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Iguidbashian J, Lun Z, Bata K, King RW, Gunn-Sandell L, Crosby D, Stoebner K, Tharp D, Lin CT, Cumbler E, Wiler J, Yi J. Novel Electronic Health Records-Based Consultation Workflow Improves Time to Operating Room for Vascular Surgery Patients in an Acute Setting. Ann Vasc Surg 2023; 97:139-146. [PMID: 37495093 DOI: 10.1016/j.avsg.2023.07.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/04/2023] [Accepted: 07/11/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Inefficient clinical workflows can have downstream effects of increased costs, poor resource utilization, and worse patient outcomes. The surgical consultation process can be complex with unclear communication, potentially delaying care for patients requiring time-sensitive intervention in an acute setting. A novel electronic health records (EHR)-based workflow was implemented to improve the consultation process. After implementation, we assessed the impact of this initiative in patients requiring vascular surgery consultation. METHODS An EHR-driven consultation workflow was implemented at a single institution, standardizing the process across all consulting services. This order-initiated workflow automated notification to clinicians of consult requests, communication of patient data, patient addition to consultants' lists, and tracking consult completion. Preimplementation (1/1/2020-1/31/2022) and postimplementation (2/1/2022-12/4/2022) vascular surgery consultation cohorts were compared to evaluate the impact of this initiative on timeliness of care. RESULTS There were 554 inpatient vascular surgery consultations (255 preimplementation and 299 postimplementation); 45 and 76 consults required surgery before and after implementation, respectively. The novel workflow resulted in placement of a consult note 32 min faster than preimplementation (preimplementation: 462 min, postimplementation: 430 min, P = 0.001) for all vascular surgery consults. Furthermore, vascular surgery patients with ASA class III or IV status requiring an urgent or emergent operation were transported to the operating room 63.3% faster after implementation of the workflow (preimplementation: 284 min, postimplementation: 180 min, P = 0.02). There were no differences in procedure duration, postoperative disposition, or intraoperative complication rates. CONCLUSIONS We implemented a novel workflow utilizing the EHR to standardize and automate the consultation process in the acute inpatient setting. This institutional initiative significantly improved timeliness of care for vascular surgery patients, including decreased time to operation. Innovations such as this can be further disseminated across shared EHR platforms across institutions, representing a powerful tool to increase the value of care in vascular surgery and healthcare overall.
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Affiliation(s)
- John Iguidbashian
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO.
| | - Zhixin Lun
- Department of Biostatistics, Center of Innovative Design and Analysis, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Kyle Bata
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Robert W King
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Lauren Gunn-Sandell
- Department of Biostatistics, Center of Innovative Design and Analysis, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Derek Crosby
- Division of Vascular Medicine, University of Colorado Health, Aurora, CO
| | - Kristin Stoebner
- Division of Vascular Medicine, University of Colorado Health, Aurora, CO
| | - David Tharp
- Division of Vascular Medicine, University of Colorado Health, Aurora, CO
| | - C T Lin
- Department of Medicine, University of Colorado, Aurora, CO
| | - Ethan Cumbler
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO; Department of Medicine, University of Colorado, Aurora, CO
| | - Jennifer Wiler
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Jeniann Yi
- Division of Vascular Surgery and Endovascular Therapy, University of Colorado Anschutz Medical Campus, Aurora, CO
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2
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Boucher N, Dreksler H, Hooper J, Nagpal S, MirGhassemi A, Miller E. Anaesthesia for vascular emergencies - a state of the art review. Anaesthesia 2023; 78:236-246. [PMID: 36308289 DOI: 10.1111/anae.15899] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2022] [Indexed: 01/11/2023]
Abstract
In this state-of-the-art review, we discuss the presenting symptoms and management strategies for vascular emergencies. Although vascular emergencies are best treated at a vascular surgical centre, patients may present to any emergency department and may require both immediate management and safe transport to a vascular centre. We describe the surgical and anaesthetic considerations for management of aortic dissection, aortic rupture, carotid endarterectomy, acute limb ischaemia and mesenteric ischaemia. Important issues to consider in aortic dissection are extent of the dissection and surgical need for bypasses in addition to endovascular repair. From an anaesthetist's perspective, aortic dissection requires infrastructure for massive transfusion, smooth management should an endovascular procedure require conversion to an open procedure, haemodynamic manipulation during stent deployment and prevention of spinal cord ischaemia. Principles in management of aortic rupture, whether open or endovascular treatment is chosen, include immediate transfer to a vascular care centre; minimising haemodynamic changes to reduce aortic shear stress; permissive hypotension in the pre-operative period; and initiation of massive transfusion protocol. Carotid endarterectomy for carotid stenosis is managed with general or regional techniques, and anaesthetists must be prepared to manage haemodynamic, neurological and airway issues peri-operatively. Acute limb ischaemia is a result of embolism, thrombosis, dissection or trauma, and may be treated with open repair or embolectomy, under either general or local anaesthesia. Due to hypercoagulability, there may be higher numbers of acutely ischaemic limbs among patients with COVID-19, which is important to consider in the current pandemic. Mesenteric ischaemia is a rare vascular emergency, but it is challenging to diagnose and associated with high morbidity and mortality. Several peri-operative issues are common to all vascular emergencies: acute renal injury; management of transfusion; need for heparinisation and reversal; and challenging postoperative care. Finally, the important development of endovascular techniques for repair in many vascular emergencies has improved care, and the availability of transoesophageal echocardiography has improved monitoring as well as aids in surgical placement of endovascular grafts and for post-procedural evaluation.
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Affiliation(s)
- N Boucher
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada
| | - H Dreksler
- Division of Vascular Surgery, Department of Surgery, University of Ottawa, ON, Canada
| | - J Hooper
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada.,Department of Critical Care, The Ottawa Hospital, University of Ottawa, ON, Canada
| | - S Nagpal
- Division of Vascular Surgery, Department of Surgery, University of Ottawa, ON, Canada
| | - A MirGhassemi
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada
| | - E Miller
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada
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Abstract
Chronic limb-threatening ischemia requires aggressive risk factor management and a thoughtful approach to the complex decision of best strategy for revascularization. Patients often have multilevel disease amenable to endovascular, open surgical, or hybrid approaches. Limited high-quality evidence is available to support a specific strategy; randomized trials are ongoing. Acute limb ischemia is associated with a high risk of limb loss and mortality. Catheter-directed thrombolysis is mainstay of therapy in patients with marginally threatened limbs, whereas those immediately threatened with motor deficits require more rapid restoration of flow with open or endovascular techniques that can establish flow in single setting.
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Affiliation(s)
- Jocelyn M Beach
- Section of Vascular Surgery, Heart and Vascular Institute, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA.
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4
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Low M, Gray BH. Navigating between the science and art of acute limb ischemia treatment. Prog Cardiovasc Dis 2021; 65:29-33. [PMID: 33587961 DOI: 10.1016/j.pcad.2021.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 02/08/2021] [Indexed: 11/19/2022]
Abstract
The diagnosis and treatment of acute limb ischemia (ALI) has long been a fierce adversary that has evolved over the last several decades with scientific advancements in endovascular therapy. History and physical examination remain the mainstay of diagnosis enhanced by detailed imaging to guide therapy. Many endovascular tools are available for prompt restoration of flow that compliment traditional surgical options. These devices incorporate the mechanical removal of thrombus and the chemical dissolution of thrombus . Medical decision-making for ALI patients must take into account the patient characteristics, anatomic variables, mechanism of ischemia, degree of ischemia, and operator skill to employ the right strategy for the right patient. This moving target challenges scientific study, making the therapeutic bedside decision making an artform. We present an overview of the field, supportive data, and a treatment algorithm that hopefully captures this delicate balance.
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Affiliation(s)
- Matthew Low
- Department of Surgery/Vascular Medicine, Prisma Health System, Greenville, SC, United States of America
| | - Bruce H Gray
- Department of Surgery/Vascular Medicine, Prisma Health System, Greenville, SC, United States of America.
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Franco RDL, Iora PH, Dutra AC, Belczak SQ, Vissoci J, Staton C, Andrade L. Spatial inequalities of major lower limb amputation rates in Paraná state, Brazil. BMJ Open 2020; 10:e038980. [PMID: 33361072 PMCID: PMC7768970 DOI: 10.1136/bmjopen-2020-038980] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The aim of this observational cross-sectional study was to analyse the spatial distribution of major lower limb amputation (MLLA) rates and associate them to socioeconomic, demographic and public healthcare access-related variables in the State of Paraná, Brazil, from 2012 to 2017. METHOD Data on MLLA, revascularisation surgeries, diagnostic exams and healthcare coverage were obtained from the Brazilian Public Hospital Information System. Socioeconomic data were obtained from the Brazilian Institute of Geography and Statistics. Spatial autocorrelation of the MLLA rates was tested using Moran's I method. Multivariate spatial regression models using ordinary least squares regression (OLS) and geographically weighted regression (GWR) were used to identify the variables significantly correlated with MLLA. RESULTS A total of 5270 MLLA were included in the analysis. Mean MLLA rates were 24.32 (±18.22)/100 000 inhabitants, showing a positive global spatial autocorrelation (Moran's I=0.66; p<0.001). Queen contiguity matrix demonstrates that MLLA rates ranged from 7.6 to 46.6/100 000 with five large clusters of high MLLA rates. OLS showed that four of the nine studied variables presented significant spatial correlation with MLLA rates. Colour Doppler ultrasound showed a negative association (p<0.001), while revascularisation surgeries and illiteracy showed a positive correlation (p<0.01). GWR presented the best model (adjusted R2=0.77) showing that the predictors differentially affect the MLLA rates geographically. CONCLUSION The high MLLA rates in some regions of the state are influenced by the high rate of illiteracy and low utilisation rate of colour Doppler, indicating a social problem and difficulty in accessing health. On the other hand, the high rates of revascularisation surgeries are related to higher MLLA rates, possibly due to delayed access to specialised hospitals. This indicates that attention must be given to population access to public healthcare in the State of Paraná in order to ensure proper and timely medical attention.
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Affiliation(s)
| | | | | | | | - João Vissoci
- Division of Emergency Medicine, Duke University, Durham, North Carolina, USA
| | - Catherine Staton
- Division of Emergency Medicine, Duke University, Durham, North Carolina, USA
| | - Luciano Andrade
- Medicine Department, Universidade Estadual de Maringa, Maringa, Brazil
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Shah MP, Bowens NM, de Virgilio C. Cold, Painful Right Lower Extremity. Surgery 2020. [DOI: 10.1007/978-3-030-05387-1_59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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7
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Combined treatment (image-guided thrombectomy and endovascular therapy with open femoral access) for acute lower limb ischemia: Clinical efficacy and outcomes. PLoS One 2019; 14:e0225136. [PMID: 31730625 PMCID: PMC6857913 DOI: 10.1371/journal.pone.0225136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 10/29/2019] [Indexed: 11/19/2022] Open
Abstract
Objectives To evaluate the effectiveness and safety of combined treatment (image guided thrombectomy and endovascular therapy with open femoral access) for acute lower limb ischemia. Methods From 2009 to 2017, 52 patients (44 men, eight women, mean 67.2 years) underwent combined treatment for acute thrombotic occlusion of lower extremity arteries. The patients presented with acute limb ischemia and we selectively perform combined treatment in the cases with challenging clinical considerations (e.g. various spectrum of thrombus, underlying atherosclerotic lesions). Combined treatment included cutdown of common femoral artery, thrombectomy using a Fogarty balloon catheter, balloon angioplasty, stenting, and catheter-introduced thrombus fragmentation and aspiration. Patients’ medical records were retrospectively reviewed and follow-up data were collected. The technical and clinical success rates and limb salvage were assessed. The Kaplan-Meier method was used to analyze primary patency rates and overall survival rates. Univariate analyses were performed to determine the factors related to clinical outcomes. Results Technical and clinical success rate was 90.4% and 80.8%, respectively. The mean follow-up duration was 26.5 ± 25.8 months. Primary patency was 91.4%, 86.1%, and 74.6% at six months, 1-, and 2-year, respectively. Limb salvage without amputation was 88.5% (46/52). The overall survival rates at six months, 1-, and 3-year were 82.6%, 80.2, and 56.9%, respectively. The 30-day mortality was 5.8% (3/52). Univariate analysis showed that percutaneous transluminal angioplasty (PTA) type (balloon versus stent) was related to clinical failure. Conclusions Combined treatment can be effective and safe for ALI patients even under challenging clinical conditions.
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Lee CH, Jung KH. Brachial artery occlusion mimicking stroke in patients at high risk of cardioembolic stroke. Acta Neurol Belg 2019; 119:501-503. [PMID: 31228021 DOI: 10.1007/s13760-019-01175-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 06/14/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Chan-Hyuk Lee
- Department of Neurology, Chonbuk National University Hospital, Jeonju, Republic of Korea
| | - Keun-Hwa Jung
- Department of Neurology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
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Outcomes of intravenous thrombolytic and adjuvant surgery in acute limb ischemia: Review of 23 patients. JOURNAL OF SURGERY AND MEDICINE 2019. [DOI: 10.28982/josam.525350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Darwood R, Berridge DC, Kessel DO, Robertson I, Forster R. Surgery versus thrombolysis for initial management of acute limb ischaemia. Cochrane Database Syst Rev 2018; 8:CD002784. [PMID: 30095170 PMCID: PMC6513660 DOI: 10.1002/14651858.cd002784.pub3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Both peripheral arterial thrombolysis and surgery can be used in the management of peripheral arterial ischaemia. Much is known about the indications, risks, and benefits of thrombolysis. However, whether thrombolysis works better than surgery for initial management of acute limb ischaemia remains unknown. This is the second update of the review first published in 2002. OBJECTIVES To determine whether thrombolysis or surgery is the more effective technique in the initial management of acute limb ischaemia due to thromboembolism. SEARCH METHODS For this update, the Cochrane Vascular Information Specialist (CIS) searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE Ovid, Embase Ovid, CINAHL, AMED, and clinical trials registries up to 7 May 2018. SELECTION CRITERIA All randomised controlled studies comparing thrombolysis and surgery for initial treatment of acute limb ischaemia. DATA COLLECTION AND ANALYSIS We independently assessed trial quality and extracted data. Agreement was reached by consensus. We performed analyses using odds ratios (ORs) and 95% confidence intervals (CIs). MAIN RESULTS We identified no new studies for this update. We included five trials with a total of 1292 participants; agents used for thrombolysis were recombinant tissue plasminogen activator and urokinase. Trials were generally of moderate methodological quality. The quality of evidence according to GRADE was generally low owing to risk of bias (lack of blinding), imprecision in estimates, and heterogeneity.Trial results showed no clear differences in limb salvage, amputation, or death at 30 days (odds ratio (OR) 1.02, 95% confidence interval (CI) 0.41 to 2.55, 4 studies, 636 participants; OR 0.97, 95% CI 0.51 to 1.85, 3 studies, 616 participants; OR 0.59, 95% CI 0.31 to 1.14, 4 studies, 636 participants, respectively), and we rated the evidence as low, low, and moderate quality, respectively. Trial results show no clear differences for any of the three outcomes at six months or one year between initial surgery and initial thrombolysis. A single study evaluated vessel patency, so no overall association could be determined (OR 0.46, 95% CI 0.08 to 2.76, 20 participants; very low-quality evidence). Evidence of increased risk of major haemorrhage (OR 3.22, 95% CI 1.79 to 5.78, 4 studies, 1070 participants; low-quality evidence) and distal embolisation (OR 31.68, 95% CI 6.23 to 161.07, 3 studies, 678 participants; very low-quality evidence) was associated with thrombolysis treatment at 30 days, and there was no clear difference in stroke (OR 5.33, 95% CI 0.95 to 30.11, 5 studies, 1180 participants; low-quality evidence). Participants treated by initial thrombolysis had a greater reduction in the level of intervention required, compared with a pre-intervention prediction, at 30 days (OR 9.06, 95% CI 4.95 to 16.56, 2 studies, 502 participants). None of the included studies evaluated time to thrombolysis as an outcome. AUTHORS' CONCLUSIONS There is currently no evidence in favour of either initial thrombolysis or initial surgery as the preferred option in terms of limb salvage, amputation, or death at 30 days, six months, or one year. Low-quality evidence suggests that thrombolysis may be associated with higher risk of haemorrhagic complications and ongoing limb ischaemia (distal embolisation). The higher risk of complications must be balanced against risks of surgery in each individual case. Trial results show no statistical difference in stroke, but the confidence interval is very wide, making it difficult to interpret whether this finding is clinically important. We used GRADE criteria to assess the quality of the evidence as generally low. We downgraded quality owing to risk of bias, imprecision, and heterogeneity between included studies.
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Affiliation(s)
| | - David C Berridge
- Trust HeadquartersLeeds Teaching Hospitals NHS TrustSt James's HospitalBeckett StreetLeedsYorkshireUKLS9 7TF
| | - David O Kessel
- University of LeedsDepartment of Clinical RadiologyBeckett StreetLeedsWest YorkshireUKLS2 9JT
| | - Iain Robertson
- Gartnavel General HospitalDepartment of Radiology1053 Great Western RoadGlasgowUKG12 0XN
| | - Rachel Forster
- University of EdinburghUsher Institute of Population Health Sciences and InformaticsEdinburghUKEH8 9AG
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Administration of FTY720 during Tourniquet-Induced Limb Ischemia Reperfusion Injury Attenuates Systemic Inflammation. Mediators Inflamm 2017; 2017:4594035. [PMID: 29410598 PMCID: PMC5749296 DOI: 10.1155/2017/4594035] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 09/01/2017] [Accepted: 09/12/2017] [Indexed: 12/14/2022] Open
Abstract
Acute ischemia-reperfusion injury (IRI) of the extremities leads to local and systemic inflammatory changes which can hinder limb function and can be life threatening. This study examined whether the administration of the T-cell sequestration agent, FTY720, following hind limb tourniquet-induced skeletal muscle IRI in a rat model would attenuate systemic inflammation and multiple end organ injury. Sprague-Dawley rats were subjected to 1 hr of ischemia via application of a rubber band tourniquet. Animals were randomized to receive an intravenous bolus of either vehicle control or FTY720 15 min after band placement. Rats (n = 10/time point) were euthanized at 6, 24, and 72 hr post-IRI. Peripheral blood as well as lung, liver, kidney, and ischemic muscle tissue was analyzed and compared between groups. FTY720 treatment markedly decreased the number of peripheral blood T cells (p < 0.05) resulting in a decreased systemic inflammatory response and lower serum creatinine levels and had a modest but significant effect in decreasing the transcription of injury-associated target genes in multiple end organs. These findings suggest that early intervention with FTY720 may benefit the treatment of IRI of the limb. Further preclinical studies are necessary to characterize the short-term and long-term beneficial effects of FTY720 following tourniquet-induced IRI.
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Tanaka M, Kawahara T, Nishikoshi T, Hagiwara M, Imai K, Hasegawa K, Koya A, Matsuno N, Takei H, Azuma N, Furukawa H. Successful surgical treatment for huge retroperitoneal liposarcoma involving the pancreas, right kidney, abdominal aorta and inferior vena cava. J Surg Case Rep 2017; 2017:rjx200. [PMID: 29423155 PMCID: PMC5798155 DOI: 10.1093/jscr/rjx200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 11/14/2017] [Indexed: 12/20/2022] Open
Abstract
Retroperitoneal liposarcoma is a rare neoplasm that often involves other organs and major blood vessels. Complete surgical resection with negative margins is the only potential curative treatment. Here, we report the case of a patient with a large retroperitoneum liposarcoma that was removed by resection of the descending abdominal aorta and infrahepatic inferior vena cava, right nephrectomy and pancreatoduodenectomy following creation of an extra anatomical femoro-femoral crossover bypass after left axillo-left femoral bypass. The patient developed leg edema for a few weeks after surgery but this condition was gradually resolved with diuretics. Otherwise, no serious postoperative complication was observed, and the patient was discharged at 37 days after surgery. There has been no evidence of recurrence for 16 months. In conclusion, radical surgical resection is a possible therapeutic option for retroperitoneal liposarcoma involving major vessels or other organs, and may improve survival if negative resection margins can be achieved.
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Affiliation(s)
- Mariko Tanaka
- Department of Surgery, Asahikawa Medical University, Midorigaoka-higashi 2-1-1-1, Asahikawa city, Hokkaido 078-8510, Japan
| | - Toshiyasu Kawahara
- Department of Surgery, Asahikawa Medical University, Midorigaoka-higashi 2-1-1-1, Asahikawa city, Hokkaido 078-8510, Japan
| | - Takahiro Nishikoshi
- Department of Surgery, Asahikawa Medical University, Midorigaoka-higashi 2-1-1-1, Asahikawa city, Hokkaido 078-8510, Japan
| | - Masahiro Hagiwara
- Department of Surgery, Asahikawa Medical University, Midorigaoka-higashi 2-1-1-1, Asahikawa city, Hokkaido 078-8510, Japan
| | - Koji Imai
- Department of Surgery, Asahikawa Medical University, Midorigaoka-higashi 2-1-1-1, Asahikawa city, Hokkaido 078-8510, Japan
| | - Kimiharu Hasegawa
- Department of Surgery, Asahikawa Medical University, Midorigaoka-higashi 2-1-1-1, Asahikawa city, Hokkaido 078-8510, Japan
| | - Atsuhiro Koya
- Department of Surgery, Asahikawa Medical University, Midorigaoka-higashi 2-1-1-1, Asahikawa city, Hokkaido 078-8510, Japan
| | - Naoto Matsuno
- Department of Surgery, Asahikawa Medical University, Midorigaoka-higashi 2-1-1-1, Asahikawa city, Hokkaido 078-8510, Japan
| | - Hidehiro Takei
- Department of Pathology, Asahikawa Medical University, Midorigaoka-higashi 2-1-1-1, Asahikawa city, Hokkaido 078-8510, Japan
| | - Nobuyoshi Azuma
- Department of Surgery, Asahikawa Medical University, Midorigaoka-higashi 2-1-1-1, Asahikawa city, Hokkaido 078-8510, Japan
| | - Hiroyuki Furukawa
- Department of Surgery, Asahikawa Medical University, Midorigaoka-higashi 2-1-1-1, Asahikawa city, Hokkaido 078-8510, Japan
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Piffaretti G, Angrisano A, Franchin M, Ferrario M, Rivolta N, Bacuzzi A, Castelli P, Tozzi M. Risk factors analysis of thromboembolectomy for acute thromboembolic lower extremity ischemia in native arteries. THE JOURNAL OF CARDIOVASCULAR SURGERY 2016; 59:810-816. [PMID: 27901322 DOI: 10.23736/s0021-9509.16.09673-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Aim of this study is to report the results of thromboembolectomy (ThEmb) for acute thromboembolic lower limb ischemia (ATLI) in native arteries and to create a predictive score for amputation-free survival (AFS) at 30 days. METHODS It is a single center, retrospective analysis of a four years period. All patients had ThEmb: adjunctive procedures included femoral and/or popliteal endarterectomy in 30 (18.3%) cases, PTA-stent in 24 (14.6%), and femoral endarterectomy plus PTA-stent in 12 (7.3%). Fasciotomies were performed in 6 (3.6%) patients. Predictors of AFS identified on univariate screen (inclusion threshold, P<.20) were included in a multivariable model. The resulting significant predictors were assigned an integer score to stratify patients into risk groups. RESULTS Authors analyzed 164 limbs in 164 patients. Mean age was 80±10 years (range, 40-99). In-hospital mortality was 9.8% (N.=16); AFS at 30 days was 84.7% (N.=139). The anatomic level (iliac vs. femoropopliteal vs. infrapopliteal) of the occlusion did not affect AFS (P=.326). Multivariable analysis identified six significant predictors of AFS at 30 days: age >85 (P=0.050), chronic obstructive pulmonary disease (P=0.008), chronic renal insufficiency (P=0.019), late (>6 hours) onset (P=0.004), the presence of major neurologic deficit (P=0.023), and an increased (>800IU/L) level of creatine phosphokinase (P=0.001). An integer score generated two risk groups (low-risk 0-2 [70.1% of cohort], and high-risk ≥3 [29.9% of cohort]): stratification of the patients according to risk category yielded significantly different AFS at 30 days (low-risk 5.2% vs. high-risk 38.8%, P<0.0001). CONCLUSIONS Among patients selected to undergo ThEmb for ATLI in native arteries, this risk score identified a group of patients with a 40% chance of death or major amputation at 30 days. The score can help to optimize the operative strategy, but further prospective validation is needed.
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Affiliation(s)
- Gabriele Piffaretti
- Division of Vascular Surgery, Department of Surgery and Morphological Sciences, University of Insubria School of Medicine, Circolo University Hospital, Varese, Italy -
| | - Alessandro Angrisano
- Division of Vascular Surgery, Department of Surgery and Morphological Sciences, University of Insubria School of Medicine, Circolo University Hospital, Varese, Italy
| | - Marco Franchin
- Division of Vascular Surgery, Department of Surgery and Morphological Sciences, University of Insubria School of Medicine, Circolo University Hospital, Varese, Italy
| | - Massimo Ferrario
- Division of Vascular Surgery, Department of Surgery and Morphological Sciences, University of Insubria School of Medicine, Circolo University Hospital, Varese, Italy
| | - Nicola Rivolta
- Division of Vascular Surgery, Department of Surgery and Morphological Sciences, University of Insubria School of Medicine, Circolo University Hospital, Varese, Italy
| | - Alessandro Bacuzzi
- Unit of Anesthesia and Palliative Care, Circolo University Hospital, Varese, Italy
| | - Patrizio Castelli
- Division of Vascular Surgery, Department of Surgery and Morphological Sciences, University of Insubria School of Medicine, Circolo University Hospital, Varese, Italy
| | - Matteo Tozzi
- Division of Vascular Surgery, Department of Surgery and Morphological Sciences, University of Insubria School of Medicine, Circolo University Hospital, Varese, Italy
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14
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Deguara J, Ali T, Modarai B, Burnand KG. Upper Limb Ischemia: 20 Years Experience from a Single Center. Vascular 2016; 13:84-91. [PMID: 15996362 DOI: 10.1258/rsmvasc.13.2.84] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The objective of this study was to review a single center's experience of upper limb revascularization over 20 years. All patients undergoing operative or endovascular upper limb revascularization between June 1983 and July 2003 were identified. One hundred eighty-four upper limb revascularization procedures were carried out on 172 patients. Sixty-one patients had a thromboembolic event (35%), 53 patients presented with a traumatic vascular injury (31%), and 29 patients had symptoms of chronic atherosclerotic upper limb ischemia (17%). Fifteen patients had subclavian steal syndrome, eight patients had thoracic outlet compression, and six patients had iatrogenic injuries of the upper limb arteries. Fifty-five thromboembolectomies were performed, 37 under locoregional anesthesia. Ten patients (18.2%) died from cardiopulmonary causes following embolectomy. Fifteen reversed saphenous vein bypass grafts were performed for traumatic damage. Twenty-seven patients had a primary repair, and five required a vein patch. One patient subsequently had an arm amputation, and two patients died. Twelve patients presenting with chronic arm ischemia had a subclavian angioplasty, 12 patients had a proximal bypass, and in 5 patients, stenoses were stented. The mortality in this group was 6.9% (2 of 29). The mortality for upper limb revascularization was 8.7%. Almost all deaths occurred after upper limb embolectomy, and the mortality of this procedure was similar to that of lower limb embolectomy. Deaths were the result of cardiac comorbidity, and this should be actively sought and treated if outcomes are to improve.
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Affiliation(s)
- Jean Deguara
- Academic Department of Surgery, St. Thomas' Hospital, London, United Kingdom
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De Haro J, Bleda S, Varela C, Cañibano C, Acin F. Meta-analysis and adjusted indirect comparison of direct oral anticoagulants in prevention of acute limb ischemia in patients with atrial fibrillation. Curr Med Res Opin 2016; 32:1167-73. [PMID: 26949899 DOI: 10.1185/03007995.2016.1163256] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Direct oral anticoagulants are being presented as alternatives to warfarin for preventing stroke in patients with atrial fibrillation. Yet direct comparative trials between these agents in prevention of acute limb ischemia (ALI) are unavailable so far. OBJECTIVE To conduct an adjusted indirect comparison meta-analysis between direct oral agents for prevention of acute limb ischemia in atrial fibrillation. METHODS We conducted a systematic literature review searching electronic databases (MEDLINE and Embase) and the Cochrane Library from January 1990 through November 2014. Two blinded investigators reviewed all potentially relevant articles in a parallel manner by using a priori defined criteria. To assess the long-term efficacy and safety of these agents, only randomized clinical trials (RCTs) with follow-up durations of >1 year were included. The primary efficacy outcome was the end point of acute limb ischemia and/or extremity embolism. RESULTS A total of 44,563 patients from three RCTs met criteria for inclusion. Patients randomized to direct oral anticoagulants had a non-significant decreased risk for acute limb ischemia (risk ratio [RR]: 0.57, 95% confidence interval [CI]: 0.26-1.2). In the analysis between agents, however, rivaroxaban significantly lowered the risk of ALI compared to warfarin (RR: 0.23, 95% CI: 0.064-0.82), apixaban (RR: 0.26, 95% CI: 0.081-0.83), and dabigatran (RR: 0.24, 95% CI: 0.077-0.83). CONCLUSIONS Significant differences in prevention of acute limb ischemia may exist between oral anticoagulant agents in patients with atrial fibrillation. Rivaroxaban lowers the risk of limb embolism versus warfarin, apixaban and dabigatran.
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Affiliation(s)
- J De Haro
- a Angiology and Vascular Surgery Department , Getafe University Hospital , Getafe , Madrid , Spain
| | - S Bleda
- a Angiology and Vascular Surgery Department , Getafe University Hospital , Getafe , Madrid , Spain
| | - C Varela
- a Angiology and Vascular Surgery Department , Getafe University Hospital , Getafe , Madrid , Spain
| | - C Cañibano
- a Angiology and Vascular Surgery Department , Getafe University Hospital , Getafe , Madrid , Spain
| | - F Acin
- a Angiology and Vascular Surgery Department , Getafe University Hospital , Getafe , Madrid , Spain
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¿Son los nuevos anticoagulantes orales iguales a las antivitaminas K para la isquemia aguda de los miembros inferiores? Revisión sistemática de la evidencia. ANGIOLOGIA 2016. [DOI: 10.1016/j.angio.2015.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Risk Factors for Long-Term Mortality and Amputation after Open and Endovascular Treatment of Acute Limb Ischemia. Ann Vasc Surg 2015; 30:82-92. [PMID: 26560838 DOI: 10.1016/j.avsg.2015.10.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 10/01/2015] [Accepted: 10/27/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Acute limb ischemia (ALI) is a highly morbid and fatal vascular emergency with little known about contemporary, long-term patient outcomes. The goal was to determine predictors of long-term mortality and amputation after open and endovascular treatment of ALI. METHODS A retrospective review of ALI patients at a single institution from 2005 to 2011 was performed to determine the impact of revascularization technique on 5-year mortality and amputation. For each main outcome 2 multivariable models were developed; the first adjusted for preoperative clinical presentation and procedure type, the second also adjusted for postoperative adverse events (AEs). RESULTS A total of 445 limbs in 411 patients were treated for ALI. Interventions included surgical thrombectomy (48%), emergent bypass (18%), and endovascular revascularization (34%). Mean age was 68 ± 15 years, 54% were male, and 23% had cancer. Most patients presented with Rutherford classification IIa (54%) or IIb (39%). The etiology of ALI included embolism (27%), in situ thrombosis (28%), thrombosed bypass grafts (32%), and thrombosed stents (13%). Patients treated with open procedures had significantly more advanced ischemia and higher rates of postoperative respiratory failure, whereas patients undergoing endovascular interventions had higher rates of technical failure. Rates of postprocedural bleeding and cardiac events were similar between both treatments. Excluding Rutherford class III patients (n = 12), overall 5-year mortality was 54% (stratified by treatment, 65% for thrombectomy, 63% for bypass, and 36% for endovascular, P < 0.001); 5-year amputation was 28% (stratified by treatment, 18% for thrombectomy, 27% for bypass, and 17% for endovascular, P = 0.042). Adjusting for comorbidities, patient presentation, AEs, and treatment method, the risk of mortality increased with age (hazard ratio [HR] = 1.04, P < 0.001), female gender (HR = 1.50, P = 0.031), cancer (HR = 2.19, P < 0.001), fasciotomy (HR = 1.69, P = 0.204) in situ thrombosis or embolic etiology (HR = 1.73, P = 0.007), cardiac AEs (HR = 2.25, P < 0.001), respiratory failure (HR = 2.72, P < 0.001), renal failure (HR = 4.70, P < 0.001), and hemorrhagic events (HR = 2.25, P = 0.003). Risk of amputation increased with advanced ischemia (Rutherford IIb compared with IIa, HR = 2.57, P < 0.001), thrombosed bypass etiology (HR = 3.53, P = 0.002), open revascularization (OR; HR = 1.95, P = 0.022), and technical failure of primary intervention (HR = 6.01, P < 0.001). CONCLUSIONS After the treatment of ALI, long-term mortality and amputation rates were greater in patients treated with open techniques; OR patients presented with a higher number of comorbidities and advanced ischemia, while also experiencing a higher rate of major postoperative complications. Overall, mortality rates remained high and were most strongly associated with baseline comorbidities, acuity of presentation, and perioperative AEs, particularly respiratory failure. Comparatively, amputation risk was most highly associated with advanced ischemia, thrombosed bypass, and failure of the initial revascularization procedure.
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Bae M, Chung SW, Lee CW, Choi J, Song S, Kim SP. Upper Limb Ischemia: Clinical Experiences of Acute and Chronic Upper Limb Ischemia in a Single Center. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2015; 48:246-51. [PMID: 26290835 PMCID: PMC4541062 DOI: 10.5090/kjtcs.2015.48.4.246] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 11/20/2014] [Accepted: 11/21/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Upper limb ischemia is less common than lower limb ischemia, and relatively few cases have been reported. This paper reviews the epidemiology, etiology, and clinical characteristics of upper limb ischemia and analyzes the factors affecting functional sequelae after treatment. METHODS The records of 35 patients with acute and chronic upper limb ischemia who underwent treatment from January 2007 to December 2012 were retrospectively reviewed. RESULTS The median age was 55.03 years, and the number of male patients was 24 (68.6%). The most common etiology was embolism of cardiac origin, followed by thrombosis with secondary trauma, and the brachial artery was the most common location for a lesion causing obstruction. Computed tomography angiography was the first-line diagnostic tool in our center. Twenty-eight operations were performed, and conservative therapy was implemented in seven cases. Five deaths (14.3%) occurred during follow-up. Twenty patients (57.1%) complained of functional sequelae after treatment. Functional sequelae were found to be more likely in patients with a longer duration of symptoms (odds ratio, 1.251; p=0.046) and higher lactate dehydrogenase (LDH) levels (odds ratio, 1.001; p=0.031). CONCLUSION An increased duration of symptoms and higher initial serum LDH levels were associated with the more frequent occurrence of functional sequelae. The prognosis of upper limb ischemia is associated with prompt and proper treatment and can also be predicted by initial serum LDH levels.
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Affiliation(s)
- Miju Bae
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital
| | - Sung Woon Chung
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital
| | - Chung Won Lee
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital
| | - Jinseok Choi
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital
| | - Seunghwan Song
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital
| | - Sang-Pil Kim
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital
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Al-Nouri O, Sinacore J, Halandras P, Hershberger R. Should Age Limit the Use of Catheter-Directed Thrombolysis: Results of National Survey. Vasc Endovascular Surg 2015; 49:4-7. [PMID: 25835023 DOI: 10.1177/1538574415572639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine whether advanced age should be a contraindication to catheter-directed thrombolysis (CDT) based on hemorrhagic complication rate. METHODS A survey was generated via Survey Monkey and sent out to vascular surgeons who were members of the society of vascular surgery (SVS). RESULTS Of the responders, 32.7% state they do not have an age limit for tissue plasminogen activator (TPA) infusion, and the remaining 29.2% of the responders use 80 years of age as their limitation. When asked why place limits on age for TPA infusion, 56.6% stated concern for intracranial hemorrhage. Major complications were access site hemorrhage (58.4%) and intracranial hemorrhage (41.6%). Chi-square analysis did not show age as a limiting factor to thrombolysis. Furthermore, when asked in which age-group complications occurred most commonly, 72.4% were less than 80. CONCLUSION Among vascular specialist, there seems to be no consensus on age limitations for TPA infusion. Serious complications do not seem to be age related and thus age alone should not be a contraindication for catheter-directed thrombolysis.
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Affiliation(s)
- Omar Al-Nouri
- Vascular Surgery and Endovascular Therapy, Loyola University Medical Center, Maywood, IL, USA
| | - James Sinacore
- Department of Public Health Sciences, Loyola University Medical Center, Maywood, IL, USA
| | - Pegge Halandras
- Vascular Surgery and Endovascular Therapy, Loyola University Medical Center, Maywood, IL, USA
| | - Richard Hershberger
- Vascular Surgery and Endovascular Therapy, Loyola University Medical Center, Maywood, IL, USA
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Schmidt CA, Rancic Z, Lachat ML, Mayer DO, Veith FJ, Wilhelm MJ. Hypothermic, Initially Oxygen-Free, Controlled Limb Reperfusion for Acute Limb Ischemia. Ann Vasc Surg 2015; 29:560-72. [DOI: 10.1016/j.avsg.2014.09.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 08/16/2014] [Accepted: 09/14/2014] [Indexed: 11/26/2022]
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Burke ZDC, Jabaji Z, de Virgilio C. Cold, Painful Right Lower Extremity. Surgery 2015. [DOI: 10.1007/978-1-4939-1726-6_58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Fatic N, Zornic N, Radojevic N, Bulatovic N. Acute Iliac and Femoral Arterial Thrombosis Secondary to Total Hip Arthroplasty. Open Access Maced J Med Sci 2014. [DOI: 10.3889/oamjms.2014.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
In the presented case report, we evaluated the mechanism of the external iliac, the common femoral and the superficial femoral arterial thrombosis secondary to total hip arthroplasty. A 75-year-old female sufferd from 5.5 cm shorter left lower limb and same sade coxarthritis. Next day after arthroplasty and eqalisation of the lower limbs, an acute ishemia of the treated leg was presented. Multyscan CT angiography revealed the presence of the external iliac, the common femoral and the superficial femoral arterial thrombosis. From the best of our knowledge, it seems to be the only case of this arterial segment thrombosis after total hip arthroplasty and equalistaion of the lower limbs reported.
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Londero LS, Nørgaard B, Houlind K. Patient delay is the main cause of treatment delay in acute limb ischemia: an investigation of pre- and in-hospital time delay. World J Emerg Surg 2014; 9:56. [PMID: 25400690 PMCID: PMC4232613 DOI: 10.1186/1749-7922-9-56] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 10/14/2014] [Indexed: 11/14/2022] Open
Abstract
Background The prognosis of acute limb ischemia is severe, with amputation rates of up to 25% and in-hospital mortality of 9-15%. Delay in treatment increases the risk of major amputation and may be present at different stages, including patient delay, doctors´ delay and waiting time in the emergency department. It is important to identify existing problems in order to reduce time delay. The aim of this study was to collect data for patients with acute limb ischemia and to evaluate the time delay between the different events from onset of symptoms to specialist evaluation and further treatment with focus on pre-hospital and in-hospital time delays. Methods We conducted a prospective cross-sectional cohort study including all patients suspected with acute limb ischemia who were admitted to the emergency department of a community hospital in a six months period. Temporal delay in the different phases between the time of occurrence of symptoms and completion of treatment was recorded prospectively. All patients who underwent intervention had a 30 days follow-up with regard to major amputation of the leg and survival. Results A total of 42 patients (21 men and 21 women) age 73 (20–95) years (median (range)) was identified. From onset of symptoms to first contact with a doctor the time for all patients were 24 (0–1200) hours. Thirty patients needed immediate intervention. In the group of fourteen patients who had immediate operation, the median time from vascular evaluation to revascularization was 324.5 (122–873) minutes and in the group of eight patients that went through an imaging procedure before an operation the median delay was 822 (494–1185) minutes from specialist assessment to revascularization. The median time for revascularization among four patients, who were treated with arterial thrombolysis was 5621 (1686–8376) minutes. At 30 days follow up, six patients had had the ischemic limb amputated above the ankle and four patients had died. Conclusions We found that the largest time delay was between onset of symptoms and first contact to a medical doctor. A greater public awareness is needed, so as to facilitate urgent revascularisation and improve outcomes.
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Affiliation(s)
- Louise S Londero
- Department of Cardiothoracic- and Vascular Surgery, University Hospital of Odense, Sdr. Boulevard 29, 5000 Odense C, Denmark
| | - Birgitte Nørgaard
- Institute of Public Health, University of Southern Denmark, Sdr. Boulevard 29, 5000 Odense C, Denmark
| | - Kim Houlind
- Department of Vascular Surgery, Kolding Hospital, Skovvangen 2, 6000 Kolding, Denmark
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Kempe K, Starr B, Stafford JM, Islam A, Mooney A, Lagergren E, Corriere MA, Edwards MS. Results of surgical management of acute thromboembolic lower extremity ischemia. J Vasc Surg 2014; 60:702-7. [DOI: 10.1016/j.jvs.2014.03.273] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 03/21/2014] [Indexed: 10/25/2022]
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Abstract
Critical limb ischaemia (CLI) is a severe form of peripheral arterial disease (PAD). CLI often causes disabling symptoms of pain and can lead to loss of the affected limb. It is also associated with increased risk of myocardial infarction, stroke and death from cardiovascular disease. The aims of management in patients with CLI are to relieve ischaemic pain, heal ulcers, prevent limb loss, improve function and quality of life and prolong survival. Here, current evidence regarding the medical management of CLI is reviewed. Cardiovascular risk factors should be assessed in all patients with CLI; smoking cessation and treatment of hypertension, hyperlipidaemia and diabetes all reduce the mortality rate in those with PAD. Antiplatelet agents (either aspirin or clopidogrel) are recommended to reduce both the incidence of cardiovascular events and risk of arterial occlusion. By contrast, routine use of anticoagulation (either warfarin or heparin) is not recommended. Treatment of the limbs themselves is often more challenging. Prostanoids may have some efficacy for treating rest pain and for ulcer healing, and iloprost shows favourable results in reducing the risk of major amputations, but long-term follow-up data regarding disease progression are lacking. There is insufficient evidence to support the use of naftidrofuryl or cilostazol, and pentoxifylline is not beneficial. Furthermore, there is no evidence of proven benefit of hyperbaric oxygen. A number of angiogenic growth factors have been studied in Phase I studies and randomized controlled trials (RCTs). They appear to be safe, but efficacy results have been mixed. Treatment with stem cells also shows some potential from early trials, but further larger RCTs are needed to demonstrate clear benefit. Thrombolysis may be an alternative for patients who develop acute limb ischaemia and are unsuitable for surgical intervention. However, newer endovascular techniques are likely to have a greater role in the future.
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Affiliation(s)
- M A Lambert
- Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
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Maeda A, Wakabayashi K, Suzuki H. Acute limb ischemia due to abdominal compartment syndrome. Catheter Cardiovasc Interv 2013; 83:141-3. [PMID: 23785012 DOI: 10.1002/ccd.25083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2012] [Revised: 04/16/2013] [Accepted: 06/09/2013] [Indexed: 11/06/2022]
Abstract
Acute limb ischemia (ALI) is caused by embolisms or progressive atherosclerosis. We report the case of a 68-year-old female who presented with acute total occlusion of left iliac artery due to remarkably massive ascites from pancreatic cancer. To our knowledge, no other case reports of ALI caused by acute compartment syndrome have been published. We treated our case successfully by draining the ascites fluid without any balloon angioplasty or stent implantation. The removal of extrinsic compression may be the best treatment for cases of this type.
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Affiliation(s)
- Atsuo Maeda
- Division of Cardiology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Kanagawa, 227-8501, Japan
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Tsang JS, Naughton PA, O'Donnell J, Wang TT, Moneley DS, Kelly CJ, Leahy AL. Acute limb ischemia in cancer patients: should we surgically intervene? Ann Vasc Surg 2011; 25:954-60. [PMID: 21821390 DOI: 10.1016/j.avsg.2011.06.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2010] [Revised: 05/25/2011] [Accepted: 06/14/2011] [Indexed: 12/21/2022]
Abstract
BACKGROUND Cancer patients have an increased risk of venous thromboembolic events. Certain chemotherapeutic agents have also been associated with the development of thrombosis. Reported cases of acute arterial ischemic episodes in cancer patients are rare. METHODS Patients who underwent surgery for acute limb ischemia associated with malignancy in a university teaching hospital over a 10-year period were identified. Patient demographics, cancer type, chemotherapy use, site of thromboembolism, treatment and outcome were recorded. RESULTS Four hundred nineteen patients underwent surgical intervention for acute arterial ischemia, 16 of these patients (3.8%) had associated cancer. Commonest cancer sites were the urogenital tract (n = 5) and the lungs (n = 5). Eight patients (50%) had been recently diagnosed with cancer, and four (25%) of these cancers were incidental findings after presentation with acute limb ischemia. Four patients (25%) developed acute ischemia during chemotherapy. The superficial femoral artery was the most frequent site of occlusion (50%), followed by the brachial (18%) and popliteal (12%) arteries. All patients underwent thromboembolectomy, but two (12%) patients subsequently required a bypass procedure. Six patients (37%) had limb loss, and in-patient mortality was 12%. Histology revealed that all occlusions were due to thromboembolism, with no tumor cells identified. At follow-up, 44% of patients were found to be alive after 1 year. CONCLUSION Cancer and chemotherapy can predispose patients to acute arterial ischemia. Unlike other reports that view this finding as a preterminal event most appropriately treated by palliative measures, in this series, early diagnosis and surgical intervention enabled limb salvage and patient survival.
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Affiliation(s)
- Julian S Tsang
- Department of Vascular Surgery, Royal College of Surgeons Ireland, Beaumont Hospital, Dublin, Ireland.
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Neary P, Behan C, Powell T, Owens T, MacErlaine D, Mehigan D, Sheehan S, Keaveny T. Early outcomes following alternative treatment strategies in the management of the acutely ischemic limb. Int J Angiol 2011. [DOI: 10.1007/s00547-004-1029-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Szijártó A, Turóczi Z, Arányi P, Nagy Z, Gyurkovics E. [Acute and critical ischemia of the lower limb]. Orv Hetil 2010; 151:2057-66. [PMID: 21126948 DOI: 10.1556/oh.2010.28980] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Acute limb arterial occlusion has great clinical significance due to its high mortality and complication rates. Its diagnosis is easy; however staging after long-term occlusions can be very difficult with lack of exact criteria. It is crucial, since reversible stage should undergo revascularization, while with irreversible stage only amputation is curative. Due to occlusion, long-term ischemia occurs, resulting in injury of the muscle fibers and endothelial cells. In case of revascularization the reperfusion causes more damage, than ischemia alone locally and initiates a remote organ injury. The aim of the review is to summarize the knowledge and fact and focus on some exact methods or parameters which can determine the degree of injury. One of these methods is a new approach which is the use of enzyme-histochemical reactions, and could give rapid, precise results even preoperatively regarding tissue viability. Routine clinical application of it is predictable after proper standardization.
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Affiliation(s)
- Attila Szijártó
- Semmelweis Egyetem, Általános Orvostudományi Kar I. Sebészeti Klinika, Budapest.
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Andersen LV, Mortensen LS, Lindholt JS, Faergeman O, Henneberg EW, Frost L. Upper-limb thrombo-embolectomy: national cohort study in Denmark. Eur J Vasc Endovasc Surg 2010; 40:628-34. [PMID: 20619701 DOI: 10.1016/j.ejvs.2010.06.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Accepted: 06/14/2010] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We investigated the incidence of thrombo-embolectomy in upper-limb and prognosis with respect to arm amputation, stroke and death. METHODS We performed a national cohort study of individuals, aged 40-99 years, and undergoing first-time thrombo-embolectomy in the brachial, ulnar or radial artery in Denmark from 1990 to 2002. The data were retrieved from the National Vascular Registry and from the National Registry of Patients and the Civil Registration System. Patients were followed until 2006 to ascertain the occurrence of amputation and stroke and until 2007 with respect to death. RESULTS In total, 1377 incident cases of thrombo-embolectomy were registered, comprising 504 (36.6%) males with a mean age of 72.0 (standard deviation (SD) 12.4) years and 873 (63.4%) females with a mean age of 77.2 (SD 11.7) years. Incidence was 3.3 (95% confidence interval (CI): 3.1-3.7) for males and 5.2 (95% CI: 4.9-5.6) for females per 100000 person-years. After thrombo-embolectomy, upper-limb amputation was performed in 11 (incidence 2.2%; 95% CI: 1.2-3.4) males and 31 (3.6%; 95% CI: 2.5-4.9) females. Age- and sex-specific risk of stroke was 2-16 times higher, and risk of death 3-11 times higher, than in the general population. CONCLUSIONS Upper-limb thrombo-embolectomy is associated with an increased risk of limb amputation, stroke and death.
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Affiliation(s)
- L V Andersen
- Department of Pharmacology, Odense University Hospital, Odense, Denmark.
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Murphy CG, Chen G, Winter DC, Bouchier-Hayes DJ. Glutamine preconditioning protects against tourniquet-induced local and distant organ injury in a rodent ischemia-reperfusion model. Acta Orthop 2007; 78:559-66. [PMID: 17966012 DOI: 10.1080/17453670710014220] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Ischemia-reperfusion (IR) injury is a common surgical event, with tourniquet use being a recognized cause in orthopedic surgery. Preconditioning is a highly evolutionarily conserved endogenous protective mechanism, but finding a clinically safe, acceptable method of induction has proven difficult. Glutamine, a known inducer of the heat shock protein response, offers pharmacological modulation of injury through clinically acceptable preconditioning. Our aim was to test the hypothesis that glutamine preconditioning protects against tourniquet-induced regional and remote IR injury in a rodent model. ANIMALS AND METHODS 40 adult male Sprague-Dawley rats were randomized into 4 groups: control, IR injury, normal saline-pretreated and IR injury, and glutamine-pretreated and IR injury. Pretreated groups received either normal saline or glutamine by intravenous bolus 24 h before injury. A bilateral hindlimb tourniquet model was used. Blood samples were analyzed, bronchioalveolar lavage (BAL) performed, and skeletal muscle and lung harvested for evaluation. RESULTS The glutamine-pretreated group showed significantly lower muscle myeloperoxidase (MPO) content and creatine kinase levels than the untreated or saline-pretreated injury groups. Lung tissue showed reduced MPO content and a significantly reduced neutrophil count by BAL fluid microscopy. INTERPRETATION These data suggest that preconditioning with glutamine offers local and distant organ protection in the setting of tourniquet-induced IR injury.
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Affiliation(s)
- Colin G Murphy
- Department of Surgery, RCSI Research and Education Centre, Beaumont Hospital, Dublin.
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Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FGR. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007; 45 Suppl S:S5-67. [PMID: 17223489 DOI: 10.1016/j.jvs.2006.12.037] [Citation(s) in RCA: 3942] [Impact Index Per Article: 231.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- L Norgren
- Department of Surgery, University Hospital, Orebro, Sweden
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Plasma creatine kinase indicates major amputation or limb preservation in acute lower limb ischemia. J Vasc Surg 2007; 45:733-9. [DOI: 10.1016/j.jvs.2006.12.050] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2006] [Accepted: 12/15/2006] [Indexed: 11/19/2022]
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Harkin DW, Arnold R, Hoper M. Anti-endotoxin Hyperimmune Globulin Attenuates Portal Cytokinaemia, Phagocytic Cell Priming, and Acute Lung Injury after Lower Limb Ischaemia-reperfusion Injury. Eur J Vasc Endovasc Surg 2007; 33:330-9. [PMID: 17161961 DOI: 10.1016/j.ejvs.2006.10.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2006] [Accepted: 10/23/2006] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Acute limb ischaemia is a common and often lethal clinical event. Reperfusion of an ischaemic limb has been shown to induce a remote gut injury associated with transmigration of endotoxin into the portal and systemic circulation, which in turn has been implicated in the conversion of the sterile inflammatory response to a sepsis syndrome, after lower torso ischaemia-reperfusion injury. This study tests the hypothesis that an anti-endotoxin hyperimmune globulin attenuates ischaemia-reperfusion (I/R) associated sepsis syndrome. DESIGN Prospective, randomised placebo controlled trial, animal experiment. MATERIALS AND METHODS Experimental porcine model, bilateral hind limb I/R injury, randomised to receive anti-endotoxin hyperimmune globulin or placebo. RESULTS Bilateral hind limb I/R injury significantly increased intestinal mucosal acidosis, portal endotoxaemia, plasma cytokine (TNF-alpha, IL-6, IL-8) concentrations, circulating phagocytic cell priming and pulmonary leukosequestration, oedema, and capillary-alveolar protein leak. Conversely, pigs treated with anti-endotoxin hyperimmune globulin (IgG) 20mg/kg at onset of reperfusion had significantly reduced portal endotoxaemia, early circulating phagocytic cell priming, plasma cytokinaemia and attenuation of acute lung injury. CONCLUSIONS Endotoxin translocation across a hyperpermeable gut barrier, phagocytic cell priming and cytokinaemia are key events of limb I/R injury induced systemic inflammation and acute lung injury. This study shows that an anti-endotoxin hyperimmune globulin attenuates portal endotoxaemia, which may reduce early phagocytic cell activation, cytokinaemia and ultimately acute lung injury.
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Affiliation(s)
- D W Harkin
- Regional Vascular Surgical Unit, The Royal Victoria Hospital, Grosvenor Road, Belfast BT12 6BJ, Northern Ireland, UK.
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Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FGR, Bell K, Caporusso J, Durand-Zaleski I, Komori K, Lammer J, Liapis C, Novo S, Razavi M, Robbs J, Schaper N, Shigematsu H, Sapoval M, White C, White J, Clement D, Creager M, Jaff M, Mohler E, Rutherford RB, Sheehan P, Sillesen H, Rosenfield K. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg 2006; 33 Suppl 1:S1-75. [PMID: 17140820 DOI: 10.1016/j.ejvs.2006.09.024] [Citation(s) in RCA: 1822] [Impact Index Per Article: 101.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2006] [Accepted: 09/15/2006] [Indexed: 01/19/2023]
Affiliation(s)
- L Norgren
- Department of Surgery, University Hospital, Orebro, Sweden.
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Mahmood A, Hardy R, Garnham A, Samman Y, Sintler M, Smith SRG, Vohra RK, Simms MH. Microtibial embolectomy. Eur J Vasc Endovasc Surg 2003; 25:35-9. [PMID: 12525809 DOI: 10.1053/ejvs.2002.1768] [Citation(s) in RCA: 15] [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
BACKGROUND microtibial embolectomy is an important technique in cases of limb threatening acute arterial occlusion affecting native crural and pedal vessels. It is particularly useful when thrombolysis is contraindicated or ineffective as in "trash foot". METHODS in order to evaluate the efficacy of this technique, a retrospective case note review was carried out for patients undergoing microtibial embolectomy from 1990 to 1999. Data collected included the causes and degree of ischaemia, additional procedures required, vessel patency, limb salvage and complications encountered. RESULTS twenty-two limbs underwent exploration of the crural/pedal vessels with ankle level arteriotomies under local anaesthetic in 12 cases, general anaesthetic in nine and epidural in one. The causes of ischaemia were cardiac emboli (8), "trash foot" (7), emboli from aortic and popliteal aneurysms (3) and thrombotic occlusion of crural vessels (4). The vessel patency rate was 69% and limb salvage rate 62% (13/21) up to 5-years follow-up. Six of the seven cases with "trash foot" were salvaged while one required an amputation at 3-months post-operatively. The 30-day mortality was 22% (5/22). CONCLUSIONS microtibial embolectomy is effective in acute occlusion of the crural/pedal arteries including cases of "trash foot", offering limb salvage to a worthwhile proportion of cases.
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Affiliation(s)
- A Mahmood
- Department of Vascular Surgery, University Hospital Birmingham NHS Trust, Selly Oak Hospital, Raddlebarn Road, Selly Oak, Birmingham B29 6JD, UK
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Kasirajan K, Ouriel K. Current options in the diagnosis and management of acute limb ischemia. PROGRESS IN CARDIOVASCULAR NURSING 2002; 17:26-34. [PMID: 11872978 DOI: 10.1111/j.0889-7204.2002.00617.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Acute limb ischemia occurs due to a sudden decrease in the blood flow to a limb, resulting in a potential threat to the viability of the extremity. Unfortunately, the threat is not only to the limb, but these patients are also at high risk for death. Limb hypoperfusion results in systemic acid-base and electrolyte abnormalities that impair cardiopulmonary and renal function. Successful reperfusion may result in the release of highly toxic free radicals, further compromising these critically ill patients. Therapeutic choices are often few and patient expectations are not always realistic. The management of acute limb ischemia requires a thorough understanding of the anatomy of the arterial occlusion and the open surgical and percutaneous options for restoring limb perfusion. Priorities for the diagnosis and effective management of these critically ill patients are provided.
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Affiliation(s)
- Karthikeshwar Kasirajan
- Department of Vascular Surgery, University of New Mexico Hospital, Albuquerque, NM 87131, USA.
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Prytherch DR, Ridler BM, Beard JD, Earnshaw JJ. A model for national outcome audit in vascular surgery. Eur J Vasc Endovasc Surg 2001; 21:477-83. [PMID: 11397019 DOI: 10.1053/ejvs.2001.1369] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The aim was to model vascular surgical outcome in a national study using POSSUM scoring. METHODS One hundred and twenty-one British and Irish surgeons completed data questionnaires on patients undergoing arterial surgery under their care (mean 12 patients, range 1-49) in May/June 1998. A total of 1480 completed data records were available for logistic regression analysis using P-POSSUM methodology. Information collected included all POSSUM data items plus other factors thought to have a significant bearing on patient outcome: "extra items". The main outcome measures were death and major postoperative complications. The data were checked and inconsistent records were excluded. The remaining 1313 were divided into two sets for analysis. The first "training" set was used to obtain logistic regression models that were applied prospectively to the second "test" dataset. RESULTS using POSSUM data items alone, it was possible to predict both mortality and morbidity after vascular reconstruction using P-POSSUM analysis. The addition of the "extra items" found significant in regression analysis did not significantly improve the accuracy of prediction. It was possible to predict both mortality and morbidity derived from the preoperative physiology components of the POSSUM data items alone. CONCLUSION this study has shown that P-POSSUM methodology can be used to predict outcome after arterial surgery across a range of surgeons in different hospitals and could form the basis of a national outcome audit. It was also possible to obtain accurate models for both mortality and major morbidity from the POSSUM physiology scores alone.
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Kalbassi MR, Tierney S, Grace PA, Burke PE. Regional vascular surgical units: a practical means of providing specialist services. Ir J Med Sci 2000; 169:107-9. [PMID: 11006664 DOI: 10.1007/bf03166910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND A comprehensive regional emergency and elective vascular surgical service was established in Limerick Regional General Hospital between 1994 and 1996 following the appointment of three surgeons with vascular training. AIM To compare vascular surgical activity before and after the establishment of a regional vascular service. METHODS This study used local and national computerised databases, clinic letters, theatre registers and radiology records to compare vascular surgical activity before (1992) and after (1997) this service was established. RESULTS Total outpatient activity increased almost six-fold and total number of inpatient vascular procedures (including radiological) increased from 146 to 432, but the venous proportion declined from 70% to 36%. The number of major arterial procedures increased from 37 to 165 in 1997 including 10 carotid endarterectomies, 24 aortic reconstructions and 54 lower limb reconstructions representing rates of 3/100,000, 8/100,000 and 17/100,000 population respectively. CONCLUSION As substantial changes in disease patterns are unlikely, these data indicate that patients previously diverted elsewhere for therapy are now cared for within the health board region and that further increases in workload may be expected. We suggest that these data mandate the reallocation of resources to fund appropriately staffed and audited regional vascular units.
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Affiliation(s)
- M R Kalbassi
- Department of Surgery, Mid-Western Regional Hospital, Limerick, Ireland
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Campbell WB, Verfaillie P, Ridler BM, Thompson JF. Non-operative treatment of advanced limb ischaemia: the decision for palliative care. Eur J Vasc Endovasc Surg 2000; 19:246-9. [PMID: 10753687 DOI: 10.1053/ejvs.1999.1052] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES to identify and describe patients with advanced limb ischaemia who were selected for palliative care, rather than surgical intervention. DESIGN case-note review of patients identified from a prospective register. MATERIALS AND METHODS thirty patients (22 female; median age 87 years) were identified during 1993-1998, for whom a clearly documented decision was made for palliative care, rather than major amputation or possible revascularisation. RESULTS two-thirds of the patients had limiting cardiac problems, two-thirds were immobile, and 47% had suffered a stroke. Half had three or more important co-morbidities. Twelve (40%) had unsalvageable acute ischaemia. There were clear records of the decision about non-intervention being made by a consultant in 87%; being discussed with the patient in 43%; and with known relatives in 90%. Survival after this decision ranged from <24 hours to 42 days (median 3.5 days). CONCLUSION there is a small subgroup of patients with advanced ischaemia who are best treated palliatively, and who have not been well described before. Recognising these patients, recording discussions about their management, and a high standard of terminal care are all important.
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Affiliation(s)
- W B Campbell
- Department of Surgery, Royal Devon and Exeter Hospital, Exeter, EX2 5DW, UK
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Campbell WB, Ridler BM, Szymanska TH. Two-year follow-up after acute thromboembolic limb ischaemia: the importance of anticoagulation. Eur J Vasc Endovasc Surg 2000; 19:169-73. [PMID: 10727366 DOI: 10.1053/ejvs.1999.0999] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND evidence on the effectiveness and usage of long-term anticoagulant therapy after acute thromboembolic limb ischaemia is very sparse. This study correlated medical events with administration of warfarin. METHOD during a three-month audit in 1996, 287 patients with embolism or thrombosisin situ survived for 30 days, and 214 (75%) were reviewed by questionnaires returned from clinicians throughout the United Kingdom. Minimum follow-up was two years. RESULTS thirty-five per cent had died. Recurrent acute limb ischaemia was reported in 11%, arterial intervention in 11%, and major amputation in 12%. Warfarin was given initially to 57% patients, but at follow-up only 43% were still taking warfarin (p<0. 05); reasons for stopping anticoagulation were often unknown. Recurrent limb ischaemia was less common in patients given warfarin initially (7% versus 17%) and still taking warfarin (3% versus 19%) -p;<0.05. Amputation was also less common in patients given warfarin initially (5% versus 21%) and still on warfarin (3% versus 21%) -p;<0.05. CONCLUSION long-term oral anticoagulation was associated with reduced risk of recurrent limb ischaemia and amputation, but more research is needed to define the benefits and risks, especially for thrombosisin situ. Clinicians should give clear advice about anticoagulation when patients are discharged from hospital.
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