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Hicks CW, Conte MS, Dun C, Makary MA. Appropriateness of Care Measures: A Novel Approach to Quality. Ann Vasc Surg 2024:S0890-5096(24)00162-6. [PMID: 38582205 DOI: 10.1016/j.avsg.2024.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/18/2024] [Indexed: 04/08/2024]
Abstract
The clinical judgment of a physician is one of the most important aspects of medical quality, yet it is rarely captured with quality measures in use today. We propose a novel approach using individualized physician benchmarking that measures the appropriateness of care that a physician delivers by looking at their practice pattern in a specific clinical situation. A prime application of our novel approach to appropriateness measures is the surgical management of peripheral artery disease and claudication. We discuss 4 potential consensus metrics for the treatment of claudication that explore appropriateness of care of claudication management and are meaningful, actionable, and quantifiable. Given the multitude of medical specialties involved in the care of patients with peripheral artery disease and the consequences of both preemptive and delayed care, it is in all of our interests to promote data transparency with confidential communications to outlier physicians while advocating for evidence-based management.
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Affiliation(s)
- Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Chen Dun
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Martin A Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Marulanda K, Genovese EA. Adjunctive Utilization of Intravascular Ultrasound in Peripheral Arterial Disease Treatment. Ann Vasc Surg 2024:S0890-5096(24)00163-8. [PMID: 38582216 DOI: 10.1016/j.avsg.2024.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 01/17/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND The utility and benefit of intravascular ultrasound (IVUS) has been well established in coronary interventions, however widespread adoption for peripheral interventions has lagged. The objectives of this review article were to discuss the technical components of IVUS, describe key learning pearls for IVUS utilization, and review the literature describing the clinical outcomes of endovascular peripheral arterial interventions using IVUS. METHODS A scoping review of the current literature utilizing Pubmed. Terms used to search the literature included "intravascular ultrasound (IVUS)" in conjunction with "peripheral arterial disease (PAD)," "endovascular interventions," "chronic limb threatening ischemia," "balloon angioplasty" "stenting," "percutaneous coronary intervention," and "outcomes." All types of articles were reviewed including review articles, retrospective reviews, meta-analyses, and prospective observational and randomized studies. RESULTS Published literature regarding IVUS use in peripheral arterial interventions is heterogeneous and limited to mainly retrospective studies, registry analyses and metanalyses. Outcomes are generally favorable with the adjunct of IVUS compared to traditional angiography-driven peripheral interventions. The addition of IVUS improves stent expansion, stent patency, and reduces reintervention rates, particularly in infrainguinal arterial lesions. Long-term costs may also be lower with IVUS-guided procedures. CONCLUSIONS Expert consensus largely supports the implementation of IVUS in endovascular interventions for peripheral arterial disease. However, more robust high-quality data evaluating the efficacy, durability, and cost of IVUS in peripheral arterial disease are still needed.
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Tsukagoshi J, Shimoda T, Yokoyama Y, Secemsky EA, Shirasu T, Nakama T, Jujo K, Wiley J, Takagi H, Aikawa T, Kuno T. The mid-term effect of intravascular ultrasound on endovascular interventions for lower extremity peripheral arterial disease: A systematic review and meta-analysis. J Vasc Surg 2024; 79:963-972.e11. [PMID: 37678642 DOI: 10.1016/j.jvs.2023.08.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/15/2023] [Accepted: 08/17/2023] [Indexed: 09/09/2023]
Abstract
OBJECTIVE Intravascular ultrasound (IVUS) is an important adjunctive tool for patients with lower extremity peripheral arterial disease (PAD) undergoing endovascular therapy (EVT). The evidence regarding the advantages of IVUS use is evolving, and recent studies have reported conflicting results. We aimed to perform a meta-analysis to evaluate the efficacy of IVUS during angiography-guided EVT for patients with PAD. METHODS MEDLINE and EMBASE were searched through April 2023 to identify studies that investigated the outcomes of IVUS with angiography-guided EVT vs angiography-alone-guided EVT. The primary outcome was restenosis/occlusion rate; secondary outcomes were target lesion revascularization, major amputation, and mortality. RESULTS One randomized controlled trial and 14 observational studies, largely of moderate quality, were included, yielding a total of 708,808 patients with 709,189 lesions that were treated with IVUS-guided EVT (n = 101,405) vs angiography-alone (n = 607,784). Compared with angiography alone, IVUS-guided EVT was associated with a non-significant trend towards decreased restenosis/occlusion (relative risk [RR], 0.74; 95% confidence interval [CI], 0.54-1.00; I2 = 60%). Although the risk of target lesion revascularization and mortality were comparable (RR, 0.85; 95% CI, 0.65-1.10; I2 = 70%; RR, 1.01; 95% CI, 0.79-1.28; I2 = 43%, respectively), the use of IVUS was also associated with significantly lower risk of major amputation (RR, 0.74; 95% CI, 0.67-0.82; I2 = 47%). Subgroup analysis focusing on femoropopliteal disease demonstrated significantly higher patency (RR, 0.72; 95% CI, 0.52-0.98; I2 = 73%). However, superiority with major amputation was not observed. CONCLUSIONS IVUS-guided EVT for PAD may possibly be associated with a lower major amputation rate compared with angiography alone-guided EVT, although the difference in patency remained an insignificant trend in favor of IVUS-guided EVT. Adjunctive use of IVUS during EVT may be beneficial, and further prospective studies are warranted to delineate this relationship and the applicability of this technology in routine practice.
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Affiliation(s)
- Junji Tsukagoshi
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | | | - Yujiro Yokoyama
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI
| | - Eric A Secemsky
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Takuro Shirasu
- Division of Vascular Surgery, Department of Surgery, The University of Tokyo, Tokyo, Japan
| | - Tatsuya Nakama
- Department of Cardiology, Tokyo Bay Medical Center, Urayasu, Japan
| | - Kentaro Jujo
- Department of Cardiology, Saitama Medical University, Iruma, Japan
| | - Jose Wiley
- Section of Cardiology, Department of Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Tadao Aikawa
- Department of Cardiology, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Toshiki Kuno
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Department of Cardiology, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY.
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Secemsky EA, Aronow HD, Kwolek CJ, Meissner M, Muck PE, Parikh SA, Winokur RS, George JC, Salazar G, Murphy EH, Costantino MM, Zhou W, Li J, Lookstein R, Desai KR. Intravascular Ultrasound Use in Peripheral Arterial and Deep Venous Interventions: Multidisciplinary Expert Opinion From SCAI/AVF/AVLS/SIR/SVM/SVS. J Vasc Interv Radiol 2024; 35:335-348. [PMID: 38206255 DOI: 10.1016/j.jvir.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/21/2023] [Accepted: 10/03/2023] [Indexed: 01/12/2024] Open
Abstract
Percutaneous revascularization is the primary strategy for treating lower extremity venous and arterial disease. Angiography is limited by its ability to accurately size vessels, precisely determine the degree of stenosis and length of lesions, characterize lesion morphology, or correctly diagnose postintervention complications. These limitations are overcome with use of intravascular ultrasound (IVUS). IVUS has demonstrated the ability to improve outcomes following percutaneous coronary intervention, and there is increasing evidence to support its benefits in the setting of peripheral vascular intervention. At this stage in its evolution, there remains a need to standardize the use and approach to peripheral vascular IVUS imaging. This manuscript represents considerations and consensus perspectives that emerged from a roundtable discussion including 15 physicians with expertise in interventional cardiology, interventional radiology, and vascular surgery, representing 6 cardiovascular specialty societies, held on February 3, 2023. The roundtable's aims were to assess the current state of lower extremity revascularization, identify knowledge gaps and need for evidence, and determine how IVUS can improve care and outcomes for patients with peripheral arterial and deep venous pathology.
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Affiliation(s)
- Eric A Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology and Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Herbert D Aronow
- Department of Medicine, Michigan State University, East Lansing, Michigan; Heart & Vascular Services, Henry Ford Health, Detroit, Michigan
| | - Christopher J Kwolek
- Harvard Medical School, Boston, Massachusetts; Newton-Wellesley Hospital, Wellesley, Massachusetts
| | - Mark Meissner
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Patrick E Muck
- Department of Vascular Surgery, Good Samaritan Hospital, Cincinnati, Ohio
| | - Sahil A Parikh
- Center for Interventional Cardiovascular Care, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Ronald S Winokur
- Weill Cornell Vein Treatment Center and Division of Interventional Radiology, Department of Radiology, Weill Cornell Medicine, New York, New York
| | - Jon C George
- Division of Interventional Cardiology and Endovascular Medicine, Pennsylvania Hospital, Philadelphia, Pennsylvania
| | - Gloria Salazar
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Erin H Murphy
- Venous and Lymphatic Center, Division of Vascular Surgery, Sanger Heart and Vascular, Atrium Health, Charlotte, North Carolina
| | | | - Wei Zhou
- Division of Vascular Surgery, University of Arizona and Banner University Medical Center, Tucson, Arizona
| | - Jun Li
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, Ohio
| | | | - Kush R Desai
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Kaminski C, Beardslee LA, Rajani R. Sensorized Endovascular Technologies: Additional Data to Enhance Decision-Making. Ann Vasc Surg 2024; 99:105-116. [PMID: 37922964 DOI: 10.1016/j.avsg.2023.10.001] [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: 06/07/2023] [Revised: 09/29/2023] [Accepted: 10/07/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Current endovascular procedures rely mostly on anatomic information, guided by fluoroscopy, to perform interventions (i.e. angioplasty, stent placement, coils). However, the structural parameters provided by these imaging technologies do not provide any physiological data on either the disease state or efficacy of intervention. Additional endovascular tools are needed to collect physiologic and other both anatomic and nonanatomic data to further individualize endovascular interventions with the ultimate goal of improving patient outcomes. This review details the current state of the art for these sensorized endovascular technologies and details systems under development with the aim of identifying gaps and new directions. The objective of this review was to survey the Vascular Surgery literature, engineering literature, and commercially available products to determine what exists in terms of sensor-enabled endovascular devices and where gaps and opportunities exist for further sensor integration. METHODS Search terms were entered into search engines such as Google and Google Scholar to identify endovascular devices containing sensors. A variety of terms were used including directly search for items such as "sensor-enabled endovascular devices" and then also completing more refined searches bases on areas of interest (i.e. fractional flow reserve, navigation, retrograde endovascular balloon occlusion of the aorta, etc.). For the most part, systems were included where the sensor was mounted directly onto the catheter and implantable sensors such as those that have been investigated for use with stents have been excluded. RESULTS The authors were able to identify a body of literature in the area of endovascular devices that contain sensors to measure physiologic information. However, areas where additional sensing capabilities may be useful were identified. CONCLUSIONS Several different types of sensors and sensing systems were identified that have been integrated with endovascular catheters. Although a great deal of work has been done in this field, there are additional useful data that could be obtained from additional novel sensing technologies. Furthermore, significant effort needs to be allocated to carefully studying how these new technologies can be employed to actually improve patient outcomes.
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Affiliation(s)
- Candice Kaminski
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Luke A Beardslee
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Ravi Rajani
- Department of Surgery, Emory University School of Medicine, Atlanta, GA.
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Monteleone P, Farr A, Bunte MC. Looking into the future: Endovascular intervention with intravascular ultrasound. Vasc Med 2023; 28:422-424. [PMID: 37554115 DOI: 10.1177/1358863x231190077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Affiliation(s)
- Peter Monteleone
- The University of Texas at Austin Dell School of Medicine, Austin, TX, USA
- Ascension Texas Cardiovascular, Austin, TX, USA
| | - Alexander Farr
- The University of Texas at Austin Dell School of Medicine, Austin, TX, USA
| | - Matthew C Bunte
- Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
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Divakaran S, Parikh SA, Hawkins BM, Chen S, Song Y, Banerjee S, Rosenfield K, Secemsky EA. Temporal Trends, Practice Variation, and Associated Outcomes With IVUS Use During Peripheral Arterial Intervention. JACC Cardiovasc Interv 2022; 15:2080-2090. [PMID: 36265940 PMCID: PMC9758975 DOI: 10.1016/j.jcin.2022.07.050] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/12/2022] [Accepted: 07/19/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Intravascular ultrasound (IVUS) has been shown in limited prospective studies to improve procedural outcomes for patients undergoing lower extremity peripheral arterial intervention (PVI). OBJECTIVES The authors aimed to study temporal trends, practice variation, and associated outcomes with the use of IVUS during PVI among Medicare beneficiaries. METHODS All PVIs performed from 2016 to 2019 among Medicare beneficiaries aged >65 years were included. Temporal trends in IVUS use were stratified by procedural location (inpatient, outpatient, or ambulatory surgery center [ASC]/office-based laboratory [OBL]) and physician specialty. The primary outcome was major adverse limb events (MALE). Inverse probability weighting was used to account for differences in baseline characteristics. Cox regression with competing risks was used to estimate weighted hazard ratios. RESULTS During the study period, 543,488 PVIs were included, of which 63,372 (11.7%) used IVUS. A substantial growth in IVUS use was observed, which was driven by procedures performed in ASCs/OBLs (23.6% increase from quarter 1 of 2016 through quarter 4 of 2019). Among operators who used IVUS, there was also notable variation in use (median operator use 5.4% of cases; IQR: 2.2%-15.0%; range, <1%-100%). In weighted analysis, IVUS use during PVI was associated with a lower risk of MALE through a median of 514 days (adjusted hazard ratio: 0.73; 95% CI: 0.70-0.75; P < 0.0001). CONCLUSIONS In contemporary nationwide data, IVUS use during PVI has increased since 2016, driven by growth in the ASC/OBL setting. However, there remains substantial variation in operator practice. When used during PVI, IVUS was associated with a lower risk of short- and long-term MALE.
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Affiliation(s)
- Sanjay Divakaran
- Division of Cardiovascular Medicine and Cardiovascular Imaging Program, Brigham and Women's Hospital, Boston, Massachusetts, USA; Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/SanjayDivakaran
| | - Sahil A Parikh
- Division of Cardiovascular Medicine, Columbia University Medical Center, New York, New York, USA
| | - Beau M Hawkins
- Section of Cardiovascular Diseases, University of Oklahoma, Oklahoma City, Oklahoma, USA
| | - Siyan Chen
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Yang Song
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Subhash Banerjee
- Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Kenneth Rosenfield
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eric A Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
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