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Tariq M, Novak Z, Spangler EL, Passman MA, Patterson MA, Pearce BJ, Sutzko DC, Brokus SD, Busby C, Beck AW. Clinical Impact of an Enhanced Recovery Program for Lower-extremity Bypass. Ann Surg 2024; 279:1077-1081. [PMID: 38258556 DOI: 10.1097/sla.0000000000006212] [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] [Indexed: 01/24/2024]
Abstract
OBJECTIVE To determine the association of Enhanced Recovery Program (ERP) implementation with length of stay (LOS) and perioperative outcomes after lower-extremity bypass (LEB). BACKGROUND ERPs have been shown to decrease hospital LOS and improve perioperative outcomes, but their impact on patients undergoing vascular surgery remains unknown. METHODS Patients undergoing LEB who received or did not receive care under the ERP were included; pre-ERP (January 1, 2016-May 13, 2018) and ERP (May 14, 2018-July 31, 2022). Clinicopathologic characteristics and perioperative outcomes were analyzed. RESULTS Of 393 patients who underwent LEB [pre-ERP: n = 161 (41%); ERP: n = 232 (59%)], most were males (n = 254, 64.6%), White (n = 236, 60%), and government-insured (n = 265, 67.4%). Pre-ERP patients had higher Body Mass Index (28.8 ± 6.0 vs 27.4 ± 5.7, P = 0.03) and rates of diabetes (52% vs 36%, P = 0.002). ERP patients had a shorter total [6 (3-13) vs 7 (5-14) days, P = 0.01) and postoperative LOS [5 (3-8) vs 6 (4-8) days, P < 0.001]. Stratified by indication, postoperative LOS was shorter in ERP patients with claudication (3 vs 5 days, P = 0.01), rest pain (5 vs 6 days, P = 0.02), and tissue loss (6 vs 7 days, P = 0.03). ERP patients with rest pain also had a shorter total LOS (6 vs 7 days, P = 0.04) and lower 30-day readmission rates (32%-17%, P = 0.02). After ERP implementation, the average daily oral morphine equivalents decreased [median (interquartile range): 52.5 (26.6-105.0) vs 44.12 (22.2-74.4), P = 0.019], while the rates of direct discharge to home increased (83% vs 69%, P = 0.002). CONCLUSIONS This is the largest single-center cohort study evaluating ERP in LEB, showing that ERP implementation is associated with shorter LOS and improved perioperative outcomes.
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Affiliation(s)
- Marvi Tariq
- Department of Surgery, Heersink School of Medicine, University of Alabama, Birmingham, Alabama, USA
| | - Zdenek Novak
- Department of Surgery, Heersink School of Medicine, University of Alabama, Birmingham, Alabama, USA
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Emily L Spangler
- Department of Surgery, Heersink School of Medicine, University of Alabama, Birmingham, Alabama, USA
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Marc A Passman
- Department of Surgery, Heersink School of Medicine, University of Alabama, Birmingham, Alabama, USA
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Mark A Patterson
- Department of Surgery, Heersink School of Medicine, University of Alabama, Birmingham, Alabama, USA
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Benjamin J Pearce
- Department of Surgery, Heersink School of Medicine, University of Alabama, Birmingham, Alabama, USA
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Danielle C Sutzko
- Department of Surgery, Heersink School of Medicine, University of Alabama, Birmingham, Alabama, USA
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sara Danielle Brokus
- Department of Surgery, Heersink School of Medicine, University of Alabama, Birmingham, Alabama, USA
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Courtney Busby
- Department of Surgery, Heersink School of Medicine, University of Alabama, Birmingham, Alabama, USA
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Adam W Beck
- Department of Surgery, Heersink School of Medicine, University of Alabama, Birmingham, Alabama, USA
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Banks CA, Blakeslee-Carter J, Nkie V, Spangler EL, Still SA, Eudailey KW, McElwee SK, Blood MS, Novak Z, Beck AW. Occurrence, Predictors, and Management of Late Vascular Complications following Extracorporeal Membrane Oxygenation. J Vasc Surg 2024:S0741-5214(24)01064-4. [PMID: 38657701 DOI: 10.1016/j.jvs.2024.04.041] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 04/09/2024] [Accepted: 04/13/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Vascular complications (VC) associated with Extracorporeal Membrane Oxygenation (ECMO) during index hospitalization are prevalent and associated with increased mortality. Few studies have evaluated late VC following ECMO; this study aims to assess occurrence and management practices of late VC following discharge. METHODS A retrospective single-institution review was performed of all patients surviving initial hospitalization after being cannulated for central or peripheral veno-venous (VV) or veno-arterial (VA) ECMO between January 1st 2019 and December 31st 2020. Primary outcomes were to categorize and determine the rate late VC. Late VCs were defined as any cannulated vessel injury resulting from ECMO cannulation presenting after discharge from index hospitalization. Analysis was conducted by cannulated vessel and stratified by VV or VA ECMO configurations. RESULTS A total of 229 patients were identified, of which 50.6% (n=116) survived until discharge. Late VC occurred in 7.8% of the surviving cohort (n=9/116); with a median time until presentation of 150 days (IQR 83-251). The most common late VC was infection (n=5, 55.6%) followed by progression to limb threatening ischemia (n=4, 44.4%). Urgent procedures were required in 55.6% of patients (n=5), while 44.4% (n=4) were elective interventions. Interventions performed for management of late VC included lower extremity arterial revascularization (n=6, 66.7%), major (n=1, 11.1%) or minor amputation (n=1, 11.1%), and wound debridement (n=1, 11.1%). The majority of patients presenting with late VC had initially been cannulated for peripheral-VA ECMO (n=8, 88.9%) and 1 patient (11.1%) was cannulated for peripheral-VV ECMO. VC during index hospitalization were seen in 77.8% (n=7) of patients returning with late VC. Odds for late VC were significantly increased in patients that had been cannulated for ECMO as part of extracorporeal-cardio-pulmonary resuscitation (E-CPR) (OR 8.4, p=0.016) and in cases were patient had experienced an index VC during index hospitalization (OR 19.3, p=0.001). CONCLUSION Late vascular complications after peripheral ECMO cannulation are not rare, particularly after arterial cannulation. Patients should be followed closely early after surviving ECMO with wound evaluation and formal assessment of perfusion with ankle-branchial indices in the cannulated limb.
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Affiliation(s)
- C Adam Banks
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL, US
| | - Juliet Blakeslee-Carter
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL, US
| | | | - Emily L Spangler
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL, US
| | - Shasha A Still
- University of Alabama at Birmingham, Division of Cardiothoracic Surgery, Birmingham, AL, US
| | - Kyle W Eudailey
- University of Alabama at Birmingham, Division of Cardiothoracic Surgery, Birmingham, AL, US
| | - Samuel K McElwee
- University of Alabama at Birmingham, Division of Cardiovascular Disease, Birmingham, AL, US
| | - Margaret S Blood
- University of Alabama at Birmingham, Division of Cardiothoracic Surgery, Birmingham, AL, US
| | - Zdenek Novak
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL, US
| | - Adam W Beck
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL, US.
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Motyl CM, Pearce BJ, Spangler EL, Beck AW. Aortic endarterectomy in patients with severe multivessel paravisceral and aortoiliac occlusive disease. J Vasc Surg 2024; 79:837-844. [PMID: 38141738 DOI: 10.1016/j.jvs.2023.11.062] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/01/2023] [Accepted: 11/06/2023] [Indexed: 12/25/2023]
Abstract
OBJECTIVE Aortic endarterectomy (AE), once a treatment of choice for aortoiliac occlusive disease, is now rarely performed in favor of endovascular procedures or open aortobifemoral bypass. However, in select patients with paravisceral or aortoiliac occlusive disease, AE remains a viable alternative for revascularization, either as a primary procedure or after prior interventions have failed. Here, we evaluated outcomes for an extended series of patients undergoing paravisceral or aortoiliac endarterectomy, demonstrating that these procedures can be an excellent alternative with acceptable morbidity and mortality in properly selected patients. METHODS A single institution retrospective review of 20 patients who underwent AE from 2017 to 2023 was performed. RESULTS Five patients (25%) underwent paravisceral endarterectomy and 15 (75%) underwent aortoiliac endarterectomy. There were no perioperative mortalities. One paravisceral patient died 3 months postoperatively from complications of pneumonia. Three patients in the paravisceral group required reinterventions; one acutely due to thrombosis of the superior mesenteric artery (SMA) requiring extension of the endarterectomy and patch angioplasty on postoperative day 0, one due to stenosis at the distal edge of the endarterectomy 1 month postoperatively, successfully treated with SMA stenting, and one at 10-month follow-up due to SMA stenosis at the distal aspect of the endarterectomy, also successfully treated with SMA stenting. With these reinterventions, the 1-year primary patency in the paravisceral group was 40%, primary-assisted patency was 80%, and secondary patency was 100%. In the aortoiliac group, 1-year primary, primary-assisted, and secondary patency were 91%, 91%, and 100%, respectively. One patient developed iliac thrombosis 10 days postoperatively owing to an intimal flap distal to the endarterectomy site. She and one other patient, a young man with an undefined hypercoagulable disorder, ultimately required neoaortoiliac reconstructions at 18 and 32 months postoperatively, respectively (the latter in the setting of stopping anticoagulation). The remaining 13 patients experienced no complications. All patients had rapid resolution of clinical symptoms, and median postoperative ankle-brachial indexes of 1.06 on the right and 1.00 on the left, representing a median improvement from preoperative ankle-brachial indexes of +0.59 on the right and +0.56 on the left (P < .01 and P < .01). CONCLUSIONS In this series of 20 patients undergoing paravisceral and infrarenal aortoiliac endarterectomy, AE was associated with no perioperative mortality, relatively low and manageable morbidity, and excellent clinical outcomes in patients with both paravisceral and aortoiliac occlusive disease. SMA-related early reintervention was not uncommon in the paravisceral group, and attention should be given particularly to the distal endarterectomy site. AE remains a viable treatment for severe multivessel paravisceral or aortoiliac occlusive disease isolated to the aorta and common iliac arteries in select patients.
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Affiliation(s)
- Claire M Motyl
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Benjamin J Pearce
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Emily L Spangler
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL.
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Rakestraw SL, Novak Z, Wang M, Banks CA, Spangler EL, Levitan EB, Locke JE, Beck AW, Sutzko DC. Treatment Location Variation for Chronic Limb-Threatening Ischemia in Patients With Kidney Failure. J Surg Res 2024; 293:300-306. [PMID: 37806215 PMCID: PMC10799673 DOI: 10.1016/j.jss.2023.09.009] [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: 03/01/2023] [Revised: 08/13/2023] [Accepted: 09/04/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION End-stage kidney disease (ESKD) is an established risk factor for chronic limb-threatening ischemia (CLTI). Procedural location for ESKD patients has not been well described. This study aims to examine variation in index procedural location in ESKD versus non-ESKD patients undergoing peripheral vascular intervention for CLTI and identify preoperative risk factors for tibial interventions. METHODS Chronic limb-threatening ischemia (CLTI) patients were identified in the Vascular Quality Initiative (VQI) peripheral vascular intervention dataset. Patient demographics and comorbidities were compared between patients with and without ESKD and those undergoing index tibial versus nontibial interventions. A multivariable logistic regression evaluating risk factors for tibial intervention was conducted. RESULTS A total of 23,480 procedures were performed on CLTI patients with 13.6% (n = 3154) with ESKD. End-stage kidney disease (ESKD) patients were younger (66.56 ± 11.68 versus 71.66 ± 12.09 y old, P = 0.019), more often Black (40.6 versus 18.6%, P < 0.001), male (61.2 versus 56.5%, P < 0.001), and diabetic (81.8 versus 60.0%, P < 0.001) than non-ESKD patients. Patients undergoing index tibial interventions had higher rates of ESKD (19.4 versus 10.6%, P < 0.001) and diabetes (73.4 versus 57.5%, P < 0.001) and lower rates of smoking (49.9 versus 73.0%, P < 0.001) than patients with nontibial interventions. ESKD (odds ratio (OR) 1.67, 95% confidence interval (CI) 1.52-1.86, P < 0.001), Black race (OR 1.19, 95% CI 1.09-1.30, P < 0.001), and diabetes (OR 1.82, 95% CI 1.71-2.00, P < 0.001) were risk factors for tibial intervention. CONCLUSIONS Patients with ESKD and CLTI have higher rates of diabetes and tibial disease and lower rates of smoking than non-ESKD patients. Tibial disease was associated with ESKD, diabetes, and Black race.
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Affiliation(s)
| | - Zdenek Novak
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michael Wang
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Charles A Banks
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Emily L Spangler
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Emily B Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jayme E Locke
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Adam W Beck
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Danielle C Sutzko
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama.
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Moffatt C, Bath J, Rogers RT, Colglazier JJ, Braet DJ, Coleman DM, Scali ST, Back MR, Magee GA, Plotkin A, Dueppers P, Zimmermann A, Afifi RO, Khan S, Zarkowsky D, Dyba G, Soult MC, Mani K, Wanhainen A, Setacci C, Lenti M, Kabbani LS, Weaver MR, Bissacco D, Trimarchi S, Stoecker JB, Wang GJ, Szeberin Z, Pomozi E, Gelabert HA, Tish S, Hoel AW, Cortolillo NS, Spangler EL, Passman MA, De Caridi G, Benedetto F, Zhou W, Abuhakmeh Y, Newton DH, Liu CM, Tinelli G, Tshomba Y, Katoh A, Siada SS, Khashram M, Gormley S, Mullins JR, Schmittling ZC, Maldonado TS, Politano AD, Rynio P, Kazimierczak A, Gombert A, Jalaie H, Spath P, Gallitto E, Czerny M, Berger T, Davies MG, Stilo F, Montelione N, Mezzetto L, Veraldi GF, D'Oria M, Lepidi S, Lawrence P, Woo K. International Multi-Institutional Experience with Presentation and Management of Aortic Arch Laterality in Aberrant Subclavian Artery and Kommerell's Diverticulum. Ann Vasc Surg 2023; 95:23-31. [PMID: 37236537 DOI: 10.1016/j.avsg.2023.05.005] [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: 04/11/2023] [Revised: 05/11/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND Aberrant subclavian artery (ASA) with or without Kommerell's diverticulum (KD) is a rare anatomic aortic arch anomaly that can cause dysphagia and/or life-threatening rupture. The objective of this study is to compare outcomes of ASA/KD repair in patients with a left versus right aortic arch. METHODS Using the Vascular Low Frequency Disease Consortium methodology, a retrospective review was performed of patients ≥18 years old with surgical treatment of ASA/KD from 2000 to 2020 at 20 institutions. RESULTS 288 patients with ASA with or without KD were identified; 222 left-sided aortic arch (LAA), and 66 right-sided aortic arch (RAA). Mean age at repair was younger in LAA 54 vs. 58 years (P = 0.06). Patients in RAA were more likely to undergo repair due to symptoms (72.7% vs. 55.9%, P = 0.01), and more likely to present with dysphagia (57.6% vs. 39.1%, P < 0.01). The hybrid open/endovascular approach was the most common repair type in both groups. Rates of intraoperative complications, death within 30 days, return to the operating room, symptom relief and endoleaks were not significantly different. For patients with symptom status follow-up data, in LAA, 61.7% had complete relief, 34.0% had partial relief and 4.3% had no change. In RAA, 60.7% had complete relief, 34.4% had partial relief and 4.9% had no change. CONCLUSIONS In patients with ASA/KD, RAA patients were less common than LAA, presented more frequently with dysphagia, had symptoms as an indication for intervention, and underwent treatment at a younger age. Open, endovascular and hybrid repair approaches appear equally effective, regardless of arch laterality.
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Affiliation(s)
- Clare Moffatt
- Division of Vascular and Endovascular Surgery, Department of Surgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA
| | - Jonathan Bath
- Division of Vascular Surgery, University of Missouri, Columbia, MO
| | - Richard T Rogers
- Division of Vascular and Endovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Jill J Colglazier
- Division of Vascular and Endovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Drew J Braet
- Division of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Dawn M Coleman
- Division of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Salvatore T Scali
- Division of Vascular and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL
| | - Martin R Back
- Division of Vascular and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL
| | - Gregory A Magee
- Division of Vascular and Endovascular Therapy, Department of Surgery, University of Southern California, Los Angeles, CA
| | - Anastasia Plotkin
- Division of Vascular and Endovascular Therapy, Department of Surgery, University of Southern California, Los Angeles, CA
| | - Philip Dueppers
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | | | - Rana O Afifi
- Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth, Houston, TX
| | - Sophia Khan
- Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth, Houston, TX
| | - Devin Zarkowsky
- Division of Vascular Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Gregory Dyba
- Division of Vascular Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Michael C Soult
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Loyola University Chicago, Stritch School of Medicine, Maywood, IL
| | - Kevin Mani
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Wanhainen
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Carlo Setacci
- Division of Vascular and Endovascular Surgery, Department of Medicine, Surgery, and Neurosciences, University of Siena, Siena, Italy
| | - Massimo Lenti
- Division of Vascular and Endovascular Surgery, Department of Medicine, Surgery, and Neurosciences, University of Siena, Siena, Italy
| | - Loay S Kabbani
- Division of Vascular Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI
| | - Mitchell R Weaver
- Division of Vascular Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI
| | - Daniele Bissacco
- Department of Vascular Surgery, IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Santi Trimarchi
- Department of Vascular Surgery, IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Jordan B Stoecker
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Zoltan Szeberin
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Eniko Pomozi
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Hugh A Gelabert
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Shahed Tish
- Division of Vascular Surgery, University of Missouri, Columbia, MO
| | - Andrew W Hoel
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Nicholas S Cortolillo
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Emily L Spangler
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Marc A Passman
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Giovanni De Caridi
- Division of Vascular Surgery, Department of Medical Sciences and Morpho-Functional-Imaging, University of Messina, Messina, Italy
| | - Filippo Benedetto
- Division of Vascular Surgery, Department of Medical Sciences and Morpho-Functional-Imaging, University of Messina, Messina, Italy
| | - Wei Zhou
- Division of Vascular Surgery, Department of Surgery, University of Arizona, Tucson, AZ
| | - Yousef Abuhakmeh
- Division of Vascular Surgery, Department of Surgery, University of Arizona, Tucson, AZ
| | - Daniel H Newton
- Division of Vascular Surgery, Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Christopher M Liu
- Division of Vascular Surgery, Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Giovanni Tinelli
- Unit of Vascular Surgery, Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Yamume Tshomba
- Unit of Vascular Surgery, Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Airi Katoh
- Department of Surgery, University of California San Francisco at Fresno, Fresno, CA
| | - Sammy S Siada
- Department of Surgery, University of California San Francisco at Fresno, Fresno, CA
| | - Manar Khashram
- Department of Surgery, University of Auckland, Waikato, New Zealand
| | - Sinead Gormley
- Department of Surgery, University of Auckland, Waikato, New Zealand
| | - John R Mullins
- Division of Vascular Surgery, Department of Surgery, CoxHealth, Springfield, MO
| | | | - Thomas S Maldonado
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Amani D Politano
- Division of Vascular Surgery, Department of Surgery, Oregon Health and Sciences University, Portland, OR
| | - Pawel Rynio
- Department of Vascular Surgery, Pomeranian Medical University, Szczecin, Poland
| | | | - Alexander Gombert
- Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany
| | - Houman Jalaie
- Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany
| | - Paolo Spath
- Department of Vascular Surgery, University of Bologna, DIMES, Bologna, Italy
| | - Enrico Gallitto
- Department of Vascular Surgery, University of Bologna, DIMES, Bologna, Italy
| | - Martin Czerny
- University Heart Center Freiburg-Bad Krozingen, Clinic for Cardiovascular Surgery, University Clinic Freiburg, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Tim Berger
- University Heart Center Freiburg-Bad Krozingen, Clinic for Cardiovascular Surgery, University Clinic Freiburg, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Mark G Davies
- Division of Vascular and Endovascular Surgery, Long School of Medicine, UT Health San Antonio, San Antonio, TX
| | - Francesco Stilo
- Operative Research Unit of Vascular Surgery, Department of Medicine and Surgery, University Campus Bio-Medico of Rome, Rome, Italy
| | - Nunzio Montelione
- Operative Research Unit of Vascular Surgery, Department of Medicine and Surgery, University Campus Bio-Medico of Rome, Rome, Italy
| | - Luca Mezzetto
- Division of Vascular Surgery, Integrated University Hospital of Verona, Verona, Italy
| | - Gian Franco Veraldi
- Division of Vascular Surgery, Integrated University Hospital of Verona, Verona, Italy
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | - Sandro Lepidi
- Division of Vascular Surgery, University of Missouri, Columbia, MO
| | - Peter Lawrence
- Division of Vascular and Endovascular Surgery, Department of Surgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA
| | - Karen Woo
- Division of Vascular and Endovascular Surgery, Department of Surgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA.
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Banks CA, Novak Z, Beck AW, Pearce BJ, Patterson MA, Passman MA, Sutzko DC, Tariq M, Morgan M, Spangler EL. Investigating glycemic control in patients undergoing lower extremity bypass within an enhanced recovery pathway at a single institution. J Vasc Surg 2023; 78:754-763. [PMID: 37116596 DOI: 10.1016/j.jvs.2023.04.027] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/30/2023] [Accepted: 04/04/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Enhanced recovery pathways (ERPs) aim to lower perioperative stress to facilitate recovery. Limited fasting combined with carbohydrate loading is a common ERP element. The effect of limited fasting has not been elucidated in patients with diabetes. Given the known deleterious effects of poor glycemic control in the perioperative period, such as increased rates of surgical site infection, the associations of preoperative limited fasting with perioperative glycemic control and early outcomes after lower extremity bypass (LEB) were investigated. METHODS A single institutional retrospective review of patients who underwent infrainguinal LEB from 2016 to 2022 was performed. The ERP was initiated in May 2018. Patients were stratified by diabetes diagnosis and preoperative hemoglobin A1C (HbA1C) levels. Perioperative glycemic control was compared between the limited fasting and traditional fasting patients (nil per os at midnight). Limited fasting was defined as a clear liquid diet until 2 hours before surgery with recommended carbohydrate loading consisting of 400 cc of a clear sports drink (approximately 30 g of carbohydrates). All limited fasting patients were within the ERP. Early perioperative hyperglycemia (EPH) was defined as blood glucose of >180 mg/dL within the first 24 hours of surgery. Perioperative outcomes such as surgical site infection, readmission, reinterventions, and complications were also compared. RESULTS A total of 393 patients were included (limited fasting patients N = 135; traditional fasting patients N = 258). A trend toward EPH was seen in all limited fasting groups. Evaluating limited fasting within diabetic patients revealed that 74.5% of limited fasting-diabetic patients had EPH compared with 49.6% of traditional fasting-diabetic patients (P = .001). When stratified by the HbA1C level, a significantly higher rate of EPH was seen in the HbA1c >8.0% groups, with 90.5% in the limited fasting patients compared with 67.9% in traditional fasting patients (P = .05). Limited fasting-diabetic patients experience a longer postoperative length of stay at 5.0 days (interquartile range: 3, 9) vs 4.0 days (2, 6) in nondiabetic patients (P = .016). CONCLUSIONS ERP limited fasting was associated with early perioperative hyperglycemia after LEB, particularly in patients with HbA1C >8.0%. Due to the high prevalence of diabetic patients undergoing LEB under ERP, the role of limited fasting and common glycemic elements of ERP may need to be re-evaluated in this subpopulation.
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Affiliation(s)
- Charles A Banks
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Zdenek Novak
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Benjamin J Pearce
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Mark A Patterson
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Marc A Passman
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Danielle C Sutzko
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Marvi Tariq
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | | | - Emily L Spangler
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL.
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Rakestraw SL, Novak Z, Wang MY, Banks CA, Spangler EL, Levitan EB, Locke JE, Beck AW, Sutzko DC. Differences in Long-Term Outcomes in End-Stage Kidney Disease Patients with Chronic Limb-Threatening Ischemia. Ann Vasc Surg 2023; 95:162-168. [PMID: 37225013 PMCID: PMC10799672 DOI: 10.1016/j.avsg.2023.05.002] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 05/05/2023] [Accepted: 05/07/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND End-stage kidney disease (ESKD) is a risk factor for peripheral arterial disease and major adverse limb events following infra-inguinal bypass. Despite comprising an important patient population, ESKD patients are rarely analyzed as a subgroup and are underrepresented in vascular surgery guidelines. This study aims to compare the long-term outcomes of patients with and without ESKD undergoing endovascular peripheral vascular intervention (PVI) for chronic limb-threatening ischemia (CLTI). METHODS CLTI patients with and without ESKD from 2007-2020 were identified in the Vascular Quality Initiative PVI dataset. Patients with prior bilateral interventions were excluded. Patients undergoing femoral-popliteal and tibial interventions were included. Mortality, reintervention, amputation, and occlusion rates at 21 months following intervention were examined. Statistical analyses were completed with the t-test, chi-square, and Kaplan-Meier curves. RESULTS The ESKD cohort was younger (66.4 ± 11.8 vs. 71.6 ± 12.1 years, P < 0.001) with higher rates of diabetes (82.2 vs. 60.9%, P < 0.001) the non-ESKD cohort. Long-term follow-up was available for 58.4% (N = 2,128 procedures) of ESKD patients and 60.8% (N = 13,075 procedures) of non-ESKD patients. At 21 months, ESKD patients had a higher mortality (41.7 vs. 17.4%, P < 0.001) and a higher amputation rate (22.3 vs. 7.1%, P < 0.001); however, they had a lower reintervention rate (13.2 vs. 24.6%, P < 0.001). CONCLUSIONS CLTI patients with ESKD have worse long-term outcomes at 2 years following PVI than non-ESKD patients. Mortality and amputation are higher with ESKD, while the reintervention rate is lower. Development of guidelines within the ESKD population has the potential to improve limb salvage.
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Affiliation(s)
| | - Zdenek Novak
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Michael Y Wang
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Charles A Banks
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Emily L Spangler
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Emily B Levitan
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jayme E Locke
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Adam W Beck
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Danielle C Sutzko
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL.
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McGinigle KL, Spangler EL, Ayyash K, Arya S, Settembrini AM, Thomas MM, Dell KE, Swiderski IJ, Davies MG, Setacci C, Urman RD, Howell SJ, Garg J, Ljungvist O, de Boer HD. A framework for perioperative care for lower extremity vascular bypasses: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery. J Vasc Surg 2023; 77:1295-1315. [PMID: 36931611 DOI: 10.1016/j.jvs.2023.01.018] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/30/2022] [Accepted: 01/03/2023] [Indexed: 03/17/2023]
Abstract
The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based suggestions for coordinated perioperative care for patients undergoing infrainguinal bypass surgery for peripheral artery disease. Structured around the ERAS core elements, 26 suggestions were made and organized into preadmission, preoperative, intraoperative, and postoperative sections.
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Affiliation(s)
- Katharine L McGinigle
- Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Emily L Spangler
- Department of Surgery, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Katie Ayyash
- Department of Perioperative Medicine (Merit), York and Scarborough Teaching Hospitals NHS Foundation Trust, York, United Kingdom
| | - Shipra Arya
- Department of Surgery, School of Medicine, Stanford University, Palo Alto, CA
| | | | - Merin M Thomas
- Lenox Hill Hospital, Northwell Health, New Hyde Park, NY
| | | | | | - Mark G Davies
- Department of Surgery, Joe R. & Teresa Lozano Long School of Medicine, University of Texas Health Sciences Center, San Antonio, TX
| | - Carlo Setacci
- Department of Surgery Surgery, University of Siena, Siena, Italy
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Simon J Howell
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, United Kingdom
| | - Joy Garg
- Department of Vascular Surgery, Kaiser Permanente San Leandro, San Leandro, CA
| | - Olle Ljungvist
- Department of Surgery, Orebro University, Orebro, Sweden
| | - Hans D de Boer
- Department of Anesthesiology, Pain Medicine, and Procedure Sedation and Analgesia, Martini General Hospital Groningen, Groningen, the Netherlands
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Banks CA, Beck AW, Tariq M, Novak Z, Pearce BJ, Patterson MA, Sutzko DC, Morgan M, Passman M, Spangler EL. Investigating Glycemic Control in Patients Undergoing Lower Extremity Bypass Within an Enhanced Recovery Pathway at a Single Institution. J Vasc Surg 2023. [DOI: 10.1016/j.jvs.2022.11.028] [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: 12/24/2022]
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10
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Blakeslee-Carter J, Novak Z, Axley J, Gaillard WF, McFarland GE, Pearce BJ, Spangler EL, Passman MA, Beck AW. Migration of High Cardiac Risk Patients from Open to Endovascular Procedures is Evident within the Society for Vascular Surgery Vascular Quality Initiative. Ann Vasc Surg 2022; 85:110-118. [PMID: 35429603 PMCID: PMC9587804 DOI: 10.1016/j.avsg.2022.03.029] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 03/23/2022] [Accepted: 03/24/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND In this study, pre-operative medical complexity is estimated by the independently validated Vascular Quality Initiative VQI Cardiac Risk Index (CRI). This study aims to identify and correlate trends of CRI for open abdominal aortic aneurysm (OAR) with trends in the CRI for corresponding endovascular aortic repair (EVAR). This assessment of differences in estimated procedural risks will be used to support the theory that, patient migration is an important factor contributing to decreased POMI following open vascular procedures. METHODS A retrospective review of VQI data from 2003 to 2020 for all patients undergoing elective aortic repairs (OAR and EVAR) was conducted. The CRI scoring developed for the open repair (oCRI) was applied to both the OAR and EVAR cohorts, with variables specific to EVAR translated from similar open repair factors in the model where feasible. To evaluate for changes across time, patients were grouped into Eras based on year of procedure, subsequently, univariate analysis of post-operative myocardial infarction (POMI) rates and CRI scores were perfomed between each era. RESULTS A total of 56,067 elective aortic repairs were identified (83% EVAR, 17% OAR). Within the OAR cohort, the average oCRI estimate was 7.1% with significant decrease across the studied timeframe (8% ± 4.6%→6.9% ± 4.4%, P < 0.001), which corresponded to a significant decrease in observed clinical myocardial infarction (MI) rate (4.1%→1.4%, P < 0.001). Over that same time period, the open CRI was applied to the EVAR cohort, and the average oCRI estimate was 7.2% and showed a significant increase (6.6% ± 2.8%→7.2% ± 4.4%, P < 0.001). Within the EVAR cohort, the eCRI estimate did not show any significant changes over time (average 0.48%), while the actual rate of clinical MI showed a significant decrease (1.1%→0.3%, P = 0.002). Gap analysis was conducted within the EVAR cohort between CRI estimates of procedural risks from an open operation versus an EVAR, which demonstrated that patients within the EVAR cohort would, on an average, has had 6.7% higher risk of POMI had they undergone an open procedure. CONCLUSIONS Paradigm shifts with regard to patient selection for aortic repair is evident within this large national cohort. Over time, OAR patients had fewer preoperative estimated cardiac comorbidities and there is a corresponding decrease in POMI rates. As high-risk patients migrate from OAR to EVAR, there has been a subsequent increase in EVAR estimated pre-operative risks as the patients become more medically high-risk. Despite increasing complexity, rates of POMI in EVAR significantly decreased, potentially explained by improved operative technique and peri-operative care.
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Affiliation(s)
- Juliet Blakeslee-Carter
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - Zdenek Novak
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - John Axley
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - William F Gaillard
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - Graeme E McFarland
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - Benjamin J Pearce
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - Emily L Spangler
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - Marc A Passman
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - Adam W Beck
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL.
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11
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Eid MA, Barry MJ, Tang GL, Henke PK, Johanning JM, Tzeng E, Scali ST, Stone DH, Suckow BD, Lee ES, Arya S, Brooke BS, Nelson PR, Spangler EL, Murebee L, Dosluoglu HH, Raffetto JD, Kougais P, Brewster LP, Alabi O, Dardik A, Halpern VJ, O’Connell JB, Ihnat DM, Zhou W, Sirovich BE, Metha K, Moore KO, Voorhees A, Goodney PP. Effect of a Decision Aid on Agreement Between Patient Preferences and Repair Type for Abdominal Aortic Aneurysm: A Randomized Clinical Trial. JAMA Surg 2022; 157:e222935. [PMID: 35947375 PMCID: PMC9366657 DOI: 10.1001/jamasurg.2022.2935] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 05/04/2022] [Indexed: 12/19/2022]
Abstract
Importance Patients with abdominal aortic aneurysm (AAA) can choose open repair or endovascular repair (EVAR). While EVAR is less invasive, it requires lifelong surveillance and more frequent aneurysm-related reinterventions than open repair. A decision aid may help patients receive their preferred type of AAA repair. Objective To determine the effect of a decision aid on agreement between patient preference for AAA repair type and the repair type they receive. Design, Setting, and Participants In this cluster randomized trial, 235 patients were randomized at 22 VA vascular surgery clinics. All patients had AAAs greater than 5.0 cm in diameter and were candidates for both open repair and EVAR. Data were collected from August 2017 to December 2020, and data were analyzed from December 2020 to June 2021. Interventions Presurgical consultation using a decision aid vs usual care. Main Outcomes and Measures The primary outcome was the proportion of patients who had agreement between their preference and their repair type, measured using χ2 analyses, κ statistics, and adjusted odds ratios. Results Of 235 included patients, 234 (99.6%) were male, and the mean (SD) age was 73 (5.9) years. A total of 126 patients were enrolled in the decision aid group, and 109 were enrolled in the control group. Within 2 years after enrollment, 192 (81.7%) underwent repair. Patients were similar between the decision aid and control groups by age, sex, aneurysm size, iliac artery involvement, and Charlson Comorbidity Index score. Patients preferred EVAR over open repair in both groups (96 of 122 [79%] in the decision aid group; 81 of 106 [76%] in the control group; P = .60). Patients in the decision aid group were more likely to receive their preferred repair type than patients in the control group (95% agreement [93 of 98] vs 86% agreement [81 of 94]; P = .03), and κ statistics were higher in the decision aid group (κ = 0.78; 95% CI, 0.60-0.95) compared with the control group (κ = 0.53; 95% CI, 0.32-0.74). Adjusted models confirmed this association (odds ratio of agreement in the decision aid group relative to control group, 2.93; 95% CI, 1.10-7.70). Conclusions and Relevance Patients exposed to a decision aid were more likely to receive their preferred AAA repair type, suggesting that decision aids can help better align patient preferences and treatments in major cardiovascular procedures. Trial Registration ClinicalTrials.gov Identifier: NCT03115346.
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Affiliation(s)
- Mark A. Eid
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Michael J. Barry
- Massachusetts General Hospital Center for Shared Decision Making, Boston
| | | | | | | | - Edith Tzeng
- Pittsburgh VA Medical Center, Pittsburgh, Pennsylvania
| | | | - David H. Stone
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Bjoern D. Suckow
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | | | - Shipra Arya
- Palo Alto VA Medical Center, Palo Alto, California
| | | | | | | | | | | | | | | | | | | | - Alan Dardik
- West Haven VA Medical Center, West Haven, Connecticut
| | | | | | | | - Wei Zhou
- Tucson VA Medical Center, Tucson, Arizona
| | - Brenda E. Sirovich
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Kunal Metha
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Kayla O. Moore
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont
| | - Amy Voorhees
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont
| | - Philip P. Goodney
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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12
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Spangler EL, Jackson EA, Richman J. Mortality Trends in Contemporary Abdominal Aortic Aneurysm Repairs Among Veterans. J Surg Res 2022; 279:383-392. [PMID: 35820320 DOI: 10.1016/j.jss.2022.06.005] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 05/10/2022] [Accepted: 06/08/2022] [Indexed: 10/31/2022]
Abstract
INTRODUCTION Clinical trials at the advent of endovascular aortic aneurysm repairs (EVARs) demonstrated improved early survival with EVAR compared to open repairs; however, characterizations of routine contemporary care have been limited. This study compares postoperative survival among Veterans in clinical care following abdominal aortic aneurysm (AAA) repair with EVAR versus open repairs since the widespread adoption of EVAR. MATERIALS AND METHODS This retrospective cohort analysis of Veterans with AAA repairs from 2007 to 2020 at Veterans Affairs (VA) facilities evaluated survival by a repair method. Administrative International Classification of Diseases 9/10 codes and sociodemographic characteristics from structured charting were used for characterization and adjusted analyses. Demographics were compared via Chi-squared and Wilcoxon rank-sum testing and mortality evaluated using Kaplan-Meier and Cox proportional hazard analyses. RESULTS Among 15,480 AAA repairs (3566 open, and 11,914 EVAR), patients receiving open repairs were younger with lower Charlson scores compared to EVARs. EVAR was associated with better survival until 2.4 y post-procedure. Mean long-term survival, however, was higher for open surgery (6.3 ± 3.8 versus 5.8 ± 3.1 y in EVAR). After adjustment for gender, race, and ethnicity, EVAR was associated with worse survival (mortality hazard ratio [HR] 1.17; 95% confidence interval [CI], 1.11-1.24) as was each increment in Charlson score (HR 1.11; CI 1.10-1.12), whereas service-connected care (HR 0.73; CI, 0.70-0.77) and age (HR 0.99; CI, 0.98-0.99) were associated with better survival. CONCLUSIONS In contemporary Veteran aneurysm repairs, although a higher early survival rate was observed in EVAR repairs, long-term survival was higher for open repairs. Service-connected care was independently associated with greater survival after aneurysm repair.
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Affiliation(s)
- Emily L Spangler
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Alabama; Birmingham VA Medical Center, Birmingham, Alabama.
| | - Elizabeth A Jackson
- Birmingham VA Medical Center, Birmingham, Alabama; Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
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13
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Banks CA, Spangler EL, Beck AW, Novak Z, Zheng X, Mao J, Sutzko DC, McFarland G, Scali ST. Readmissions Following Endovascular Thoracoabdominal Aortic Repairs in the Vascular Implant Surveillance and Interventional Outcomes Network. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.03.257] [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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14
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Blakeslee-Carter J, Pearce B, McFarland G, Sutzko DC, Spangler EL, Beck AW. Aortic Instability in Medically Managed Acute and Subacute Type 3B Aortic Dissections. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.03.174] [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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15
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McGinigle KL, Spangler EL, Pichel AC, Ayyash K, Arya S, Settembrini AM, Garg J, Thomas MM, Dell KE, Swiderski IJ, Lindo F, Davies MG, Setacci C, Urman RD, Howell SJ, Ljungqvist O, de Boer HD. Perioperative care in open aortic vascular surgery: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery. J Vasc Surg 2022; 75:1796-1820. [PMID: 35181517 DOI: 10.1016/j.jvs.2022.01.131] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [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: 12/15/2021] [Accepted: 01/03/2022] [Indexed: 12/12/2022]
Abstract
The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS®) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based recommendations related to all of the health care received in the perioperative period for patients undergoing open abdominal aortic operations (both transabdominal and retroperitoneal approaches, including supraceliac, suprarenal, and infrarenal clamp sites, for aortic aneurysm and aortoiliac occlusive disease). Structured around the ERAS® core elements, 36 recommendations were made and organized into preadmission, preoperative, intraoperative, and postoperative recommendations.
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Affiliation(s)
- Katharine L McGinigle
- Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Emily L Spangler
- Department of Surgery, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Adam C Pichel
- Department of Anaesthesia, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Katie Ayyash
- Department of Perioperative Medicine (Merit), York and Scarborough Teaching Hospitals NHS Foundation Trust, York, UK
| | - Shipra Arya
- Department of Surgery, School of Medicine, Stanford University, Palo Alto, CA
| | | | - Joy Garg
- Department of Vascular Surgery, Kaiser Permanente San Leandro, San Leandro, CA
| | - Merin M Thomas
- Lenox Hill Hospital, Northwell Health, New Hyde Park, NY
| | | | | | - Fae Lindo
- Stanford University Hospital, Palo Alto, CA
| | - Mark G Davies
- Department of Surgery, Joe R. & Teresa Lozano Long School of Medicine, University of Texas Health Sciences Center, San Antonio, TX
| | - Carlo Setacci
- Department of Surgery, University of Siena, Siena, Italy
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Simon J Howell
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | - Olle Ljungqvist
- Department of Surgery, School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Hans D de Boer
- Department of Anesthesiology, Pain Medicine and Procedure Sedation and Analgesia, Martini General Hospital Groningen, Groningen, the Netherlands
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Boudreau H, Blakeslee-Carter J, Novak Z, Sutzko DC, Spangler EL, Passman MA, Scali ST, McFarland GE, Pearce BJ, Beck AW. Association of Statin and Antiplatelet Use with Survival in Patients with AAA with and without Concomitant Atherosclerotic Occlusive Disease. Ann Vasc Surg 2022; 83:70-79. [PMID: 35108555 DOI: 10.1016/j.avsg.2022.01.014] [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: 08/15/2021] [Revised: 01/09/2022] [Accepted: 01/10/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVES Statin therapy has been associated with improved clinical outcomes in patients undergoing treatment for vascular disease. Current guidelines do not address statin therapy in isolated abdominal aortic aneurysm (AAA) in the absence of other atherosclerotic cardiovascular disease (ASCVD). This study aims to elucidate effects of statin therapy, either as monotherapy or combined with antiplatelet agents, on the long-term mortality of patients with and without ASCVD who undergo elective AAA repair. METHODS A retrospective review was performed on all AAA patients treated electively with endovascular (EVAR) and open aortic repair (OAR) in the Society for Vascular Surgery Vascular Quality Initiative from 2003-2020. Long-term mortality was evaluated based on the presence of statin and antiplatelet medication use at discharge stratified by those with and without a history of ASCVD. Unadjusted survival was estimated by Kaplan Meier methodology. Cox proportional hazards modeling was used to determine mortality risk after adjusting for key factors. RESULTS A total of 47,012 AAA repairs were selected for analysis: 80.7% EVAR (N=40,153) and 19.3% OAR (N=6,859). EVAR patients on combined statin/antiplatelet (AP) therapy had significantly better survival irrespective of whether they had known ASCVD. In the presence of ASCVD, EVAR patients on statin alone had improved survival compared to those not on a statin (10.9±0.5 vs 10.5±0.4 years, Log Rank <.001), with survival being even greater among those receiving combined statin/AP therapy (12.2±0.2 vs 10.5±0.4 years, Log Rank <.001). In the absence of ASCVD, EVAR patients on statin alone also had better mean survival compared to patients not on a statin (8.7±0.5 vs 8.4±0.4 years, Log Rank<.001), with higher survival among statin/AP therapy patients (9.4±0.2 years vs 8.7±0.5 years, Log Rank <.001). Comparison of adjusted survival via Cox multivariable regression demonstrated a protective effect of statins (HR=0.737, p=0.04, vs no medication) and combined statin/AP therapy (HR=0.659, p=0.001, vs no medication) in patients with ASCVD history. A similar protective effect (statin: HR 0.826, p=0.05. Combination statin/AP: HR 0.726, p<.001, vs no medication) was identified in patients without ASCVD history. Within the OAR cohort, statin therapy was not associated with improved survival among patients without ASCVD; however, combined statin/AP therapy had a protective effect for patients with a known ASCVD diagnosis. Based on KM analysis, OAR patients with ASCVD on combined statin/AP therapy had significantly higher mean survival compared to isolated statin therapy (12.7±0.2 vs 10.3±0.65 years) and no medical therapy (10.5±0.8 years, Log Rank <.001). In KM analysis, OAR patients without known ASCVD indications (N=3591) had no significant survival differences based on the presence of combined statin/AP therapy (8.4 ± .07 vs. 8.5 ± .11 years, Log Rank=.638). CONCLUSION Isolated statin therapy and combined statin/AP therapy showed significant survival benefit in all EVAR and OAR patients with ASCVD indications, as well as among EVAR patients without a known ASCVD diagnosis. OAR patients without ASCVD did not have a significant survival benefit from statin therapy, but low numbers in this group may have confounded the findings. Combined statin/AP therapy appears to have significant post-repair survival benefits even in isolated AAA without ASCVD, as demonstrated in post-EVAR patients in this study. Expansion of statin use recommendations within aneurysm treatment guidelines may be warranted.
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Affiliation(s)
- Hunter Boudreau
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - Juliet Blakeslee-Carter
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - Zdenek Novak
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - Danielle C Sutzko
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - Emily L Spangler
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - Marc A Passman
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - Salvatore T Scali
- University of Florida College of Medicine, Division of Vascular Surgery and Endovascular Therapy, Gainesville, FL
| | - Graeme E McFarland
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - Benjamin J Pearce
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - Adam W Beck
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL.
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Novak Z, Zaky A, Spangler EL, Beck AW. Reply. J Vasc Surg 2021; 74:2122. [PMID: 34809823 DOI: 10.1016/j.jvs.2021.08.063] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 08/29/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Zdenek Novak
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Ahmed Zaky
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Ala
| | - Emily L Spangler
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
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Blakeslee-Carter J, Beck AW, Spangler EL. Type 3 Endoleaks in Complex Endovascular Abdominal Aortic Aneurysm Repair within the Vascular Quality Initiative. J Vasc Surg 2021; 75:1172-1180. [PMID: 34740805 DOI: 10.1016/j.jvs.2021.10.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 10/21/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Type 3 Endoleaks (T3EL) following complex EVAR (c-EVAR) for abdominal aortic aneurysm have been historically difficult to study due to their relative rarity. Previous studies within standard infrarenal EVAR have found an association between T3EL and decreased survival. This study aims to evaluate the occurrence of T3EL in a national multicenter cohort, identify potential procedural characteristics associated with T3EL development, and determine their impact on clinical outcomes in c-EVAR. METHODS A retrospective cohort review was conducted of elective c-EVAR for non-ruptured aneurysms within the Vascular Quality Initiative (VQI) between January 2010 and March 2020. The VQI standards define c-EVAR as suprarenal or pararenal AAA repaired with any thoracoabdominal repairs, fenestrated/branched repairs, parallel stent repairs, custom manufactured devices, and physician modified endografts. End-points assessed were rates of T3EL within c-EVAR, and impact of T3EL on reintervention and survival. Index endoleaks were defined as endoleaks discovered during index hospitalization. Incident endoleaks were defined as new endoleaks, that were not present at index hospitalization, discovered at follow-up. RESULTS 4,070 c-EVAR cases were identified between January 2010 and March 2020, of which, 2,656 (65.2%) had appropriate follow-up data. Half the cohort had a modified or custom graft (n=2,055/4,070, 50.5%). Branches were employed in 3,687 patients (90.5%), while fenestrations and chimney techniques were documented in 13% (n=533) and 15.1% (n=613) respectively . The rate of index T3EL was 4.1% (n=167), and the rate of incident T3EL at follow-up was 0.04% (n=1). Devices categorized as either custom or physician modified were utilized more frequently in patients with index T3EL (78.4%, n=131/167) compared to patients without index T3EL (49.2%, n=1,924/3,903) (p<0.001). Compared to those without T3EL, the presence of index T3EL was not statistically associated with increased aortic reinterventions or increased mortality. CONCLUSIONS T3EL in c-EVAR remain relatively uncommon and are identified predominately at index hospitalization. Development of T3EL was associated with higher device modularity and modification, which suggests that as device technologies continue to advance and become more intricate the occurrence of T3EL may persist and continue to require evaluation. In this study, the presence of T3EL did not appear to have a statistically significant relationship with aortic reinterventions or survival, however these findings are not definitive due to low event rate numbers and high potential for Type 2 errors. Amid the theoretical risk of device fatigue and degeneration, continued evaluations of large cohorts at extended follow-up intervals and diligent reporting remain paramount.
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Affiliation(s)
- Juliet Blakeslee-Carter
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - Adam W Beck
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - Emily L Spangler
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL.
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Spangler EL, Jackson E, Richman JS. Surveillance Imaging Receipt in Veterans Following Abdominal Aortic Aneurysm Repair. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.667] [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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20
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Jones JM, Hu YD, Eid MA, Sensenig CJ, Mehta KS, Goldwag JL, Barnes JA, Kang R, Barry MJ, Spangler EL, Nelson PR, Mureebe L, Tang G, Tzeng E, Alabi O, Halpern VJ, Stone DH, Brooke BS, Moore K, Henke P, Scali S, O'Connell J, Goodney PP. Short-Term Concerns Primarily Determine Patient Preference for Abdominal Aortic Aneurysm Repair. J Surg Res 2021; 269:119-128. [PMID: 34551368 DOI: 10.1016/j.jss.2021.07.019] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/26/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Abdominal aortic aneurysm (AAA) repair may be performed through open or endovascular approaches, but the factors influencing a patient's repair-type preference are not well characterized. Here we performed a qualitative analysis to better understand factors influencing patient preference within the Preference for Open Versus Endovascular Repair of AAA Trial. METHODS Open-ended responses regarding primary (n = 21) and secondary (n = 47) factors influencing patient preference underwent qualitative analysis using the constant comparative method with iterative reviews. Codes were used to generate themes and themes grouped into categories, with each step conducted via consensus agreement between three researchers. Relative prevalence of themes were compared to ascertain trends in patient preference. RESULTS Patient responses regarding both primary and secondary factors fell into four categories: Short-term concerns, long-term concerns, advice & experience, and other. Patients most frequently described short-term concerns (23) as their primary influence, with themes including post-op complications, hospitalization & recovery, and intraoperative concerns. Long-term concerns were more prevalent (20) as secondary factors, which included themes such as survival, and chronic management. The average age of patients voicing only long-term concerns as a primary factor was 11 years younger than those listing only short-term concerns. CONCLUSION Short-term concerns relating to the procedure and recovery are more often the primary factor influencing patient preference, while long term concerns play a more secondary role. Long-term concerns are more often a primary factor in younger patients. Vascular surgeons should consider this information in shared decision making to reach an optimal outcome.
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Affiliation(s)
- J M Jones
- The Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Y D Hu
- The Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - M A Eid
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont
| | | | - K S Mehta
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont
| | - J L Goldwag
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont
| | - J A Barnes
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont
| | - R Kang
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - M J Barry
- Massachusetts General Hospital Center for Shared Decision Making, Boston, Massachusetts
| | | | - P R Nelson
- Muskogee VAMC, Muskogee, Okla; Tampa VAMC, Tampa Bay, Florida
| | | | - G Tang
- Seattle VAMC, Seattle, Washington
| | - E Tzeng
- Pittsburgh VAMC, Pittsburgh, Pennsylvania
| | - O Alabi
- Atlanta VAMC, Atlanta, Georgia
| | | | - D H Stone
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | | | - K Moore
- The Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - P Henke
- Ann Arbor VAMC, Ann Arbor, Michigan
| | - S Scali
- Gainesville VAMC, Gainesville, Florida
| | | | - P P Goodney
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont.
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21
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Blakeslee-Carter J, Banks CA, Passman M, Scali ST, Spangler EL, Beck AW. Aortic Visceral Segment Instability Is Evident After Thoracic Endovascular Aortic Repair for Acute Type B Aortic Dissections. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.330] [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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22
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Hansen-Estruch C, Spangler EL, McFarland G, Pearce BJ, Eudailey K, DiBartolomeo A, Magee GA, Beck AW. Outcomes of Thoracic Endovascular Aorta Repair of Ascending Aorta and Aortic Arch Pathology. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.178] [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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23
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Novak Z, Zaky A, Spangler EL, McFarland GE, Tolwani A, Beck AW. Incidence and predictors of early and delayed renal function decline after aortic aneurysm repair in the Vascular Quality Initiative database. J Vasc Surg 2021; 74:1537-1547. [PMID: 34019992 DOI: 10.1016/j.jvs.2021.04.049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 06/25/2020] [Accepted: 04/16/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Postoperative acute kidney injury (AKI) may complicate both open and endovascular aortic aneurysm repair (EVAR) and is associated with substantial morbidity, mortality, and health care expense. We aim to evaluate the incidence of postoperative AKI and factors associated with its occurrence and the effects of postoperative AKI on long-term renal function and mortality after open and EVAR in the Society for Vascular Surgery Vascular Quality Initiative registry. METHODS Elective aneurysm cases were identified including thoracic endovascular aortic aneurysm repair (TEVAR) and complex endovascular aortic aneurysm repair (cEVAR), infrarenal endovascular repair (EVAR) and infrarenal open repair (OAR) from 2003 to 2019. The preoperative estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease formula and stratified based on chronic kidney disease (CKD) grades. Postoperative AKI was defined per the Vascular Quality Initiative definition as a creatinine increase of 0.5 mg/dL or if postoperative dialysis was required. Patients on preprocedural hemodialysis and those with previous renal transplant were excluded. Demographics and procedural factors were evaluated for predicting in-hospital postoperative AKI (all approaches) and at 9 to 21 months of long-term follow-up (EVAR only) using logistic regression modeling. RESULTS We identified a total of 2813 cEVAR, 2995 TEVAR, 39,945 EVAR, and 8143 OAR patients. Of those, postoperative AKI occurred in 377 cEVAR (13.5%), 199 TEVAR (6.7%), 1099 EVAR (2.8%), and 1249 OAR (15.5%). Risk factors for postoperative AKI across all groups were worse preoperative eGFR, total number of blood transfusions, perioperative anemia, reinterventions, and postoperative respiratory complications. Additional procedure-specific risk factors of postoperative AKI were preoperative hemoglobin of less than 10 and contrast volume of 125 to 150 mL, hypertension, a low ejection fraction, and a history of percutaneous revascularization for EVAR; for both EVAR/cEVAR, renal artery coverage was a risk factor, whereas for OAR, male sex, non-White race, hypertension, suprarenal aortic cross-clamp, and increased renal ischemic time were risk factors. Among 8133 EVAR patients with long-term follow-up, a decrease in kidney function occurred in 56.7% of patients with postoperative AKI vs 19.9% without postoperative AKI (P < .001). The following risk factors were associated with a decrease in renal function at long-term follow-up: postoperative AKI, a preoperative eGFR of less than 90, and hypertension. A preoperative hemoglobin of greater than 12 was protective. Postoperative AKI was associated with significantly lower survival compared with no postoperative AKI across all procedures (log rank <0.001). CONCLUSIONS Postoperative AKI occurs more often in patients with worse preoperative renal function, lower preoperative hemoglobin, and in open surgeries with inter-renal or suprarenal cross-clamping. Importantly, postoperative AKI is associated with increased mortality across all types of aortic repair. Given the long-term impact of postoperative AKI on outcomes for all aortic repairs and the limitations of current insensitive functional indices, there is a need to seek more sensitive indicators of decreases in early renal structural in this population.
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Affiliation(s)
- Zdenek Novak
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Ahmed Zaky
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Ala.
| | - Emily L Spangler
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Graeme E McFarland
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Ashita Tolwani
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Ala
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
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24
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Aucoin VJ, Bolaji B, Novak Z, Spangler EL, Sutzko DC, McFarland GE, Pearce BJ, Passman MA, Scali ST, Beck AW. Trends in the use of cerebrospinal drains and outcomes related to spinal cord ischemia after thoracic endovascular aortic repair and complex endovascular aortic repair in the Vascular Quality Initiative database. J Vasc Surg 2021; 74:1067-1078. [PMID: 33812035 DOI: 10.1016/j.jvs.2021.01.075] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 01/23/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Spinal cord ischemia (SCI) is a dreaded complication of thoracic and complex endovascular aortic repair (TEVAR/cEVAR). Controversy exists surrounding cerebrospinal fluid drain (CSFD) use, especially preoperative prophylactic placement, owing to concerns regarding catheter-related complications. However, these risks are balanced by the widely accepted benefits of CSFDs during open repair to prevent and/or rescue patients with SCI. The importance of this issue is underscored by the paucity of data on CSFD practice patterns, limiting the development of practice guidelines. Therefore, the purpose of the present analysis was to evaluate the differences between patients who developed SCI despite preoperative CSFD placement and those treated with therapeutic postoperative CSFD placement. METHODS All elective TEVAR/cEVAR procedures for degenerative aneurysm pathology in the Society for Vascular Surgery Vascular Quality Initiative from 2014 to 2019 were analyzed. CSFD use over time, the factors associated with preoperative prophylactic vs postoperative therapeutic CSFD placement in patients with SCI (transient or permanent), and outcomes were evaluated. Survival differences were estimated using the Kaplan-Meier method. RESULTS A total of 3406 TEVAR/cEVAR procedures met the inclusion criteria, with an overall SCI rate of 2.3% (n = 88). The SCI rate decreased from 4.55% in 2014 to 1.43% in 2018. Prophylactic preoperative CSFD use was similar over time (2014, 30%; vs 2018, 27%; P = .8). After further exclusions to evaluate CSFD use in those who had developed SCI, 72 patients were available for analysis, 48 with SCI and prophylactic CSFD placement and 24 with SCI and therapeutic CSFD placement. Specific to SCI, the patient demographics and comorbidities were not significantly different between the prophylactic and therapeutic groups, with the exception of previous aortic surgery, which was more common in the prophylactic CSFD cohort (46% vs 23%; P < .001). The SCI outcome was significantly worse for the therapeutic group because 79% had documented permanent paraplegia at discharge compared with 54% of the prophylactic group (P = .04). SCI patients receiving a postoperative therapeutic CSFD had had worse survival than those with a preoperative prophylactic CSFD (50% ± 10% vs 71% ± 9%; log-rank P = .1; Wilcoxon P = .05). CONCLUSIONS Prophylactic CSFD use with TEVAR/cEVAR remained stable during the study period. Of the SCI patients, postoperative therapeutic CSFD placement was associated with worse sustained neurologic outcomes and overall survival compared with preoperative prophylactic CSFD placement. These findings highlight the need for a randomized clinical trial to examine prophylactic vs therapeutic CSFD placement in association with TEVAR/cEVAR.
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Affiliation(s)
- Victoria J Aucoin
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Bolanle Bolaji
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Zdenek Novak
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Emily L Spangler
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Danielle C Sutzko
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Graeme E McFarland
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Benjamin J Pearce
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Marc A Passman
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala.
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Boudreau HS, Blakeslee-Carter J, Zdenek N, Spangler EL, Beck AW. Effects Of Statin And Antiplatelet Therapy On Mortality Rates In Abdominal Aortic Aneurysm Patients. Ann Vasc Surg 2021. [DOI: 10.1016/j.avsg.2021.01.016] [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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Axley J, Blakeslee-Carter J, Novak Z, McFarland G, Spangler EL, Pearce BJ, Patterson MA, Passman MA, Sutzko DC, Beck AW. Describing Clinically Significant Arrhythmias in Postoperative Vascular Surgery Patients. Ann Vasc Surg 2020; 73:68-77. [PMID: 33359693 DOI: 10.1016/j.avsg.2020.11.020] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 11/07/2020] [Accepted: 11/11/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The American Heart Association guidelines instruct use of postoperative telemetry (POT) should be reserved for patients undergoing cardiac procedures and/or those with ischemic cardiac symptoms, but acknowledge that major vascular procedures deserve unique consideration. Telemetry remains a limited resource in many hospitals; however, it has been poorly defined which vascular patients have greatest need for POT. The purpose of this study is to define the rates of postoperative arrhythmias (POAs) after major vascular operations using the Society for Vascular Surgery Vascular Quality Initiative (VQI) registry, identify independent predictors of POA, and determine the effect of POA on mortality to guide the use of POT in vascular patients. METHODS A retrospective cohort study was performed using the following VQI modules: open abdominal aortic aneurysm repair (oAAA), complex endovascular aneurysm repair (EVAR) (thoracic endovascular aortic repair [TEVAR]/c-EVAR), EVAR, suprainguinal bypass (SIB), and infrainguinal bypass (IIB). POA was defined in the VQI as a new rhythm disturbance requiring treatment with medication or cardioversion. The incidence of POA, preoperative risk factors, and demographics were determined for each procedure. RESULTS A total of 121,652 procedures were identified with an overall POA event rate of 5.1% (n = 6,265). Procedure-specific event rates for POA among VQI registries are as follows: oAAA 14.4%, TEVAR/c-EVAR 8.5%, EVAR 2.7%, SIB 6.2%, and IIB 3.8%. Across all procedure types, POA was associated with emergent operations and increased procedure time. Procedure-specific multivariable regression revealed additional independent preoperative intraoperative factors associated with POA that were unique with each procedure. Across all procedural groups, the presence of POA was associated with increased rates of clinical myocardial infarction and decreased survival on Kaplan-Meier analysis. CONCLUSIONS Rates of POA in patients undergoing vascular procedures appear higher than previously reported, and POA is associated with decreased survival. Our study elucidated patient- and procedure-specific predictor factors associated with POA that can be used to inform the use of POT.
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Affiliation(s)
- John Axley
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Juliet Blakeslee-Carter
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Zdenek Novak
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Graeme McFarland
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Emily L Spangler
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Benjamin J Pearce
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Mark A Patterson
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Marc A Passman
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Danielle C Sutzko
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL.
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Stewart LM, Passman MA, Spangler EL, Sutzko DC, Pearce BJ, McFarland GE, Patterson MA, Novak Z, Beck AW. Thoracofemoral bypass outcomes in the Vascular Quality Initiative. J Vasc Surg 2020; 73:1991-1997.e3. [PMID: 33340694 DOI: 10.1016/j.jvs.2020.11.039] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 11/17/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Thoracofemoral bypass (TFB) has been used infrequently but is an alternative for select patients with aortoiliac occlusive disease. Limited data are available in the reported data regarding TFB, with all studies small, single-center series. We aimed to describe the perioperative and long-term survival, patency, and rate of major perioperative complications after TFB in a large national registry. METHODS The Vascular Quality Initiative suprainguinal bypass module was used to identify patients who had undergone TFB for occlusive disease from 2009 to 2019. A descriptive analysis was performed to provide the rates of survival, patency, major complications, and freedom from major amputation in the perioperative period and at 1 year of follow-up. Major complications were compared by procedure indication, with categorical variables analyzed using χ2 tests and continuous variables using analysis of variance. Kaplan-Meier curve analysis was used to estimate survival at the 1- and 5-year follow-up intervals and freedom from major amputation at 1 year. RESULTS A total of 154 TFB procedures were identified. Of the 154 patients, 59 (38.3%) had undergone previous inflow bypass and 22 (14.2%) had undergone previous leg bypass. The procedure indications included claudication (n = 66; 42.9%), rest pain (n = 59; 38.3%), tissue loss (n = 19; 12.3%), and acute limb ischemia (n = 10; 6.5%). Major complications (eg, wound infection, respiratory, major stroke, new dialysis, cardiac, embolic, major amputation, occlusion) occurred in 31.2% of the cohort. When examined by indication, the acute limb ischemia and claudication cohorts had an increased rate of major complications (acute limb ischemia, 60.0%; claudication, 34.8%; critical limb ischemia, 24.4%; P = .05). The survival rate at 30 days was 95.5%, with a Kaplan-Meier estimated 1-year survival rate of 92.7% ± 2.2%. Primary patency at discharge from the index hospitalization was 92.9% and 89.0% at 1 year. Postoperative major amputation was required for 1 patient during the index hospitalization, for a Kaplan-Meier estimated freedom from major amputation at 1 year of 97.1% ± 2.2%. Two patients developed in-hospital bypass occlusion and three patients developed occlusion within 1 year, for an overall freedom from occlusion rate of 96.8% at 1 year. CONCLUSIONS TFB is associated with a high rate of perioperative major complications; however, the long-term survival and patency after TFB remained acceptable when performed for limb salvage. The high perioperative complication rates of TFB procedures performed for claudication suggest TFB should be used rarely in this population. These data can be used to counsel patients and aid in decision making before operative intervention.
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Affiliation(s)
- Luke M Stewart
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Marc A Passman
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Emily L Spangler
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Danielle C Sutzko
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Benjamin J Pearce
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Graeme E McFarland
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Mark A Patterson
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Zdenek Novak
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala.
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Axley J, Novak Z, Blakeslee-Carter J, McFarland GE, Spangler EL, Pearce BJ, Passman MA, Patterson MA, Sutzko DC, Beck AW. Long-Term Trends in Preoperative Cardiac Evaluation and Myocardial Infarction after Elective Vascular Procedures. Ann Vasc Surg 2020; 71:19-28. [PMID: 32976946 DOI: 10.1016/j.avsg.2020.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/04/2020] [Accepted: 09/04/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Vascular surgery has seen rapid increase in the use of less invasive endovascular therapies along with advancements in cardiac perioperative optimization in the past 2 decades. However, a recent American College of Surgeons National Surgical Quality Improvement Program database study found no improvement in postoperative myocardial infarction (POMI) over a 10-year period in high-risk procedures. The national Society for Vascular Surgery Vascular Quality Initiative (VQI) registry provides a more in-depth characterization of vascular surgery procedures. Here, we sought to evaluate long-term trends in POMI using VQI registry data for patients undergoing carotid endarterectomy (CEA), thoracic endovascular aortic repair (TEVAR), endovascular aortic repair (EVAR), open abdominal aortic aneurysm repair (oAAA), suprainguinal bypass (SIB), and infrainguinal bypass (IIB). METHODS A retrospective cohort study was performed using data on elective procedures from 2003 to 2017. Procedures were subdivided by date of operation into 3-year era consecutive groups for subanalysis (2003-05, 2006-08, 2009-11, 2012-14, and 2015-17). The incidence of POMI, preoperative risk factors (including individual patient VQI cardiac risk index (CRI)), and demographics were determined over time. RESULTS A total of 227,837 elective procedures were identified: CEA (n = 88,805, 39.0%), TEVAR (n = 7,494, 3.3%), EVAR (n = 34,376, 15.1%), oAAA (n = 7,568, 3.3%), SIB (n = 11,354, 5.0%), and IIB (n = 34,661, 15.2%). Across all procedures, the overall rate of POMI was 1.3%. POMI rates from 2003-05 to 2015-17 for CEA decreased from 0.9% to 0.7% (P = 0.21), EVAR from 2.0% to 0.7%, P = 0.003, oAAA from 6.8% to 5.1% (P = 0.12), and IIB from 3.8% to 2.4% (P = 0.003). SIB POMI decreased from 3.06% to 2.95%, P = 0.85 from 2009 to 17. While POMI after TEVAR increased from 2.40% to 2.56% from 2009 to 17, P = 0.91. Over these same time periods, only EVAR and IIB had a reduction in CRIs (P = 0.059 and P < 0.001, respectively). CEA, EVAR, IIB, and oAAA all showed a significant (P < 0.001) increase in preoperative statin use. CONCLUSIONS Except for TEVAR, the incidence of POMI has remained unchanged or decreased over the past 15 years in VQI registries. Patients undergoing IIB and EVAR demonstrated decreases in POMI rates that correspond with a reduction in CRIs and increased preoperative statin use. CEA and SIB had no significant change in POMI rates nor CRIs. The etiology of decreased POMI rate is uncertain, but increasing statin use, patient-specific factors, and patient selection for procedures may be important drivers of this improvement.
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Affiliation(s)
- John Axley
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Zdenek Novak
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Juliet Blakeslee-Carter
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Graeme E McFarland
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Emily L Spangler
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Benjamin J Pearce
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Marc A Passman
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Mark A Patterson
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Danielle C Sutzko
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL.
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Mullins CH, Novak Z, Axley JC, Sutzko DC, Spangler EL, Pearce BJ, Patterson MA, Passman MA, Haverstrock BD, Siracuse JJ, Beck AW, McFarland GE. Prevalence and Outcomes of Endovascular Infrapopliteal Interventions for Intermittent Claudication. Ann Vasc Surg 2020; 70:79-86. [PMID: 32866579 DOI: 10.1016/j.avsg.2020.08.097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 08/10/2020] [Accepted: 08/12/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although endovascular peripheral vascular interventions (PVI) are typically limited to vessels above the knee in intermittent claudication (IC), some patients have concomitant or isolated infrapopliteal disease with IC. The benefits and risks of undergoing tibial intervention remain unclear in IC patients. The purpose of this study is to evaluate the prevalence and outcomes of infrapopliteal PVI for IC. METHODS The Vascular Quality Initiative was queried for PVI procedures performed for IC between 2003 and 2018. Patients were divided into 3 groups: isolated femoropopliteal (FP), isolated infrapopliteal (IP), and combined above and below knee interventions (COM). Multivariable logistic regression models identified predictors of minor and major amputation, as well as freedom from reintervention. Kaplan-Meier plots estimate amputation-free survival. RESULTS We identified 34,944 PVI procedures for IC. There were 31,110 (89.0%) FP interventions, 1,045 (3.0%) IP interventions, and 2,789 (8.0%) COM interventions. Kaplan-Meier plots of amputation-free survival revealed that patients with any IP intervention had significantly higher rates of both minor and major amputation (log rank <0.001). Freedom from reintervention at 1-year was 89.2% for the FP group, 91.3% for the IP group, and 85.3% for the COM group (P < 0.0001). In multivariable analysis, factors associated with an increased risk of major amputation included isolated IP intervention (OR 6.47, 95% CI, 6.45-6.49; P < 0.0001), COM interventions (OR 2.32, 95% CI, 2.31-2.33; P < 0.0001), dialysis dependence (OR 3.34, 95% CI, 3.33-3.35; P < 0.0001), CHF (OR 1.86, 95% CI, 1.85-1.86; P = 0.021) and, nonwhite race (OR 1.64, 95% CI, 1.63-1.64; P = 0.013). CONCLUSIONS PVI in the infrapopliteal vessels for IC is associated with higher amputation rates. This observation may suggest the need for more careful patient selection when performing PVI in patients with IC where disease extends into the infrapopliteal level.
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Affiliation(s)
- C Haddon Mullins
- School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Zdenek Novak
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - John C Axley
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Danielle C Sutzko
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Emily L Spangler
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Benjamin J Pearce
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Mark A Patterson
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Marc A Passman
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Brent D Haverstrock
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston University, Boston, MA
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Graeme E McFarland
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL.
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Witcher A, Axley J, Novak Z, Laygo-Prickett M, Guthrie M, Xhaja A, Chu DI, Brokus SD, Spangler EL, Passman MA, McGinigle KL, Pearce BJ, Schlitz R, Short RT, Simmons JW, Cross RC, McFarland GE, Beck AW. Implementation of an enhanced recovery program for lower extremity bypass. J Vasc Surg 2020; 73:554-563. [PMID: 32682069 DOI: 10.1016/j.jvs.2020.06.106] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 11/04/2019] [Accepted: 06/12/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Enhanced recovery programs (ERPs) have gained wide acceptance across multiple surgical disciplines to improve postoperative outcomes and to decrease hospital length of stay (LOS). However, there is limited information in the existing literature for vascular patients. We describe the implementation and early results of an ERP and barriers to its implementation for lower extremity bypass surgery. Our intention is to provide a framework to assist with implementation of similar ERPs. METHODS Using the plan, do, check, adjust methodology, a multidisciplinary team was assembled. A database was used to collect information on patient-, procedure-, and ERP-specific metrics. We then retrospectively analyzed patients' demographics and outcomes. RESULTS During 9 months, an ERP (n = 57) was successfully developed and implemented spanning preoperative, intraoperative, and postoperative phases. ERP and non-ERP patient demographics were statistically similar. Early successes include 97% use of fascia iliaca block and multimodal analgesia administration in 81%. Barriers included only 47% of patients achieving day of surgery mobilization and 19% receiving celecoxib preoperatively. ERP patients had decreased total and postoperative LOS compared with non-ERP patients (n = 190) with a mean (standard deviation) total LOS of 8.32 (8.4) days vs 11.14 (10.1) days (P = .056) and postoperative LOS of 6.12 (6.02) days vs 7.98 (7.52) days (P = .089). There was significant decrease in observed to expected postoperative LOS (1.28 [0.66] vs 1.82 [1.38]; P = .005). Variable and total costs for ERP patients were significantly reduced ($13,208 [$9930] vs $18,777 [$19,118; P < .01] and $29,865 [$22,110] vs $40,328 [$37,820; P = .01], respectively). CONCLUSIONS Successful implementation of ERP for lower extremity bypass carries notable challenges but can have a significant impact on practice patterns. Further adjustment of our current protocol is anticipated, but early results are promising. Implementation of a vascular surgery ERP reduced variable and total costs and decreased total and postoperative LOS. We believe this protocol can easily be implemented at other institutions using the pathway outlined.
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Affiliation(s)
- Adam Witcher
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Ala
| | - John Axley
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Zdenek Novak
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Maria Laygo-Prickett
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Meredith Guthrie
- UAB Clinical Effectiveness, University of Alabama at Birmingham, Birmingham, Ala
| | - Anisa Xhaja
- UAB Clinical Effectiveness, University of Alabama at Birmingham, Birmingham, Ala
| | - Daniel I Chu
- Division of Gastrointestinal Surgery, Section of Colorectal Surgery, University of Alabama at Birmingham, Birmingham, Ala
| | - S Danielle Brokus
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Emily L Spangler
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Marc A Passman
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | | | - Benjamin J Pearce
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Ryne Schlitz
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Ala
| | - Roland T Short
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Ala
| | - Jeffrey W Simmons
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Ala
| | - Richard C Cross
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Ala
| | - Graeme E McFarland
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala.
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Torrent DJ, McFarland GE, Wang G, Malas M, Pearce BJ, Aucoin V, Neal D, Spangler EL, Novak Z, Scali ST, Beck AW. Timing of thoracic endovascular aortic repair for uncomplicated acute type B aortic dissection and the association with complications. J Vasc Surg 2020; 73:826-835. [PMID: 32623110 DOI: 10.1016/j.jvs.2020.05.073] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [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: 03/02/2020] [Accepted: 05/29/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Previous publications have clearly established a correlation between timing of thoracic endovascular aortic repair (TEVAR) and complications after treatment of complicated acute type B aortic dissection (ATBAD). However, the temporal association of TEVAR with morbidity after uncomplicated presentations is poorly understood and has not previously been examined using real-world national data. Therefore, the objective of this analysis was to determine whether TEVAR timing of uncomplicated ATBAD (UATBAD) is associated with postoperative complications. METHODS The Vascular Quality Initiative TEVAR and complex endovascular aneurysm repair registry was analyzed from 2010 to 2019. Procedures performed for non-dissection-related disease as well as for ATBAD with malperfusion or rupture were excluded. Because of inherent differences between timing cohorts, propensity score matching was performed to ensure like comparisons. Univariate and multivariable analysis after matching was used to determine differences between timing groups (symptom onset to TEVAR: acute, 1-14 days; subacute, 15-90 days) for postoperative mortality, in-hospital complications, and reintervention. RESULTS A total of 688 cases meeting inclusion criteria were identified. After matching 187 patients in each of the 1- to 14-day and 15- to 90-day treatment groups, there were no statistically significant differences between groups. On univariate analysis, the 1- to 14-day treatment group had a higher proportion of cases requiring reintervention within 30 days (15.3%) compared with UATBAD patients undergoing TEVAR within 15 to 90 days (5.2%; P = .02). There was also a difference (P = .007) at 1 year, with 33.8% of the 1- to 14-day UATBAD patients undergoing reintervention compared with 14.5% for the 15- to 90-day group. There were no statistically significant differences on multivariable analysis for long-term survival, complications, or long-term reintervention. There was a trend toward significance (P = .08) with the 1- to 14-day group having 2.3 times the odds of requiring an in-hospital reintervention compared with the 15- to 90-day group. CONCLUSIONS Timing of TEVAR for UATBAD does not appear to predict mortality or postoperative complications. However, there is a strong association between repair within 1 to 14 days and higher risk of reintervention. This may in part be related to the 1- to 14-day group's representing an inherently higher anatomic or physiologic risk population that cannot be entirely accounted for with propensity analysis. The role of optimal timing to intervention should be incorporated into future study design of TEVAR trials for UATBAD.
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Affiliation(s)
- Daniel J Torrent
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Graeme E McFarland
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Grace Wang
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Mahmoud Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, Calif
| | - Benjamin J Pearce
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Victoria Aucoin
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Dan Neal
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| | - Emily L Spangler
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Zdenek Novak
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala.
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Novak Z, Zaky A, Spangler EL, McFarland GE, Beck AW. Prevalence and Prognosis of Acute Kidney Injury After Aortic Aneurysm Repair in the Vascular Quality Initiative Data. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.04.215] [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: 11/15/2022]
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Stewart LM, Passman MA, Spangler EL, Sutzko DC, McFarland GE, Pearce BJ, Novak Z, Beck AW. Carotid Endarterectomy With Shunt for Preoperative or Intraoperative Indication Is Associated With Increased Rate of Stroke. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.04.205] [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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Stewart LM, Passman MA, Spangler EL, Sutzko DC, McFarland GE, Pearce BJ, Novak Z, Beck AW. Outcomes of Thoracofemoral Bypass in the Vascular Quality Initiative. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.04.340] [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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Spangler EL, Aucoin VJ, Novak Z, McFarland GE, Beck AW. Achieving a Normal Perfusion State From Peroneal Bypass Impacts Limb Outcomes for Patients With Tissue Loss But Not Rest Pain. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.04.262] [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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Stewart LM, Spangler EL, Sutzko DC, McFarland GE, Passman MA, Pearce BJ, Novak Z, Beck AW. Carotid Endarterectomy With Concomitant Distal Endovascular Intervention Is Associated With Increased Rates of Stroke and Death. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.04.196] [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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Stewart L, Pearce BJ, Beck AW, Spangler EL. Examination of race and infrainguinal bypass conduit use in the Society for Vascular Surgery Vascular Quality Initiative. Vascular 2020; 28:739-746. [PMID: 32449478 DOI: 10.1177/1708538120927704] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Vein conduit is known to have better patency than prosthetic for infrainguinal bypass. Here we explore if racial disparities exist in infrainguinal bypass vein conduit use amid preoperative patient and systemic factors. METHODS Retrospective Society for Vascular Surgery Vascular Quality Initiative data for 23,959 infrainguinal bypasses between 2003 and 2017 for occlusive disease were analyzed. For homogeneity, only infrainguinal bypasses originating from the common femoral artery were included. Demographics of patients receiving vein vs prosthetic were compared and logistic regression analyses were performed with race and preoperative factors to evaluate for predictors of vein conduit use. RESULTS Adjusted regression models demonstrated black patients were 76% as likely (p < .001) and Hispanic patients 79% as likely (p = .003) to have vein conduit compared to white patients. Factors positively correlating with vein use included vein mapping, more distal bypass target, tissue loss or acute ischemia bypass indications, commercial insurance, and weight. Factors against vein use included advanced age, female gender, ASA class 4, urgent procedure, preoperative mobility limitation, prior CABG or leg bypass, prior smoking, preoperative anticoagulation, and a bypass performed in the Southern US or before 2012. While black and Hispanic patients were less likely to receive vein, they were vein mapped at similar or higher rates than other groups. CONCLUSION Racial disparities exist in conduit use for infrainguinal bypass, with black and Hispanic patients less likely to receive vein bypasses. However, the contribution of race to conduit selection is small in adjusted and unadjusted models. Overall, pre-operative variables in the Vascular Quality Initiative poorly predicted vein conduit use for infrainguinal bypass.
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Affiliation(s)
- Luke Stewart
- Division of Vascular Surgery and Endovascular Therapy, 9968University of Alabama at Birmingham, AL, USA
| | - Benjamin J Pearce
- Division of Vascular Surgery and Endovascular Therapy, 9968University of Alabama at Birmingham, AL, USA
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, 9968University of Alabama at Birmingham, AL, USA
| | - Emily L Spangler
- Division of Vascular Surgery and Endovascular Therapy, 9968University of Alabama at Birmingham, AL, USA
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Columbo JA, Kang R, Spangler EL, Newhall K, Brooke BS, Dosluoglu H, Lee ES, Raffetto JD, Henke PK, Tang GS, Mureebe L, Kougias P, Johanning J, Arya S, Scali ST, Stone DH, Suckow BD, Orion K, Halpern V, O'Connell J, Inhat D, Nelson P, Tzeng E, Zhou W, Barry M, Sirovich B, Goodney PP. Design of the PReferences for Open Versus Endovascular Repair of Abdominal Aortic Aneurysm (PROVE-AAA) Trial. Ann Vasc Surg 2020; 65:247-253. [PMID: 31075459 PMCID: PMC10740366 DOI: 10.1016/j.avsg.2019.02.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/25/2019] [Accepted: 02/21/2019] [Indexed: 10/26/2022]
Abstract
For patients with abdominal aortic aneurysm (AAA), randomized trials have found endovascular AAA repair (EVAR) is associated with lower perioperative morbidity and mortality than open surgical repair (OSR). However, OSR has fewer long-term aneurysm-related complications, such as endoleak or late rupture. Patients treated with EVAR and OSR have similar survival rates within two years after surgery, and OSR does not require intensive surveillance. Few have examined if patient preferences are aligned with the type of treatment they receive for their AAA. Although many assume that patients may universally prefer the less-invasive nature of EVAR, our preliminary work suggests that patients who value the lower risk of late complications may prefer OSR. In this study, called The PReferences for Open Versus Endovascular Repair of Abdominal Aortic Aneurysm (PROVE-AAA) trial, we describe a cluster-randomized trial to test if a decision aid can better align patients' preferences and their treatment type for AAA. Patients enrolled in the study are candidates for either endovascular or open repair and are followed up at VA hospitals by vascular surgery teams who regularly perform both types of repair. In Aim 1, we will determine patients' preferences for endovascular or open repair and identify domains associated with each repair type. In Aim 2, we will assess alignment between patients' preferences and the repair type elected and then compare the impact of a decision aid on this alignment between the intervention and control groups. This study will help us to accomplish two goals. First, we will better understand the factors that affect patient preference when choosing between EVAR and OSR. Second, we will better understand if a decision aid can help patients be more likely to receive the treatment strategy they prefer for their AAA. Study enrollment began on June 1, 2017. Between June 1, 2017 and November 1, 2018, we have enrolled 178 of a total goal of 240 veterans from 20 VA medical centers and their vascular surgery teams across the country. We anticipate completing enrollment in PROVE-AAA in June 2019, and study analyses will be performed thereafter.
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Affiliation(s)
- Jesse A Columbo
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, VT
| | - Ravinder Kang
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, VT
| | - Emily L Spangler
- Department of Vascular Surgery, Birmingham VA Medical Center, Birmingham, AL
| | - Karina Newhall
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, VT
| | - Benjamin S Brooke
- Department of Vascular Surgery, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT
| | - Hasan Dosluoglu
- Department of Vascular Surgery, Buffalo VA Medical Center, Buffalo, NY
| | - Eugene S Lee
- Department of Vascular Surgery, Sacramento VA Medical Center, Mather, CA
| | - Joseph D Raffetto
- Department of Vascular Surgery, West Roxbury VA Medical Center, West Roxbury, MA
| | - Peter K Henke
- Department of Vascular Surgery, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Gale S Tang
- Department of Vascular Surgery, VA Puget Sound Health Care System, Seattle, WA
| | - Leila Mureebe
- Department of Vascular Surgery, Durham VA Health Care System, Durham, NC
| | - Panagoitis Kougias
- Department of Vascular Surgery, Michael E. DeBakey VA Medical Center, Houston, TX
| | - Jason Johanning
- Department of Vascular Surgery, Omaha VA Medical Center-VA Nebraska-Western Iowa HCS, Omaha, NE
| | - Shipra Arya
- Department of Vascular Surgery, Atlanta VA Medical Center, Decatur, GA
| | - Salvatore T Scali
- Department of Vascular Surgery, Malcom Randall VA Medical Center, Gainesville, FL
| | - David H Stone
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, VT
| | - Bjoern D Suckow
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, VT
| | - Kristine Orion
- Department of Vascular Surgery, West Haven VA Medical Center, West Haven, CT
| | - Vivienne Halpern
- Department of Vascular Surgery, Phoenix VA Health Care System, Phoenix, AZ
| | - Jessica O'Connell
- Department of Vascular Surgery, West Los Angeles Medical Center, Los Angeles, CA
| | - Daniel Inhat
- Department of Vascular Surgery, Minneapolis VA Health Care System, Minneapolis, MN
| | - Peter Nelson
- Department of Vascular Surgery, James A. Haley Veterans' Hospital, Tampa, FL
| | - Edith Tzeng
- Department of Vascular Surgery, VA Pittsburg Healthcare System, Pittsburg, PA
| | - Wei Zhou
- Department of Vascular Surgery, Southern Arizona VA Health Care System, Tucson, AZ
| | - Michael Barry
- Massachusetts General Hospital Center for Shared Decision Making, Massachusetts General Hospital, Boston, MA
| | - Brenda Sirovich
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, VT
| | - Philip P Goodney
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, VT.
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Mullins CH, Novak Z, Axley JC, Sutzko DC, Spangler EL, Pearce BJ, Patterson MA, Passman MA, Beck AW, McFarland GE. Prevalence and Outcomes Of Endovascular Infrapopliteal Interventions For Intermittent Claudication. Ann Vasc Surg 2020. [DOI: 10.1016/j.avsg.2020.01.029] [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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Anderson PB, Wanken ZJ, Perri JL, Columbo JA, Kang R, Spangler EL, Newhall K, Brooke BS, Dosluoglu H, Lee ES, Raffetto JD, Henke PK, Tang GL, Mureebe L, Kougias P, Johanning J, Arya S, Scali ST, Stone DH, Suckow BD, Orion K, Halpern V, O'Connell J, Inhat D, Nelson P, Tzeng E, Zhou W, Barry M, Sirovich B, Goodney PP. Patient information sources when facing repair of abdominal aortic aneurysm. J Vasc Surg 2020; 71:497-504. [PMID: 31353272 PMCID: PMC10767985 DOI: 10.1016/j.jvs.2019.04.460] [Citation(s) in RCA: 4] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 04/04/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Shared medical decision making is most important when there are competing options for repair such as in treatment of abdominal aortic aneurysm (AAA). We sought to understand the sources of patients' pre-existing knowledge about AAA to better inform treating physicians about patients' needs for preoperative counseling. METHODS We performed a multicenter survey of patients facing AAA repair at 20 Veterans Affairs hospitals across the United States as part of the Preferences for Open Versus Endovascular Repair of AAA study. A validated survey instrument was administered to examine the sources of information available and commonly used by patients to learn about their repair options. The survey was administered by study personnel before the patient had any interaction with the vascular surgeon because survey data were collected before the vascular clinic visit. RESULTS Preliminary analysis of data from 99 patients showed that our cohort was primarily male (99%) and elderly (mean age 73 years). Patients commonly had a history of hypertension (86%), prior myocardial infarction (32%), diabetes (32%), and were overweight (58%). Patients arrived at their surgeon's office appointment with limited information. A majority of patients (52%) reported that they had not talked to their primary care physician at all about their options for AAA repair, and one-half (50%) reported that their view of the different surgical options had not been influenced by anyone. Slightly less than one-half of patients reported that they did not receive any information about open surgical aneurysm repair and endovascular aortic aneurysm repair (41% and 37%, respectively). Few patients indicated using the internet as their main source of information about open surgical aneurysm repair and endovascular aortic aneurysm repair (10% and 11%, respectively). CONCLUSIONS Patients are commonly referred for AAA repair having little to no information regarding AAA pathology or repair options. Fewer than one in five patients searched the internet or had accessed other sources of information on their own. Most vascular surgeons should assume that patients will present to their first vascular surgery appointment with minimal understanding of the treatment options available to them.
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Affiliation(s)
- Peter B Anderson
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vt; Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Zachary J Wanken
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vt
| | - Jennifer L Perri
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vt
| | - Jesse A Columbo
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vt
| | - Ravinder Kang
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vt
| | | | - Karina Newhall
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vt
| | | | | | | | | | | | | | | | | | | | | | | | - David H Stone
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vt
| | - Bjoern D Suckow
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vt
| | | | | | | | | | | | | | | | - Michael Barry
- Massachusetts General Hospital Center for Shared Decision Making, Boston, Mass
| | - Brenda Sirovich
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vt
| | - Philip P Goodney
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vt.
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Axley JC, McFarland GE, Novak Z, Scali ST, Patterson MA, Pearce BJ, Spangler EL, Passman MA, Beck AW. Factors Associated with Amputation after Peripheral Vascular Intervention for Intermittent Claudication. Ann Vasc Surg 2020; 62:133-141. [DOI: 10.1016/j.avsg.2019.08.073] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 08/15/2019] [Accepted: 08/22/2019] [Indexed: 11/27/2022]
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Wilson R, Novak Z, Spangler EL, McFarland G, Passman MA, Patterson MA, Beck AW. Assessing the Relationship Between Post-Operative Myocardial Infarction, Preoperative Hemoglobin and Perioperative Blood Usage. Ann Vasc Surg 2019. [DOI: 10.1016/j.avsg.2019.10.028] [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: 11/16/2022]
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Novak Z, Moore JL, Axley JC, Spangler EL, Pearce BJ, McFarland GE, Patterson MA, Passman MA, Beck AW. The Impact of Achieving a Normal ABI on Patency and Limb Salvage After Peripheral Vascular Intervention. Ann Vasc Surg 2019. [DOI: 10.1016/j.avsg.2018.12.007] [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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Moore JL, Novak Z, McFarland GE, Patterson MA, Passman MA, Spangler EL, Pearce BJ, Beck AW. Effects of Statin and Antiplatelet Therapy Noncompliance and Intolerance on Patient Outcomes Following Vascular Surgery. J Vasc Surg 2019. [DOI: 10.1016/j.jvs.2018.10.033] [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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Torrent D, Wang GJ, Malas MB, Pearce BJ, Spangler EL, Novak Z, Beck AW. PC046. Timing of Thoracic Endovascular Aortic Repair for Uncomplicated Acute Type B Aortic Dissection and Association With Complications. J Vasc Surg 2018. [DOI: 10.1016/j.jvs.2018.03.268] [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: 10/16/2022]
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Novak Z, Jackson W, Spangler EL, Pearce BJ, Passman MA, Patterson MA, Beck AW. PC158. The Impact of Achieving a Normal Ankle-Brachial Index on Patency and Limb Salvage After Lower Extremity Bypass. J Vasc Surg 2018. [DOI: 10.1016/j.jvs.2018.03.322] [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: 10/16/2022]
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Carlson SJ, Suckow BD, Stone DH, Goodney PP, Powell RJ, Stableford J, Spangler EL, Nolan B. IP211. Recanalization of Long Chronic Total Occlusions Through Retrograde Pedal Access in High-Risk Patients With Critical Limb Ischemia. J Vasc Surg 2018. [DOI: 10.1016/j.jvs.2018.03.192] [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: 10/16/2022]
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Goodney PP, Henke P, Nelson P, Tang G, Spangler EL, Suckow BD, Stone DH, Scali ST. PC186. Are They a Clean Slate? Patient Knowledge and Information Sources When Facing Repair of Abdominal Aortic Aneurysm. J Vasc Surg 2018. [DOI: 10.1016/j.jvs.2018.03.337] [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: 11/16/2022]
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Spangler EL, Brooke BS, Beck AW, Hoel A, Farber A, Goodney PP. Design and initial enrollment in the Vascular Physicians Offer and Report (VAPOR) trial. J Vasc Surg 2016; 63:1121-5.e2. [PMID: 27016862 DOI: 10.1016/j.jvs.2015.12.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 12/15/2015] [Indexed: 10/22/2022]
Abstract
Although patient smoking cessation is a key priority for vascular surgeons, significant variation exists in the manner in which vascular surgeons address this key process of care. We describe a multicenter, cluster-randomized trial that compares a standardized, brief smoking cessation intervention to usual care for patients facing vascular surgery or endovascular interventions. Eight centers were randomized to provide usual care for smoking cessation or a standardized protocol consisting of (1) physician "very brief advice" to stop smoking, (2) offering nicotine replacement therapy, and (3) referral to a phone-based counseling service. Trial enrollment began on September 1, 2014. At present, 142 patients had been enrolled in the trial across eight sites. Compared with patients in the usual care arm, patients enrolled in the smoking cessation intervention arm were more likely to receive physician advice (98% vs 77%), a prescription for nicotine replacement therapy (77% vs 13%), and quitline referral (93% vs 33%; all P < .001). Although final results of the intervention on smoking cessation rates are still forthcoming, surgeon delivery of a brief, evidence-based smoking cessation intervention appears feasible for patients facing invasive vascular care.
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Affiliation(s)
- Emily L Spangler
- Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Benjamin S Brooke
- Section of Vascular Surgery, The University of Utah School of Medicine, Salt Lake City, Utah
| | - Adam W Beck
- Section of Vascular Surgery, the University of Florida, Gainesville, Fla
| | - Andrew Hoel
- Division of Vascular Surgery, The Northwestern Memorial Hospital, Chicago, Ill
| | - Alik Farber
- Division of Vascular Surgery, Boston Medical Center, Boston, Mass
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
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DeCarlo CS, Spangler EL, Stableford JA. A Case of Endofibrosis Presenting with Embolic Symptoms in a 43-Year-Old Cyclist. Ann Vasc Surg 2016; 36:292.e5-292.e8. [PMID: 27423721 DOI: 10.1016/j.avsg.2016.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 02/26/2016] [Accepted: 03/11/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Endofibrosis is a rare clinical entity that usually manifests as claudication in cyclists and other endurance athletes. We report a case of a 43-year-old cyclist presenting with pain and cyanosis of his toes due to an embolism to his left anterior tibial artery. The source of the embolus was found to be an ulcerated, endofibrotic plaque in his left common femoral artery. METHODS We performed an extensive literature search using the PubMed database and identified 60 results on endofibrosis. Eight articles described thrombosis relating to endofibrosis. None of the articles described an embolic phenomenon relating to endofibrosis. The following search terms were used: endofibrosis, embolic, emboli, embolism, "distal occlusion," cyanosis, thrombosis, and thrombus. RESULTS The patient is a 43-year-old male cyclist who presented with pain and cyanosis of his second and third toes on his left foot for 1 week. The affected toes had a dark-purple discoloration involving the tissue overlying the distal phalanges. Computed tomography angiography showed an abrupt occlusion of the left anterior tibial artery in the mid-calf with a non-calcified plaque in the left common femoral artery. There were no other signs of arterial disease. He underwent left common femoral endofibrosectomy with patch angioplasty that revealed an ulcerated endofibrotic plaque with mural thrombus. CONCLUSIONS This case demonstrates an unusual presentation of a rare clinical entity. While there have been previous reports of thrombosis associated with endofibrosis, to our knowledge this is the first reported case of endofibrosis presenting with embolic symptoms.
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Affiliation(s)
- Charles S DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA.
| | - Emily L Spangler
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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