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Mohammed MK, Andraska EA, Mohapatra A, Avgerinos ED, Madigan MC, Salem KM. Incidence and Outcomes of Visceral Ischemia in Acute Aortic Occlusion. Ann Vasc Surg 2024; 98:164-172. [PMID: 37516427 DOI: 10.1016/j.avsg.2023.07.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/28/2023] [Accepted: 07/03/2023] [Indexed: 07/31/2023]
Abstract
BACKGROUND Acute aortic occlusion (AAO) is a morbid diagnosis in which mortality correlates with severity of ischemia on presentation. Visceral ischemia (VI) is challenging to diagnose and its presentation as a consequence of AAO is not well-studied. We aim to identify characteristics associated with VI in AAO to facilitate diagnosis. METHODS Patients diagnosed with AAO who underwent revascularization were identified retrospectively from institutional records (2006-2020). The primary outcome was the development of VI (intra-abdominal ischemia). Univariate analysis was used to compare demographic, exam, imaging, and intraoperative variables between patients with and without VI in the setting of AAO. RESULTS Ninety-one patients were included. The prevalence of VI was 20.9%. Preoperative comorbidities, time to revascularization, and operative approach did not differ between patients with and without VI. Patients with VI more frequently were transferred from outside institutions (100% vs. 53%, P = 0.02), presented with advanced acute limb ischemia (Rutherford III 36.9% vs. 7.5%, P < 0.01), and had elevated preoperative serum lactate (4.31 vs. 2.41 mmol/L, P < 0.01). VI patients had an increased occurrence of bilateral internal iliac artery (IIA) occlusion (47.4% vs. 18.1%, P = 0.01). Unilateral IIA occlusion, level of aortic occlusion, and patency of inferior mesenteric arteries were not associated with VI. Patients with VI had worse postoperative outcomes. In particular, VI conferred significant risk of mortality (odds ratio 5.45, P < 0.01). CONCLUSIONS Visceral ischemia is a common consequence of AAO. Elevated lactate, bilateral IIA occlusion, and advanced acute limb ischemia (ALI) should increase clinical suspicion for concomitant VI with AAO and may facilitate earlier diagnosis to improve outcomes.
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Affiliation(s)
- Maryam K Mohammed
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Elizabeth A Andraska
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Michael C Madigan
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Karim M Salem
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA; Division of Vascular Surgery, VA Pittsburgh Healthcare System, Pittsburgh, PA.
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2
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Andraska EA, Bonaroti J, Zhang Y, Rivera-Lebron B, Chaer RA, Avgerinos ED. Predictors of chronic thromboembolic pulmonary hypertension in patients with submassive pulmonary embolism treated with catheter-directed thrombolysis versus anticoagulation alone: A secondary analysis of the SUNSET sPE trial. J Vasc Surg Venous Lymphat Disord 2023; 11:1157-1164. [PMID: 37353154 PMCID: PMC10630068 DOI: 10.1016/j.jvsv.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 05/19/2023] [Accepted: 06/04/2023] [Indexed: 06/25/2023]
Abstract
OBJECTIVE Chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary embolism (PE) is a morbid complication with suboptimal treatment. We aimed to evaluate the biomarker profile and functional outcomes in patients with submassive PE (sPE) treated with catheter-directed thrombolysis (CDT) compared with anticoagulation alone (ACA). We performed a secondary biomarker and survey analysis of the SUNSET sPE (standard vs ultrasound-assisted catheter thrombolysis for submassive pulmonary embolism) randomized trial comparing standard CDT to ultrasound-assisted thrombolysis in patients with sPE. METHODS As a part of the SUNSET sPE study, patients who did not receive an intervention were enrolled in the medical (ACA) arm. The biomarkers associated with CTEPH in the literature (ie, CCL2, CXCL10, PTX3, GDF-15, RAGE, BCA-1, TFPI) were collected and measured using a multiplex assay at diagnosis, discharge, and 3-month follow-up. Patients underwent a 6-minute walk test and answered quality-of-life questionnaires (pulmonary embolism quality of life; University of California, San Diego, shortness of breath questionnaire; 36-item short-form survey) at 3 months after diagnosis. Comparisons were made using the Student t test. Nonparametric tests were used when the distributions were not normal. Significance was set at P ≤ .05. RESULTS A total of 72 patients (age, 56 ± 15 years; 40.3% women) were included in the present analysis. Of these 72 patients, 53 underwent CDT and 19 were included in the ACA arm. The baseline right ventricle/left ventricle ratios were similar between the two groups (CST, 1.8; ACA, 1.7). The survival and complication rates were similar between the two groups. At discharge, CXCL10 (768.9 ± 148.6 pg/mL vs 3032.0 ± 1201.0 pg/mL; P = .018) and PTX3 (3203.5 ± 1298.0 pg/mL vs 12,716.2 ± 6961.5 pg/mL; P = .029) were lower in the CDT group and displayed a quicker return to baseline than in the ACA group. This trend, although not significant, was also seen with the other biomarkers. At 3 months, the 6-minute walking distance and quality-of-life scores were similar between both groups. CONCLUSIONS In patients with sPE, the biomarkers of CTEPH were lower with CDT compared with ACA. At 3 months, both groups demonstrated similar biomarker levels, 6-minute walking distances, and quality-of-life scores.
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Affiliation(s)
- Elizabeth A Andraska
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA.
| | | | - Yingze Zhang
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Belinda Rivera-Lebron
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Rabih A Chaer
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
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Hussein EA, Semaan DB, Phillips AR, Andraska EA, Rivera-Lebron BN, Chaer RA, Eslami MH, Sridharan N. Pulmonary embolism response team for hospitalized patients with submassive and massive pulmonary embolism: A single-center experience. J Vasc Surg Venous Lymphat Disord 2023; 11:741-747.e2. [PMID: 36906104 DOI: 10.1016/j.jvsv.2023.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/30/2023] [Accepted: 03/01/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND Pulmonary embolism (PE) is a major cause of mortality with presentation varying between few or no symptoms to sudden death. This makes timely and appropriate treatment extremely important. Multidisciplinary PE response teams (PERT) have emerged to improve the management of acute PE. This study aims to describe the experience of a large multihospital single-network institution with PERT. METHODS A retrospective cohort study of patients admitted for submassive and massive PE between 2012 and 2019 was conducted. The cohort was divided based on time of diagnosis and hospital into two groups: non-PERT included patients treated at hospitals that did not initiate PERT and patients diagnosed before the introduction of PERT (June 1, 2014); and the PERT group included those admitted after June 1, 2014, to a hospital with PERT. Patients with low-risk PE and those who had admissions in both time periods were excluded. Primary outcomes included all-cause mortality at 30, 60, and 90 days. Secondary outcomes included causes of death, intensive care unit (ICU) admission, ICU length of stay (LOS), total hospital LOS, type of treatment, and specialty consultations. RESULTS We analyzed 5190 patients, with 819 (15.8%) being in the PERT group. Patients in the PERT group were more likely to receive extensive workup that included troponin-I (66.3% vs 42.3%; P < .001) and brain natriuretic peptide (50.4% vs 20.3%; P < .001). They also more often received catheter-directed interventions (12% vs 6.2%; P < .001) rather than anticoagulation monotherapy. Mortality outcomes were similar between both groups at all measured timepoints. Rates of ICU admission (65.2% vs 29.7%; P < .001), ICU LOS (median, 64.7 hours; interquartile range [IQR], 41.9-89.1 hours vs median, 38 hours; IQR, 22-66.4 hours; P < .001), and total hospital LOS (median, 5 days; IQR, 3-8 days vs median, 4 days; IQR, 2-6 days; P < .001) were all higher among the PERT group. Patients in the PERT group were more likely to receive vascular surgery consultation (5.3% vs 0.8%; P < .001) and the consultation occurred earlier in the admission when compared with the non-PERT group (median, 0 days; IQR, 0-1 days vs median, 1 day; IQR, 0-1; P = .04). CONCLUSIONS The data presented here showed that there was no difference in mortality after PERT implementation. These results suggest that the presence of PERT increases the number of patients receiving a full PE workup with cardiac biomarkers. PERT also leads to more specialty consultations and more advanced therapies such as catheter-directed interventions. Further research is needed to assess the effect of PERT on long-term survival of patients with massive and submassive PE.
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Affiliation(s)
- Emad A Hussein
- Department of Vascular Surgery, Ain Shams University, Cairo, Egypt.
| | - Dana B Semaan
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Amanda R Phillips
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Elizabeth A Andraska
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Belinda N Rivera-Lebron
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Mohammad H Eslami
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Natalie Sridharan
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
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Xie B, Semaan DB, Binko MA, Agrawal N, Kulkarni RN, Andraska EA, Sachdev U, Chaer RA, Eslami MH, Makaroun MS, Sridharan N. COVID-associated acute limb ischemia during the Delta surge and the effect of vaccines. J Vasc Surg 2023; 77:1165-1173.e1. [PMID: 36526086 PMCID: PMC9744677 DOI: 10.1016/j.jvs.2022.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/29/2022] [Accepted: 12/02/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Hypercoagulability is common in severe acute respiratory syndrome coronavirus 2 and has been associated with arterial thrombosis leading to acute limb ischemia (ALI). Our objective was to determine the outcomes of concurrent coronavirus disease 2019 (COVID-19) infection and ALI, particularly during the Delta variant surge and the impact of vaccination status. METHODS A retrospective review was performed of patients treated at a single health care system between March 2020 and December 2021 for ALI and recent (<14 days) COVID-19 infection or who developed ALI during hospitalization for the same disease. Patients were grouped by year as well as by pre and post Delta variant emergence in 2021 based on the World Health Organization timeline (January to May vs June to December). Baseline demographics, imaging, interventions, and outcomes were evaluated. A control cohort of all patients with ALI requiring surgical intervention for a 2-year period prior to the pandemic was used for comparison. Primary outcomes were in-hospital mortality and amputation-free survival. Kaplan-Meier survival and Cox proportional hazards analysis were performed. RESULTS Forty acutely ischemic limbs were identified in 36 patients with COVID-19, the majority during the Delta surge (52.8%) and after the wide availability of vaccines. The rate of COVID-19-associated ALI, although low overall, nearly doubled during the Delta surge (0.37% vs 0.20%; P = .09). Intervention (open or endovascular revascularization vs primary amputation) was performed on 31 limbs in 28 individuals, with the remaining eight treated with systemic anti-coagulation. Postoperative mortality was 48%, and overall mortality was 50%. Major amputation following revascularization was significantly higher with COVID-19 ALI (25% vs 3%; P = .006) compared with the pre-pandemic group. Thirty-day amputation-free survival was significantly lower (log-rank P < .001). COVID-19 infection (adjusted hazard ratio, 6.2; P < .001) and age (hazard ratio, 1.1; P = .006) were associated with 30-day amputation in multivariate analysis. Severity of COVID-19 infection, defined as vasopressor usage, was not associated with post-revascularization amputation. There was a higher incidence of re-thrombosis in the latter half of 2021 with the Delta surge, as reintervention for recurrent ischemia of the same limb was more common than our previous experience (21% vs 0%; P = .55). COVID-19-associated limb ischemia occurred almost exclusively in non-vaccinated patients (92%). CONCLUSIONS ALI observed with Delta appears more resistant to standard therapy. Unvaccinated status correlated highly with ALI occurrence in the setting of COVID-19 infection. Information of limb loss as a COVID-19 complication among non-vaccinated patients may help to increase compliance.
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Affiliation(s)
- Bowen Xie
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Dana B Semaan
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Mary A Binko
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Rohan N Kulkarni
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Elizabeth A Andraska
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Ulka Sachdev
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Mohammad H Eslami
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Michel S Makaroun
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Natalie Sridharan
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
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Habib SG, Semaan DB, Andraska EA, Madigan MC, Al-Khoury GE, Chaer RA, Eslami MH. A Decade’s Experience with Retrograde Open Mesenteric Stenting for Acute Mesenteric Ischemia. J Vasc Surg 2023. [DOI: 10.1016/j.jvs.2022.12.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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Fields AT, Andraska EA, Kaltenmeier C, Matthay ZA, Herrera K, Nuñez-Garcia B, Jones CM, Wick KD, Liu S, Luo JH, Yu YP, Matthay MA, Hendrickson CM, Bainton RJ, Barrett TJ, Berger JS, Neal MD, Kornblith LZ. Effects of the circulating environment of COVID-19 on platelet and neutrophil behavior. Front Immunol 2023; 14:1130288. [PMID: 36999030 PMCID: PMC10043426 DOI: 10.3389/fimmu.2023.1130288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 02/23/2023] [Indexed: 04/01/2023] Open
Abstract
Introduction Thromboinflammatory complications are well described sequalae of Coronavirus Disease 2019 (COVID-19), and there is evidence of both hyperreactive platelet and inflammatory neutrophil biology that contributes to the thromoinflammatory milieu. It has been demonstrated in other thromboinflammatory diseases that the circulating environment may affect cellular behavior, but what role this environment exerts on platelets and neutrophils in COVID-19 remains unknown. We tested the hypotheses that 1) plasma from COVID-19 patients can induce a prothrombotic platelet functional phenotype, and 2) contents released from platelets (platelet releasate) from COVID-19 patients can induce a proinflammatory neutrophil phenotype. Methods We treated platelets with COVID-19 patient and disease control plasma, and measured their aggregation response to collagen and adhesion in a microfluidic parallel plate flow chamber coated with collagen and thromboplastin. We exposed healthy neutrophils to platelet releasate from COVID-19 patients and disease controls and measured neutrophil extracellular trap formation and performed RNA sequencing. Results We found that COVID-19 patient plasma promoted auto-aggregation, thereby reducing response to further stimulation ex-vivo. Neither disease condition increased the number of platelets adhered to a collagen and thromboplastin coated parallel plate flow chamber, but both markedly reduced platelet size. COVID-19 patient platelet releasate increased myeloperoxidasedeoxyribonucleic acid complexes and induced changes to neutrophil gene expression. Discussion Together these results suggest aspects of the soluble environment circulating platelets, and that the contents released from those neutrophil behavior independent of direct cellular contact.
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Affiliation(s)
- Alexander T. Fields
- Department of Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
| | - Elizabeth A. Andraska
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Christof Kaltenmeier
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Zachary A. Matthay
- Department of Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
| | - Kimberly Herrera
- Department of Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
| | - Brenda Nuñez-Garcia
- Department of Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
| | - Chayse M. Jones
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Katherine D. Wick
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA, United States
| | - Silvia Liu
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jian-Hua Luo
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Yan-Ping Yu
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Michael A. Matthay
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA, United States
| | - Carolyn M. Hendrickson
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Roland J. Bainton
- Department of Anesthesia and Perioperative Care, School of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Tessa J. Barrett
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University (NYU) Grossman School of Medicine, New York, NY, United States
| | - Jeffrey S. Berger
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University (NYU) Grossman School of Medicine, New York, NY, United States
- New York University (NYU) Center for the Prevention of Cardiovascular Disease, New York University (NYU) Langone Health, New York, NY, United States
- Division of Vascular Surgery, Department of Surgery, New York University (NYU) Grossman School of Medicine, New York, NY, United States
| | - Matthew D. Neal
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Lucy Z. Kornblith
- Department of Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
- *Correspondence: Lucy Z. Kornblith,
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Andraska EA, Phillips AR, Asaadi S, Painter L, Bump G, Chaer R, Myers S. Gender Bias in Risk Management Reports Involving Physicians in Training - A Retrospective Qualitative Study. J Surg Educ 2023; 80:102-109. [PMID: 36207255 PMCID: PMC9890406 DOI: 10.1016/j.jsurg.2022.08.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/24/2022] [Accepted: 08/27/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Gender bias, which contributes to burnout and attrition of female medical trainees, may manifest as disparate workplace evaluations. Here, we explore gender-based differences in perceived competence and professionalism as described in an institutional electronic risk management reporting system. DESIGN In this retrospective qualitative study, recurring themes were identified from anonymous entries reported to an electronic institutional risk management database from July 2014 to July 2015, and from July 2019 to July 2020 using inductive methods. This electronic system is often used by hospital staff to document complaints against physicians under the pretext of poor patient care, regardless of whether an adverse event occurred. Two individuals independently coded entries. Themes were determined from event indicator codes (EIC) using Delphi methodology and compared between gender and specialty using bivariate statistics. SETTING A multi-center integrated healthcare delivery system. PARTICIPANTS Risk management entries pertaining to physician trainees by hospital staff as written submissions to the institution's electronic risk management reporting system. Main outcomes included themes defined as: (1) lack of professionalism (i.e., delay in response, attitude, lack of communication), (2) perceived medical error, (3) breach of institutional protocol. RESULTS Of the 207 entries included for analysis, 52 entries identified men (25%) and 31 entries identified women (15%). The gender was not available in 124 entries and, therefore, categorized as ambiguous. The most common complaint about men involved a physician-related EIC (n = 12, 23%, EIC TX39) and the most common complaint about women involved a communication-related EIC (n = 7, 23%, EIC TX55). Eighty-eight (43%) entries involved medical trainees; 82 (40%) involved surgical trainees. Women were more often identified by their name only (n = 8, 26% vs. n = 3, 6%; p < 0.001). This finding was consistent in both medical (n = 0, 0% vs. n = 5, 31%; p < 0.001) and surgical (n = 2, 7% vs. n = 3, 25%; p = 0.006) specialties. In entries involving women, a lack of professionalism was most frequently cited (n = 29, 94%). Entries identifying medical errors more frequently involved men (n = 25, 48% vs. n = 7, 23%; p = 0.02). CONCLUSIONS Gender-based differences exist in how hospital staff interpret trainees' actions and attitudes. These differences have consequences for training paradigms, perceptions of clinical competence, physician burnout, and ultimately, patient outcomes.
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Affiliation(s)
- Elizabeth A Andraska
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Amanda R Phillips
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sina Asaadi
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lisa Painter
- UPMC Corporate Risk Management, Pittsburgh, Pennsylvania
| | - Gregory Bump
- UPMC Medical Education, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rabih Chaer
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sara Myers
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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Andraska EA, Phillips AR, Reitz KM, Asaadi S, Ho J, McDonald MM, Madigan M, Liang N, Eslami M, Sridharan N. Young patients without prior vascular disease are at increased risk of limb loss and reintervention after acute limb ischemia. J Vasc Surg 2022; 76:1354-1363.e1. [PMID: 35709858 PMCID: PMC9890507 DOI: 10.1016/j.jvs.2022.04.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/16/2022] [Accepted: 04/24/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND The objective of the present study was to categorize the presentation and treatment of acute limb ischemia (ALI) in young patients and compare the adverse outcomes after revascularization compared with that of older patients. METHODS All the patients who had presented to a multi-institution healthcare system with ALI from 2016 to 2020 were identified. The presenting features, operative details, and outcomes were included in the present analysis. Patients with existing peripheral arterial disease (acute on chronic) were analyzed separately from those without (de novo thrombosis or embolus). Within these groups, younger patients (age, ≤50 years) were compared with older patients (age, >50 years). The 3-month major adverse limb event-free survival was the primary outcome. RESULTS A total of 232 patients (age, 60 ± 16 years; 44% female sex, 87% white race) were included in the analysis. Of the 232 patients, 119 were in the acute on chronic cohort and 113 were in the de novo thrombosis/embolism cohort. Age did not affect the overall outcomes (P = .45) or the outcomes for the acute on chronic group (P = .17). However, in the de novo thrombosis/embolism cohort, patients aged ≤50 years had worse major adverse limb event-free survival compared with patients aged >50 years (hazard ratio, 2.47; 95% confidence interval, 1.08-5.68; P = .03) after adjustment for Rutherford class, interval from presentation to the operating room, and smoking status. In the de novo thrombosis/embolism group, the operative approach was similar across the age groups (endovascular, 12% vs 14%; open, 48% vs 41%; hybrid, 41% vs 45%; P = .78). In the younger patients, embolism was more likely from a proximal arterial source (71%). In contrast, in the older patients, the source of embolism was more often a cardiac source (86%). The rates of hypercoagulable disease were equal across the age groups (10% vs 10%; P = .95). The In-hospital mortality was 3% overall (acute on chronic, 5%; de novo, 3%). CONCLUSIONS Despite advances in interventional options, for patients with ALI due to de novo thrombosis or embolus, younger age was associated with worse short-term limb-related outcomes.
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Affiliation(s)
- Elizabeth A Andraska
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Amanda R Phillips
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Katherine M Reitz
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Sina Asaadi
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jonathan Ho
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Michael Madigan
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Nathan Liang
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Mohammad Eslami
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Natalie Sridharan
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
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Phillips AR, Andraska EA, Reitz KM, Habib S, Martinez-Meehan D, Dai Y, Johnson AE, Liang NL. Association between neighborhood deprivation and presenting with a ruptured abdominal aortic aneurysm before screening age. J Vasc Surg 2022; 76:932-941.e2. [PMID: 35314299 PMCID: PMC9482667 DOI: 10.1016/j.jvs.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 03/04/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Recent data indicate social determinants of health (SDOH) have a great impact on prevention and treatment outcomes across a broad variety of disease states, especially cardiovascular diseases. The area deprivation index (ADI) is a validated measure of neighborhood level disadvantage capturing key social determinate factors. Abdominal aortic aneurysm rupture (rAAA) is highly morbid, but also preventable through evidence-based screening. However, the association between rAAA and SDOH is poorly characterized. Our objective is to study the association of SDOH with rAAA and screening age. METHODS This retrospective study included patients who underwent operative repair of a rAAA at a multihospital healthcare system (2003-2019). Deprivation was measured by the ADI (scale 1-100), grouped into quintiles for simplicity, with higher quintiles indicating greater deprivation. Patients with the highest quintile ADI (89-100) were categorized as the most deprived. We investigated the association between neighborhood deprivation with the odds of (i) undergoing repair for rAAA before screening age 65 and (ii) undergoing endovascular aortic repair (EVAR) using logistic regression, sequentially modeling nonmodifiable then both nonmodifiable and modifiable confounding variables. RESULTS There were 632 patients who met the inclusion criteria (aged 74.2 ± 9.4 years; 174 women [27.6%]; 564 White [89.2%]; ADI 66.8 ± 22.3). Those from the most deprived neighborhoods (n = 118) were younger (71.7 ± 10.0 years vs 74.8 ± 9.2 years; P = .002), more likely to be female (36% vs 26%; P = .031), more likely to be Black (5.9% vs 0.4%; P = .007), and fewer underwent EVAR (28% vs 39.5%; P = .020) compared with those from other neighborhoods. On sequential modeling, residing in the most deprived neighborhoods was associated with undergoing rAAA repair before age 65 after adjusting for nonmodifiable factors (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.39-2.95; P < .001), and nonmodifiable as well as modifiable factors (OR, 2.22; 95% CI, 1.56-3.16; P < .001). Those in the most deprived neighborhoods had a lower odds of undergoing EVAR compared with open repair after adjusting for nonmodifiable factors (OR, 0.64; 95% CI, 0.41-0.98; P = .042), and nonmodifiable as well as modifiable factors (OR, 0.61; 95% CI, 0.37-0.99; P = .047). CONCLUSIONS Among patients who underwent rAAA, residing in the most deprived neighborhoods was associated with greater adjusted odds of presenting under age 65 and undergoing an open repair. These neighborhoods represent tangible geographic targets that may benefit from a younger screening age, enhanced education, and access to care. These findings stress the importance of developing strategies for early prevention and diagnosis of cardiovascular diseases among patients with disadvantageous SDOH.
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Affiliation(s)
- Amanda R Phillips
- Department of Surgery, Division of Vascular Surgery, UPMC, Pittsburgh, PA.
| | | | - Katherine M Reitz
- Department of Surgery, Division of Vascular Surgery, UPMC, Pittsburgh, PA
| | - Salim Habib
- Department of Surgery, Division of Vascular Surgery, UPMC, Pittsburgh, PA
| | | | - Yancheng Dai
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Amber E Johnson
- Department of Medicine, Division of Cardiology, UPMC, Pittsburgh, PA
| | - Nathan L Liang
- Department of Surgery, Division of Vascular Surgery, UPMC, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
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10
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Cruz MA, Bohinc D, Andraska EA, Alvikas J, Raghunathan S, Masters NA, van Kleef ND, Bane KL, Hart K, Medrow K, Sun M, Liu H, Haldeman S, Banerjee A, Lessieur EM, Hageman K, Gandhi A, de la Fuente M, Nieman MT, Kern TS, Maas C, de Maat S, Neeves KB, Neal MD, Sen Gupta A, Stavrou EX. Nanomedicine platform for targeting activated neutrophils and neutrophil-platelet complexes using an α 1-antitrypsin-derived peptide motif. Nat Nanotechnol 2022; 17:1004-1014. [PMID: 35851383 PMCID: PMC9909445 DOI: 10.1038/s41565-022-01161-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 05/24/2022] [Indexed: 05/30/2023]
Abstract
Targeted drug delivery to disease-associated activated neutrophils can provide novel therapeutic opportunities while avoiding systemic effects on immune functions. We created a nanomedicine platform that uniquely utilizes an α1-antitrypsin-derived peptide to confer binding specificity to neutrophil elastase on activated neutrophils. Surface decoration with this peptide enabled specific anchorage of nanoparticles to activated neutrophils and platelet-neutrophil aggregates, in vitro and in vivo. Nanoparticle delivery of a model drug, hydroxychloroquine, demonstrated significant reduction of neutrophil activities in vitro and a therapeutic effect on murine venous thrombosis in vivo. This innovative approach of cell-specific and activation-state-specific targeting can be applied to several neutrophil-driven pathologies.
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Affiliation(s)
- Michelle A Cruz
- Department of Pathology, Immunology Training Program, CWRU School of Medicine, Cleveland, OH, USA
| | - Dillon Bohinc
- Department of Medicine, Hematology and Oncology Division, CWRU School of Medicine, Cleveland, OH, USA
| | - Elizabeth A Andraska
- Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jurgis Alvikas
- Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Shruti Raghunathan
- Department of Biomedical Engineering, Case Western Reserve University (CWRU), Cleveland, OH, USA
| | - Nicole A Masters
- Department of Civil and Environmental Engineering, Colorado School of Mines, Golden, CO, USA
| | - Nadine D van Kleef
- CDL Research, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Kara L Bane
- Department of Medicine, Hematology and Oncology Division, CWRU School of Medicine, Cleveland, OH, USA
| | - Kathryn Hart
- Department of Biomedical Engineering, Case Western Reserve University (CWRU), Cleveland, OH, USA
| | - Kathryn Medrow
- Department of Biomedical Engineering, Case Western Reserve University (CWRU), Cleveland, OH, USA
| | - Michael Sun
- Department of Biomedical Engineering, Case Western Reserve University (CWRU), Cleveland, OH, USA
| | - Haitao Liu
- Department of Ophthalmology, Children's Hospital of University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Shannon Haldeman
- Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ankush Banerjee
- Department of Biomedical Engineering, Case Western Reserve University (CWRU), Cleveland, OH, USA
| | - Emma M Lessieur
- Center for Translational Vision Research, Gavin Herbert Eye Institute, University of California Irvine, Irvine, CA, USA
| | - Kara Hageman
- Department of Biomedical Engineering, Case Western Reserve University (CWRU), Cleveland, OH, USA
| | - Agharnan Gandhi
- Department of Medicine, Hematology and Oncology Division, CWRU School of Medicine, Cleveland, OH, USA
| | | | - Marvin T Nieman
- Department of Pharmacology, CWRU School of Medicine, Cleveland, OH, USA
| | - Timothy S Kern
- Center for Translational Vision Research, Gavin Herbert Eye Institute, University of California Irvine, Irvine, CA, USA
- Veterans Administration Medical Center Research Service, Long Beach, CA, USA
| | - Coen Maas
- CDL Research, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Steven de Maat
- CDL Research, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Keith B Neeves
- Department of Bioengineering and Pediatrics, Section of Hematology, Oncology, and Bone Marrow Transplant Hemophilia and Thrombosis Center, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Matthew D Neal
- Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Anirban Sen Gupta
- Department of Pathology, Immunology Training Program, CWRU School of Medicine, Cleveland, OH, USA.
- Department of Biomedical Engineering, Case Western Reserve University (CWRU), Cleveland, OH, USA.
- Department of Pharmacology, CWRU School of Medicine, Cleveland, OH, USA.
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, USA.
| | - Evi X Stavrou
- Department of Medicine, Hematology and Oncology Division, CWRU School of Medicine, Cleveland, OH, USA.
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, USA.
- Department of Medicine, Section of Hematology-Oncology, Louis Stokes Veterans Administration Medical Center, Cleveland, OH, USA.
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11
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Mak AK, Andraska EA, Reitz KM, Chaer R, Eslami MH, Avgerinos E. A single institutional experience with suction thrombectomy in acute mesenteric ischemia. Ann Vasc Surg Brief Rep Innov 2022; 2:100070. [PMID: 36733720 PMCID: PMC9890405 DOI: 10.1016/j.avsurg.2022.100070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Acute mesenteric ischemia (AMI) is typically treated by open surgery or hybrid techniques. Catheter-based aspiration thrombectomy represents another minimally invasive alternative with a potential additional safety benefit of minimizing the bleeding risk associated with thrombolytics. In this institutional case series, we present five clinical cases of aspiration thrombectomy for high-risk AMI using the Penumbra aspiration system. All patients underwent technically successful endovascular thrombectomy as demonstrated by intraoperative angiography results. However, bowel necrosis and sepsis adversely affected postoperative outcomes. Lack of intraoperative bowel assessment is a limitation of endovascular methods, highlighting the importance of patient selection.
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Affiliation(s)
- Allison K Mak
- University of Pittsburgh School of Medicine, United States
| | - Elizabeth A Andraska
- Department of Surgery, Division of Vascular Surgery, UPMC Heart and Vascular Institute, UPMC Presbyterian Hospital, Room E362.4, South Tower, 200 Lothrop Street, Pittsburgh, PA 15213-2582, United States
| | - Katherine M Reitz
- Department of Surgery, Division of Vascular Surgery, UPMC Heart and Vascular Institute, UPMC Presbyterian Hospital, Room E362.4, South Tower, 200 Lothrop Street, Pittsburgh, PA 15213-2582, United States
| | - Rabih Chaer
- Department of Surgery, Division of Vascular Surgery, UPMC Heart and Vascular Institute, UPMC Presbyterian Hospital, Room E362.4, South Tower, 200 Lothrop Street, Pittsburgh, PA 15213-2582, United States
| | - Mohammed H Eslami
- Department of Surgery, Division of Vascular Surgery, UPMC Heart and Vascular Institute, UPMC Presbyterian Hospital, Room E362.4, South Tower, 200 Lothrop Street, Pittsburgh, PA 15213-2582, United States
| | - Efthymios Avgerinos
- Department of Surgery, Division of Vascular Surgery, UPMC Heart and Vascular Institute, UPMC Presbyterian Hospital, Room E362.4, South Tower, 200 Lothrop Street, Pittsburgh, PA 15213-2582, United States
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12
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Phillips AR, Andraska EA, Reitz KM, Gabriel L, Salem KM, Sridharan ND, Tzeng E, Liang NL. Any Postoperative Surveillance Improves Survival after Endovascular Repair of Ruptured Abdominal Aortic Aneurysms. Ann Vasc Surg 2022; 80:50-59. [PMID: 34775012 PMCID: PMC8897248 DOI: 10.1016/j.avsg.2021.09.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/20/2021] [Accepted: 09/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Endovascular aortic repair (EVAR) has advanced the care of patients with ruptured abdominal aortic aneurysms (rAAA) with improved early postoperative morbidity and mortality. However, this comes at the cost of a rigorous postoperative surveillance schedule to monitor for further aneurysmal degeneration. Adherence to surveillance recommendations is known to be poor in the elective setting, but has yet to be studied in the ruptured population. The aim of this study is to investigate predictors of incomplete surveillance after EVAR for rAAA (rEVAR) and examine how adherence impacts outcomes. METHODS This was a retrospective case control study of patients undergoing rEVAR at a multiple hospital single healthcare center (2003-2020). Patients were excluded if they underwent open conversion during their index hospitalization or died within 60 days of surgery. Follow-up was broadly categorized as complete surveillance (60-day postoperative visit and annually thereafter) or incomplete surveillance, comprising both patients with less than recommended surveillance (minimal surveillance) and completely lost to follow-up (LTF). Any follow-up was defined as patients with complete or minimal surveillance. We investigated predictors of complete versus incomplete surveillance by multivariate logistic regression. Secondary outcomes included overall survival and cumulative incidence of reintervention controlling for the competing risk of mortality, generating hazard ratios (HR) and subdistribution hazard ratios (SHR). RESULTS One-hundred and sixty patients (mean age 74 ± 10.1 years, 81.2% male) out of 673 total rAAA met study inclusion criteria. Complete surveillance was seen in 41.3% of our cohort, with the remainder with minimal surveillance (29.4%) or LTF (29.4%). Incomplete surveillance was associated with male sex (odds ratio [OR] 2.56; 95% CI 1.02-6.43), lack of a primary care provider (PCP; OR 0.20; 95% CI 0.04-0.99), and longer driving distance from home to treating hospital (OR 2.37; 95% CI 1.08-5.20). Survival was not different between complete and incomplete surveillance groups, however any follow-up conferred improved survival over LTF (HR 0.57; 95% CI 0.331-0.997; P = 0.049). Reintervention was associated with incomplete surveillance (SHR 0.29; 95% CI 0.11-0.75), and discharge to a facility (SHR 0.25; 95% CI 0.067-0.94). CONCLUSIONS Incomplete surveillance was observed in over 50% of patients who underwent rEVAR and was associated with male sex, lack of PCP, and longer driving distance. Any follow-up conferred a survival benefit, yet incomplete surveillance was associated with a lower risk of reintervention. Targeted strategies to prevent LTF, and less stringent, personalized follow-up plans that may confer similar survival benefit with better patient adherence should be investigated.
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Affiliation(s)
- Amanda R. Phillips
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213
| | - Elizabeth A. Andraska
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213
| | - Katherine M. Reitz
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213
| | - Lucine Gabriel
- University of Pittsburgh School of Medicine. 3550 Terrace Street, Pitsburgh, PA 15213
| | - Karim M. Salem
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213,University of Pittsburgh School of Medicine. 3550 Terrace Street, Pitsburgh, PA 15213
| | - Natalie D. Sridharan
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213,University of Pittsburgh School of Medicine. 3550 Terrace Street, Pitsburgh, PA 15213
| | - Edith Tzeng
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213,University of Pittsburgh School of Medicine. 3550 Terrace Street, Pitsburgh, PA 15213
| | - Nathan L. Liang
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213,University of Pittsburgh School of Medicine. 3550 Terrace Street, Pitsburgh, PA 15213
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13
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McCreary DD, Skirtich NF, Andraska EA, Tzeng E, McEnaney RM. Survey of the extracellular matrix architecture across the rat arterial tree. JVS Vasc Sci 2022; 3:1-14. [PMID: 35028599 PMCID: PMC8739875 DOI: 10.1016/j.jvssci.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/17/2021] [Indexed: 11/01/2022] Open
Abstract
Objective Methods Results Conclusions Arterial pathologies affect and depend on elastic fibers and collagen. Medial arterial calcification involves mineral deposition onto elastic fibers and smooth muscle cell osteogenesis, which can be induced by elastin degradation. Degradation or remodeling of the extracellular matrix can be a critical component of atherosclerosis and hypertension. Pathologies can also be site-specific. Aneurysms are most common in the abdominal aorta (Ao), followed by the popliteal artery, which shows age-related changes to wall properties comparable to those in central elastic arteries. Visceral artery aneurysms, however, are rare. Location differences in arterial extracellular matrix structure could inform site-specific differences in arterial pathology.
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14
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Andraska EA, Kulkarni R, Chaudhary M, Sachdev U. Three cases of acute venous thromboembolism in females after vaccination for coronavirus disease 2019. J Vasc Surg Venous Lymphat Disord 2022; 10:14-17. [PMID: 34352418 PMCID: PMC8327605 DOI: 10.1016/j.jvsv.2021.07.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 07/22/2021] [Indexed: 11/18/2022]
Abstract
Since December 2020, four vaccines for SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) have been developed, and three have been approved for immediate use in the United States. Two are mRNA vaccines, and one uses a viral vector mechanism. Thrombotic complications have been reported after vaccine administration, which were primarily cerebral sinus thromboses after administration of the viral vector vaccines. To the best of our knowledge, we are the first to report venous thrombotic complications within days of administration of the mRNA-1273 (Moderna) vaccine. We present a series of three women who developed venous thromboembolism after RNA-1273 vaccination at a single healthcare system.
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Affiliation(s)
- Elizabeth A Andraska
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
| | - Rohan Kulkarni
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Mirnal Chaudhary
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ulka Sachdev
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
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15
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McEnaney RM, McCreary DD, Skirtich NO, Andraska EA, Sachdev U, Tzeng E. Elastic Laminar Reorganization Occurs with Outward Diameter Expansion during Collateral Artery Growth and Requires Lysyl Oxidase for Stabilization. Cells 2021; 11:7. [PMID: 35011567 PMCID: PMC8750335 DOI: 10.3390/cells11010007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/14/2021] [Accepted: 12/17/2021] [Indexed: 01/16/2023] Open
Abstract
When a large artery becomes occluded, hemodynamic changes stimulate remodeling of arterial networks to form collateral arteries in a process termed arteriogenesis. However, the structural changes necessary for collateral remodeling have not been defined. We hypothesize that deconstruction of the extracellular matrix is essential to remodel smaller arteries into effective collaterals. Using multiphoton microscopy, we analyzed collagen and elastin structure in maturing collateral arteries isolated from ischemic rat hindlimbs. Collateral arteries harvested at different timepoints showed progressive diameter expansion associated with striking rearrangement of internal elastic lamina (IEL) into a loose fibrous mesh, a pattern persisting at 8 weeks. Despite a 2.5-fold increase in luminal diameter, total elastin content remained unchanged in collaterals compared with control arteries. Among the collateral midzones, baseline elastic fiber content was low. Outward remodeling of these vessels with a 10-20 fold diameter increase was associated with fractures of the elastic fibers and evidence of increased wall tension, as demonstrated by the straightening of the adventitial collagen. Inhibition of lysyl oxidase (LOX) function with β-aminopropionitrile resulted in severe fragmentation or complete loss of continuity of the IEL in developing collaterals. Collateral artery development is associated with permanent redistribution of existing elastic fibers to accommodate diameter growth. We found no evidence of new elastic fiber formation. Stabilization of the arterial wall during outward remodeling is necessary and dependent on LOX activity.
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Affiliation(s)
- Ryan M. McEnaney
- VA Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA; (D.D.M.); (N.O.S.); (E.T.)
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; (E.A.A.); (U.S.)
| | - Dylan D. McCreary
- VA Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA; (D.D.M.); (N.O.S.); (E.T.)
| | - Nolan O. Skirtich
- VA Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA; (D.D.M.); (N.O.S.); (E.T.)
| | - Elizabeth A. Andraska
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; (E.A.A.); (U.S.)
| | - Ulka Sachdev
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; (E.A.A.); (U.S.)
| | - Edith Tzeng
- VA Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA; (D.D.M.); (N.O.S.); (E.T.)
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; (E.A.A.); (U.S.)
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16
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Andraska EA, Sachdev U. Reply. J Vasc Surg Venous Lymphat Disord 2021; 10:285. [PMID: 34920849 PMCID: PMC8668423 DOI: 10.1016/j.jvsv.2021.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 09/24/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Elizabeth A Andraska
- Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ulka Sachdev
- Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
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17
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Andraska EA, Tran LM, Haga LM, Mak AK, Madigan MC, Makaroun MS, Eslami MH, Chaer RA. Contemporary management of acute and chronic mesenteric ischemia: 10-year experience from a multihospital healthcare system. J Vasc Surg 2021; 75:1624-1633.e8. [PMID: 34788652 PMCID: PMC9038632 DOI: 10.1016/j.jvs.2021.11.040] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 11/05/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Endovascular and hybrid methods are being increasingly used to treat mesenteric ischemia. However, long-term outcomes and risk of symptom recurrence remain unknown. The objective of this study was to define predictors of post-operative morbidity, mortality, and patency loss in acute (AMI) or chronic mesenteric ischemia (CMI). METHODS Inpatient and follow-up records for all patients who underwent revascularization for AMI and CMI from 2010 to 2020 at a multicenter hospital system were reviewed. Patency and mortality were evaluated with Cox regression, visualized with Kaplan-Meier curves, and compared using log rank testing. Patency was further evaluated with Fine-Gray regression utilizing death as a competing risk. Post-operative major adverse events (MAE) and 30-day mortality were evaluated with logistic regression. RESULTS 407 patients were included; 148 AMI and 259 CMI. In AMI, 30-day mortality was 31%. Open surgery was associated with lower rates of bowel resection (OR 0.23, 95% CI 0.13, 0.61). Etiology of AMI also did not change outcomes (OR 1.30, 95% CI 0.77, 2.19). Adjusted analyses indicates that a history of diabetes (OR 2.77, 95% CI 1.37, 5.61) and sepsis on presentation (OR 2.32, 95% CI 1.18, 4.58) were independently associated with increased risk of 30-day MAE. In CMI, open surgery and CKD were associated with higher MAE (OR 3.03, 95% CI 1.14, 8.05; OR 2.37, 95% CI 1.31, 4.31) while CKD (OR 3.02, 95% CI 1.10, 8.37) and inpatient status prior to revascularization (OR 2.78, 95% CI 1.01, 7.61) were associated with increased 30-day mortality. In CMI, patients in the endovascular cohort had higher rates of symptom recurrence (29% vs. 13%) with faster onset (endovascular 64 days vs. bypass 338 days). CONCLUSIONS AMI remains a morbid disease despite evolving revascularization techniques. An open approach should remain the gold standard as it reduces likelihood of bowel resection. In CMI, endovascular interventions have improved post-operative morbidity but result in early symptom recurrence and re-interventions. An endovascular-first approach should be standard in CMI with close surveillance.
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Affiliation(s)
- Elizabeth A Andraska
- University of Pittsburgh Medical Center, Department of Surgery, Heart and Vascular Institute.
| | - Lillian M Tran
- University of Pittsburgh Medical Center, Department of Surgery
| | - Lindsey M Haga
- University of Pittsburgh Medical Center, Department of Surgery, Heart and Vascular Institute
| | | | - Michael C Madigan
- University of Pittsburgh Medical Center, Department of Surgery, Heart and Vascular Institute
| | - Michel S Makaroun
- University of Pittsburgh Medical Center, Department of Surgery, Heart and Vascular Institute
| | - Mohammad H Eslami
- University of Pittsburgh Medical Center, Department of Surgery, Heart and Vascular Institute
| | - Rabih A Chaer
- University of Pittsburgh Medical Center, Department of Surgery, Heart and Vascular Institute
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18
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Mohammed MK, Andraska EA, Mohapatra A, Avgerinos ED, Madigan MC, Salem KM. Clinical Characteristics Associated with Visceral Ischemia in Acute Aortic Occlusion: Retrospective Analysis of Single-Institution Data. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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19
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Phillips AR, Reitz KM, Myers S, Thoma F, Andraska EA, Jano A, Sridharan N, Smith RE, Mulukutla SR, Chaer R. Association Between Black Race, Clinical Severity, and Management of Acute Pulmonary Embolism: A Retrospective Cohort Study. J Am Heart Assoc 2021; 10:e021818. [PMID: 34431356 PMCID: PMC8649302 DOI: 10.1161/jaha.121.021818] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Existing evidence indicates Black patients have higher incidence of pulmonary embolism (PE) and PE‐related mortality compared with other races/ethnicities, yet disparities in presenting severity and treatment remain incompletely understood. Methods and Results We retrospectively queried a multihospital healthcare system for all hospitalizations for acute PE (2012–2019). Of 10 329 hospitalizations, 8743 met inclusion criteria. Black patients (14.3%) were significantly younger (54.6±17.8 versus 63.1±16.6 years; P<0.001) and more female (56.1% versus 51.6%; P=0.003) compared with White patients. Using ordinal regression, Black race was significantly associated with higher PE severity after matching 1:3 on age and sex (1210:3264; odds ratio [OR], 1.08; 95% CI, 1.03–1.14), adjusting for clinical (OR, 1.13; 95% CI, 1.01–1.27), and socioeconomic (OR, 1.05; 95% CI, 1.05–1.35) characteristics. Among intermediate and high‐severity PE, Black race was associated with a decreased risk of intervention controlling for the competing risk of mortality and censoring on hospital discharge. This effect was modified by PE severity (P value <0.001), with a lower and higher risk of intervention for intermediate and high‐severity PE, respectively. Race was not associated with in‐hospital mortality (OR, 0.84; 95% CI, 0.69–1.02). Conclusions Black patients hospitalized with PE are younger with a higher severity of disease compared with White patients. Although Black patients are less likely to receive an intervention overall, this differed depending on PE severity with higher risk of intervention only for life‐threatening PE. This suggests nuanced racial disparities in management of PE and highlights the complexities of healthcare inequalities.
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Affiliation(s)
| | - Katherine M Reitz
- Division of Vascular Surgery University of Pittsburgh Pittsburgh PA.,Department of Surgery University of Pittsburgh Pittsburgh PA
| | - Sara Myers
- Department of Surgery University of Pittsburgh Pittsburgh PA
| | - Floyd Thoma
- Division of Cardiology University of Pittsburgh Pittsburgh PA
| | | | - Antalya Jano
- School of Medicine University of Pittsburgh Pittsburgh PA
| | - Natalie Sridharan
- Division of Vascular Surgery University of Pittsburgh Pittsburgh PA.,School of Medicine University of Pittsburgh Pittsburgh PA
| | - Roy E Smith
- School of Medicine University of Pittsburgh Pittsburgh PA.,Division of Hematology/Oncology University of Pittsburgh Pittsburgh PA
| | - Suresh R Mulukutla
- Division of Cardiology University of Pittsburgh Pittsburgh PA.,School of Medicine University of Pittsburgh Pittsburgh PA
| | - Rabih Chaer
- Division of Vascular Surgery University of Pittsburgh Pittsburgh PA.,School of Medicine University of Pittsburgh Pittsburgh PA
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Phillips AR, Andraska EA, Martinez-Meehan D, Dai Y, Reitz KM, Johnson AE, Tzeng E, Liang NL. Rupture Before the Age of Abdominal Aortic Aneurysm Screening—Another Example of Disparities in Vascular Surgery? J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Andraska EA, Tran L, Mak A, Haga L, Madigan M, Makaroun M, Eslami MH, Chaer RA. Contemporary Management of Acute and Chronic Mesenteric Ischemia. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Andraska EA, Phillips AR, Reitz KM, Asaadi S, Dai Y, Tzeng E, Makaroun M, Liang NL. Longer Follow-Up Intervals After EVAR Is Safe and Appropriate After Marked Aneurysm Sac Regression. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Andraska EA, Phillips AR, Asaadi S, Madigan M, Siracuse JJ, Eslami MH. Effects of Medicaid Expansion of the 2014 Affordable Care Act (ACA) on Elective Vascular Surgery Care of Nonelderly. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Zaghloul MS, Andraska EA, Leake A, Chaer R, Avgerinos ED, Hager ES, Makaroun MS, Eslami MH. Poor runoff and distal coverage below the knee are associated with poor long-term outcomes following endovascular popliteal aneurysm repair. J Vasc Surg 2021; 74:153-160. [PMID: 33347999 DOI: 10.1016/j.jvs.2020.12.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 12/05/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Reports of good short-term outcomes for endovascular repair of popliteal artery aneurysms have led to an increased use of the technique. However, data are lacking on long-term limb-related outcomes and factors associated with the failure of endovascular repair. METHODS All patients who underwent endovascular popliteal aneurysm repair (EPAR) at a single institution from January 2006 to December 2018 were included in the study. Demographics, indications, anatomic and operative details, and outcomes were reviewed. Long-term patency, major adverse limb event-free survival (MALE-FS) and graft loss/occlusion were analyzed with multivariable cox regression analysis and Kaplan-Meier curves. RESULTS We included 117 limbs from 101 patients with a mean follow-up of 55.6 months (range, 0.43-158 months). The average age was 73 ± 9.3 years. Thirty-two patients (29.1%) were symptomatic (claudication, rest pain, tissue loss, or rupture). The stent grafts crossed the knee joint in 91.4% of cases. In all, 36.8% of procedures used one stent graft, 41.0% used two stent grafts, and 22.2% of procedures used more than two stent grafts. The median arterial length covered was 100 mm, with an average length of stent overlap of 25 mm. Tapered configurations were used in 43.8% of cases. The majority of limbs (62.8%) had a three-vessel runoff, 20.2% had a two-vessel runoff, and 17% has a one-vessel runoff. The Kaplan-Meier estimates of graft occlusion at 1 and 3 years were 6.3% and 16.2%, respectively. The 1- and 3-year primary patency rates were 88.2% and 72.6%, and the 1- and 3-year major adverse limb event-free survival (MALE-FS) rates were 82% and 57.4%. The 1- and 3-year survival rates were 92.9% and 76.2%, respectively. On multivariable Cox regression, aneurysm size, one-vessel runoff, and coverage below the knee were associated with a lower 3-year MALE-FS. Coverage below the knee was also associated with a lower 3-year MALE-FS. Other anatomic or technical details were not associated with limb-related events or patency. CONCLUSIONS This study is the largest single center analysis to describe the predictors of poor outcomes after EPAR. EPAR is a safe and effective way to treat popliteal artery aneurysms. Factors associated with poor MALE-FS after EPAR include single-vessel tibial runoff and coverage below the knee.
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Affiliation(s)
- Mohamed S Zaghloul
- University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, Pa
| | - Elizabeth A Andraska
- University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, Pa
| | - Andrew Leake
- Vascular Surgery Associates of Richmond, PC, Richmond, Va
| | - Rabih Chaer
- University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, Pa
| | - Efthymios D Avgerinos
- University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, Pa
| | - Eric S Hager
- University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, Pa
| | - Michel S Makaroun
- University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, Pa
| | - Mohammad H Eslami
- University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, Pa.
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Zaghloul MS, Andraska EA, Leake A, Chaer R, Avgerinos ED, Hager ES, Makaroun MS, Eslami MH. Long-term Outcomes of Popliteal Endovascular Aneurysm Repair Depend on Runoff and Extent of Popliteal Coverage. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.04.447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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26
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Mohapatra A, Holtzman MP, Andraska EA, Singh MJ. Robotic-Assisted Median Arcuate Ligament Release. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.04.457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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27
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Salem KM, Andraska EA, Zaghloul MS, Martinez Garcia RJ, Abdul-Malak OM, Eslami MH, Chaer R, Avgerinos ED. Stenting of Popliteal Lesions Improves Patency Compared to Drug-Coated Balloon Angioplasty. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.04.264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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28
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Smith ME, Andraska EA, Sutzko DC, Boniakowski AM, Coleman DM, Osborne NH. The decline of open abdominal aortic aneurysm surgery among individual training programs and vascular surgery trainees. J Vasc Surg 2020; 71:1371-1377. [DOI: 10.1016/j.jvs.2019.06.204] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 06/11/2019] [Indexed: 11/25/2022]
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Castaneda PR, Duffy B, Andraska EA, Stevens J, Reschke K, Osborne N, Henke PK. Outcomes and safety of electronic consult use in vascular surgery. J Vasc Surg 2019; 71:1726-1732. [PMID: 31611112 DOI: 10.1016/j.jvs.2019.08.231] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/05/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The objective of this study was to determine how electronic consults (eConsults) are used in vascular surgery in a veterans health care setting and whether their use is safe for patients. METHODS A retrospective review was performed of all eConsults completed by the vascular surgery service at the Ann Arbor Veterans Affairs Healthcare System between October 10, 2012 and November 15, 2013. Patients' demographics and comorbidities were collected. eConsult recommendations and patient and provider compliance with recommendations were collected. Data on adverse outcomes up to 1 year after consultation and data on all-cause mortality at 1 year and 5 years were collected. RESULTS Between October 10, 2012 and November 15, 2013, of 350 eConsults completed, 123 (35%) were for peripheral artery disease, 93 (27%) for carotid stenosis, and 57 (16%) for abdominal aortic aneurysm. Unique recommendations were made for 291 consults (83%). Medication recommendations were made in 140 consults (40%). The most commonly recommended medication was cilostazol. Compliance with medication recommendations ranged from 30% to 61%. Noninvasive imaging was recommended in 220 consults (60.3%). Procedures overall were recommended in only six consults (1.7%). Five-year all-cause mortality for categorized diagnoses ranged from 8.3% for nonabdominal aneurysm to 28.1% for abdominal aortic aneurysm. CONCLUSIONS Within the Veterans Affairs vascular surgery service, eConsults provide a safe and effective means of triaging and providing recommendations for patients with vascular disease. eConsults used to augment traditional consultations may provide an important means of reducing clinic congestion for providers and reducing time and cost for patients.
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Affiliation(s)
| | - Blake Duffy
- University of Michigan Medical School, Ann Arbor, Mich
| | - Elizabeth A Andraska
- Heart and Vascular Institute, University of Pittsburgh Medical Centers, Pittsburgh, Pa
| | | | | | - Nicholas Osborne
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Peter K Henke
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich.
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Go CC, Chun Y, Chen Y, Andraska EA, McDaniel B, Markel K, Tillman BW. E-Mag Cannulation Approach Reduces Radiation Exposure During Simulated Fenestrated Endograft Repair. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sutzko DC, Andraska EA, Obi AT, Sadek M, Kabnick LS, Wakefield TW, Osborne NH. Age is not a barrier to good outcomes after varicose vein procedures. J Vasc Surg Venous Lymphat Disord 2018; 5:647-657.e1. [PMID: 28818215 DOI: 10.1016/j.jvsv.2017.04.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 04/16/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND The Vascular Quality Initiative (VQI) Varicose Vein Registry (VVR) represents a patient-centered database launched in January 2015. Previous work describing overall trends and outcomes of varicose vein procedures across the United States demonstrates a benefit from these procedures. The existing gaps in evidence to support current and future Medicare coverage of varicose vein procedures necessitate further description of clinical outcomes in patients ≥65 years old compared with the population <65 years old. METHODS This study analyzed prospectively captured anatomic, procedural, and outcome data for all patients in a national cohort of all VQI VVR-participating centers. The VQI VVR database was queried for all patients undergoing varicose vein procedures between January 2015 and July 2016. Preprocedural and postprocedural Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) classification, Venous Clinical Severity Score (VCSS), and patient-reported outcomes (PROs) were compared between patients <65 years and ≥65 years old. Univariate descriptive statistics of demographic and procedural data were performed. Student t-tests were then performed on change in CEAP classification, VCSS score, and PROs (heaviness, achiness, throbbing, swelling, itching, appearance, and impact on work) for each group. RESULTS There were 4841 varicose vein procedures performed from January 2015 to May 2016. There were 3441 procedures performed in 2691 patients (3631 limbs) in the group <65 years old and 1400 procedures performed in 1068 patients (1467 limbs) in the group ≥65 years old. Truncal veins alone were the most common veins treated in both groups. The majority of patients were white and female in both groups. Most of the demographic characteristics were clinically similar (although statistically different) in both groups with the exception of a higher body mass index in the group <65 years old and a history of bilateral varicose vein treatment, and anticoagulation was more common among patients ≥65 years old. Patients in both groups experienced statistically significant improvement in VCSS, PROs, and CEAP class. There was no difference in overall complications between age groups. CONCLUSIONS All patients demonstrated an associated improvement in both clinical outcomes (CEAP class, VCSS) and PROs. There was no significant difference in the improvement in CEAP class and VCSS between patients younger and older than 65 years, although the younger population reported greater improvement in PROs. Given these findings, patients older than 65 years appear to benefit from varicose vein procedures and should not be denied interventions on their varicose veins and venous insufficiency on the basis of their age only.
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Affiliation(s)
- Danielle C Sutzko
- Section of Vascular Surgery, University of Michigan Medical School, Ann Arbor, Mich.
| | - Elizabeth A Andraska
- Section of Vascular Surgery, University of Michigan Medical School, Ann Arbor, Mich
| | - Andrea T Obi
- Section of Vascular Surgery, University of Michigan Medical School, Ann Arbor, Mich
| | - Mikel Sadek
- Division of Vascular and Endovascular Surgery, New York University Langone Medical Center, New York, NY
| | - Lowell S Kabnick
- Division of Vascular and Endovascular Surgery, New York University Langone Medical Center, New York, NY
| | - Thomas W Wakefield
- Section of Vascular Surgery, University of Michigan Medical School, Ann Arbor, Mich
| | - Nicholas H Osborne
- Section of Vascular Surgery, University of Michigan Medical School, Ann Arbor, Mich
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Andraska EA, Luke CE, Elfline MA, Henke SP, Madapoosi SS, Metz AK, Hoinville ME, Wakefield TW, Henke PK, Diaz JA. Pre-Clinical Model to Study Recurrent Venous Thrombosis in the Inferior Vena Cava. Thromb Haemost 2018; 118:1048-1057. [PMID: 29695021 DOI: 10.1055/s-0038-1645855] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Patients undergoing deep vein thrombosis (VT) have over 30% recurrence, directly increasing their risk of post-thrombotic syndrome. Current murine models of inferior vena cava (IVC) VT model host one thrombosis event. OBJECTIVE We aimed to develop a murine model to study IVC recurrent VT in mice. MATERIALS AND METHODS An initial VT was induced using the electrolytic IVC model (EIM) with constant blood flow. This approach takes advantage of the restored vein lumen 21 days after a single VT event in the EIM demonstrated by ultrasound. We then induced a second VT 21 days later, using either EIM or an IVC ligation model for comparison. The control groups were a sham surgery and, 21 days later, either EIM or IVC ligation. IVC wall and thrombus were harvested 2 days after the second insult and analysed for IVC and thrombus size, gene expression of fibrotic markers, histology for collagen and Western blot for citrullinated histone 3 (Cit-H3) and fibrin. RESULTS Ultrasound confirmed the first VT and its progressive resolution with an anatomical channel allowing room for the second thrombus by day 21. As compared with a primary VT, recurrent VT has heavier walls with significant up-regulation of transforming growth factor-β (TGF-β), elastin, interleukin (IL)-6, matrix metallopeptidase 9 (MMP9), MMP2 and a thrombus with high citrullinated histone-3 and fibrin content. CONCLUSION Experimental recurrent thrombi are structurally and compositionally different from the primary VT, with a greater pro-fibrotic remodelling vein wall profile. This work provides a VT recurrence IVC model that will help to improve the current understanding of the biological mechanisms and directed treatment of recurrent VT.
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Affiliation(s)
- Elizabeth A Andraska
- Department of Surgery, Section of Vascular Surgery, Conrad Jobst Vascular Research Laboratories, University of Michigan, Ann Arbor, Michigan, United States
| | - Catherine E Luke
- Department of Surgery, Section of Vascular Surgery, Conrad Jobst Vascular Research Laboratories, University of Michigan, Ann Arbor, Michigan, United States
| | - Megan A Elfline
- Department of Surgery, Section of Vascular Surgery, Conrad Jobst Vascular Research Laboratories, University of Michigan, Ann Arbor, Michigan, United States
| | - Samuel P Henke
- Department of Surgery, Section of Vascular Surgery, Conrad Jobst Vascular Research Laboratories, University of Michigan, Ann Arbor, Michigan, United States
| | - Siddharth S Madapoosi
- Department of Surgery, Section of Vascular Surgery, Conrad Jobst Vascular Research Laboratories, University of Michigan, Ann Arbor, Michigan, United States
| | - Allan K Metz
- Department of Surgery, Section of Vascular Surgery, Conrad Jobst Vascular Research Laboratories, University of Michigan, Ann Arbor, Michigan, United States
| | - Megan E Hoinville
- Department of Surgery, Section of Vascular Surgery, Conrad Jobst Vascular Research Laboratories, University of Michigan, Ann Arbor, Michigan, United States
| | - Thomas W Wakefield
- Department of Surgery, Section of Vascular Surgery, Conrad Jobst Vascular Research Laboratories, University of Michigan, Ann Arbor, Michigan, United States
| | - Peter K Henke
- Department of Surgery, Section of Vascular Surgery, Conrad Jobst Vascular Research Laboratories, University of Michigan, Ann Arbor, Michigan, United States
| | - Jose A Diaz
- Department of Surgery, Section of Vascular Surgery, Conrad Jobst Vascular Research Laboratories, University of Michigan, Ann Arbor, Michigan, United States
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Sutzko DC, Andraska EA, Gonzalez AA, Chakrabarti AK, Osborne NH. Examining variation in Medicare payments and drivers of cost for carotid endarterectomy. J Surg Res 2018; 228:299-306. [PMID: 29907225 DOI: 10.1016/j.jss.2018.03.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 01/28/2018] [Accepted: 03/15/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND There is a growing interest in providing high quality and low-cost care to Americans. A pursuit exists to measure not only how well hospitals are performing but also at what cost. We examined the variation in costs associated with carotid endarterectomy (CEA), to determine which components contribute to the variation and what drives increased payments. MATERIALS AND METHODS Patients undergoing CEA between 2009 and 2012 were identified in the Medicare provider and analysis review database. Hospital quintiles of cost were generated and variation examined. Multivariable logistic regression was performed to identify independent predictors of high-payment hospitals for both asymptomatic and symptomatic patients undergoing CEA. RESULTS A total of 264,018 CEAs were performed between 2009 and 2012; 250,317 were performed in asymptomatic patients in 2302 hospitals and 13,701 in symptomatic patients in 1851 hospitals. Higher payment hospitals had a higher percentage of nonwhite patients and comorbidity burden. The largest contributors to variation in overall payments were diagnosis-related groups, postdischarge, and readmission payments. After accounting for clustering at the hospital level, independent predictors of high-payment hospitals for all patients were postoperative stroke, length of stay, and readmission ,whereas in the symptomatic group, additional drivers included yearly volume and serious complications. CONCLUSIONS CEA Medicare payments vary nationwide with diagnosis-related group, readmission, and postdischarge payments being the largest contributors to overall payment variation. In addition, stroke, length of stay, and readmission were the only independent predictors of high payment for all patients undergoing CEA.
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Affiliation(s)
- Danielle C Sutzko
- Section of Vascular Surgery, Michigan Medicine, Ann Arbor, Michigan.
| | - Elizabeth A Andraska
- Section of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Jacobs BN, Andraska EA, Obi AT, Wakefield TW. Pathophysiology of varicose veins. J Vasc Surg Venous Lymphat Disord 2017; 5:460-467. [DOI: 10.1016/j.jvsv.2016.12.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Accepted: 12/27/2016] [Indexed: 01/09/2023]
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Andraska EA, Jackson T, Chen H, Gallagher KA, Eliason JL, Coleman DM. Natural History of Iatrogenic Pediatric Femoral Artery Injury. Ann Vasc Surg 2017; 42:205-213. [PMID: 28341498 DOI: 10.1016/j.avsg.2016.11.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 11/04/2016] [Accepted: 11/10/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Iatrogenic femoral artery trauma complicates the course of critically ill neonates and children. Complications from persistent arterial occlusion may include claudication and limb length discrepancies. Data supporting risk factors for such and need for revascularization are lacking. METHODS Review of a prospectively maintained database at a tertiary institution of iatrogenic pediatric femoral artery injuries incurred between 2013 and 2014 was performed. Additional injuries were identified by review of pediatric arterial duplex performed between 2008 and 2013. Demographics, risk factors, and outcomes were queried. Data analysis utilized Fischer's exact t-test and logistic regression. RESULTS Seventy-six patients were identified of which 68 presented with acute limb ischemia (ALI) and 8 with chronic iliofemoral arterial occlusion resulting in claudication (n = 6) or limb length discrepancy (n = 2). Mean weight at injury was 6.3 kg; mean age at injury was 49 weeks (50% aged <3 months). Mean follow-up was 14 months (out to 11 years). Six patients required surgery for ALI, and 6 required delayed operation for limb length discrepancy (n = 4) or for persistent external iliac artery (EIA) occlusion. Mean age at delayed revascularization was 6 years (range: 2-13 years). Vasopressor use, mechanism/location of injury, and concomitant venous thrombosis were not significantly correlated with need for operation; trends suggested that cardiac catheterization and EIA thrombosis may correlate with chronic disease. Increased age at injury was associated with need for operation. CONCLUSIONS Although a majority of children with ALI may be successfully treated medically, 9% will require operation for ALI and 16% ultimately required revascularization during follow-up. Persistent iliofemoral arterial thrombosis is a likely risk factor for limb length discrepancy with growth; identifying risk factors for this and improved methods for surveillance requires ongoing investigation.
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Affiliation(s)
- Elizabeth A Andraska
- Section of Vascular Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI
| | - Tatum Jackson
- Section of Vascular Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI
| | - Huiting Chen
- Section of Vascular Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI
| | - Katherine A Gallagher
- Section of Vascular Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI
| | - Jonathan L Eliason
- Section of Vascular Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI
| | - Dawn M Coleman
- Section of Vascular Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI.
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Sammarco AG, Abualnadi NM, Andraska EA, Tracy PV, Berger MB, Haefner HK. Plexiform schwannoma: an unusual clitoral mass. Am J Obstet Gynecol 2017; 216:319.e1-319.e2. [PMID: 27818132 DOI: 10.1016/j.ajog.2016.10.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 10/17/2016] [Accepted: 10/27/2016] [Indexed: 11/27/2022]
Abstract
Acquired clitoral enlargement is a rare condition resulting from a variety of etiologies, including tumors and excess androgens. Few cases of nonmalignant schwannoma, a benign tumor of the peripheral nerve sheath, have been reported in the literature as causes of clitoral enlargement in patients without known neurofibromatosis. These painless, slow-growing tumors rarely recur once excised. We present the initial investigation of a patient with a large clitoral schwannoma and subsequent treatment with partial vulvectomy. The workup, including advanced pelvic imaging for diagnosis and surgical planning, as well as removal of the clitoral tumor with preservation of functional tissue and restoration of normal vulvar anatomy despite a large excision, is demonstrated.
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Cron DC, Kapeles SR, Andraska EA, Kwon ST, Kirk PS, McNeish BL, Lee CS, Hughes DT. Predictors of operative failure in parathyroidectomy for primary hyperparathyroidism. Am J Surg 2017; 214:509-514. [PMID: 28108069 DOI: 10.1016/j.amjsurg.2017.01.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 01/08/2017] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Many adjuncts guide surgical decision making in parathyroidectomy, yet their independent associations with outcome are poorly characterized. We examined a broad range of perioperative factors and used multivariate techniques to identify independent predictors of operative failure (persistent disease) after parathyroidectomy. METHODS This was a retrospective review of 2239 patients with primary hyperparathyroidism who underwent parathyroidectomy at a single-center from 1999 to 2014. We used multivariate logistic regress to measure associations between multiple perioperative factors and an operative failure (persistent hypercalcemia). RESULTS Operative failure was identified in 67 patients (3.0%). The following variables were independently associated with operative failure on multivariate analysis: IOPTH criteria met (protective, OR = 0.22, P < 0.001), preoperative calcium (risk factor, OR = 2.27 per unit increase, P < 0.001), weight of excised gland(s) (protective, OR = 0.70 per two-fold increase, P = 0.003), and preoperative PTH (protective, OR = 0.55 per two-fold increase, P = 0.008). CONCLUSION In addition to the well-established IOPTH criteria, we suggest that consideration of the above independent perioperative risk factors may further inform surgical decision-making in parathyroidectomy.
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Affiliation(s)
- David C Cron
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Steven R Kapeles
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Elizabeth A Andraska
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Sebastian T Kwon
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Peter S Kirk
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Brendan L McNeish
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Christopher S Lee
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - David T Hughes
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA.
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Andraska EA, Horne DC, Campbell DN, Eliason JL, Wakefield TW, Coleman DM. Patterns of pediatric venous disease. J Vasc Surg Venous Lymphat Disord 2016; 4:422-5. [PMID: 27638996 DOI: 10.1016/j.jvsv.2016.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 06/03/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The spectrum of chronic venous disease (CVD) is well documented in adults; clinical guidelines standardize diagnosis and treatment. There is a paucity of data published commenting on pediatric CVD exclusive of Klippel-Trénaunay syndrome (KTS) and post-thrombotic syndrome. METHODS This study aimed to define patterns of pediatric venous disease. All venous reflux studies performed on patients <18 years of age between January 2012 and June 2014 were reviewed. Study indication, patient history, clinical examination, and duplex ultrasound results were queried and described. Venous reflux parameters were compared using one-way analysis of variance. RESULTS Twenty patients were evaluated. All presented through the vascular surgery or multidisciplinary venous clinic at a tertiary academic medical center. Indications for referral included swelling (n = 10), varicose veins (n = 9), and rubor/acrocyanosis (n = 3); two patients carried a diagnosis of KTS. Mean age at study was 13 years (range, 5-17 years). Clinical examination revealed the following: dependent rubor (n = 3); edema (n = 9); and varicose veins or venous abnormality concerning for venous malformation (n = 9). There were no stigmata of chronic inflammation, hyperpigmentation, or ulceration; 90% of patients (n = 18) demonstrated venous reflux by duplex ultrasound interrogation. Mean right great saphenous vein (GSV) diameter was 0.49 cm (range, 0.31-0.66 cm); mean left GSV diameter was 0.55 cm (range, 0.24-0.93 cm). Adjunctive studies were often used (including magnetic resonance venography and lymphoscintigraphy). Despite the presence of venous reflux on imaging, an alternate diagnosis was made in 8 of 18 children (44%), including postural orthostatic hypotension syndrome (n = 2), vascular malformation (n = 2), lymphedema (n = 2), complex regional pain syndrome (n = 1), and acrocyanosis of disuse (n = 1). An additional case of KTS was identified. Three cases referred for varicose veins were diagnosed with venous malformation. Maximum GSV diameter and venous reflux time were compared across patients with isolated CVD, KTS, or an alternate diagnosis (as before). Whereas there was no significant difference in maximum GSV diameter, superficial venous reflux time was significantly increased in the patients with primary CVD and KTS (P = .0394). CONCLUSIONS The differential diagnosis for pediatric lower extremity edema and varicosities is broad; workup often requires adjunctive studies to secure the appropriate diagnosis. Often there is venous reflux present despite an alternative clinical diagnosis. Superficial venous reflux time may aid in the diagnosis of primary CVD. Whereas the clinical significance of pediatric venous reflux remains unclear, ongoing work to expand on venous parameters in healthy pediatric controls is warranted, as is additional follow-up to assess the natural history of pediatric venous disease.
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Affiliation(s)
- Elizabeth A Andraska
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Danielle C Horne
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Danielle N Campbell
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Jonathan L Eliason
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Thomas W Wakefield
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Dawn M Coleman
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich.
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Affiliation(s)
| | - D Horne
- University of Michigan, Ann Arbor, Mich
| | | | - J Eliason
- University of Michigan, Ann Arbor, Mich
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