment of structural cardiac diseases. Concomitant technological innovations, procedural advancements, and operator experience have contributed to effective therapies with low complication rates, making early hospital discharge safe and common. Same-day discharge presents numerous potential benefits for patients, providers, and health care systems. There are several key elements that are shared across the spectrum of interventional cardiology procedures to create a successful same-day discharge pathway. These include appropriate patient and procedure selection, close postprocedural observation, predischarge assessments specific for each type of procedure, and the existence of a patient support system beyond hospital discharge. This review provides the rationale, available data, and a framework for same-day discharge across the spectrum of coronary, peripheral, and structural cardiovascular interventions.
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Affiliation(s)
- Amar Krishnaswamy
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Toshiaki Isogai
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Emmanouil S Brilakis
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Aravinda Nanjundappa
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Khaled M Ziada
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sahil A Parikh
- Division of Cardiology and Center for Interventional Vascular Therapy, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Josep Rodés-Cabau
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA.
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Malgor RD, Baker JM, Malgor EA, Blebea J. Endovascular experience at an academic office-based procedure center. Vascular 2023; 31:226-233. [PMID: 35331076 DOI: 10.1177/17085381211059651] [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] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The number of office-based procedure centers with the capability of performing a wide range of endovascular procedures has substantially increased over the past decade. This shift in practice settings has occurred faster in the private sector as compared to the academic environment. The purpose of our study was to evaluate the clinical outcomes of endovascular procedures performed at a dedicated academic outpatient procedural center. METHODS We reviewed the clinical data of 400 patients who underwent 499 endovascular procedures in a university-based, academic outpatient procedure center between November 2013 and December 2016. Outcomes analyzed included procedure-related complications, limb loss, mortality, and emergency department visits or hospital admissions that occurred within 30 days following the procedure. RESULTS The 400 patients had a mean age of 65 ± 13 years with slightly more females (51%; n = 203) as compared to males (49%; n = 197). Most patients (71%; 284) were Caucasian while 80 (20%) were African-Americans. Associated comorbidities included hypertension (86%), diabetes mellitus (51%), chronic kidney disease (42%), and obesity (mean body mass index of 29 ± 6). Based on anesthetic risk, most were ASA class 3 (81%), while ASA 1 and 2 comprised 17% and ASA 4 only 2%. Medicare beneficiaries accounted for 254 (64%) of our patients. Pre-operative studies included mainly duplex ultrasound (62%) and other noninvasive arterial studies (57%).The mean procedural time was 58 min (range, 7 to 200) with an overall technical success rate of 97%. There were no deaths. Complications developed in 10 patients following the 483 procedures (2.1%) being hospitalized with four of them transferred directly to the emergency room. The reasons for these hospitalizations included acute limb ischemia, arterial pseudoaneurysm, deep vein thrombosis, congestive heart failure, myocardial infarction, and lower extremity pain not vascular in origin. Financial reimbursement at the office-based center was higher than that seen with hospital-based procedures. CONCLUSIONS Endovascular procedures performed in an academic office-based procedure center are safe and associated with good clinical outcomes. A small minority of patients have subsequent ER visits or hospital admissions. Academic institutions should consider adding an office-based procedure center based on today's competitive healthcare market.
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Affiliation(s)
- Rafael D Malgor
- Division of Vascular Surgery, 129263University of Colorado, Aurora, CO, USA
| | - Jennifer M Baker
- Division of Vascular Surgery, 2647Ohio State University, Columbus, OH, USA
| | - Emily A Malgor
- Division of Vascular Surgery, 129263University of Colorado, Aurora, CO, USA
| | - John Blebea
- Department of Surgery, 5649Central Michigan University College of Medicine, Saginaw, MI, USA
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Safety of short 3-hour recovery and same-day discharge following lower-limb angioplasty in outpatients with intermittent claudication and critical limb ischaemia. Clin Radiol 2023; 78:e182-e189. [PMID: 36462943 DOI: 10.1016/j.crad.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 09/21/2022] [Accepted: 10/13/2022] [Indexed: 12/03/2022]
Abstract
AIM To investigate the safety and efficacy of short recovery day-case pathway following lower-limb angioplasty in both intermittent claudication and critical limb ischaemia patients. MATERIALS AND METHODS A retrospective analysis was undertaken of the medical records of consecutive outpatients treated with lower-limb angioplasty over a 1-year period within an interventional radiology (IR) day-case unit in a high-volume vascular centre. Standard post-angioplasty care at York Teaching Hospital is discharge 3 h after puncture site haemostasis without the routine use of closure devices. The rates of successful same-day discharge, procedure success, complications, and re-admissions were calculated with 30-day follow-up. RESULTS The cohort included 301 patients (57% intermittent claudication and 43% critical limb ischaemia) undergoing 605 angioplasties using access sheath size ranging from 4 to 7 F. Closure devices were used in only 7% of patients. Successful same-day discharge achieved in 98% of patients (294/301), with seven admitted overnight because of complications. Eleven patients (3.6%) were re-admitted within 30 days. Technical success rates were 92%, and 96% when including partially successful interventions, with 4% technical failure. Twelve patients (4%) developed minor complications and four major complications (1%). There were no significant differences in complication rates between small and larger sheath sizes (p>0.05). No procedure-related death was recorded within 30 days. CONCLUSION Lower-limb angioplasty can be performed safely as day-case procedure with a short recovery protocol within IR departments for both patients with intermittent claudication (IC) and critical limb ischaemia (CLI). This may significantly increase patient throughput and alleviate pressure on stretched hospital inpatient resources by safely discharging patients on the day of procedure.
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Miller SM, Sumpio BJ, Miller MS, Erben Y, Cordova AC, Sumpio BE. Higher Inpatient Mortality for Women after Intervention for Lifestyle Limiting Claudication. Ann Vasc Surg 2019; 58:54-62. [DOI: 10.1016/j.avsg.2019.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 10/23/2018] [Accepted: 01/13/2019] [Indexed: 10/27/2022]
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Safety of elective percutaneous peripheral revascularization in outpatients: A 10-year single-center experience. Diagn Interv Imaging 2019; 100:347-352. [DOI: 10.1016/j.diii.2018.11.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 11/21/2018] [Accepted: 11/22/2018] [Indexed: 11/19/2022]
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Islam AM, Alreja G, Mallidi J, Ziaul Hoque M, Friderici J. Feasibility, safety, and patient satisfaction of same-day discharge following peripheral arterial interventions: A randomized controlled study. Catheter Cardiovasc Interv 2018. [DOI: 10.1002/ccd.27580] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
| | | | - Jaya Mallidi
- Baystate Medical Center; Springfield Massachusetts
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Janas A, Milewski K, Buszman PP, Janas K, Blachut A, Pruski M, Wiernek S, Zurakowski A, Buszman PE, Kiesz SR. Safety and feasibility of same-day early discharge after endovascular revascularization of lower extremities in elderly. SENIOR-ER registry. Catheter Cardiovasc Interv 2017; 91:515-520. [DOI: 10.1002/ccd.27338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 07/29/2017] [Accepted: 08/23/2017] [Indexed: 11/10/2022]
Affiliation(s)
- Adam Janas
- San Antonio Endovascular & Heart Institute, American Heart of Poland; Katowice Poland
- Center of Cardiovascular Research and Development, American Heart of Poland; Katowice Poland
| | - Krzysztof Milewski
- Center of Cardiovascular Research and Development, American Heart of Poland; Katowice Poland
| | - Piotr P. Buszman
- Center of Cardiovascular Research and Development, American Heart of Poland; Katowice Poland
| | - Ksenia Janas
- San Antonio Endovascular & Heart Institute, American Heart of Poland; Katowice Poland
| | - Aleksandra Blachut
- San Antonio Endovascular & Heart Institute, American Heart of Poland; Katowice Poland
- Center of Cardiovascular Research and Development, American Heart of Poland; Katowice Poland
| | - Maciej Pruski
- San Antonio Endovascular & Heart Institute, American Heart of Poland; Katowice Poland
- Center of Cardiovascular Research and Development, American Heart of Poland; Katowice Poland
| | - Szymon Wiernek
- San Antonio Endovascular & Heart Institute, American Heart of Poland; Katowice Poland
| | - Aleksander Zurakowski
- Center of Cardiovascular Research and Development, American Heart of Poland; Katowice Poland
| | - Pawel E. Buszman
- Center of Cardiovascular Research and Development, American Heart of Poland; Katowice Poland
| | - Stefan R. Kiesz
- San Antonio Endovascular & Heart Institute, American Heart of Poland; Katowice Poland
- Center of Cardiovascular Research and Development, American Heart of Poland; Katowice Poland
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Chen CK, Boos J, Sarwar A, O'Bryan-Alberts B, Ahmed M, Brook OR. Observation time after outpatient non-arterial interventional procedures: standards, safety, and outcomes. Abdom Radiol (NY) 2017; 42:1571-1578. [PMID: 28097389 DOI: 10.1007/s00261-017-1046-2] [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: 11/28/2022]
Abstract
PURPOSE To evaluate the impact of standardized reduced post-procedure observation time on subsequent healthcare encounters such as emergency department (ED) visits, hospital admissions, and clinic visits. METHODS 800 consecutive patients undergoing outpatient non-arterial interventional radiologic procedures within the vascular interventional department between 1 June 2013 and 21 July 2014 were included in this IRB-approved, HIPAA-compliant single center observational retrospective study. Electronic medical records were reviewed for subsequent healthcare encounters, such as ED visits, hospital admissions, and clinic visits. An attending interventional radiologist and radiology resident reviewed, in consensus, medical records for relevance of the encounter to the index procedure. Procedure-related encounters were analyzed to determine relationship to length of observation time, using Matlab for statistical analysis. RESULTS 397 and 403 patients were in the pre- and post-standardization groups, respectively. Median observation time decreased overall from 1.67 h [interquartile range (IQR) 1.17-2.17] to 1.42 h (IQR 1.08-1.92), p < 0.001. There was no significant change in either overall or procedure-related ED visits (16.6% [66/397] and 1.0% [4/397] pre-standardization vs. 20.1% [81/403] and 2.2% [9/403] post-standardization, p = 0.24 and 0.26), hospital admissions (27.7% [110/397] and 4.0% [16/397] prestandardization vs. 28.3% [114/403] and 2.7% [11/403] post-standardization, p = 0.88 and 0.33), or clinic visits (41.3% [164/397] and 1.0% [4/397] pre-standardization vs. 39.5% [159/403] and 2.2% [9/403] post-standardization, p = 0.61 and 0.26). CONCLUSION Proposed standardized shortened observation times after outpatient interventional radiologic procedures are safe, without change in either total or procedure-related ED visits, hospital admissions, or clinic visits.
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Affiliation(s)
- Christine K Chen
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA, 02215, USA.
| | - Johannes Boos
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA, 02215, USA
| | - Ammar Sarwar
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA, 02215, USA
| | - Bridget O'Bryan-Alberts
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA, 02215, USA
| | - Muneeb Ahmed
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA, 02215, USA
| | - Olga R Brook
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA, 02215, USA
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Lin PH, Yang KH, Kollmeyer KR, Uceda PV, Ferrara CA, Feldtman RW, Caruso J, Mcquade K, Richmond JL, Kliner CE, Egan KE, Kim W, Saines M, Leichter R, Ahn SS. Treatment outcomes and lessons learned from 5134 cases of outpatient office-based endovascular procedures in a vascular surgical practice. Vascular 2016; 25:115-122. [PMID: 27381926 DOI: 10.1177/1708538116657506] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction The office-based endovascular facility has increased in number recently due in part to expedient patient experience. This study analyzed treatment outcomes of procedures performed in our office-based endovascular suite. Methods Treatment outcomes of 5134 consecutive procedures performed in our office-based endovascular suites from 2006 to 2013 were analyzed. Five sequential groups (group I-V) of 1000 consecutive interventions were compared with regard to technical success and treatment outcomes. Results Our patients included 2856 (56%) females and 2267 (44%) males. Procedures performed included diagnostic arteriogram, arterial interventions, venous interventions, dialysis access interventions, and venous catheter management, which were 1024 (19.9%), 1568 (30.6%), and 3073 (60.0%), 621(12.1%), and 354 (6.9%), respectively. The complication rates for group I, II, III, IV, and V were 3%, 1.5%, 1%, 1.1%, and 0.7%, respectively. The complication rate was higher in group I when compared to each of the remaining four groups ( p < 0.05). Nine patients (0.18%) died within the 30-day period following their procedures, and none were procedure related. Conclusions Endovascular procedure can be performed safely in an office-based facility with excellent outcomes. Lessons learned in establishing office-based endovascular suites with efforts to reduce procedural complications and optimize quality patient care are discussed.
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Affiliation(s)
- Peter H Lin
- 1 Division of Vascular Surgery & Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, USA.,2 University Vascular Associates, Los Angeles, CA, USA
| | - Keun-Ho Yang
- 3 Division of Vascular Surgery, Department of Surgery, Sanggye Paik Hospital, College of Medicine Inje University, Republic of Korea.,4 DFW Vascular Group, Dallas, TX, USA
| | - Kenneth R Kollmeyer
- 3 Division of Vascular Surgery, Department of Surgery, Sanggye Paik Hospital, College of Medicine Inje University, Republic of Korea
| | - Pablo V Uceda
- 3 Division of Vascular Surgery, Department of Surgery, Sanggye Paik Hospital, College of Medicine Inje University, Republic of Korea
| | - Craig A Ferrara
- 3 Division of Vascular Surgery, Department of Surgery, Sanggye Paik Hospital, College of Medicine Inje University, Republic of Korea
| | - Robert W Feldtman
- 3 Division of Vascular Surgery, Department of Surgery, Sanggye Paik Hospital, College of Medicine Inje University, Republic of Korea
| | - Joseph Caruso
- 3 Division of Vascular Surgery, Department of Surgery, Sanggye Paik Hospital, College of Medicine Inje University, Republic of Korea
| | - Karen Mcquade
- 3 Division of Vascular Surgery, Department of Surgery, Sanggye Paik Hospital, College of Medicine Inje University, Republic of Korea
| | - Jasmine L Richmond
- 3 Division of Vascular Surgery, Department of Surgery, Sanggye Paik Hospital, College of Medicine Inje University, Republic of Korea
| | - Cameron E Kliner
- 3 Division of Vascular Surgery, Department of Surgery, Sanggye Paik Hospital, College of Medicine Inje University, Republic of Korea
| | - Kaitlyn E Egan
- 3 Division of Vascular Surgery, Department of Surgery, Sanggye Paik Hospital, College of Medicine Inje University, Republic of Korea
| | - Walter Kim
- 2 University Vascular Associates, Los Angeles, CA, USA
| | - Marius Saines
- 2 University Vascular Associates, Los Angeles, CA, USA
| | | | - Samuel S Ahn
- 2 University Vascular Associates, Los Angeles, CA, USA.,4 DFW Vascular Group, Dallas, TX, USA
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Prasad A, Ortiz-Lopez C, Khan A, Levin D, Kaye DM. Acute kidney injury following peripheral angiography and endovascular therapy: A systematic review of the literature. Catheter Cardiovasc Interv 2016; 88:264-73. [DOI: 10.1002/ccd.26466] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Revised: 12/19/2015] [Accepted: 01/22/2016] [Indexed: 01/22/2023]
Affiliation(s)
- Anand Prasad
- Department of Medicine, Division of Cardiology; University of Texas Health Science Center San Antonio; San Antonio Texas
| | - Carolina Ortiz-Lopez
- Department of Medicine, Division of Cardiology; University of Texas Health Science Center San Antonio; San Antonio Texas
| | - Aazib Khan
- Department of Medicine, Division of Cardiology; University of Texas Health Science Center San Antonio; San Antonio Texas
| | - Daniel Levin
- Department of Medicine, Division of Cardiology; University of Texas Health Science Center San Antonio; San Antonio Texas
| | - David M. Kaye
- Baker IDI Heart and Diabetes Institute; Melbourne Australia
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13
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Percutaneous radial access for peripheral transluminal angioplasty. J Vasc Surg 2015; 61:463-8. [DOI: 10.1016/j.jvs.2014.07.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 07/12/2014] [Indexed: 01/25/2023]
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14
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Mell MW, Pettinger M, Proulx-Burns L, Heckbert SR, Allison MA, Criqui MH, Hlatky MA, Burwen DR. Evaluation of Medicare claims data to ascertain peripheral vascular events in the Women's Health Initiative. J Vasc Surg 2014; 60:98-105. [PMID: 24636641 DOI: 10.1016/j.jvs.2014.01.056] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 01/15/2014] [Accepted: 01/21/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Capturing long-term outcomes from large clinical databases by use of claims data is a potential strategy for improving efficiency while reducing study costs. We sought to compare the use of Medicare data with data from the Women's Health Initiative (WHI) to determine peripheral vascular events, as defined by the WHI study design. METHODS We studied participants from the WHI with both adjudicated outcomes and links to Medicare enrollment and utilization data through 2007. Outcomes of interest included hospitalizations for treatment of abdominal aortic aneurysm (AAA), lower extremity peripheral artery disease (LE PAD), and carotid artery stenosis (CAS). Events determined by WHI adjudication were compared with events defined by coding algorithms using diagnosis and procedure codes from Medicare data with a pilot data set and then validated with a test data set. We assessed agreement by a κ statistic and evaluated reasons for disagreement. RESULTS In the pilot set, records from 50,511 participants were analyzed. Agreement between the Centers for Medicare and Medicaid Services and WHI for admissions with a diagnosis but no treatment procedures for vascular conditions was poor (κ, 0.02-0.18). On the basis of WHI outcome data collection, vascular treatment procedures occurred in 29 participants for AAA, 204 for LE PAD events, and 281 for CAS. Medicare hospital claims recorded 41 treatments for AAA, 255 for LE PAD, and 317 for CAS. For participants with a Centers for Medicare and Medicaid Services-captured vascular procedure and a record adjudicated by WHI, κ values for treatment procedures were 0.81 for AAA, 0.77 for PAD, and 0.93 for CAS. For vascular procedures identified by WHI but not by Medicare hospital data (n = 82), 55% were captured by Medicare physician claims. Conversely, for treatments identified by Medicare hospital data but not captured by WHI adjudication (n = 57), 74% had physician claims consistent with the procedure. Fifteen participants with AAA or LE PAD procedures in hospital claims had medical records available for review, and nine of these had definitive documentation of procedures that were not captured by the WHI adjudication process. Estimated positive predictive value of Medicare data was 91% to 94% for AAA, 92% to 95% for LE PAD, and 94% to 99% for CAS. Available test set data (n = 50,253) yielded generally similar results with κ of 0.77 for AAA, 0.79 for LE PAD, and 0.94 for CAS. CONCLUSIONS Medicare data appear useful for identifying vascular treatment procedures for WHI participants. Medicare hospital claims identify more procedures than WHI does, with high positive predictive value, but also may not capture some procedures identified in WHI.
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Affiliation(s)
| | | | | | | | | | | | | | - Dale R Burwen
- National Heart, Lung, and Blood Institute, Bethesda, Md
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Clinical and economic evaluation of ambulatory endovascular treatment of peripheral arterial occlusive lesions. Ann Vasc Surg 2013; 28:137-43. [PMID: 24183403 DOI: 10.1016/j.avsg.2013.06.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 06/11/2013] [Accepted: 06/13/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND Ambulatory management of patients is an alternative to conventional hospitalization. In this study we evaluate the results of a prospective cohort study of patients receiving ambulatory endovascular treatment for peripheral arterial lesions. METHODS From June 2008 to October 2010, ambulatory management was proposed for endovascular treatment of peripheral arterial lesions. An arterial closure device (Angio-Seal(®); St. Jude Medical) was used. For ambulatory treatment, patients were prohibited from driving a vehicle at discharge, had to be accompanied the first night after the procedure, had to live <1 hour from a medical facility, had to be reachable by telephone the day after the intervention, and had to remain hospitalized in the event of a complication. The principal criterion was morbimortality at 1 month. Secondary criteria were clinical improvement, patency, complications related to the arterial closure, and costs evaluation at 1 month. RESULTS Forty-five patients were included and 50 ambulatory procedures were carried out. The patients presented with claudication (92%) or a critical ischemia (8%) of the lower extremities. All procedures were carried out by femoral puncture (retrograde in 94% and anterograde in 6% of the cases). The patients presented with iliac (68%) and femoropopliteal (64%) lesions. Lesions included stenoses (70%), thromboses (16%), and intrastent restenoses (14%). The rate of failure of ambulatory hospitalization was 16% (n = 8) without a serious undesirable event: 2 patients were hospitalized after a surgical conversion for iliac rupture and disinsertion of stent; 3 patients developed a hematoma during the intervention at the point of puncture; and in 3 cases the system of percutaneous closure failed. The mean duration of hospitalization was 1.36 ± 1.33 days. At 1 month, clinical improvement was observed in 97.5% of cases, with a primary patency of 100%. No perioperative rehospitalization or puncture site complications were observed. Ambulatory management made it possible to save 42 days of hospitalization, with associated costs of 10,971€, compared with conventional hospitalization. The additional costs related to use of the Angio-Seal amounted to 7427€. CONCLUSION Ambulatory endovascular treatment of patients presenting with peripheral arterial lesions is reliable and effective and may contribute to savings in healthcare spending.
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Gouicem D, Palcau L, Le Hello C, Cameliere L, Dufranc J, Coffin O, Berger L. Feasibility of ambulatory percutaneous femoral access without the use of arterial closure systems. Ann Vasc Surg 2013; 28:132-6. [PMID: 24183456 DOI: 10.1016/j.avsg.2013.06.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 06/11/2013] [Accepted: 06/12/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND To evaluate the feasibility of early ambulation in patients treated for peripheral occlusive lesions by femoral percutaneous access, without the use of closure systems and the application to ambulatory practice. METHODS This single-center observational exploratory study was undertaken among 99 consecutive patients between August 1-December 31, 2011 (mean age: 72 years; 72 men) who were treated by percutaneous femoral route for peripheral arterial lesions. All the patients had a manual compression then pressure bandage. A clinical evaluation was carried out after 4 hours, seeking a local or a general complication and checking the procedure. Rising and walking in the unit of hospitalization were authorized in the absence of complication as of 4 hours postoperatively. All patients remained in hospital for at least 1 night, with a clinical revaluation before discharge. All patients were contacted by telephone at postoperative day 7 in order to verify the absence of local complications. All the individual factors and those related to the procedure were analyzed. RESULTS With criteria of complications related to the gesture, 72 patients (72.7%) were considered ready to be discharged as of postoperative hour 4. Among the 27 patients who were not able to leave, 7 presented with an early local complication without reoperation, and 20 could not walk because of a necrotic lesion (n = 8), their advanced age (n = 4), morbid obesity (n = 2), or a choice of the surgeon in charge (n = 6). Twenty-five patients could, however, stroll after 12 hours. The mean duration of hospitalization was 1.3 days (range: 0-10 days). Two patients required distal amputation during the same hospitalization, and 1 underwent a femoropopliteal bypass after failure of a femoropopliteal recanalization. With univariate analysis, the treatment by anticoagulants and the duration of the hospitalization were the only factors significantly related to the impossibility of early ambulation. The occurrence of complications was linked with the experience of the surgeon, the age of the patient, and the female sex. Three patients, including 2 regarded as ready to walk by postoperative hour 4, were rehospitalized after 1 week for reoperation because of 1 major hematoma and 2 femoral false aneurysms. CONCLUSION Percutaneous endovascular surgery by the femoral route without using an arterial closure system is feasible in an ambulatory practice in nearly 75% of cases. Particular monitoring must be done in the oldest patients, women, and those treated with anticoagulants.
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Affiliation(s)
- Djelloul Gouicem
- Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Laura Palcau
- Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Claire Le Hello
- Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Lucie Cameliere
- Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Julie Dufranc
- Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Olivier Coffin
- Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Ludovic Berger
- Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire de Caen, Caen, France.
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Park JK, Oh SJ, Shin JY. Delayed rupture of the iliac artery after percutaneous angioplasty. Ann Vasc Surg 2013; 28:491.e1-4. [PMID: 24161439 DOI: 10.1016/j.avsg.2013.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2013] [Revised: 05/04/2013] [Accepted: 05/08/2013] [Indexed: 11/16/2022]
Abstract
Rupture of the iliac artery during percutaneous angioplasty is a life-threatening condition that requires prompt diagnosis and treatment to rescue the patient. Recently, percutaneous angioplasty has become an outpatient procedure, but there is no reliable guideline for observation time in the hospital after percutaneous angioplasty. We describe a 67-year-old man with bilateral lesions in the iliac artery who experienced a delayed rupture of the iliac artery 2 days after percutaneous balloon angioplasty and placement of a self-expandable stent. The patient was successfully treated by endovascular intervention with a stent graft. In our department, percutaneous angioplasty is not performed in an outpatient clinic, and all patients are admitted to the hospital and observed for at least 3 days after percutaneous angioplasty. Because our patient was in the hospital when the iliac artery ruptured, prompt diagnosis and treatment were possible. Moreover, because appropriately sized stent grafts were prepared in the hospital, timely endovascular treatment could be performed, and the patient recovered successfully. From this case, we conclude that observing patients for a sufficient time in the hospital and preparing appropriately sized stent grafts are 2 important factors for the safety of patients who undergo percutaneous angioplasty.
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Affiliation(s)
- Jong Kwon Park
- Department of Surgery, Haeundae Paik Hospital, College of Medicine, Inje University, Busan, Republic of Korea.
| | - Sung Jin Oh
- Department of Surgery, Haeundae Paik Hospital, College of Medicine, Inje University, Busan, Republic of Korea
| | - Jin Yong Shin
- Department of Surgery, Haeundae Paik Hospital, College of Medicine, Inje University, Busan, Republic of Korea
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Lo RC, Bensley RP, Dahlberg SE, Matyal R, Hamdan AD, Wyers M, Chaikof EL, Schermerhorn ML. Presentation, treatment, and outcome differences between men and women undergoing revascularization or amputation for lower extremity peripheral arterial disease. J Vasc Surg 2013; 59:409-418.e3. [PMID: 24080134 DOI: 10.1016/j.jvs.2013.07.114] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 07/24/2013] [Accepted: 07/29/2013] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Prior studies have suggested treatment and outcome disparities between men and women for lower extremity peripheral arterial disease after surgical bypass. Given the recent shift toward endovascular therapy, which has increasingly been used to treat claudication, we sought to analyze sex disparities in presentation, revascularization, amputation, and inpatient mortality. METHODS We identified individuals with intermittent claudication and critical limb ischemia (CLI) using International Classification of Diseases, Ninth Revision codes in the Nationwide Inpatient Sample from 1998 to 2009. We compared presentation at time of intervention (intermittent claudication vs CLI), procedure (open surgery vs percutaneous transluminal angioplasty or stenting vs major amputation), and in-hospital mortality for men and women. Regional and ambulatory trends were evaluated by performing a separate analysis of the State Inpatient and Ambulatory Surgery Databases from four geographically diverse states: California, Florida, Maryland, and New Jersey. RESULTS From the Nationwide Inpatient Sample, we identified 1,797,885 patients (56% male) with intermittent claudication (26%) and CLI (74%), who underwent 1,865,999 procedures (41% open surgery, 20% percutaneous transluminal angioplasty or stenting, and 24% amputation). Women were older at the time of intervention by 3.5 years on average and more likely to present with CLI (75.9% vs 72.3%; odds ratio [OR], 1.21; 95% confidence interval [CI], 1.21-1.23; P < .01). Women were more likely to undergo endovascular procedures for both intermittent claudication (47% vs 41%; OR, 1.27; 95% CI, 1.25-1.28; P < .01) and CLI (21% vs 19%; OR, 1.14; 95% CI, 1.13-1.15; P < .01). From 1998 to 2009, major amputations declined from 18 to 11 per 100,000 in men and 16 to 7 per 100,000 in women, predating an increase in total CLI revascularization procedures that was seen starting in 2005 for both men and women. In-hospital mortality was higher in women regardless of disease severity or procedure performed even after adjusting for age and baseline comorbidities (.5% vs .2% after percutaneous transluminal angioplasty or stenting for intermittent claudication; 1.0% vs .7% after open surgery for intermittent claudication; 2.3% vs 1.6% after percutaneous transluminal angioplasty or stenting for CLI; 2.7% vs 2.2% after open surgery for CLI; P < .01 for all comparisons). CONCLUSIONS There appears to be a preference to perform endovascular over surgical revascularization among women, who are older and have more advanced disease at presentation. Percutaneous transluminal angioplasty or stenting continues to be popular and is increasingly being performed in the outpatient setting. Amputation and in-hospital mortality rates have been declining, and women now have lower amputation but higher mortality rates than men. Recent improvements in outcomes are likely the result of a combination of improved medical management and risk factor reduction.
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Affiliation(s)
- Ruby C Lo
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Rodney P Bensley
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Suzanne E Dahlberg
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Robina Matyal
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Allen D Hamdan
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Mark Wyers
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Elliot L Chaikof
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass.
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Safety of endovascular treatment of chronic cerebrospinal venous insufficiency: a report of 240 patients with multiple sclerosis. J Vasc Interv Radiol 2011; 23:55-9. [PMID: 22088659 DOI: 10.1016/j.jvir.2011.09.019] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Revised: 09/19/2011] [Accepted: 09/20/2011] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To evaluate the safety of outpatient endovascular treatment in patients with multiple sclerosis (MS) and chronic cerebrospinal venous insufficiency (CCSVI). MATERIALS AND METHODS A retrospective analysis was performed to assess complications occurring within 30 days of endovascular treatment of CCSVI. The study population comprised 240 patients; 257 procedures were performed over 8 months. The indication for treatment in all patients was symptomatic MS. Of the procedures, 49.0% (126 of 257) were performed in a hospital, and 51.0% (131 of 257) were performed in the office. Primary procedures accounted for 93.0% (239 of 257) of procedures, and repeat interventions accounted for 7% (18 of 257). For patients treated primarily, 87% (208 of 239) had angioplasty, and 11% (26 of 239) had stent placement; 5 patients were not treated. Of patients with restenosis, 50% (9 of 18) had angioplasty, and 50% (9 of 18) had stent placement. RESULTS After the procedure, all but three patients were discharged within 3 hours. Headache after the procedure was reported in 8.2% (21 of 257) of patients; headache persisted > 30 days in 1 patient. Neck pain was reported in 15.6% (40 of 257); 52.5% (21 of 40) of these patients underwent stent placement. Three patients experienced venous thrombosis requiring retreatment within 30 days. Sustained intraprocedural arrhythmias were observed in three patients, and two required hospital admission. One of these patients, who was being retreated for stent thrombosis, was hospitalized because of a stress-induced cardiomyopathy. CONCLUSIONS Endovascular treatment of CCSVI is a safe procedure; there is a 1.6% risk of major complications. Cardiac monitoring is essential to detect intraprocedural arrhythmias. Ultrasonography after the procedure is recommended to confirm venous patency and to identify patients experiencing acute venous thrombosis.
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Maurel B, Paumier A, Jacobi D, Bleuet F, Martinez R, Lermusiaux P. Ambulatory percutaneous angioplasty in patients with claudication. Ann Vasc Surg 2010; 25:191-6. [PMID: 21131175 DOI: 10.1016/j.avsg.2010.08.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Revised: 08/08/2010] [Accepted: 08/14/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the feasibility of outpatient peripheral angioplasty in patients who were treated for lower limb claudication. METHODS Between February 1 and December 31, 2007, a monocentric observational study was carried out on 98 consecutive patients who presented with claudication (mean age: 63 years [range: 31-90]; 81 men) and were treated by using a percutaneous femoral approach for either iliac (n = 62) or femoropopliteal lesions (n = 36). Exclusion criteria were requiring a renal angioplasty or an associated surgical procedure, having a creatinine clearance value of <30 mL/min/1.73 m(2), body mass index exceeding 35 kg/m(2), and critical ischemia or vascular surgery history at the site of femoral puncture. Treatment involved manual compression and/or use of a closure system, after which the patients were made to wear a compression bandage. After 4 hours, the patients were carefully examined for the presence of a local complication (puncture site), a general complication (thoracic pain), or a complication related to the surgical procedure (early thrombosis). When no complications were detected, the patients were allowed to get up and walk. At the sixth hour, the patients were again examined for the presence of the aforementioned complications. In the absence of any complications, the patients were deemed as "fit to be discharged" and were allowed to stroll about inside the hospital. The following day, a final evaluation was carried out just before their discharge. The risk factors and comorbidities were evaluated. RESULTS At the sixth postoperative hour, 78 patients (80%) were deemed as "fit to be discharged." The remaining 20 (20%) were deemed as "unfit to be discharged" because of either a major hematoma (n = 3, including two redo surgeries and a blood transfusion) or a minor evolutive hematoma. All the complications (n = 17) occurred before the fourth postoperative hour. Bilateral femoral puncture was the only risk factor found to be associated with contraindication to being discharged in the evening (OR = 3.8, p = 0.02). CONCLUSION Ambulatory treatment for patients with claudication treated with an endovascular approach was possible because complications that required overnight surveillance always occurred within the first 4 postoperative hours. Bilateral femoral puncture is a potential risk factor for failure of outpatient management.
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Samson RH. Setting up an imaging center, adding computed tomographic, magnetic resonance, and an angiography suite to vascular labs. J Vasc Surg 2009; 49:1073-6. [DOI: 10.1016/j.jvs.2008.11.099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2008] [Revised: 11/17/2008] [Accepted: 11/21/2008] [Indexed: 10/20/2022]
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Mitchell JW, O'Connell WG, Kisza P, Klyde DP, Gonzalez SF, Maldjian P, Bahramipour P, Contractor SG. Safety and feasibility of outpatient transcatheter hepatic arterial embolization for hepatocellular carcinoma. J Vasc Interv Radiol 2008; 20:203-8. [PMID: 19097805 DOI: 10.1016/j.jvir.2008.10.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2008] [Revised: 10/28/2008] [Accepted: 10/29/2008] [Indexed: 01/28/2023] Open
Abstract
PURPOSE To evaluate the feasibility and safety of performing image-guided bland embolization and chemoembolization as an outpatient-based procedure in selected patients with hepatocellular carcinoma (HCC). MATERIALS AND METHODS This is a retrospective review of the authors' experience with outpatient embolization and chemoembolization from January 2005 to June 2006. Patients with nonresectable HCC not eligible for liver transplantation were enrolled. Patients with Child-Pugh class A and early class B liver disease were treated by using the outpatient protocol, patients with Child-Pugh class C and late class B liver disease and those with elevated bilirubin or creatinine levels were excluded and treated as inpatients or denied embolization therapy. One hundred thirty-three bland embolizations or chemoembolizations were performed in 77 patients on an outpatient basis during the study period. RESULTS Patients were discharged home on the same day after 131 of the 133 procedures (99%; 95% confidence interval [CI]: +/-2%), in two cases (2%, 95% CI: +/-2%), patients were admitted the day of the procedure. In two of the 131 cases (2%, 95% CI: +/-2%), patients discharged home returned to the emergency department 1-6 days after the procedure. One hundred twenty-nine of the 133 cases (97%, 95% CI: +/-3%) were successfully treated by using the outpatient embolization or chemoembolization protocol, with subsequent hospitalization needed in only four of 133 cases (3%, 95% CI: +/-3%). CONCLUSIONS Image-guided hepatic bland embolization and chemoembolization performed with an outpatient protocol in carefully selected patients with HCC with aggressive follow-up is safe, with relatively few complications and few requirements for admission or revisitation to the emergency department.
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Affiliation(s)
- Jason W Mitchell
- Department of Radiology, University Hospital, UMDNJ-New Jersey Medical School, 150 Bergen St, Ste C-318, Newark, NJ 07103, USA
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Huang DY, Ong CM, Walters HL, Wilkins CJ, Evans DR, Edmondson RD, Jones K, Rashid HI, Deane CD, Goss DE, Sidhu PS. Day-case diagnostic and interventional peripheral angiography: 10-year experience in a radiology specialist nurse-led unit. Br J Radiol 2008; 81:537-44. [PMID: 18347026 DOI: 10.1259/bjr/54749779] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We describe a prospective evaluation of the safety of peripheral angiography procedures performed on day-case patients in a dedicated radiological nurse-led and administrated unit. Patients referred for peripheral vascular angiography, over a 10-year period, were pre-assessed by a radiology specialist nurse in a nurse-led clinic. Radiologists performed all procedures, whereas radiology specialist nurses were responsible for patient care before, during and after angiography and during the 24 h follow-up. Procedures were divided into diagnostic or interventional; complications were divided into immediate or delayed (24 h follow-up) either requiring hospital admission (major) or day-case unit management (minor). Patient acceptability was assessed using a standard questionnaire. Cost analysis was also performed. 401 day-case peripheral angiography procedures (144 diagnostic and 257 interventional) were performed in 310 patients. 109/401 (27.2%) procedures were performed on patients with diabetes mellitus. In diagnostic studies, 16/144 (11.1%) immediate and 6/144 (4.2%) delayed complications occurred whereas, in interventional studies, 65/257 (25.3%) immediate and 13/257 (5.1%) delayed complications were noted. A major complication occurred in 17/257 (6.6%) of patients in the interventional group and 3/144 (2.1%) in the diagnostic group. Puncture site haematoma was the most common complication. Nurse-led care was acceptable to the patient, with a high level of patient satisfaction seen. In conclusion, day-case diagnostic and interventional peripheral angiography procedures can be performed safely in a specialist nurse-led and administrated unit, with complication rates being within the accepted guidelines.
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Affiliation(s)
- D Y Huang
- Department of Radiology, King's College Hospital, Denmark Hill, London SE5 9RS, UK
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Watson K, Watson BD, Pater KS. Peripheral Arterial Disease: A Review of Disease Awareness and Management. ACTA ACUST UNITED AC 2006; 4:365-79. [PMID: 17296541 DOI: 10.1016/j.amjopharm.2006.12.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Peripheral arterial disease (PAD) is a progressive atherosclerotic condition affecting approximately 27 million people in North America and Europe. Albeit a common clinical malady, it is underrecognized and undertreated. OBJECTIVE The goal of this article was to review the pathophysiology, clinical implications, diagnosis, and management of PAD. METHODS Relevant published information was identified through a search of MEDLINE (1966-2006). Search terms used included peripheral vascular diseases, intermittent claudication, arterial occlusive diseases, antiplatelet therapy, HMG-CoA reductase inhibitors, risk factors, smoking cessation, adrenergic beta-antagonists, and angiotensin-converting enzymes. RESULTS PAD is associated with an increased risk of cardiovascular and cerebrovascular disease as well as a reduction in quality of life. PAD symptoms are not always present with the disease; therefore, improvements in screening methods for at-risk patients are necessary. Patients at risk for PAD should be routinely screened, and appropriate management--including antiplatelet therapy and risk factor modifications--should be initiated once the disease is recognized. Risk factor modifications should include smoking cessation as well as blood pressure and cholesterol management. Acetylsalicylic acid (ASA) is the antiplatelet of choice, and clopidogrel should be used as an alternative if ASA therapy is contraindicated or an intolerance is present. Cilostazol has a minimal role for the symptomatic relief in patients with disabling intermittent claudication. All patients with PAD should be treated with a 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor and potentially an angiotensin-converting enzyme inhibitor. Beta-Blockers should not be avoided unless documented worsening of symptoms is associated with their use. CONCLUSIONS Patients at risk for PAD should be routinely screened, and appropriate management including antiplatelet therapy and risk factor modifications should be initiated once the disease is recognized.
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Affiliation(s)
- Kristin Watson
- Department o f Pharmacy Practice and Sciences, University o f Maryland, School of Pharmacy, Baltimore, Maryland 21201, USA.
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Akopian G, Katz SG. Peripheral angioplasty with same-day discharge in patients with intermittent claudication. J Vasc Surg 2006; 44:115-8. [PMID: 16730157 DOI: 10.1016/j.jvs.2006.03.025] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2006] [Accepted: 03/20/2006] [Indexed: 11/28/2022]
Abstract
BACKGROUND As the number of endovascular interventions increase and resources become scarce, surgeons need to be aware of cost-effective and efficient practice options. Many surgeons routinely admit their patients for overnight observation after uneventful endovascular interventions. Although this may be appropriate for patients with tissue loss and rest pain, we believe that peripheral angioplasty in patients with claudication can be safely performed as an outpatient procedure with significant cost savings. METHODS All patients with intermittent claudication undergoing peripheral angioplasty by a single vascular surgeon were enrolled prospectively in a same-day discharge protocol. Involved arteries and use of stent and closure device were recorded. Time to mobilization and time to discharge were determined. Patients were observed in an observation unit by a registered nurse, and were examined by the surgeon at the time of ambulation and before discharge. Patients were admitted to the hospital if complications arose during the predetermined observation period. Periprocedural complications and reasons for admission were noted. Patients were evaluated at 1 week, 6 weeks, and 3 to 6 months after the intervention. RESULTS During 27 months, 112 interventions were performed in 97 patients. The superficial femoral artery was the most frequent site of intervention (47%). Multiple sites had angioplasty in 27 (24%) procedures. Nine (8%) procedures resulted in admission. One patient was admitted for a major puncture site hematoma requiring blood transfusion, two patients for observation of a minor hematoma at the puncture site, one for chest pain, and one for observation of transient bradycardia. The mean time to mobilization was 1.4 +/- 1.3 hours, and the mean time to discharge was 2.8 +/- 1.2 hours. The average postprocedural cost for patients undergoing same-day discharge was $320 per patient, which contrasts with $1800 for routine overnight observation. No deaths or unplanned admissions to the hospital occurred < or =30 days of intervention. CONCLUSIONS Same-day discharge after peripheral angioplasty is safe and cost-effective. Need for admission is evident within 2 hours. Routine admission after peripheral angioplasty for patients with claudication is unnecessary and should no longer be the standard of care.
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Affiliation(s)
- Gabriel Akopian
- Department of Surgery, Division of Vascular Surgery, Keck School of Medicine, Huntington Hospital, Pasadena, CA 91105, USA
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Bottner RK, Blankenship JC, Klein LW. Current usage and attitudes among interventional cardiologists regarding the performance of percutaneous coronary intervention (PCI) in the outpatient setting. Catheter Cardiovasc Interv 2005; 66:455-61. [PMID: 16217779 DOI: 10.1002/ccd.20567] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Gradinscak DJ, Young N, Jones Y, O'Neil D, Sindhusake D. Risks of Outpatient Angiography and Interventional Procedures: A Prospective Study. AJR Am J Roentgenol 2004; 183:377-81. [PMID: 15269028 DOI: 10.2214/ajr.183.2.1830377] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate complications in diagnostic and interventional angiographic procedures performed on outpatients. MATERIALS AND METHODS Data were collected prospectively for 2,683 procedures performed on an outpatient basis in 2,248 patients from the period March 1997 to March 2002. Patients were assessed by nursing or medical staff within 2-4 hr of the procedure and again via telephone 24-48 hr after the procedure. The collected data were summarized on the basis of procedure type into four main groupings: aortofemoral studies, cerebral studies, interventional procedures, and other studies. Complication frequency distribution was determined for each procedure type. An interim summary of complication rates was prepared for the period March 1997 to June 1999. Statistical analysis using a two-tailed z-test for the comparison of two proportions was performed to determine if a significant difference existed in the rates of complications from data collected before and after the June 1999 summary. RESULTS Ninety-one percent of cases completed follow-up. In total, 561 complications were identified in 2,436 cases (23%). Most complications consisted of either local pain or puncture site hematoma and bruising. No deaths occurred. In the 1,128 diagnostic aortofemoral studies performed, 211 complications (19%) occurred. In the 359 cerebral studies, 87 complications (24%) occurred. The 441 interventional procedures resulted in 146 complications (33%). In the remaining 508 procedures, 117 complications (23%) occurred. Major complications in each group are presented. CONCLUSION We observed a low incidence of complications requiring further treatment or resulting in a permanent deficit. The rates are comparable to published data from similar studies and practice standards guidelines. A statistically significant improvement was seen in the total complication rate between the periods March 1997-June 1999 and July 1999-March 2002 (p = 0.01).
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Affiliation(s)
- Denis J Gradinscak
- Radiology Department, Level 2, Westmead Hospital, Westmead 2145, NSW, Australia
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Dowling K, Todd D, Siskin G, Stainken B, Dolen E, Sansivero G, Quarfordt S, Mitchell N, Clement Darling R. Early Ambulation After Diagnostic Angiography Using 4-F Catheters and Sheaths: A Feasibility Study. J Endovasc Ther 2002. [DOI: 10.1583/1545-1550(2002)009<0618:eaadau>2.0.co;2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Dowling K, Todd D, Siskin G, Stainken B, Dolen E, Sansivero G, Quarfordt S, Mitchell N, Darling RC. Early ambulation after diagnostic angiography using 4-f catheters and sheaths: a feasibility study. J Endovasc Ther 2002; 9:618-21. [PMID: 12431146 DOI: 10.1177/152660280200900512] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To assess the feasibility and safety of early ambulation in patients undergoing transfemoral diagnostic angiography using 4-F catheters or sheaths. METHODS In this prospective study approved by the institutional review board, patients undergoing diagnostic angiography were randomized to ambulate 3 or 6 hours after catheter or sheath removal. All patients were assessed for hematoma formation, pseudoaneurysm development, and other groin complications during the in-hospital recovery period and after 30 days. Patient satisfaction and comfort level were also assessed by survey. RESULTS Of 110 patients (66 men; mean age 64.9 +/- 12.8 years) who participated in this study, 47 were randomized to the 6-hour (6-H) group and 63 to the 3-hour (3-H) group. In the 3-H and 6-H groups, respectively, a 4-F catheter was used in 45 (71%) and 35 (74%) patients and a 4-F sheath in 18 (29%) and 12 (26%). No clinically significant groin complications were encountered in either group. Moderate to severe discomfort was reported in 9 (16%) of the 56 patients responding to the discomfort survey in the 3-H group compared to 10 (26%) of the 38 in the 6-H survey respondents. CONCLUSIONS It is feasible and safe to ambulate patients 3 hours after diagnostic angiography performed with a 4-F catheter with or without a 4-F sheath. Early ambulation of patients after angiography has the additional benefits of increasing patient satisfaction and resource utilization.
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Affiliation(s)
- Kyran Dowling
- Institute for Vascular Health and Disease, Albany Medical College, Albany, New York 12208, USA.
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Butterfield JS, Fitzgerald JB, Razzaq R, Willard CJ, Ashleigh RJ, England RE, Chalmers N, Andrew HM. Early mobilization following angioplasty. Clin Radiol 2000; 55:874-7. [PMID: 11069744 DOI: 10.1053/crad.2000.0595] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM To assess the incidence of puncture site complications in in-patients undergoing early mobilization following angioplasty with a view to performing day case angioplasty. MATERIALS AND METHODS One hundred and twenty-eight patients undergoing peripheral and renal angioplasty using a sheath size of up to 6 French were recruited prospectively. The mobilization protocol consisted of supine bed rest for 2 h, followed by gradual mobilization, so that the patient was ambulant 4 h after the procedure. Mobilization was delayed if clinically appropriate. Puncture sites were scored for discomfort, paraesthesia, visible bruising and palpable haematoma after groin compression and the following morning. RESULTS One hundred and forty-four puncture sites were studied. There were 44 haematomas in total, of which 37 (26%) were less than 2.5 cm and seven (4.9%) were between 2.5 cm and 7.5 cm. Four patients (2.8%) had visible bruising greater than 7.5 cm. No patient assessed discomfort higher than moderate at any stage. Mobilization was delayed in 15 patients. In 11 this was due to puncture site oozing, haematoma in one, two were hypertensive and one required surgery for limb ischaemia. All complications occurred within 4 h of angioplasty. No patient required surgery or transfusion for haemorrhagic complications. CONCLUSION Mobilization at 4 h was successful in 90% of cases but 10% require more prolonged bed rest. No delayed complications occurred. These results suggest that day case angioplasty is feasible in most cases.Butterfield, J. S. (2000). Clinical Radiology55, 874-877
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Affiliation(s)
- J S Butterfield
- South Manchester University Hospitals, N.H.S. Trust, Nell Lane, West Didsbury, Machester, UK
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