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Ramakrishnan G, Beliveau L, Shinn K, Gable C, Brinkman W, Shutze W, Gable D. Real-world comparative claims analysis of a novel single-branched aortic stent graft device versus thoracic endograft placement with extra-anatomic debranching/revascularization in zone 2 aortic disease. Proc AMIA Symp 2023; 36:422-426. [PMID: 37334086 PMCID: PMC10269387 DOI: 10.1080/08998280.2023.2212585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 04/14/2023] [Accepted: 05/07/2023] [Indexed: 06/20/2023] Open
Abstract
Background Thoracic endovascular aortic repair (TEVAR) involving landing zone 2 can require extra-anatomic debranching (SR-TEVAR) to ensure left subclavian artery perfusion, resulting in increased costs. A single-branch device (Thoracic Branch Endoprosthesis [TBE], WL Gore, Flagstaff, AZ) provides a total endovascular solution. Comparative cost analysis of patients undergoing zone 2 TEVAR requiring left subclavian artery preservation with TBE versus SR-TEVAR is presented. Methods A single-center retrospective cost analysis was performed for aortic diseases requiring a zone 2 landing zone (TBE vs. SR-TEVAR) from 2014 to 2019. Facility charges were collected from the universal billing form UB-04 (form CMS 1450). Results Twenty-four patients were included in each arm. There were no significant differences in the overall mean procedural charges between the two groups: TBE, $209,736 ($57,761) vs. SR-TEVAR $209,025 ($93,943), P = 0.94. TBE resulted in reduced operating room charges ($36,849 [$8750] vs. $48,073 [$10,825], P = 0.02) and reduced intensive care unit and telemetry room charges, which did not reach statistical significance (P = 0.23 and 0.12, respectively). Device/implant charges were the primary cost driver in both groups. Charges associated with TBE were significantly higher: $105,525 ($36,137) vs. $51,605 ($31,326), P > 0.01. Conclusions TBE had similar overall procedural charges despite higher device/implant-related expenses and reduced facility resource utilization (lower operating room, intensive care unit, telemetry, and pharmacy charges).
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Affiliation(s)
- Ganesh Ramakrishnan
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Lauren Beliveau
- Division of Vascular and Endovascular Surgery, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
| | - Kathryn Shinn
- Division of Vascular and Endovascular Surgery, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
| | - Cara Gable
- Department of Biomedical Sciences, Texas A&M University, College Station, Texas
| | - William Brinkman
- Division of Cardiac and Thoracic Surgery, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
| | - William Shutze
- Division of Vascular and Endovascular Surgery, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
| | - Dennis Gable
- Division of Vascular and Endovascular Surgery, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
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Cury M, Matielo M, Soares R, Melo B, Nakamura E, Godoy M, Sacilotto R. Late outcomes of elective endovascular abdominal aortic aneurysm repair in a tertiary low-volume hospital in Brazil. Ann Vasc Surg 2022; 87:437-445. [DOI: 10.1016/j.avsg.2022.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/01/2022] [Accepted: 05/10/2022] [Indexed: 11/01/2022]
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3
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Gordon L, Soenens G, Doyen B, Sunavsky J, Wheatcroft M, de Mestral C, Palter V, Grantcharov T, Van Herzeele I. Step, Error, and Event Frameworks in Endovascular Aortic Repair. J Endovasc Ther 2022; 29:937-947. [PMID: 35012393 DOI: 10.1177/15266028211068768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Competency-based surgical education requires detailed and actionable feedback to ensure adequate and efficient skill development. Comprehensive operative capture systems such as the Operating Room Black Box (ORBB; Surgical Safety Technologies, Inc), which continuously records and synchronizes multiple sources of intraoperative data, have recently been integrated into hybrid rooms to provide targeted feedback to endovascular teams. The objective of this study is to develop step, error, and event frameworks to evaluate technical performance in elective endovascular aortic repair (EVAR) comprehensively captured by the ORBB (Surgical Safety Technologies, Inc; Toronto, Canada). METHODS This study is based upon a modified Delphi consensus process to create evaluation frameworks for steps, errors, and events in EVAR. International experts from Vascular Surgery and Interventional Radiology were identified, based on their records of publications and invited presentations, or serving on relevant journal editorial boards. In an initial open-ended survey round, experts were asked to volunteer a comprehensive list of steps, errors, and events for a standard EVAR of an infrarenal aorto-iliac aneurysm (AAA). In subsequent survey rounds, the identified items were presented to the expert panel to rate on a 5-point Likert scale. Delphi survey rounds were repeated until the process reached consensus with a predefined agreement threshold (Cronbach α>0.7). The final frameworks were constructed with items achieving an agreement (responses of 4 or 5) from greater than 70% of experts. RESULTS Of 98 invited proceduralists, 38 formed the expert consensus panel (39%), consisting of 29 vascular surgeons and 9 interventional radiologists, with 34% from North America and 66% from Europe. Consensus criteria were met following the third round of the Delphi consensus process (Cronbach α=0.82-0.93). There were 15, 32, and 25 items in the error, step, and event frameworks, respectively (within-item agreement=74%-100%). CONCLUSION A detailed evaluation tool for the procedural steps, errors, and events in infrarenal EVAR was developed. This tool will be validated on recorded procedures in future work: It may focus skill development on common errors and hazardous steps. This tool might be used to provide high-quality feedback on technical performance of trainees and experienced surgeons alike, thus promoting surgical mastery.
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Affiliation(s)
- Lauren Gordon
- Division of Vascular Surgery, University of Toronto, Toronto, ON, Canada.,International Centre for Surgical Safety, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,BioMedical Engineering, University of Toronto, ON, Canada
| | - Gilles Soenens
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Bart Doyen
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Juliana Sunavsky
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Mark Wheatcroft
- Division of Vascular Surgery, University of Toronto, Toronto, ON, Canada.,Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Charles de Mestral
- Division of Vascular Surgery, University of Toronto, Toronto, ON, Canada.,Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Vanessa Palter
- International Centre for Surgical Safety, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Teodor Grantcharov
- International Centre for Surgical Safety, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Isabelle Van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
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Heslin RT, Sutzko DC, Axley J, Novak Z, Aucoin VJ, Patterson MA, Pearce BJ, Passman MA, Scali ST, McFarland GE, Beck AW. Association between thoracoabdominal aneurysm extent and mortality after complex endovascular repair. J Vasc Surg 2020; 73:1925-1933.e3. [PMID: 33098946 DOI: 10.1016/j.jvs.2020.10.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 10/08/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Traditional open surgical repair of thoracoabdominal aortic aneurysms (TAAAs) has historically resulted in 30-day mortality rates ranging from 6% to 20%, depending on the Crawford anatomic extent. Although short-term survival is important, long-term survival is essential for patients to benefit from these often elective and potentially morbid procedures. The aneurysm extent affects the long-term survival after open repair; however, effect on endovascular repair is unknown and could influence the decision process for repair. We evaluated the association between aneurysm extent and survival and identified patient and perioperative factors associated with mortality after endovascular repair. METHODS A retrospective cohort of patients treated for TAAAs recorded in the Society for Vascular Surgery Vascular Quality Initiative thoracic and complex endovascular aneurysm repair registry were evaluated. All patients treated for asymptomatic degenerative aneurysms from 2010 to 2019 were included. Crawford extent I to V was defined according to the proximal and distal landing zones documented in the registry. Patients without extension into the visceral aorta were used for comparison and categorized as having extent 0a or 0b, depending on the distal landing zone in the thoracic aorta. Kaplan-Meier plots were used to estimate survival, and Cox proportional hazard regression models were created to identify the predictors of mortality. RESULTS From 2010 to 2019, 15,333 patients were entered into the registry, of whom 2062 met the inclusion criteria. The Crawford extent was 0a for 379, 0b for 848, I for 81, II for 98, III for 130, IV for 454, and V for 72. Three groups were created in accordance with the similar outcomes noted on a preliminary analysis: (1) extent 0a and 0b; (2) extent I, II, and III; and (3) extent IV and V. The mean survival time for the extent 0a and 0b group was 70.7 ± 1.43 months and was 48.6 ± 1.65 months for the extent I, II, and III group and 57.6 ± 1.24 months for the extent IV and V group. The corresponding 1-year mortality was 8.4%, 18.4%, and 7.8%. Cox regression analysis identified the following preoperative factors were associated with mortality: chronic obstructive pulmonary disease (odds ratio [OR], 1.70; P < .001), Crawford extent I to III (OR, 1.64; P = .015), preexisting chronic kidney disease (OR, 1.37; P = .024), and age per year (OR, 1.03; P < .001). A number of postoperative factors were also associated with mortality. CONCLUSIONS Similar to open TAAA repair, patients with more extensive aortic disease treated with endovascular repair had worse 1-year and long-term survival. The extent of aortic disease and anticipated postoperative survival should factor prominently into the surgical decision-making process for elective endovascular TAAA repair.
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Affiliation(s)
- Ryan T Heslin
- University of South Alabama College of Medicine, Mobile, Ala
| | - Danielle C Sutzko
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - John Axley
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Zdenek Novak
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Victoria J Aucoin
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Mark A Patterson
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Benjamin J Pearce
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Marc A Passman
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Graeme E McFarland
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala.
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Doonan RJ, Girsowicz E, Dubois L, Gill HL. A systematic review and meta-analysis of endovascular juxtarenal aortic aneurysm repair demonstrates lower perioperative mortality compared with open repair. J Vasc Surg 2019; 70:2054-2064.e3. [DOI: 10.1016/j.jvs.2019.04.464] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 04/06/2019] [Indexed: 11/16/2022]
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Response to 'Re. Importance of Surgeon Experience in the Relationship between Abdominal Aortic Aneurysm Surgery Volume and Peri-operative Mortality'. Eur J Vasc Endovasc Surg 2019; 57:746-747. [PMID: 30795928 DOI: 10.1016/j.ejvs.2019.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 01/07/2019] [Indexed: 11/20/2022]
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Hemmler A, Lutz B, Reeps C, Kalender G, Gee MW. A methodology for in silico endovascular repair of abdominal aortic aneurysms. Biomech Model Mechanobiol 2018; 17:1139-1164. [PMID: 29752606 DOI: 10.1007/s10237-018-1020-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 04/23/2018] [Indexed: 11/29/2022]
Abstract
Endovascular aneurysm repair (EVAR) can involve some unfavorable complications such as endoleaks or stent-graft (SG) migration. Such complications, resulting from the complex mechanical interaction of vascular tissue, SG and blood flow or incompatibility of SG design and vessel geometry, are difficult to predict. Computational vascular mechanics models can be a predictive tool for the selection, sizing and placement process of SGs depending on the patient-specific vessel geometry and hence reduce the risk of potential complications after EVAR. In this contribution, we present a new in silico EVAR methodology to predict the final state of the deployed SG after intervention and evaluate the mechanical state of vessel and SG, such as contact forces and wall stresses. A novel method to account for residual strains and stresses in SGs, resulting from the precompression of stents during the assembly process of SGs, is presented. We suggest a parameter continuation approach to model various different sizes of SGs within one in silico EVAR simulation which can be a valuable tool when investigating the issue of SG oversizing. The applicability and robustness of the proposed methods are demonstrated on the example of a synthetic abdominal aortic aneurysm geometry.
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Affiliation(s)
- André Hemmler
- Mechanics and High Performance Computing Group, Technische Universität München, Parkring 35, 85748, Garching b. München, Germany
| | - Brigitta Lutz
- Klinik für Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Christian Reeps
- Klinik für Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Günay Kalender
- Klinik für vaskuläre und endovaskuläre Chirurgie, DRK Kliniken Berlin, Salvador-Allende-Straße 2-8, 12559, Berlin, Germany
| | - Michael W Gee
- Mechanics and High Performance Computing Group, Technische Universität München, Parkring 35, 85748, Garching b. München, Germany.
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Simonte G, Parlani G, Farchioni L, Isernia G, Cieri E, Lenti M, Cao P, Verzini F. Lesson Learned with the Use of Iliac Branch Devices: Single Centre 10 Year Experience in 157 Consecutive Procedures. Eur J Vasc Endovasc Surg 2017; 54:95-103. [DOI: 10.1016/j.ejvs.2017.03.026] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 03/31/2017] [Indexed: 01/29/2023]
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9
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Banno H, Marzelle J, Becquemin JP. Who should do endovascular repair of complex aortic aneurysms and how should they do them? Surgeon 2015; 13:286-91. [DOI: 10.1016/j.surge.2015.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 01/15/2015] [Accepted: 03/31/2015] [Indexed: 10/23/2022]
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Patel KS, Calixte R, Modayil RJ, Friedel D, Brathwaite CE, Stavropoulos SN. The light at the end of the tunnel: a single-operator learning curve analysis for per oral endoscopic myotomy. Gastrointest Endosc 2015; 81:1181-7. [PMID: 25597422 DOI: 10.1016/j.gie.2014.10.002] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 10/02/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Per oral endoscopic myotomy (POEM) represents a natural orifice transluminal endoscopic surgery approach to Heller myotomy. Our center was the first to offer POEM outside of Japan, allowing us to accumulate what is likely the highest single-operator POEM volume in the United States. OBJECTIVE To define the POEM learning curve of a gastroenterologist by using a larger data set and more detailed statistical analysis than used in 2 other reports of POEM performed by surgeons. DESIGN Prospective cohort study. SETTING Tertiary-care academic medical center. PATIENTS We analyzed the first 93 consecutive POEMs on patients with achalasia aged >18 years without contraindications to POEM performed by a single operator from October 2009 to November 2013. INTERVENTIONS (1) Efficiency estimation via cumulative sum (CUSUM) analysis, (2) mastery estimation via penalized basis-spline regression and CUSUM analysis, (3) correlation of operator experience with clinical outcomes (Eckardt score improvement, lower esophageal sphincter pressure reduction) and technical errors (accidental mucosotomy rate), and (4) unadjusted and adjusted regression analysis to assess how patient characteristics affected procedure time by using a generalized linear model. MAIN OUTCOME MEASUREMENTS Clinical outcomes, procedure time, technical errors. RESULTS Efficiency was attained after 40 POEMs and mastery after 60 POEMs. When we used the adjusted regression analysis, only case number (operator experience) significantly affected procedure time (P < .0001). Improvements in clinical outcomes were excellent but not significantly affected by operator experience, as was the case with accidental mucosotomies. Procedure time was not significantly affected by age, sex, achalasia stage, baseline lower esophageal sphincter pressure, baseline Eckardt score, prior treatment of achalasia, prior botulinum toxin injection, incidence of accidental mucosotomies, length of myotomy, or type of knife used (all P > .05). LIMITATIONS Our analysis may underestimate the number of POEMs required to achieve mastery for operators with limited or no endoscopic submucosal dissection experience. CONCLUSION These results offer thresholds for efficiency and mastery of a single gastroenterologist operator that may guide the efforts of novice POEM operators.
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Affiliation(s)
- Kumkum Sarkar Patel
- Department of Internal Medicine, Winthrop University Hospital, Mineola, New York, USA
| | - Rose Calixte
- Department of Biostatistics, Winthrop University Hospital, Mineola, New York, USA
| | - Rani J Modayil
- Division of Gastroenterology, Winthrop University Hospital, Mineola, New York, USA
| | - David Friedel
- Division of Gastroenterology, Winthrop University Hospital, Mineola, New York, USA
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Bahia SS, Holt PJ, Thompson MM. Centralizing and reporting of complex endovascular interventions. ANZ J Surg 2014; 83:799-800. [PMID: 24495025 DOI: 10.1111/ans.12384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Sandeep S Bahia
- Vascular Surgery, St George's Healthcare Vascular Institute, London, UK
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