1
|
Brahmandam A, Huttler J, Bellamkonda K, Setia O, Cardella JA, Stewart W, Guzman RJ, Ochoa Chaar CI. The radiographic relationship of the femoral head, inguinal ligament, and common femoral artery bifurcation for optimal vascular access. JVS Vasc Sci 2024; 5:100196. [PMID: 38633882 PMCID: PMC11022081 DOI: 10.1016/j.jvssci.2024.100196] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 02/15/2024] [Indexed: 04/19/2024] Open
Abstract
Objective Common femoral artery (CFA) access is commonly used for endovascular interventions. Access site complications contribute to significant morbidity and mortality. This study characterizes the radiographic variability in the relationship of the femoral head, the inguinal ligament, and the CFA bifurcation, to identify the zone of optimal CFA access. Methods Human cadaver dissection of the inguinal ligament and CFA bifurcation was performed. The inguinal ligament and CFA bifurcation were marked with radiopaque pins and plain anteroposterior radiographs were obtained. Radiographic measurements of the femoral head length, the distance of the top of the femoral head to the inguinal ligament, and to the CFA bifurcation were obtained. Results were reported as percentage of femoral head covered by the inguinal ligament or the CFA bifurcation relative to the top of the femoral head. A heatmap was derived to determine a safe access zone between the inguinal ligament and CFA bifurcation. Results Forty-five groin dissections (male, n = 20; female, n = 25) were performed in 26 cadavers. The mean overlap of the inguinal ligament with the femoral head was 11.2 mm (range, -19.4 to 27.4 mm). There were no age (<85 vs ≥85 years) or sex-related differences. In 82.6% of cadaveric CFA exposures, there was overlap between the inguinal ligament and femoral head (mean, 27.7%; range, -85.7% to 70.1%), with 55.6% having a >25% overlap. In 11.1%, there was an overlap between the lower one-third of the femoral head and the CFA bifurcation. Cumulatively, heatmap analysis depicted a >80% likelihood of avoiding the inguinal ligament and CFA bifurcation below the midpoint of the femoral head. Conclusions Significant variability exists in the relationship between the inguinal ligament, CFA bifurcation, and the femoral head, suggesting the lack of a consistently safe access zone. The safest access zone in >80% of patients lies below the radiographic midpoint of the femoral head and the inferior aspect of the femoral head.
Collapse
Affiliation(s)
- Anand Brahmandam
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Kirthi Bellamkonda
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Ocean Setia
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| | - Jonathan A. Cardella
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| | - William Stewart
- Section of Anatomy, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Raul J. Guzman
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| |
Collapse
|
2
|
Alameddine D, Damara FA, Pinto Rodriguez P, Huttler J, Slade MD, Arhuidese I, Aboian E, Ochoa Chaar CI. The Use and Impact of Cilostazol on Patients Undergoing Endovascular Peripheral Interventions. Ann Vasc Surg 2024:S0890-5096(24)00057-8. [PMID: 38387798 DOI: 10.1016/j.avsg.2023.12.071] [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: 10/13/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 02/24/2024]
Abstract
OBJECTIVES Cilostazol is used for the treatment of intermittent claudication. The impact of cilostazol on the outcomes of peripheral vascular interventions (PVI) remains controversial. This study assesses the use and impact of cilostazol on patients undergoing PVI for peripheral arterial disease (PAD). METHODS The Vascular Quality Initiative (VQI) database files for PVI were reviewed. Patients with PAD who underwent PVI for CLTI or claudication were included and divided based on the use of cilostazol preoperatively. After propensity matching for patient demographics and comorbidities, the short-term and long-term outcomes of the two groups (preoperative cilostazol use versus no pre-operative cilostazol use) were compared. The Kaplan-Meier method was used to determine outcomes. RESULTS A total of 245,309 patients underwent PVI procedures and 6.6% (N=16,366) were on cilostazol prior to intervention. Patients that received cilostazol were more likely to be male (62% vs 60%; P < .001), White (77% vs 75%; P < .001), and smokers (83% vs 77%; P < .001). They were less likely to have diabetes mellitus (50% vs 56%; P < .001) and congestive heart failure (14% vs 23%; P < .001). Patient on cilostazol were more likely to be treated for claudication (63% vs 40%, P < .001), undergo prior lower extremity revascularization (55% vs 51%, P<.001) and less likely to have undergone prior minor and major amputation (10% vs 19%; P < .001) compared to patients who did not receive cilostazol. After 3:1 propensity matching, there were 50,265 patients included in the analysis with no differences in baseline characteristics. Patients on cilostazol were less likely to develop renal complications and more likely to be discharged home. Patients on cilostazol had significantly lower rates of long-term mortality (11.5% vs 13.4%, P <.001 and major amputation (4.0% vs 4.7%, P=0.022). However, there were no significant differences in rates of reintervention, major adverse limb events, or patency after PVI. Amputation-free survival rates were significantly higher for patients on cilostazol, after four years of follow-up (89% vs 87%, P=0.03). CONCLUSION Cilostazol is underutilized in the VQI database and seems to be associated with improved amputation-free survival. Cilostazol therapy should be considered in all patients with PAD who can tolerate it prior to PVI.
Collapse
Affiliation(s)
- Dana Alameddine
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT.
| | - Fachreza Aryo Damara
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| | - Paula Pinto Rodriguez
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| | | | - Martin D Slade
- Department of Internal Medicine, Section of Occupational and Environmental Medicine, Yale New Haven Hospital, Yale University School of Medicine, New Haven, CT
| | - Isibor Arhuidese
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| | - Edouard Aboian
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| |
Collapse
|
3
|
Jamil Y, Huttler J, Alameddine D, Wu Z, Zhuo H, Mena-Hurtado C, Velazquez EJ, Guzman RJ, Ochoa Chaar CI. The Impact of Ejection Fraction on Major Adverse Limb Events after Lower Extremity Revascularization. Ann Vasc Surg 2024; 98:210-219. [PMID: 37802138 DOI: 10.1016/j.avsg.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/31/2023] [Accepted: 08/04/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Peripheral arterial disease (PAD) is commonly associated with coronary artery disease, and echocardiography is frequently performed before lower extremity revascularization (LER). However, the incidence of various echocardiographic findings in patients with PAD and their impact on the outcomes of LER has not been well studied. Reduced ejection fraction (EF) ≤ 40% is associated with increased major adverse limb events (MALE) after LER. METHODS The electronic medical records of patients undergoing LER in a single center were reviewed. Patients were divided based on the presence or absence of reduced EF. Patient, transthoracic echocardiogram, procedural characteristics, and outcomes were compared between the 2 groups. RESULTS A total of 1,114 patients (N = 131, 11.8% with reduced EF) underwent LER between 2013 and 2019. Patients with reduced EF were more likely to be male and have a history of coronary artery disease and heart failure. Furthermore, they were more likely to have diastolic dysfunction with moderate to severe mitral and tricuspid valve regurgitation. Patients with reduced EF were more likely to undergo LER for chronic limb-threatening ischemia, and to be treated with endovascular procedures. Perioperatively, patients with reduced EF were more likely to develop myocardial infarction. Lastly, the 2 groups had no difference in overall MALE or major amputation. However, on Kaplan-Meier curves, MALE-free survival was significantly lower for patients with reduced EF. Regression analysis demonstrated that indication and not EF was associated with MALE and MALE-free survival. CONCLUSIONS Reduced EF is associated with decreased MALE-free survival for patients with PAD undergoing LER.
Collapse
Affiliation(s)
- Yasser Jamil
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT.
| | | | - Dana Alameddine
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Zhen Wu
- Yale School of Public Health, New Haven, CT
| | | | - Carlos Mena-Hurtado
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Raul J Guzman
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT
| |
Collapse
|
4
|
Jamil Y, Huttler J, Ochoa Chaar CI. Endovascular Recanalization and Stent Graft Placement for a Chronically Occluded Prosthetic Graft to Treat Critical Limb Ischemia. J Vasc Interv Radiol 2024; 35:143-145. [PMID: 37704039 DOI: 10.1016/j.jvir.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/28/2023] [Accepted: 09/04/2023] [Indexed: 09/15/2023] Open
Affiliation(s)
- Yasser Jamil
- Department of Internal Medicine, Yale School of Medicine, 333 Cedar St, New Haven, CT 06510.
| | | | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT
| |
Collapse
|
5
|
Bardia A, Michel G, Farela A, Fisher C, Mori M, Huttler J, Lang AL, Geirsson A, Schonberger RB. Association of adherence to individual components of Society of Thoracic Surgeons cardiac surgery antibiotic guidelines and postoperative infections. J Thorac Cardiovasc Surg 2023:S0022-5223(23)00325-2. [PMID: 37075942 PMCID: PMC10579454 DOI: 10.1016/j.jtcvs.2023.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 03/02/2023] [Accepted: 03/25/2023] [Indexed: 04/21/2023]
Abstract
OBJECTIVES The study objectives were to measure the association among the 4 components of Society of Thoracic Surgeons antibiotic guidelines and postoperative complications in a cohort of patients undergoing valve or coronary artery bypass grafting requiring cardiopulmonary bypass. METHODS In this retrospective observational study, adult patients undergoing coronary revascularization or valvular surgery who received a Surgical Care Improvement Project-compliant antibiotic from January 1, 2016, to April 1, 2021, at a single, tertiary care hospital were included. The primary exposures were adherence to the 4 individual components of Society of Thoracic Surgeons antibiotic best practice guidelines. The association of each component and a combined metric was tested in its association with the primary outcome of postoperative infection as determined by Society of Thoracic Surgeons data abstractors, controlling for several known confounders. RESULTS Of the 2829 included patients, 1084 (38.3%) received care that was nonadherent to at least 1 aspect of Society of Thoracic Surgeons antibiotic guidelines. The incidence of nonadherence to the 4 individual components was 223 (7.9%) for timing of first dose, 639 (22.6%) for antibiotic choice, 164 (5.8%) for weight-based dose adjustment, and 192 (6.8%) for intraoperative redosing. In adjusted analyses, failure to adhere to first dose timing guidelines was directly associated with Society of Thoracic Surgeons-adjudicated postoperative infection (odds ratio, 1.9; 95% confidence interval, 1.1-3.3; P = .02). Failure of weight-adjusted dosing was associated with both postoperative sepsis (odds ratio, 6.9; 95% confidence interval, 2.5-8.5; P < .01) and 30-day mortality (odds ratio, 4.3; 95% confidence interval, 1.7-11.4; P < .01). No other significant associations among the 4 Society of Thoracic Surgeons metrics individually or as a combination were observed with postoperative infection, sepsis, or 30-day mortality. CONCLUSIONS Nonadherence to Society of Thoracic Surgeons antibiotic best practices is common. Failure of antibiotic timing and weight-adjusted dosing is associated with odds of postoperative infection, sepsis, and mortality after cardiac surgery.
Collapse
Affiliation(s)
- Amit Bardia
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Mass
| | - George Michel
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Conn
| | - Andrea Farela
- Department of Anesthesiology, Yale School of Medicine, New Haven, Conn
| | - Clark Fisher
- Department of Anesthesiology, Yale School of Medicine, New Haven, Conn
| | - Makoto Mori
- Division of Cardiothoracic Surgery, Yale School of Medicine, New Haven, Conn
| | - Joshua Huttler
- Department of Anesthesiology, Yale School of Medicine, New Haven, Conn
| | - Angela Lu Lang
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Mass
| | - Arnar Geirsson
- Division of Cardiothoracic Surgery, Yale School of Medicine, New Haven, Conn
| | | |
Collapse
|
6
|
Satam KK, Aboian E, Huttler J, Zhuo H, Zhang Y, Tonnessen BH, Cardella JA, Guzman RJ, Ochoa Chaar CI. Eligibility of Patients With Chronic Limb-Threatening Ischemia for Deep Venous Arterialization Before Amputation. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.262] [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: 10/20/2022]
|
7
|
Mamillapalli R, Toffoloni N, Huttler J, Zhang Y, Chen P, Stachenfeld N, Taylor HS. Endometriosis increased atherosclerosis in a murine model. Fertil Steril 2019. [DOI: 10.1016/j.fertnstert.2019.07.944] [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]
|