Impact of Care Fragmentation after Major Lower Extremity Amputation

BACKGROUND

Care fragmentation (CF) is a known risk factor for unplanned readmission, morbidity, and mortality after surgery. The goal of this study was to evaluate the impact of CF on outcomes of major lower extremity amputation for peripheral vascular disease.

METHODS

Health-care Cost and Utilization Project Database for NY (2016) and MD/FL (2016-2017) were queried using International Classification of Diseases 10thedition to identify patients who underwent above the knee-, through the knee-, and below the knee-amputation for peripheral vascular disease. Patients with CF were identified as those with admissions to ≥2 hospitals during the study period. We compared the postamputation outcomes of mortality, readmission rate, length of stay (LOS) and hospital charges.

RESULTS

We identified a total of 13,749 encounters of 2,742 patients who underwent major lower extremity amputations. There were 1,624 (59.2%) patients with CF. Patients with CF were younger (68.4 years old vs. 69.7 years old, P = 0.005), with higher Charlson Comorbidity Indices (4.4 vs. 4.1, P < 0.001), and required more hospital resources on index admission ($113,699 vs. $91,854, P < 0.001). These patients were prevalent for higher 30-, and 90-day readmission rates (34.7% vs. 24.5%, P < 0.001 and 54.7% vs. 42.0%, P < 0.001, respectively). On their first postamputation readmission, LOS (16.3 days vs. 14.7 days, P = 0.004) and hospital charge ($48,964 vs. $44,388, P = 0.002) were significantly higher. Multivariate regression analysis demonstrated that the CF was an independent predictor for 30-day (hazard ratio (HR) 1.65, 95% confidence interval (CI) 1.39-1.96, P < 0.001) and 90-day (HR 1.66, 95% CI 1.42-1.95, P < 0.001) readmission after the major lower extremity amputation, but not for mortality (HR 0.83, 95% CI 0.56-1.23, P = 0.36).

CONCLUSIONS

CF after major lower extremity amputation is associated with higher readmission rate, LOS, and hospital charge. Collaboration of care providers to maintain continuity of care for peripheral vascular disease patients may enhance quality of care and reduce health care cost.

Impact of Interfacility Transfer of Ruptured Abdominal Aortic Aneurysm Patients

OBJECTIVES

Interfacility transfer (IT) of patients with ruptured (r) abdominal aortic aneurysm (AAA) occurs not infrequently for a higher level of care. This study evaluates using contemporary administrative database the impact of IT on mortality after rAAA repair.

METHODS

Healthcare Cost and Utilization Project Database for NY (2016) and NJ/MD/FL (2016-2017) were queried using ICD-10^th edition to identify patients who underwent open and endovascular repair of AAA. Hospitals were categorized into quartiles (Q) per overall volume. Mortality rates of IT vs non-transferred (NT) rAAA patients per treatment modality (open [rOAR] vs. endovascular [rEVAR]) were compared. Cox proportional hazard model was used to estimate hazard ratios (HR) for mortality.

RESULTS

1475 patients presented with rAAA of whom 672 (45.6%) were not treated. Of the remaining 803 patients, 226 (28.1%) were transferred; 50 (22.1%) died without a repair after IT. The remaining 752 patients (176 IT + 576 NT) underwent 491 rEVARs and 261 rOARs. Baseline characteristics were similar between IT and NT patients except for higher proportion of Blacks (P=.03), lower-income families (P=.049) and rOAR (45.5% vs 31.4%, p=.001) in IT patients. Overall mortality rates were similar between NT (30.2%) and IT (27.3%, P=.46). On sub-group analysis, operative mortality rates after rEVAR were similar between NT and IT patients, without differences among hospital quartiles. After rOAR, however, operative mortality rates were lower in IT patients, largely due to improved outcomes in Q4 hospitals (P=.001, Q4 vs Q1, 2 & 3). Cox regression analysis demonstrated age (HR 1.03, CI 1.00-1.06, P=.02) and low-volume hospitals (Q1-3) (HR 1.89, CI 1.02-3.51, P=.04) are predictors of mortality. Total charges were similar ($286,727 IT vs $265,717 NT, P=.38).

CONCLUSIONS

Less than 30% of rAAA patients deemed to be a candidate for repair are transferred. IT does not affect mortality rates after rEVAR, irrespective of hospital volume. For rOAR candidates, however, regionalization of care with prompt transfer to a high-volume center improves the survival benefits without increased health care cost.

Feasibility of Cryopreserved Conduits for Complex Vascular Reconstruction in the Pediatric Population: The Case of a 3-Year-Old With Femoral Vessels Transections

This report presents an unusual case of traumatic iliofemoral vessel transection in a 3-year-old patient successfully reconstructed using a cryopreserved greater saphenous conduit. Five years after injury, the patient continues to do well with normal ambulation. An arterial duplex demonstrated graft patency free of aneurysmal dilatation. These encouraging results suggest that the natural history of cryopreserved conduits may differ in the pediatric population and cryopreserved conduits could be used for complex vascular reconstructions.

Thoracic stent graft placement for repair of iatrogenic aortic injury secondary to sheath placement during pacemaker insertion

We describe the inadvertent cannulation of the proximal descending thoracic aortic stent with a five French sheath during attempted pacemaker placement in an 88- year-old male. The injury was managed successfully by the percutaneous placement of a thoracic aortic stent graft with good outcome. Our case highlights the feasibility of managing this uncommon injury with this technique.

Primary Endovascular Repair of Ilio-Caval Injury Encountered during Anterior Exposure Spine Surgery: Evolution of the Paradigm

BACKGROUND

Rates of major venous injury are now being reported at between 1% and 15%. Risk factors for injury include the previous spine surgery, level of exposure, and number of retractors used. To review and describe the evolution of our use of stent grafts for repair of life-threatening ilio-caval injuries encountered during anterior exposure lumbosacral (L-S) spine surgery from rescue utilization after failed direct repair to preferred modality using occlusion balloons and covered stents akin to the modern management of the ruptured abdominal aortic aneurysm (AAA) with endovascular aneurysm repair.

METHODS

Five-year retrospective review of all anterior and retroperitoneal spine procedures was performed at our institution.

RESULTS

One hundred two procedures were done. Major ilio-caval injury occurred in 3/102 (2.9%) cases. Average blood loss per case decreased as our approach evolved from unsuccessful direct open repair with percutaneous endovascular rescue to primary percutaneous endovascular repair. All treated patients had patent venous repair in short-term follow-up with computed tomography angiography.

CONCLUSIONS

Identification and rapid direct repair of major ilio-caval injuries during anterior approach spine surgery can be extremely challenging. When control of these potentially fatal injuries is required, our choice is primary endovascular repair using the modern techniques for endovascular management of ruptured AAA with endovascular aneurysm repair.

Endovascular Repair of Blunt Extremity Arterial Injury: Case Report

Objective: Surgical revascularization is the standard treatment of complex blunt traumatic extremity vascular injuries. Limb salvage may be improved with minimally invasive endovascular therapies because of the ability to perform diagnostic and therapeutic intervention simultaneously. Two cases of acute limb-threatening arterial injuries successfully treated with percutaneous endovascular therapy are reported. Results: A skier suffered hemodynamic instability after shoulder reduction. An axillary arterial injury was suspected and confirmed with angiography. A covered stent successfully controlled the hemorrhage. A morbidly obese female sustained anterior dislocation of her left knee 7 years previously requiring repair. She developed recurrent knee dislocation with acute leg ischemia. Emergent fixation was performed followed by percutaneous angiography. Short segment thrombosis of the popliteal was noted. Wire recanalization of the thrombosed artery and stent placement restored 3-vessel runoff. Conclusion: Endovascular therapy can offer faster, easier access to the extremity vascular injury facilitating revascularization and avoiding long incisions and dissections.

Fate of the ectatic infrarenal aorta: expansion rates and outcomes

The natural history of the ectatic infrarenal aorta remains undetermined. While surveillance protocols have been proposed for true aneurysms, no recommendations are currently available for ectatic aortas. The purpose of this study is to define the natural history and recommend surveillance protocols for the infrarenal aorta 2.5-2.9 cm in diameter. Screening of 12,500 yielded 223 patients with an infrarenal abdominal aorta 2.5-2.9 cm in diameter at a university-affiliated VA medical center. All patients were prospectively followed by ultrasound from August 1993 through October 2000 and expansion rates were calculated by comparing the first and last study. Multivariate analysis of risk factors classically associated with abdominal aortic aneurysm was performed. Current data suggest that ectatic infrarenal aortas expand slowly, do not rupture, and rarely meet criteria for operative repair. No risk factors linked to the development of aneurysms were identified. On the basis of this study we recommend that patients with ectatic aortas have a repeat ultrasound 5 years after the initial study.

Use of a non-contact radiant heat bandage on ischemic dermal infections in an ovine model

BACKGROUND

Chronic non-healing foot wounds are common complication in the diabetic population. Local radiant heat bandage has recently been proposed as an effective adjuvant. The purpose of this study was to evaluate the efficacy of such bandage in controlling infection in an ovine ischemic wound model.

MATERIAL/METHODS

Bilateral flank ischemic wounds were created in a total of 42 sheep. 14 sheep were challenged with Pseudomonas aeruginosa (PA), 13 with Escherichia Coli (EC), and 15 with Methicillin resistant staphylococcus aureus (MRSA). The left flank was designated the treatment side and the right the control side. The radiant heat bandage was applied for a total of 10 days. The animal were then euthanized and the wounds harvested for bacterial quantification.

RESULTS

39 sheep completed the study. Mean bacterial counts were has follows: for MRSA, control 7.6 x 10(5) CFU/gm vs. heated 2.0 x 10(5) CFU/gm (p=0.16); for EC, control 1.1 x 10(6) CFU/gm vs. heated 2.7 x 10(5) CFU/gm (p=0.006); PA, control 1.7 x 10(6) CFU/gm vs. heated 3.9 x 10(9) CFU/gm (p=0.001).

CONCLUSIONS

Non-contact radiant bandages controls bacterial growth in ischemic wounds infected with MRSA or EC and may potentially improve wound healing. Wounds infected with PA should no be submitted to such treatment.

Technical aspects and current results of carotid stenting

PURPOSE

We reviewed our experience with carotid stenting (CS), focusing on technical evolution and results.

METHODS

From September 1995 to February 2000, 77 patients with 83 internal (n = 68) and common carotid artery lesions (n = 15) were selected for CS. This patient population was categorized into three consecutive periods based on patient selection, material, and technical skills. For internal carotid artery lesions, period I included 11 patients treated by means of direct carotid puncture with balloon expandable stents; period II included 42 patients treated by means of a femoral approach with self-expandable stents; and period III included 15 patients in whom monorail system and cerebral protection devices were used. Common carotid artery lesions were treated by means of carotid puncture in five patients and by means of a femoral approach in 10 patients. In only two of the latter cases, cerebral protection devices were used.

RESULTS

The overall immediate success rate, defined as successfully treated stenosis with no neurological events, was 89.7% for internal carotid artery lesions and 100% for common carotid artery lesions. All neurological events, which consisted of reversible events (4.4%), minor stroke (1.5%), and major stroke (2.9%), occurred during periods I and II. In periods I, II, and III, the rate of surgical conversion was 18%, 9.5%, and 0%, respectively, the rate of transient ischemic attack and reversible ischemic neurologic deficit was 0%, 7%, and 0%, respectively, and the rate of minor and major stroke was 0%, 7%, and 0%, respectively. All major strokes were cleared with intra-arterial thrombolysis. At discharge, the success rates defined by means of the absence of conversion and neurological events were 82% during period I, 76% during period II, and 100% during period III. The freedom from neurological deficits rates were 100%, 97.6%, and 100%, respectively. During follow-up, six significant asymptomatic restenoses were detected with duplex scanning; however, only one patient required reintervention.

CONCLUSION

Technical skills and technological improvement, including low-profile balloon and catheter, cerebral protection device, and intra-arterial rescue techniques, may reduce the rate of neurological events associated with CS. Technical improvements should be given careful consideration before the initiation of randomized trials comparing CS and carotid endarterectomy.

Follow-up evaluation of endoluminally treated abdominal aortic aneurysms with duplex ultrasonography: validation with computed tomography

OBJECTIVE

A growing number of patients with abdominal aortic aneurysms are currently being offered endoluminal treatment. However, the incidence of endoleaks, stenosis, and thrombosis is around 25% to 30%. As a result, a strict post procedure imaging surveillance protocol is necessary. The purpose of this study was to compare duplex ultrasonography (DU) and computed tomography (CT) for the follow-up of endoluminally treated aortic aneurysms.

METHODS

A total of 89 patients were followed up with serial CT and DU at 1, 3, 6, 12, and 24 months after endoluminal treatment. Special attention was directed toward the presence of endoleaks and aneurysm diameter evolution. Preoperative CT and DU were also reviewed to assess aneurysm diameter correlation.

RESULTS

With DU, 14 type I and 21 type II endoleaks were identified. In one case the DU did not visualize a type II endoleak present on CT, and CT did not confirm three type II leaks identified with DU. There was only one false positive for type I endoleak with DU. The sensitivity of DU was 96% with a specificity of 94%, when compared with CT. A linear regression analysis of the diameters obtained with DU and CT revealed a good correlation. However, variability was high, indicating poor agreement. Regarding diameter evolution, the range was identical in 45%, and the trend was similar in 73%. However, in 9% of the cases, DU showed a decrease in diameter, whereas CT showed a significant increase.

CONCLUSION

DU is an accurate tool for the diagnosis of endoleaks, but is less valuable for diameter measurements, when compared with CT. Currently, DU is a useful tool, but CT remains a key part of the postoperative evaluation after endoluminal treatment of abdominal aortic aneurysms. At institutions where DU is used for follow-up, researchers should perform quality control studies to avoid potentially significant errors.

Percutaneous stenting of an latrogenic superior mesenteric artery dissection complicating suprarenal aortic aneurysm repair

PURPOSE

To report endovascular repair of an iatrogenic superior mesenteric artery (SMA) dissection caused by a balloon occlusion catheter.

CASE REPORT

A 68-year-old man with a suprarenal aortic aneurysm underwent conventional prosthetic replacement, during which visceral artery back bleeding was controlled with balloon occlusion catheters. Six hours postoperatively, the patient experienced an episode of bloody diarrhea with abdominal pain and tenderness and mild metabolic acidosis. Colonoscopy revealed colitis (grade I) without necrosis of the right and left colon. An emergent abdominal computed tomographic scan showed signs of mesenteric ischemia with bowel dilatation and SMA wall hematoma; angiography identified a dissection 1 cm distal to the SMA origin. An Easy Wallstent was deployed percutaneously, successfully reestablishing SMA patency. The postoperative course was uneventful, and the patient remains asymptomatic with a patent SMA stent and aortic graft at 1 year.

CONCLUSIONS

latrogenic SMA dissection should be suspected after suprarenal aortic aneurysm repair if signs of mesenteric ischemia arise. Prompt and thorough imaging studies are necessary to confirm the diagnosis and assess the potential for an endoluminal treatment.

Acute occlusion of popliteal and/or tibial arteries: the value of percutaneous treatment

OBJECTIVES

to describe early and mid-term results with a percutaneous therapeutic protocol including thromboaspiration, thrombolysis, and correction of the underlying lesion by PTA.

METHODS

thirty-three consecutive selected patients with recent (<1 month) reversible acute ischaemia associated with popliteal and/or tibial occlusion were studied. The primary endpoints were technical success (defined as residual mural thrombus less than 20% of the lumen and the presence of at least one tibial artery on angiogram), patient survival and limb salvage at 1 and 12 months. Secondary endpoints included complications, primary, assisted primary and secondary patency determined by duplex scan at 1, 6 and 12 months.

RESULTS

technical success was achieved in 27 patients (82%). Twenty patients were treated by thrombo- aspiration+/-thrombolysis only, and seven required additional PTA (26%). In six patients (18%), percutaneous techniques failed, and embolectomy was performed in two, bypass in one and major amputations in three (9%). For the entire series, the survival rate was 100% at 1 month and 94% at 1 year. The limb salvage rate was 91% at 1 month and 1 year. The cumulative primary patency, assisted primary patency and secondary patency rates were 81%, 81% and 86% respectively at 1 month and 66%, 72% and 77%, respectively, at 12 months. Early complications occurred in 10 patients (30%): five groin haematomas (15%), four compartment syndromes (12%) and one haemoglobinuria (3%).

CONCLUSION

percutaneous techniques offer excellent early and mid-term results in selected patients presenting with acute ischaemia with popliteal and/or tibial arteries occlusion.

[Metaplasia of aortic tissue into tracheal tissue. Surgical perspectives]

Tracheal reconstruction after extensive resection remains an unsolved surgical problem. Numerous attempts have been made using tracheal grafts or prosthetic conduits with disappointing results. In this study, we propose a new alternative using an aortic autograft as tracheal substitute. In a first series of experiments, a half circumference of two rings was replaced with an autologous carotid artery patch. In a second series, a complete segment of trachea was replaced with an autologous aortic graft supported by an endoluminal tracheal stent. No dehiscence or stenosis was observed. Microscopic examinations at 3 and 6 months showed the replacement of the aortic tissue by tracheal tissue comprising neoformation of cartilage and mucociliary or non-keratinizing metaplastic polystratified squamous epithelium. Although these results need to be confirmed by a larger series of experiments, they showed that a vascular tissue placed in a different environment with a different function can be submitted to a metaplastic transformation which tends to restore a normal structure adapted to its new function. These remarkable findings offer new perspectives in tracheal reconstruction in human.

Endothelial dysfunction following thrombolysis in vitro

OBJECTIVES

Thrombolytic therapy is frequently used to manage vascular graft thrombosis. However, long-term patency after thrombolysis remains poor. The purpose of this study was to characterise the morphological and functional response of endothelial cells (EC) exposed to a thrombus and subsequently lytic therapy.

METHODS

Human EC were exposed to human whole blood thrombus for 2, 6, 12, and 24 h. The thrombus was lysed with urokinase. Cell morphology was studied with electron microscopy. Northern blot analyses were performed with human c-DNA probes for endothelin-1, thrombomodulin, tissue factor, tissue plasminogen activator, plasminogen activator inhibitor, and triose phosphate isomerase.

RESULTS

EC retraction occurred for each period of incubation. Thrombomodulin expression was increased 2.2-fold at 6 h and 2.4-fold at 24 h. t-PA expression was depressed proportionally to the duration of thrombus exposure. PAI and TF expression transiently increased 1.5-fold at 2 h of exposure and returned to baseline at 6 h. Endothelin expression remained unchanged.

CONCLUSIONS

Except for a transient increase in TF expression and reversal of the tPA/PAI ratio, EC exposed to thrombus do not appear to become actively procoagulant. The increase in TM expression may reflect enhanced thromboresistance. However, EC retraction may be responsible for an increase thrombogenicity of saphenous vein graft after thrombosis and Urokinase therapy.

The role of thrombolytic therapy in the management of paradoxical embolism

Paradoxical emboli are considered a rare event, representing less than 2% of all arterial emboli. The most common intracardiac defect associated with paradoxical emboli is a patent foramen ovale. Most commonly, a pulmonary embolism is the cause of the acute increase in right atrial pressure leading to a reversal of intracardiac flow and passage of venous embolic material to the left heart. We present a patient with a pulmonary embolism and paradoxical emboli, and discuss therapeutic approach. We suggest that the treatment of choice for the patient with pulmonary embolism and non-limb-threatening acute ischemia due to a paradoxical emboli should be thrombolytic therapy and intracaval filter placement, followed by patent foramen ovale repair.