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Raulli SJ, Gomes VC, Parodi FE, Vasan P, Sun D, Marston WA, Pascarella L, McGinigle KL, Wood JC, Farber MA. Five-year outcomes of fenestrated and branched endovascular repair of complex aortic aneurysms based on aneurysm extent. J Vasc Surg 2024:S0741-5214(24)00959-5. [PMID: 38608964 DOI: 10.1016/j.jvs.2024.04.017] [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: 01/29/2024] [Revised: 03/31/2024] [Accepted: 04/04/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVE The aim of this study was to evaluate the 5-year outcomes of fenestrated/branched endovascular aortic repair (F/BEVAR) for the treatment of complex aortic aneurysms stratified by the aneurysm extent. METHODS Patients with the diagnosis of complex aortic aneurysm, who underwent F/BEVAR at a single center were included in this study and retrospectively analyzed. The cohort was divided according to the aneurysm extent, comparing group 1 (types I-III thoracoabdominal aneurysms [TAAAs]), group 2 (type IV TAAAs), and group 3 (juxtarenal [JRAAs], pararenal [PRAAs], or paravisceral [PVAAs] aortic aneurysms). The primary endpoints were 30-day and 5-year survival. The secondary endpoints were technical success, occurrence of spinal cord ischemia, primary patency of the visceral arteries, freedom from target vessel instability, and secondary interventions. RESULTS Of 436 patients who underwent F/BEVAR between July 2012 and May 2023, 131 presented with types I to III TAAAs, 69 with type IV TAAAs, and 236 with JRAAs, PRAAs, or PVAAs. All cases were treated under a physician-sponsored investigational device exemption protocol with a patient-specific company-manufactured or off-the-shelf device. Group 1 had significantly younger patients than group 2 or 3 respectively (69.6 ± 8.7 vs 72.4 ± 7.1 vs 73.2 ± 7.3 years; P < .001) and had a higher percentage of females (50.4% vs 21.7% vs 17.8%; P < .001). Prior history of aortic dissection was significantly more common among patients in group 1 (26% vs 1.4% vs 0.9%; P < .001), and mean aneurysm diameter was larger in group 1 (64.5 vs 60.7 vs 63.2 mm; P = .033). Comorbidities were similar between groups, except for coronary artery disease (P < .001) and tobacco use (P = .003), which were less prevalent in group 1. Technical success was similar in the three groups (98.5% vs 98.6% vs 98.7%; P > .99). The 30-day mortality was 4.5%, 1.4%, and 0.4%, in groups 1, 2, and 3, respectively, and was significantly higher in group 1 when compared with group 3 (P = .01). The incidence of spinal cord ischemia was significantly higher in group 1 compared with group 3 (5.3% vs 4.3% vs 0.4%; P = .004). The 5-year survival was significantly higher in group 3 when compared with group 1 (P = .01). Freedom from secondary intervention was significantly higher in group 3 when compared with group 1 (P = .003). At 5 years, there was no significant difference in freedom from target vessel instability between groups or primary patency in the 1652 target vessels examined. CONCLUSIONS Larger aneurysm extent was associated with lower 5-year survival, higher 30-day mortality, incidence of secondary interventions, and spinal cord ischemia. The prevalence of secondary interventions in all groups makes meticulous follow-up paramount in patients with complex aortic aneurysm treated with F/BEVAR.
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Affiliation(s)
- Stephen J Raulli
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC.
| | - Vivian Carla Gomes
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - F Ezequiel Parodi
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Priya Vasan
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Dichen Sun
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - William A Marston
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Luigi Pascarella
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Katharine L McGinigle
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Jacob C Wood
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Mark A Farber
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
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Ayyash K, Howell SJ, McGinigle KL. Reply. J Vasc Surg 2024; 79:986-987. [PMID: 38519221 DOI: 10.1016/j.jvs.2023.11.063] [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: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 03/24/2024]
Affiliation(s)
- Katie Ayyash
- Department of Anaesthesia and Critical Care, York and Scarborough Teaching Hospitals NHS Foundation Trust, York, UK
| | - Simon J Howell
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | - Katharine L McGinigle
- Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Kim S, Schneider A, Raulli S, Ruiz C, Marston W, McGinigle KL, Wood J, Parodi FE, Farber MA, Pascarella L. Current outcomes following upper and lower extremity arterial trauma from the National Trauma Data Bank. J Vasc Surg 2024:S0741-5214(24)00925-X. [PMID: 38570174 DOI: 10.1016/j.jvs.2024.03.438] [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: 12/04/2023] [Revised: 03/07/2024] [Accepted: 03/25/2024] [Indexed: 04/05/2024]
Abstract
OBJECTIVE The modern treatments of trauma have changed in recent years. We aim to evaluate the factors associated with limb salvage and mortality after extremity arterial trauma, especially with respect to the type of conduit used in revascularization. METHODS The National Trauma Data Bank was queried to identify patients with upper and lower extremity (UE and LE) arterial injuries between 2016 and 2020. The patients were stratified by the types of arterial repair. The primary outcome was in-hospital mortality. RESULTS 8780 patients were found with 5054 (58%) UE and 3726 (42%) LE injuries. Eighty-three percent were men, and the mean age was 34 ± 15 years. Penetrating mechanism was the predominant mode of injury in both UEs and LEs (73% and 67%, respectively) with a mean injury severity score of 14 ± 8. For UEs, the majority underwent primary repair (67%, P < .001), whereas the remainder received either a bypass (20%) or interposition graft (12%). However, LEs were more likely to receive a bypass (52%, P < .00001) than primary repair or interposition graft (34% and 14%, respectively). Compared with the extremely low rates of amputation and mortality among UE patients (2% for both), LE injuries were more likely to result in both amputation (10%, P < .001) and death (6%, P < .001). Notably, compared with primary repair, the use of a prosthetic conduit was associated with a 6.7-fold increase in the risk of amputation in UE and a 2.4-fold increase in LE (P < .0001 for both). Synthetic bypasses were associated with a nearly 3-fold increase in return to the operating room (OR) in UE bypasses (P < .05) and a 2.4-fold increase in return to the OR in LE bypasses (P < .0001). CONCLUSIONS In recent years, most extremity vascular trauma was due to penetrating injury with a substantial burden of morbidity and mortality. However, both limb salvage rates and survival rates have remained high. Overall, LE injuries more often led to amputation and mortality than UE injuries. The most frequently used bypass conduit was vein, which was associated with less risk of unplanned return to the OR and limb loss, corroborating current practice guidelines for extremity arterial trauma.
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Affiliation(s)
- Sooyeon Kim
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Andrew Schneider
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Stephen Raulli
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Colby Ruiz
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - William Marston
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Katharine L McGinigle
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Jacob Wood
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - F Ezequiel Parodi
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Mark A Farber
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Luigi Pascarella
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC.
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Abstract
Peripheral artery disease is most often caused by atherosclerosis. Arterial insufficiency from atherosclerotic blockages in the limbs can impair walking distance and put patients with severe disease at risk of limb loss. Management of the disease centers around early diagnosis, supervised exercise therapy and lifestyle modification, optimizing medical care (with the goal of reducing fatal cardiac and cerebrovascular events), and revascularization.
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Affiliation(s)
- Katharine L McGinigle
- Division of Vascular Surgery, School of Medicine, University of North Carolina at Chapel Hill, 3021 Burnett Womack Building, Campus Box 7212, Chapel Hill, NC 27599, USA.
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Betancourt A, Benrashid E, Gupta PC, McGinigle KL. Current concepts in clinical features and diagnosis of thoracic outlet syndrome. Semin Vasc Surg 2024; 37:3-11. [PMID: 38704181 DOI: 10.1053/j.semvascsurg.2024.01.005] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 12/14/2023] [Accepted: 01/19/2024] [Indexed: 05/06/2024]
Abstract
The diagnosis and clinical features of thoracic outlet syndrome have long confounded clinicians, owing to heterogeneity in symptom presentation and many overlapping competing diagnoses that are "more common." Despite the advent and prevalence of high-resolution imaging, along with the increasing awareness of the syndrome itself, misdiagnoses and untimely diagnoses can result in significant patient morbidity. The authors aimed to summarize the current concepts in the clinical features and diagnosis of thoracic outlet syndrome.
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Affiliation(s)
- Alexis Betancourt
- Division of Vascular Surgery, University of North Carolina at Chapel Hill, Burnett Womack Building, 3(rd) Floor, Campus Box 7212, Chapel Hill, NC, 27599
| | - Ehsan Benrashid
- University Surgical Associates, University of Tennessee at Chattanooga, Chattanooga, TN
| | - Prem Chand Gupta
- Department of Vascular and Endovascular Surgery, Care Hospital, Banjara Hills, Hyderabad, India
| | - Katharine L McGinigle
- Division of Vascular Surgery, University of North Carolina at Chapel Hill, Burnett Womack Building, 3(rd) Floor, Campus Box 7212, Chapel Hill, NC, 27599.
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Kalbaugh CA, Witrick B, Howard KA, Sivaraj LB, McGinigle KL, Robinson WP, Cykert S, Hicks CW, Lesko CR. Investigating the impact of suboptimal prescription of preoperative antiplatelets and statins on race and ethnicity-related disparities in major limb amputation. Vasc Med 2024; 29:17-25. [PMID: 37737127 PMCID: PMC10922837 DOI: 10.1177/1358863x231196139] [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] [Indexed: 09/23/2023]
Abstract
BACKGROUND Non-Hispanic Black and Hispanic patients with symptomatic PAD may receive different treatments than White patients with symptomatic PAD. The delivery of guideline-directed medical treatment may be a modifiable upstream driver of race and ethnicity-related disparities in outcomes such as limb amputation. The purpose of our study was to investigate the prescription of preoperative antiplatelets and statins in producing disparities in the risk of amputation following revascularization for symptomatic peripheral artery disease (PAD). METHODS We used data from the Vascular Quality Initiative, a vascular procedure-based registry in the United States (2011-2018). We estimated the probability of preoperative antiplatelet and statin prescriptions and 1-year incidence of amputation. We then estimated the amputation risk difference between race/ethnicity groups that could be eliminated under a hypothetical intervention. RESULTS Across 100,579 revascularizations, the 1-year amputation risk was 2.5% (2.4%, 2.6%) in White patients, 5.3% (4.9%, 5.6%) in Black patients, and 5.3% (4.7%, 5.9%) in Hispanic patients. Black (57.5%) and Hispanic patients (58.7%) were only slightly less likely than White patients (60.9%) to receive antiplatelet and statin therapy. However, the effect of antiplatelets and statins was greater in Black and Hispanic patients such that, had all patients received these medications, the estimated risk difference comparing Black to White patients would have reduced by 8.9% (-2.9%, 21.9%) and the risk difference comparing Hispanic to White patients would have been reduced by 17.6% (-0.7%, 38.6%). CONCLUSION Even though guideline-directed care appeared evenly distributed by race/ethnicity, increasing access to such care may decrease health care disparities in major limb amputation.
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Affiliation(s)
- Corey A Kalbaugh
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health-Bloomington, Bloomington, IN, USA
| | - Brian Witrick
- West Virginia Clinical and Translational Sciences Institute, Morgantown, WV, USA
| | - Kerry A Howard
- Department of Public Health Sciences, Clemson University, Clemson, SC, USA
- Center for Public Health Modeling and Response, Clemson University, Clemson, SC, USA
| | | | - Katharine L McGinigle
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - William P Robinson
- Division of Vascular Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Samuel Cykert
- Division of General Medicine and Clinical Epidemiology, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Caitlin W Hicks
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Catherine R Lesko
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Freeman NLB, Browder SE, McGinigle KL, Kosorok MR. Individualized treatment rule characterization via a value function surrogate. Biometrics 2024; 80:ujad012. [PMID: 38372403 PMCID: PMC10875523 DOI: 10.1093/biomtc/ujad012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 10/19/2023] [Accepted: 11/14/2023] [Indexed: 02/20/2024]
Abstract
Precision medicine is a promising framework for generating evidence to improve health and health care. Yet, a gap persists between the ever-growing number of statistical precision medicine strategies for evidence generation and implementation in real-world clinical settings, and the strategies for closing this gap will likely be context-dependent. In this paper, we consider the specific context of partial compliance to wound management among patients with peripheral artery disease. Using a Gaussian process surrogate for the value function, we show the feasibility of using Bayesian optimization to learn optimal individualized treatment rules. Further, we expand beyond the common precision medicine task of learning an optimal individualized treatment rule to the characterization of classes of individualized treatment rules and show how those findings can be translated into clinical contexts.
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Affiliation(s)
- Nikki L B Freeman
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, United States
| | - Sydney E Browder
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, United States
| | - Katharine L McGinigle
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, United States
| | - Michael R Kosorok
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, United States
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Adams UC, Moulthrop AJ, Malay B, Straube LE, McNaull PP, McGinigle KL, Phillips MR. The Use of Sequential Surveys to Shorten Implementation Time for Healthcare System-Level Enhanced Recovery After Surgery (ERAS) Pathways. Am Surg 2023; 89:5466-5473. [PMID: 36786426 DOI: 10.1177/00031348231156765] [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] [Indexed: 02/15/2023]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) pathways improve healthcare quality, safety, and cost-effectiveness. We hypothesized that the RAND Method (a hybrid Delphi approach), involving anonymous sequential surveys and face-to-face meetings, would allow for more rapid agreement and initiation of new ERAS pathways. METHODS Using the ERAS Society guidelines for cesarean section as a baseline, our institution's ERAS Leadership Team (ELT) compiled published literature and institutional practices to design a 32-component survey that was sent to obstetricians, nurse midwives, anesthesiologists, pharmacists, and nurses. Components that did not reach 90% consensus were included in a second survey the following week, and meetings were held to review results. At the conclusion of this process, time to agreement was retrospectively compared to the colorectal ERAS pathway process at this institution. RESULTS ERAS pathway components were compiled and reviewed by 121 stakeholders at 7 hospitals using iterative surveys with review meetings over a 13-week period. Survey response rates were 61% and 50% in the initial and follow-up surveys, respectively. There was agreement on 28/32 and 32/32 items on the initial and follow-up surveys. Using the RAND Method, time to agreement decreased by 54.1% (24 vs 13 weeks) compared to prior system-wide efforts to standardize the colorectal surgery ERAS pathway. DISCUSSION With rapidly expanding healthcare systems, effective methods to gain consensus and adopt ERAS pathways are critical to implementation of ERAS guidelines. We demonstrate that the RAND Method allows for a transparent and efficient means of agreement across a diverse group of clinicians practicing in several settings.
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Affiliation(s)
- Ursula C Adams
- The University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Amy J Moulthrop
- The University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Lacey E Straube
- The University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Peggy P McNaull
- The University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Michael R Phillips
- The University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Freeman NLB, Browder SE, McGinigle KL. Balancing evidence-based care with patient-centered individualized care. J Vasc Surg Venous Lymphat Disord 2023; 11:1089-1094. [PMID: 37689363 PMCID: PMC10878433 DOI: 10.1016/j.jvsv.2023.08.005] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/26/2023] [Accepted: 08/06/2023] [Indexed: 09/11/2023]
Abstract
Weak evidence, when manifested in clinical guidelines, can translate into biased vascular care. In vascular surgery, we have few randomized controlled trials with appropriate representation of females and persons of color, so generalizability of trial results can be problematic. Physicians are required to balance evidenced-based care (which is only as good as the underlying evidence) with personalized treatment recommendations that are often based on demographics, social circumstances, and/or existing therapeutic relationships. Biases, whether implicit or explicit, have an oversized effect on treatment decisions, and patient outcomes. In this commentary, we propose three principles to strengthen the vascular surgery evidence foundation and patient-centered decision-making going forward: (1) generating evidence designed for individualized care, (2) constructing clinical guidelines that are context specific and complexity aware, and (3) strengthening the training and support for surgeons to deliver patient-centered individualized care.
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Affiliation(s)
- Nikki L B Freeman
- Division of Vascular Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Sydney E Browder
- Division of Vascular Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Katharine L McGinigle
- Division of Vascular Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
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DiBartolomeo AD, Browder SE, Bazikian S, Thapa D, Kim S, Yohann A, Armstrong DG, McGinigle KL. Medial arterial calcification score is associated with increased risk of major limb amputation. J Vasc Surg 2023; 78:1286-1291. [PMID: 37527690 PMCID: PMC10878434 DOI: 10.1016/j.jvs.2023.07.052] [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: 05/19/2023] [Revised: 07/20/2023] [Accepted: 07/22/2023] [Indexed: 08/03/2023]
Abstract
OBJECTIVE The pedal medial arterial calcification (MAC) score has been associated with risk of major limb amputation in patients with chronic limb-threatening ischemia. This study aimed to validate the pedal MAC scoring system in a multi-institutional analysis to validate its usefulness in limb amputation risk prediction. METHODS A multi-institution, retrospective study of patients who underwent endovascular or open surgical infrainguinal revascularization for chronic limb-threatening ischemia was performed. MAC scores of 0 to 5 were assigned based on visible calcified arteries on foot X ray then trichotomized (0-1, 2-4, 5) for analysis. The primary outcome was major limb amputation at 6 months. Adjusted Kaplan-Meier models were used to analyze time-to-major amputation across groups. RESULTS There were 176 patients with 184 affected limbs (mean age, 66 years; 61% male; 60% White), of whom 97% presented with a wound. The MAC score was 0 in 41%, 1 in 9%, 2 in 13%, 3 in 11%, 4 in 13%, and 5 in 13% of the limbs. There were 26 major amputations (14%) and 16 deaths (8.7%) within 6 months. Patients with MAC 5 had a significantly higher risk of major limb amputation than both the 0 to 1 and 2 to 4 groups (P = .001 and P = .044, respectively), and lower overall amputation-free survival (log-rank P = .008). CONCLUSIONS Pedal MAC score is a reproducible and generalizable measure of inframalleolar arterial disease that can be used with Wound, Ischemia, and foot Infection staging to predict major limb amputation in patients with chronic limb-threatening ischemia.
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Affiliation(s)
- Alexander D DiBartolomeo
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Sydney E Browder
- Division of Vascular Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Sebouh Bazikian
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Diwash Thapa
- Division of Vascular Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Sooyeon Kim
- Division of Vascular Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Avital Yohann
- Division of Vascular Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - David G Armstrong
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Katharine L McGinigle
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA.
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Lombardi ME, Smith JR, Ruiz CS, Caruso DM, Agala CB, McGinigle KL, Farber MA, Wood JE, Marston WA, Parodi FE, Pascarella L. Gender disparities in patients with aortoiliac disease requiring open operative intervention. J Vasc Surg 2023; 78:1278-1285. [PMID: 37479089 DOI: 10.1016/j.jvs.2023.07.008] [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: 03/10/2023] [Revised: 07/08/2023] [Accepted: 07/13/2023] [Indexed: 07/23/2023]
Abstract
OBJECTIVE Peripheral artery disease is known to affect males and females in different proportions. Disparate surgical outcomes have been quantified after endovascular aortic aneurysm repair, arteriovenous fistula creation, and treatment of critical limb ischemia. The aim of this study is to objectively quantify the sex differences in outcomes in patients undergoing open surgical intervention for aortoiliac occlusive disease. METHODS Patients were identified in the aortoiliac occlusive disease Vascular Quality Initiative database who underwent aorto-bifemoral bypass or aortic thromboendarterectomy as determined by Current Procedural Terminology codes between 2012 and 2019. Patients with a minimum of 1-year follow-up were included. Risk differences (RDs) by sex were calculated using a binomial regression model in 30-day and 1-year incidence of mortality and limb salvage. Additionally, incidence of surgical complications including prolonged length of stay (>10 days), reoperation, and change in renal function (>0.5 mg/dl rise from baseline), were recorded. Inverse probability weighting was used to standardize demographic and medical history characteristics. Multivariate logistic regression models were employed to conduct analyses of the before mentioned clinical outcomes, controlling for known confounders. RESULTS Of 16,218 eligible patients from the VQI data during the study period, 6538 (40.3%) were female. The mean age, body mass index, and race were not statistically different between sexes. Although there was no statistically significant difference detected in mortality between males and females at 30 days postoperatively, females had an increased crude 1-year mortality with an RD of 0.014 (95% confidence interval, 0.01-0.02; P value < .001. Males had a higher rate of a postoperative change in renal function with an RD of -0.02 (95% confidence interval, -0.03 to -0.01; P < .001). CONCLUSIONS Although there was no sex-based mortality difference at 30 days, there was a statistically significant increase in mortality in females after open aortoiliac intervention at 1 year based on our weighted model. Male patients are statistically significantly more likely to have a decline in renal function after their procedures when compared with females. Postoperative complications including prolonged hospital stay, reoperation, and wound disruption were similar among the sexes, as was limb preservation rates at 1 year. Further studies should focus on elucidating the underlying factors contributing to sex-based differences in clinical outcomes following aortoiliac interventions.
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Affiliation(s)
- Megan E Lombardi
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC.
| | - Jonathan R Smith
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Colby S Ruiz
- Division of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Deanna M Caruso
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Chris B Agala
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Katharine L McGinigle
- Division of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Mark A Farber
- Division of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Jacob E Wood
- Division of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - William A Marston
- Division of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - F Ezequiel Parodi
- Division of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Luigi Pascarella
- Division of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
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Gomes VC, Parodi FE, Motta F, Pascarella L, McGinigle KL, Marston WA, Wood J, Farber MA. Outcome Analysis Comparing Asymptomatic Juxtarenal Aortic Aneurysms Treated with Custom-Manufactured Fenestrated-Branched Devices and the "Off-The-Shelf" Zenith p-Branch Device. Ann Vasc Surg 2023; 96:207-214. [PMID: 37003359 DOI: 10.1016/j.avsg.2023.03.017] [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: 09/16/2022] [Revised: 02/17/2023] [Accepted: 03/18/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Numerous endovascular options have been used for the repair of juxtarenal aortic aneurysms (JRAAs) over the last 15 years. This study aims to compare the performance between the Zenith p-branch device and custom-manufactured fenestrated-branched devices (CMD) for the treatment of asymptomatic JRAA. METHODS A single-center retrospective analysis of prospectively collected data was performed. Patients with a diagnosis of JRAA submitted to endovascular repair between July 2012 and November 2021 were included in the study, being divided into 2 groups: CMD and Zenith p-branch. The following variables were analyzed: preoperative information: demographics, comorbidities, and maximum aneurysm diameter; procedural data: contrast volume, fluoroscopy time, radiation dose, estimated blood loss, and technical success; and postoperative data: 30-day mortality, duration of intensive care unit and hospital stay, major adverse events, secondary interventions, target vessel instability, and long-term survival. RESULTS From a total of 373 physician-sponsored investigational device exemption (Cook Medical devices) cases performed at our institution, 102 patients presented the diagnosis of JRAA. Of these, 14 patients were treated with the p-branch device (13.7%) and 88 (86.3%) with a CMD. Both groups presented similar demographic composition and maximum aneurysm diameter. All devices were successfully deployed, with no type I or III endoleaks observed at procedure completion. The contrast volume (P = 0.023) and radiation dose (P = 0.001) were significantly higher in the p-branch group. No significant difference was observed between the groups for the remaining intraoperative data. No paraplegia or ischemic colitis has been observed during the first 30 days after the surgical procedures. There was no 30-day mortality in either group. One major cardiac adverse event was registered in the CMD group. Early outcomes were similar in both groups. No significant difference was found between the groups with respect to the presence of type I or III endoleaks during the follow-up. From a total of 313 target vessels stented in the CMD group (mean of 3.55 per patient) and 56 in the p-branch group (mean of 4 per patient), 4.79% and 5.35% presented instability, respectively, with no difference observed between the groups (P = 0.743). Secondary interventions were required in 36.4% of the CMD cases and 50% of the p-branch group, but this was not statistically different (P = 0.382). In the p-branch cohort, 2 of 7 reinterventions (28.5%) were target vessel-related and in the CMD group, 10 of 32 secondary interventions (31.2%) were target vessel-related. CONCLUSIONS Comparable perioperative outcomes were obtained when appropriately selected patients were treated with either the off-the-shelf p-branch or CMD for JRAA. The long-term target vessel instability does not appear impacted by the presence of pivot fenestrations in comparison to other target vessel configurations. Given these outcomes, delay in CMD production time should be considered when treating patients with large juxtarenal aneurysms.
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Affiliation(s)
- Vivian Carla Gomes
- Vascular Surgery Division, Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC.
| | - Federico Ezequiel Parodi
- Vascular Surgery Division, Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Fernando Motta
- Vascular Surgery Division, Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Luigi Pascarella
- Vascular Surgery Division, Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Katharine L McGinigle
- Vascular Surgery Division, Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - William A Marston
- Vascular Surgery Division, Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Jacob Wood
- Vascular Surgery Division, Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Mark A Farber
- Vascular Surgery Division, Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC
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Welch KG, Faria I, Browder SE, Drudi LM, McGinigle KL. Depression in Patients with Peripheral Artery Disease: An Underdiagnosis with Increased Mortality. Ann Vasc Surg 2023; 95:80-86. [PMID: 36948397 PMCID: PMC10866090 DOI: 10.1016/j.avsg.2023.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 02/04/2023] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Among patients with peripheral artery disease (PAD), depression is diagnosed in 17-25% and negatively impacts wound healing, quality of life, and survival. We hypothesized that depression is underdiagnosed in patients with PAD. Additionally, given the associations between depression and mortality in PAD patients, there is an increased need to investigate the strength of this relationship. The present analysis includes 2 studies to address the following aims: (1) Investigation of the prevalence of concomitant PAD and depression in a cohort from the Southeastern United States, and (2) Examination of the association between depression and all-cause mortality in a cohort of Canadian patients with PAD. METHODS STUDY 1: From June-August 2022, the Patient Health Questionnaire Module 9 (PHQ-9) was administered to all patients seeking PAD-related care including medical, wound/podiatric, or vascular interventional/surgical treatment, in the University of North Carolina-Chapel Hill Vascular, Wound, and Podiatry clinics. The PHQ-9 assesses symptoms over 2 weeks and is scored 0-27, with higher scores indicating increasingly severe depression. Demographics, primary diagnosis, depression history, and antidepressant prescription were determined through chart review. We compared the proportion of positive depression screenings (PHQ-9 ≥ 5) to known depression. Among those treated for depression, the PHQ-9 score severity was evaluated. T-tests and χ2 tests were used to compare means and proportions. STUDY 2: From July 2015 to October 2016, the Geriatric Depression Scale Short Form was administered to adult patients with PAD undergoing revascularization. The Geriatric Depression Scale Short Form is a self-report measure of depression with a score >5 consistent with depression. The prevalence of depression was determined; primary outcome was all-cause mortality at 6 months. RESULTS STUDY 1: In 104 PAD patients (mean age 66.6 ± 11.3 years, 37% female), 37% of respondents scored ≥5 on the PHQ-9 survey, indicating at least mild depression. Only 18% of PAD patients had a history of depression, demonstrating a significant difference between the PHQ-9 findings and documented medical history. While depression was underdiagnosed in both men and women, men were more likely to have unrecognized depression (chi-squared statistic = 35.117, df = 1, P < 0.001). Among those with a history of depression, 74% had a current prescription for antidepressant medication, but 57% still had an elevated PHQ-9 score indicating possible undertreatment. STUDY 2: In 148 patients (mean age 70.3 ± 11.0 years, 39% female) the prevalence of screened depression was 28.4%, but only 3.3% had a documented history of depression suggesting significant underdiagnosis. Patients with depression were significantly more likely to die within 6 months of revascularization (9.5% vs. 0.9%; odds ratio 1.48, 95% confidence interval: 1.08 to 2.29). There was no association between depression and risk of length of stay, reintervention, or readmission. CONCLUSIONS Depression is underdiagnosed and undertreated among patients with PAD, which has grave consequences as it is associated with 1.5 times the odds of mortality within 6 months of revascularization. There is a critical need for more robust screenings and comprehensive mental health treatment for patients with concomitant depression and PAD.
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Affiliation(s)
- Katherine G Welch
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Isabella Faria
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Sydney E Browder
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Laura M Drudi
- Division of Vascular Surgery, Centre Hospital de L'Université de Montréal, Montreal, Quebec, Canada
| | - Katharine L McGinigle
- Division of Vascular Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
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Browder SE, Yohann A, Filipowicz TR, Freeman NLB, Marston WA, Heisler S, Farber MA, Patel SR, Wood JC, McGinigle KL. Differential impact of missed initial wound clinic visit on 6-month wound healing by race/ethnicity among patients with chronic limb-threatening ischemia. Wound Repair Regen 2023; 31:647-654. [PMID: 37534781 PMCID: PMC10878832 DOI: 10.1111/wrr.13116] [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: 03/27/2023] [Revised: 06/07/2023] [Accepted: 07/18/2023] [Indexed: 08/04/2023]
Abstract
Chronic limb-threatening ischemia (CLTI) is associated with significant morbidity, including major limb amputation, and mortality. Healing ischemic wounds is necessary to optimise vascular outcomes and can be facilitated by dedicated appointments at a wound clinic. This study aimed to estimate the association between successful wound care initiation and 6-month wound healing, with specific attention to differences by race/ethnicity. This retrospective study included 398 patients with CLTI and at least one ischaemic wound who scheduled an appointment at our wound clinic between January 2015 and July 2020. The exposure was the completion status of patients' first scheduled wound care appointment (complete/not complete) and the primary outcome was 6-month wound healing (healed/not healed). The analysis focused on how this association was modified by race/ethnicity. We used Aalen-Johansen estimators to produce cumulative incidence curves and calculated risk ratios within strata of race/ethnicity. The final adjustment set included age, revascularization, and initial wound size. Patients had a mean age of 67 ± 14 years, were 41% female, 46% non-White and had 517 total wounds. In the overall cohort, 70% of patients completed their first visit and 34% of wounds healed within 6-months. There was no significant difference in 6-month healing based on first visit completion status for White/non-Hispanic individuals (RR [95% CI] = 1.18 [0.91, 1.45]; p-value = 0.130), while non-White individuals were roughly 3 times more likely to heal their wounds if they completed their first appointment (RR [95% CI] = 2.89 [2.66, 3.11]; p-value < 0.001). In conclusion, non-White patients were approximately three times more likely to heal their wound in 6 months if they completed their first scheduled wound care appointment while White/non-Hispanic individuals' risk of healing was similar regardless of first visit completion status. Future efforts should focus on providing additional resources to ensure minority groups with wounds have the support they need to access and successfully initiate wound care.
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Affiliation(s)
- Sydney E. Browder
- Department of Surgery—Vascular, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Avital Yohann
- Department of Surgery—Vascular, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Teresa R. Filipowicz
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Nikki L. B. Freeman
- Department of Surgery—Vascular, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
| | - William A. Marston
- Department of Surgery—Vascular, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Stephen Heisler
- Department of Surgery—Vascular, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Mark A. Farber
- Department of Surgery—Vascular, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Shrunjay R. Patel
- Department of Surgery—Vascular, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jacob C. Wood
- Department of Surgery—Vascular, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
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McGinigle KL, Menard MT, Conte MS. Transcatheter Arterialization of Veins in Chronic Limb-Threatening Ischemia. N Engl J Med 2023; 388:2201-2202. [PMID: 37285533 DOI: 10.1056/nejmc2304972] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
| | | | - Michael S Conte
- University of California at San Francisco, San Francisco, CA
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16
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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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17
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Ruiz CS, Hamrick MF, McGinigle KL, Marston WA. Iliac vein recanalisation and stenting accelerate healing of venous leg ulcers associated with severe venous outflow obstruction. Wound Repair Regen 2023; 31:193-198. [PMID: 36541712 DOI: 10.1111/wrr.13065] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 09/13/2022] [Accepted: 10/13/2022] [Indexed: 12/24/2022]
Abstract
Obstruction involving the iliac veins and/or inferior vena cava is highly comorbid in patients with chronic venous leg ulcers and is a barrier to healing. Intervention with venous stenting is recommended to promote wound healing; however, there is limited data to quantify the effects of venous outflow restoration on wound healing. We retrospectively identified patients with venous ulcers and comorbid venous outflow obstruction. Data regarding demographics, wound size, degree of obstruction, interventions, wound healing and recurrence were collected. Intervention was performed when possible and patients were grouped based on whether or not the venous outflow was reopened successfully and maintained for at least 1 year. Outcomes, including time to wound healing, wound recurrence, stent patency and ulcer-free time, were measured. Patients who maintained a patent venous outflow tract experienced higher rates of wound healing (79.3%) compared to those with persistent outflow obstruction (22.6%) at 12 months (p < 0.001). Ulcer-free time for the first year was also greater with patent venous outflow (7.6 ± 4.4 months versus 1.8 ± 3.0 months, p < 0.0025). Patients with severe obstruction of the venous outflow tract experience poor healing of VLUs despite appropriate wound care. Healing time is improved and ulcer-free time increased after venous intervention with stenting to eliminate obstruction.
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Affiliation(s)
- Colby S Ruiz
- Division of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Melissa F Hamrick
- Division of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Katharine L McGinigle
- Division of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - William A Marston
- Division of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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18
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Kindell DG, Marulanda K, Caruso DM, Duchesneau E, Agala C, Farber M, Marston WA, McGinigle KL. Incidence of venous thromboembolism in patients with peripheral arterial disease after endovascular intervention. Eur J Vasc Endovasc Surg 2023. [DOI: 10.1016/j.ejvs.2022.12.020] [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: 01/12/2023]
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19
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Kindell DG, Marulanda K, Caruso DM, Duchesneau E, Agala C, Farber M, Marston WA, McGinigle KL. Incidence of venous thromboembolism in patients with peripheral arterial disease after endovascular intervention. J Vasc Surg Venous Lymphat Disord 2023; 11:61-69. [PMID: 36182086 PMCID: PMC10681019 DOI: 10.1016/j.jvsv.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/17/2022] [Accepted: 08/23/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Venous thromboembolism (VTE) is a well-known postoperative complication; however, the incidence of VTE after peripheral vascular intervention (PVI) has not been well described. Despite the minimally invasive nature of these procedures, the patients undergoing PVI have significant risk factors for the development of VTE. In the present study, our objective was to describe the short-term incidence of VTE after PVI, identify differences between sexes, and examine the periprocedural antiplatelet and anticoagulation regimens. METHODS We identified adults (age >66 years) who had undergone PVI from January 1, 2008 to September 30, 2015 from the inpatient Medicare claims data. The patients were followed for 365 days after the procedure. VTE events during follow-up were identified using the International Classification of Diseases, 9th revision, diagnosis codes. The covariate-standardized 30- and 90-day cumulative incidence of VTE events, overall and stratified by sex, were estimated using Aalen-Johansen estimators, accounting for death as a competing risk. Differences in sex between females and males were identified using Gray's test. Any antiplatelet or anticoagulant prescription fill was defined as any fill from 14 days before the endovascular intervention through the date of the VTE event. Persistence with antiplatelet and anticoagulant therapy was assessed by creating daily logs of antiplatelet and anticoagulant coverage using the dispensing dates and days of supply. Over-the-counter medications (ie, aspirin) were not evaluated. RESULTS We identified 31,593 qualifying patients with a mean age of 76.8 ± 7.4 years. Of the 31,593 patients, 46% were male, and 12% had a history of VTE. After the procedure, deep vein thrombosis (DVT) was a commonly diagnosed complication (3.8% and 4.8% at 30 and 90 days, respectively). The cumulative incidence of pulmonary embolism was 0.9% and 1.2% at 30 and 90 days after the procedure, respectively. Throughout the 90-day postoperative period, females had had a slightly increased risk of DVT compared with males (30-day risk difference, 0.007; P < .01; 90-day risk difference, 0.008; P = .02). We found no sex-based differences in the risk of pulmonary embolism. Of the patients who had developed VTE at 90 days, 970 (55%) had had no prescription fill for an antiplatelet or anticoagulant. Assuming all the patients had been taking aspirin, only 15% of the patients who had developed VTE had been taking prescribed dual antiplatelet medication persistently after PVI. In addition, among the patients who had developed VTE at 90 days, females were less likely to have had a prescription fill for an anticoagulant. CONCLUSIONS The findings from our study have demonstrated that the incidence of VTE after PVI is high, with an increased risk of deep vein thrombosis for females. We also found that females were less likely to have been prescribed an anticoagulant after PVI. Future studies are needed to characterize the variables associated with an increased risk of VTE after PVI and to identify strategies to increase dual antiplatelet therapy or anticoagulant prescription adherence to reduce the risk of VTE.
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Affiliation(s)
- Daniel G Kindell
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Kathleen Marulanda
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Deanna M Caruso
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Emilie Duchesneau
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Chris Agala
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Mark Farber
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - William A Marston
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
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20
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Pherson MJ, Strassle PD, Aucoin VJ, Kalbaugh CA, McGinigle KL. Surgical site infection after open lower extremity revascularization associated with doubled rate of major limb amputation. J Vasc Surg 2022; 76:1014-1020. [PMID: 35697308 PMCID: PMC9765967 DOI: 10.1016/j.jvs.2022.04.040] [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: 09/29/2020] [Revised: 04/07/2022] [Accepted: 04/13/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Surgical site infection (SSI) after open lower extremity revascularization is a relatively common complication associated with increased hospital stays, graft infection, and in severe cases, graft loss. Although the short-term effects of SSI can be significant, it has not been considered a complication that increases major limb amputation. The purpose of this study was to determine the association of SSI with outcomes in patients undergoing surgical revascularization for peripheral arterial disease. METHODS We analyzed nationwide Vascular Quality Initiative (VQI) data from the infrainguinal bypass module from 2003 to 2017. The cohort included adults who underwent open lower extremity bypass for symptomatic peripheral arterial disease and had at least one follow-up record. Weighted Kaplan-Meier curves and Cox proportional hazards regression were used to assess the association between SSI and 1-year mortality and major limb amputation. Inverse-probability of treatment weights were used to account for differences in demographics and patient characteristics and allow for 'adjusted' Kaplan-Meier curves. RESULTS The analysis included 21,639 patients, and 1155 (5%) had a reported SSI within 30 days of surgery. Patients with SSI were more likely be obese (41% vs 30%), but there were no other clinically relevant differences between demographics, comorbidities, and bypass details. After weighting, patients with SSI were almost twice as likely to undergo major amputation by 6 months (hazard ratio, 1.84; 95% confidence interval, 1.07-3.17). The association with SSI and increased amputation rates persisted at 1 year. The association of SSI on amputation was no different based on preoperative Rutherford class (P = .91). The association between SSI and 1-year mortality rate was not statistically significant (hazard ratio, 1.15; 95% confidence interval, 0.91-1.46). CONCLUSIONS SSI is more common in obese patients, and patients who develop an SSI are observed to have a significantly increased rate of limb amputation after open lower extremity revascularization.
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Affiliation(s)
- Micah J Pherson
- Division of Vascular Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Paula D Strassle
- Division of Vascular Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Victoria J Aucoin
- Division of Vascular Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Corey A Kalbaugh
- Department of Public Health Sciences, Clemson University, Clemson, SC
| | - Katharine L McGinigle
- Division of Vascular Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.
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21
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Heindel P, Dieffenbach BV, Freeman NL, McGinigle KL, Menard MT. Central concepts for randomized controlled trials and other emerging trial designs. Semin Vasc Surg 2022; 35:424-430. [DOI: 10.1053/j.semvascsurg.2022.10.004] [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] [Received: 09/15/2022] [Revised: 10/11/2022] [Accepted: 10/11/2022] [Indexed: 11/11/2022]
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22
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Allen AJ, Russell D, Lombardi ME, Duchesneau ED, Agala CB, McGinigle KL, Marston WA, Farber MA, Parodi FE, Wood J, Pascarella L. Gender Disparities in Aortoiliac Revascularization in Patients with Aortoiliac Occlusive Disease. Ann Vasc Surg 2022; 86:199-209. [PMID: 35605762 PMCID: PMC10681021 DOI: 10.1016/j.avsg.2022.05.007] [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: 03/14/2022] [Revised: 05/02/2022] [Accepted: 05/06/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Gender disparities have been previously reported in aortic aneurysm and critical limb ischemia outcomes; however, limited info is known about disparities in aortoiliac occlusive disease. We sought to characterize potential disparities in this specific population. MATERIAL AND METHODS Patients who underwent aortobifemoral bypass and aortic thromboendarterectomy (Current Procedural Terminology codes 35646 and 35331) between 2012 and 2019 were identified in the National Surgical Quality Improvement Program database. A binomial regression model was used to estimate gender differences in 30-day morbidity and mortality. Inverse probability weighting was used to standardize demographic and surgical characteristics. RESULTS We identified 1,869 patients, of which 39.8% were female and the median age was 61 years. Age, body composition, and other baseline characteristics were overall similar between genders; however, racial data were missing for 26.1% of patients. Females had a higher prevalence of preexisting chronic obstructive pulmonary disease (20.9% vs. 14.7%, prevalence difference 6.1%, P < 0.01), diabetes mellitus (25.4% vs. 19.4%, prevalence difference 6.0%, P < 0.01), and high-risk anatomical features (39.4% vs. 33.7%, prevalence difference 5.8%, P = 0.01). Preprocedural medications included a statin in only 68.2% of patients and antiplatelet agent in 76.7% of patients. Females also had a higher incidence of bleeding events when compared to males (25.2% vs. 17.5%, standardized risk difference 7.2%, P < 0.01), but were less likely to have a prolonged hospitalization greater than 10 days (18.2% vs. 20.9%, standardized risk difference -5.0%, P = 0.01). The 30-day mortality rate was not significantly different between genders (4.7% vs. 3.6%, standardized risk difference 1.2%, P = 0.25). CONCLUSIONS Female patients treated with aortobifemoral bypass or aortic thromboendarterectomy are more likely to have preexisting chronic obstructive pulmonary disease, diabetes mellitus, and high-risk anatomical features. Regardless of a patient's gender, there is poor adherence to preoperative medical optimization with both statins and antiplatelet agents. Female patients are more likely to have postoperative bleeding complications while males are more likely to have a prolonged hospital stay greater than 10 days. Future work could attempt to further delineate disparities using databases with longer follow-up data and seek to create protocols for reducing these observed disparities.
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Affiliation(s)
- Austin J Allen
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Devin Russell
- Department of Surgery, Eastern Virginia Medical School, Norfolk, VA
| | - Megan E Lombardi
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Emilie D Duchesneau
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Chris B Agala
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Katharine L McGinigle
- Department of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - William A Marston
- Department of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Mark A Farber
- Department of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Federico E Parodi
- Department of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Jacob Wood
- Department of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Luigi Pascarella
- Department of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC.
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23
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Weiner S, Benton MH, Guraziu B, Yange Y, He J, Chen YT, Marston WA, McGinigle KL. High Stroke Rate in Patients With Medically Managed Asymptomatic Carotid Stenosis at an Academic Center in the Southeastern United States. Ann Vasc Surg 2022; 85:418-423. [PMID: 35472498 DOI: 10.1016/j.avsg.2022.04.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 11/09/2021] [Revised: 02/25/2022] [Accepted: 04/17/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Although the publication of randomized clinical trials defining the benefit of carotid endarterectomy (CEA) for asymptomatic carotid stenosis, medical management of carotid stenosis has changed significantly. With antiplatelet agents and statins, some question whether these trials are still relevant, suggesting that asymptomatic patients with >70% internal carotid artery (ICA) stenosis may do better with medial management alone, lessening the need for CEA and carotid stenting. The Vascular Quality Initiative (VQI) registry has shown that there are wide practice variations regarding the degree of stenosis that prompts surgical intervention but there are few reports of outcomes in patients who do not undergo intervention. We sought to determine the clinical outcomes of the >70% carotid stenosis patients who are treated with medical management alone at our institution. METHODS We identified all patients with ICA stenosis >70% based on hemodynamic consensus criteria (peak systolic velocity >230 cm/s) in our peripheral vascular laboratory from January 2013 through December 2016. With a retrospective chart review, demographics, comorbid conditions, medications, radiographic studies, clinical follow-up, interventions, and outcomes at 2 years were included. Descriptive statistics were used to define these variables. RESULTS One hundred and seventy three patients were identified with medically managed asymptomatic >70% ICA stenosis based on hemodynamic criteria on duplex ultrasound. The mean age was 67.5 years, 49% were male, 64% were White, 14% were Black, 13% race was undisclosed, 89% were prescribed antiplatelet therapy, 85% were prescribed a statin, and 60% had hypertension controlled to <140/90. Twenty patients (11.5%) experienced a cerebrovascular event during the 2-year study period. There were eight patients with transient ischemic attack, 10 with ipsilateral strokes, and 2 with strokes in unrelated territories. CONCLUSIONS Despite good adherence to current recommendations for medical therapy, patients at our institution are developing symptomatic carotid disease at a rate similar to that reported in historical clinical trials. These data supports the concept that advances in medical management have not resulted in reduced stroke rates in asymptomatic patients with high-grade carotid stenosis at a large academic institution located in the southeastern United States. CEA and stenting provide a significant risk reduction and should be considered more often in this patient population.
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Affiliation(s)
- Sarah Weiner
- Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Mary Hunter Benton
- Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Benjana Guraziu
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Yue Yange
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jie He
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Yi Tang Chen
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - William A Marston
- Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Katharine L McGinigle
- Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
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24
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Chung J, Freeman NLB, Kosorok MR, Marston WA, Conte MS, McGinigle KL. Analysis of a Machine Learning-Based Risk Stratification Scheme for Chronic Limb-Threatening Ischemia. JAMA Netw Open 2022; 5:e223424. [PMID: 35315918 PMCID: PMC8941356 DOI: 10.1001/jamanetworkopen.2022.3424] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
IMPORTANCE Valid risk stratification schemes are key to performing comparative effectiveness research; however, for chronic limb-threatening ischemia (CLTI), risk stratification schemes have limited efficacy. Improved, accurate, comprehensive, and reproducible risk stratification models for CLTI are needed. OBJECTIVE To evaluate the use of topic model cluster analysis to generate an accurate risk prediction model for CLTI. DESIGN, SETTING, AND PARTICIPANTS This multicenter, nested cohort study of existing Project of Ex Vivo Vein Graft Engineering via Transfection (PREVENT) III clinical trial data assessed data from patients undergoing infrainguinal vein bypass for the treatment of ischemic rest pain or ischemic tissue loss. Original data were collected from January 1, 2001, to December 31, 2003, and were analyzed in September 2021. All patients had 1 year of follow-up. EXPOSURES Supervised topic model cluster analysis was applied to nested cohort data from the PREVENT III randomized clinical trial. Given a fixed number of clusters, the data were used to examine the probability that a patient belonged to each of the clusters and the distribution of the features within each cluster. MAIN OUTCOMES AND MEASURES The primary outcome was 1-year CLTI-free survival, a composite of survival with remission of ischemic rest pain, wound healing, and freedom from major lower-extremity amputation without recurrent CLTI. RESULTS Of the original 1404 patients, 166 were excluded because of a lack of sufficient feature and/or outcome data, leaving 1238 patients for analysis (mean [SD] age, 68.4 [11.2] years; 800 [64.6%] male; 894 [72.2%] White). The Society for Vascular Surgery Wound, Ischemia, and Foot Infection grade 2 wounds were present in 543 patients (43.8%), with rest pain present in 645 (52.1%). Three distinct clusters were identified within the cohort (130 patients in stage 1, 578 in stage 2, and 530 in stage 3), with 1-year CLTI-free survival rates of 82.3% (107 of 130 patients) for stage 1, 61.1% (353 of 578 patients) for stage 2, and 53.4% (283 of 530 patients) for stage 3. Stratified by stage, 1-year mortality was 10.0% (13 of 130 observed deaths in stage 1) for stage 1, 13.5% (78 of 578 patients) for stage 2, and 20.2% (105 of 521 patients) for stage 3. Similarly, stratifying by stage revealed major limb amputation rates of 4.2% (5 of 119 observed major limb amputations in stage 1) for stage 1, 10.8% (55 of 509 patients) for stage 2, and 18.4% (81 of 440 patients) for stage 3. Among survivors without a major amputation, the rates of CLTI recurrence were 9.2% (11 of 119 observed recurrences in stage 1) for stage 1, 24.9% (130 of 523 patients) for stage 2, and 29.6% (132 of 446 patients) for stage 3. CONCLUSIONS AND RELEVANCE The topic model cluster analysis in this cohort study identified 3 distinct stages within CLTI. Findings suggest that CLTI-free survival is an end point that can be accurately and reproducibly quantified and may be used as a patient-centric outcome.
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Affiliation(s)
- Jayer Chung
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Nikki L. B. Freeman
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill
| | - Michael R. Kosorok
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill
| | - William A. Marston
- Division of Vascular Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill
| | - Michael S. Conte
- Department of Surgery, University of California at San Francisco, San Francisco
| | - Katharine L. McGinigle
- Division of Vascular Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill
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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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26
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Kalbaugh CA, Witrick B, Sivaraj LB, McGinigle KL, Lesko CR, Cykert S, Robinson WP. Non-Hispanic Black and Hispanic Patients Have Worse Outcomes Than White Patients Within Similar Stages of Peripheral Artery Disease. J Am Heart Assoc 2022; 11:e023396. [PMID: 34927446 PMCID: PMC9075215 DOI: 10.1161/jaha.121.023396] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/12/2021] [Indexed: 11/16/2022]
Abstract
Background Racial and ethnic disparities in outcomes following lower limb revascularization for peripheral artery disease have been ascribed to disease severity at presentation for surgery. Methods and Results We calculated 1-year risk of major adverse limb events (MALEs), major amputation, and death for patients undergoing elective revascularization for claudication or chronic limb-threatening ischemia in the Vascular Quality Initiative data (2011-2018). We report hazard ratios according to race and ethnicity using Cox (death) or Fine and Gray subdistribution hazards models (MALE and major amputation, treating death as a competing event), adjusted for patient, treatment, and anatomic factors associated with disease severity. Among 88 599 patients (age, 69 years; 37% women), 1-year risk of MALE (major amputation and death) was 12.8% (95% CI, 12.5-13.0) in 67 651 White patients, 16.5% (95% CI, 5.8-7.8) in 15 442 Black patients, and 17.2% (95% CI, 5.6-6.9) in 5506 Hispanic patients. Compared with White patients, we observed an increased hazard of poor limb outcomes among Black (MALE: 1.17; 95% CI, 1.12-1.22; amputation: 1.52; 95% CI, 1.39-1.65) and Hispanic (MALE: 1.22; 95% CI, 1.14-1.31; amputation: 1.45; 95% CI, 1.28-1.64) patients. However, Black and Hispanic patients had a hazard of death of 0.85 (95% CI, 0.79-0.91) and 0.71 (95% CI, 0.63-0.79) times the hazard among White patients, respectively. Worse limb outcomes were observed among Black and Hispanic patients across subcohorts of claudication and chronic limb-threatening ischemia. Conclusions Black and Hispanic patients undergoing infrainguinal revascularization for chronic limb-threatening ischemia and claudication had worse limb outcomes compared with White patients, even with similar disease severity at presentation. Additional investigation aimed at eliminating disparate limb outcomes is needed.
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Affiliation(s)
- Corey A. Kalbaugh
- Department of Public Health SciencesClemson UniversityClemsonSC
- Department of BioengineeringClemson UniversityClemsonSC
| | - Brian Witrick
- Department of Public Health SciencesClemson UniversityClemsonSC
| | | | - Katharine L. McGinigle
- Department of SurgerySchool of MedicineThe University of North Carolina at Chapel HillChapel HillNC
| | - Catherine R. Lesko
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
| | - Samuel Cykert
- Department of Internal MedicineSchool of MedicineThe University of North Carolina at Chapel HillChapel HillNC
| | - William P. Robinson
- Division of Vascular SurgerySouthern Illinois University School of MedicineSpringfieldIL
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27
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McGinigle KL, Ngeve SM, Browder SE, Hammrick ME, Wood JE, Parodi FE, Pascarella LE, Farber MA, Marston WA. Analysis of Wound Healing Time and Wound-free Period in Patients With Chronic Limb-threatening Ischemia Treated With and Without Revascularization. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2021.11.032] [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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28
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Levin SR, Farber A, Goodney PP, Schermerhorn ML, Eslami MH, Patel VI, Garg K, McGinigle KL, Siracuse JJ. The U.S. Preventive Services Task Force Abdominal Aortic Aneurysm Screening Guidelines Negligibly Impacted Repair Rates in Male Never-Smokers and Female Smokers. Ann Vasc Surg 2021; 82:87-95. [PMID: 34936889 DOI: 10.1016/j.avsg.2021.11.020] [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: 10/28/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE In 2014, in addition to male smokers aged 65-75, the U.S. Preventive Services Task Force (USPSTF) recommended abdominal aortic aneurysm (AAA) screening for male never-smokers aged 65-75 with cardiovascular risk factors (Grade C). The USPSTF evolved from a negative to neutral position on screening for female smokers aged 65-75 (Grade I). We sought to determine whether 2014 guidelines resulted in more AAA repairs in these populations. METHODS We queried the Vascular Quality Initiative national database (2013-2018) for elective endovascular aortic repairs and open aortic repairs. We implemented difference-in-differences (DID) analysis, a causal inference technique that adjusts for secular time trends, to isolate changes in repair numbers due to the 2014 USPSTF guidelines. Our DID models compared changes in repair numbers in patient groups targeted by the USPSTF updates (intervention group) to those in unaffected, older patient groups (control), before and after 2014. The first model compared changes in repair numbers between male never-smokers aged 65-75 (intervention group) and 76-85 (control). The second model compared repair numbers between female smokers aged 65-75 (intervention group) and 76-85 (control). RESULTS There was no significant change in male never-smokers (n=1,295) aged 65-75 (42%) vs. 76-85 (58%) undergoing AAA repairs after guideline updates, averaged over 4.5 years (+2.4 percentage points; 95% Confidence Interval [CI] -.56-5.26). However, when their primary insurer was Medicare, male never-smokers aged 65-75 compared with 76-85 underwent significantly more repairs over 4.5 years (+3.69 percentage points; 95% CI.16-7.22; representing a 10.4% relative increase from baseline in the proportion of male never-smokers on Medicare undergoing AAA repair). Comparing female smokers (n=2,312) aged 65-75 (54%) vs. 76-85 (46%), there was no significant change in repairs over 4.5 years (-.66 percentage points; 95% CI -4.57-3.26). CONCLUSIONS The USPSTF 2014 AAA guidelines were associated with modestly increased repairs in male never-smokers aged 65-75 only on Medicare. There was no impact among female smokers. Higher-grade recommendations and improved guideline adherence may be requisites for change.
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Affiliation(s)
- Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Philip P Goodney
- Division of Vascular and Endovascular Surgery, Dartmouth-Hitchcock Medical Center, Hanover, NH
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mohammad H Eslami
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Virendra I Patel
- Section of Vascular Surgery and Endovascular Interventions, NYP-Columbia University Irving Medical Center, New York, NY
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, NYU Langone Health, New York, NY
| | - Katharine L McGinigle
- Division of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA.
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29
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Allen AJ, Duchesneau ED, Russell D, McGinigle KL, Pascarella L. Gender Outcomes in Aorto-Iliac Revascularization in Patients with Suprainguinal Disease. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.665] [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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30
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Marston WA, Browder SE, Iles K, Griffith A, McGinigle KL. Early thrombosis after iliac stenting for venous outflow occlusion is related to disease severity and type of anticoagulation. J Vasc Surg Venous Lymphat Disord 2021; 9:1399-1407.e1. [PMID: 33667740 PMCID: PMC10066803 DOI: 10.1016/j.jvsv.2021.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 02/21/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND Stenting of the iliac venous system is often performed for symptomatic obstruction, with high patency rates reported. However, patients with post-thrombotic disease and those with more extensive obstruction have experienced poorer outcomes, including a higher rate of early post-stent thrombosis. In the present study, we examined the outcomes of patients with complete venous outflow occlusion. We focused on the variables associated with early post-stenting thrombosis to identify opportunities to reduce its incidence. METHODS From 2010 to 2020, the patients who had undergone stenting for chronic obstruction of the common femoral vein, iliac veins, and/or inferior vena cava were retrospectively reviewed. The pre- and intraoperative imaging studies were examined to identify those who had had total occlusion of one venous outflow segment (type III disease) or multiple venous outflow segments (type IV disease). The patient characteristics and procedural and post-stent variables were recorded. The post-procedure follow-up visits and imaging studies were reviewed to determine stent patency and thrombotic complications. Key variables were studied to determine their association with early stent reocclusion. RESULTS A total of 106 patients were identified, including 43 with type III (40.6%) and 63 with type IV (59.4%) disease. The mean patient age was 49.8 ± 13.7 years, and the mean stented length was 177.3 ± 63 mm. Stainless steel Wallstents were used solely in 44% of the cases, with a variety of nitinol stents used in the remainder. Femoral vein inflow was minimally diseased in 50% of the cases, moderately diseased in 26%, and severely diseased or occluded in 24%. Antiplatelet medications were prescribed after intervention for 52.8% and anticoagulation medication for 95.3% of the patients. Occlusion of the stented segment occurred within 3 months in 25.5%. Primary patency was 74.5% at 3 months, 63.9% at 12 months, and 58.5% at 3 years. Secondary patency was 93.4% at 3 months and 76.1% at 3 and 5 years. Univariate analysis of variables related to early stent thrombosis identified the presence of a hypercoagulable state, type IV obstruction, and the type of anticoagulation used after stenting were associated with early stent thrombosis. On multivariate analysis, each of these variables was independently associated with early stent thrombosis. The presence of type IV obstruction (odds ratio [OR], 4.596; 95% confidence interval [CI], 1.424-18.109) or a hypercoagulable state (OR, 3.835; 95% CI, 1.207-12.871) was associated with significantly greater odds of reocclusion than was class III obstruction and no hypercoagulable state. Treatment with low-molecular-weight heparin for >10 days was associated with significantly lower odds (OR, 0.012; 95% CI, 0.001-0.130) of reocclusion. CONCLUSIONS Patients who require recanalization of a completely occluded venous outflow tract before stenting have a high rate of early reocclusion. Patients with more extensive occlusion and a hypercoagulable state have greater odds of reocclusion. Treatment with low-molecular-weight heparin for >10 days reduced the odds of early reocclusion.
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Affiliation(s)
- William A Marston
- Division of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC.
| | - Sydney E Browder
- Division of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Kathleen Iles
- Division of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Anna Griffith
- Division of Hematology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Katharine L McGinigle
- Division of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
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31
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Weiner SL, Marston WA, Benton MH, Yohann AN, McGinigle KL. High Stroke Rate in Patients with Asymptomatic Severe Carotid Stenosis Who Are Medically Managed. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.655] [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: 11/24/2022]
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32
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Khoury AL, McGinigle KL, Freeman NL, El-Zaatari H, Feltner C, Long JM. Enhanced recovery after thoracic surgery: Systematic review and meta-analysis. JTCVS Open 2021; 7:370-391. [PMID: 36003715 PMCID: PMC9390629 DOI: 10.1016/j.xjon.2021.07.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/08/2021] [Indexed: 12/29/2022]
Abstract
ERATS decreased length of stay, postoperative complications, and readmission.
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Affiliation(s)
- Audrey L Khoury
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC.,Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC.,Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Katharine L McGinigle
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Nikki L Freeman
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Helal El-Zaatari
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Cynthia Feltner
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC.,Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jason M Long
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
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McGinigle KL, Freeman NLB, Marston WA, Farber A, Conte MS, Kosorok MR, Kalbaugh CA. Precision Medicine Enables More TNM-Like Staging in Patients With Chronic Limb Threatening Ischemia. Front Cardiovasc Med 2021; 8:709904. [PMID: 34336963 PMCID: PMC8322654 DOI: 10.3389/fcvm.2021.709904] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 06/24/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: In cancer, there are survival-based staging systems and tailored, stage-based treatments. There is little personalized treatment in vascular disease. The 2019 Global Vascular Guidelines on the Management of CLTI proposed successful treatment hinges upon Patient risk, Limb severity, and ANatomic complexity (PLAN). We sought to confirm a three axis approach and define how increasing severity affects mortality, not just limb loss. Methods: Patients revascularized for incident CLTI at our institution from 2013 to 2017 were included. Outcomes were mortality, limb loss, the composite endpoint of amputation-free survival. Using Bayesian machine learning, specifically supervised topic modeling, clusters of patient features associated with mortality were formed after controlling for revascularization type. Patients were assigned to the cluster they belonged to with highest probability; clusters were characterized by analyzing the characteristics of patients within them. Patient outcomes were used to order the clusters into stages with increasing mortality. Results: We defined three distinct clusters as the basis for patient- and limb-centered stages. Across stages, rates of 1-year mortality were 7.6, 13.8, 18.9% and rates of amputation-free survival were 84.8, 79.3, and 63.2%. Stage one had patients with rest pain and previous revascularization who were less likely to have wounds, diabetes, and renal disease. Stage two had doubled mortality, likely related to diabetes prevalence. Stage three is characterized by high rates of complicated comorbidities, particularly end stage renal disease, and significantly higher rate of limb loss (22.6 vs. 8% in stages one and two). Conclusion: Using precision medicine, we have demonstrated clustering of CLTI patients that can be used toward a robust staging system. We provide empiric evidence for PLAN and detail about how changes in each variable affect survival and amputation-free survival.
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Affiliation(s)
- Katharine L McGinigle
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Nikki L B Freeman
- Department of Biostatistics, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - William A Marston
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Alik Farber
- Department of Surgery, Boston University School of Medicine, Boston, MA, United States
| | - Michael S Conte
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Michael R Kosorok
- Department of Biostatistics, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Corey A Kalbaugh
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States.,Department of Bioengineering, Clemson University, Clemson, SC, United States
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McGinigle KL, Minc SD. Disparities in amputation in patients with peripheral arterial disease. Surgery 2021; 169:1290-1294. [PMID: 33648767 DOI: 10.1016/j.surg.2021.01.025] [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: 01/15/2021] [Accepted: 01/18/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND To describe peripheral arterial disease-related amputation as a marker for health disparities.
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Affiliation(s)
- Katharine L McGinigle
- Department of Surgery, Division of Vascular Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Samantha D Minc
- Department of Cardiovascular and Thoracic Surgery, Division of Vascular Surgery, West Virginia University, Morgantown, WV; Department of Occupational and Environmental Health Sciences, School of Public Health, West Virginia University, Morgantown, WV. https://twitter.com/SamanthaMinc
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Levin SR, Farber A, Goodney PP, Schermerhorn ML, Eslami MH, McGinigle KL, Raifman J, Siracuse JJ. The 2014 U.S. Preventive Services Task Force Abdominal Aortic Aneurysm Screening Guidelines Negligibly Impacted Repair Rates In Male Never-smokers And Female Smokers. Ann Vasc Surg 2021. [DOI: 10.1016/j.avsg.2021.01.042] [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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Hall MR, Kalbaugh CA, Tsujimoto TH, McGinigle KL. Regional Anaesthesia Alone is Reasonable for Major Lower Extremity Amputation in High Risk Patients and May Initiate a More Efficacious Enhanced Recovery Programme. Eur J Vasc Endovasc Surg 2020; 60:747-751. [DOI: 10.1016/j.ejvs.2020.06.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 05/19/2020] [Accepted: 06/25/2020] [Indexed: 10/23/2022]
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McGinigle KL, Freeman NL, Farber A, Kalbaugh CA. Precision Medicine Can Combine Existing Staging Systems to Predict Survival of Patients with Chronic Limb Threatening Ischemia. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.08.167] [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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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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Kalbaugh CA, Strassle PD, Paul NJ, McGinigle KL, Kibbe MR, Marston WA. Trends in Surgical Indications for Major Lower Limb Amputation in the USA from 2000 to 2016. Eur J Vasc Endovasc Surg 2020; 60:88-96. [DOI: 10.1016/j.ejvs.2020.03.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 02/17/2020] [Accepted: 03/17/2020] [Indexed: 01/03/2023]
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Levin SR, Farber A, Goodney PP, Schermerhorn ML, Eslami MH, McGinigle KL, Raifman J, Siracuse JJ. The 2014 U.S. Preventive Services Task Force Abdominal Aortic Aneurysm Screening Guidelines Had a Negligible Impact on Repair Rates in Male Never-Smokers and Female Smokers. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.04.106] [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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McGinigle KL, Kindell DG, Strassle PD, Crowner JR, Pascarella L, Farber MA, Marston WA, Arya S, Kalbaugh CA. Poor glycemic control is associated with significant increase in major limb amputation and adverse events in the 30-day postoperative period after infrainguinal bypass. J Vasc Surg 2020; 72:987-994. [PMID: 32139308 DOI: 10.1016/j.jvs.2019.11.048] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 07/10/2019] [Accepted: 11/20/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Understanding modifiable risk factors to improve surgical outcomes is increasingly important in value-based health care. There is an established association between peripheral artery disease (PAD), diabetes, and limb loss, but less is known about expected outcomes after revascularization relative to the degree of glycemic control. The purpose of this study was to determine the association between hemoglobin A1c (HbA1c) management in diabetics and surgical outcomes after open infrainguinal bypass. METHODS The Vascular Quality Initiative infrainguinal bypass module was used to identify adult patients (≥18 years) with a history of diabetes who underwent bypass for PAD between 2011 and 2018. Exclusion criteria included missing or illogical HbA1c values and if the indication for the limb treated was not PAD. Patients were categorized by preoperative HbA1c levels as low severity/controlled (<7.0%), high severity (7.0%-10.0%), and very high severity (>10.0%). Primary outcomes were 30-day incidence of major adverse cardiac events (MACEs), major adverse limb events (MALEs), ipsilateral amputation, and 1-year all-cause mortality. Thirty-day outcomes were calculated using multivariable regression to compute odds ratios; hazard ratios were calculated for all-cause mortality. All analyses were adjusted for demographics, comorbidities, and clinical characteristics. RESULTS The final sample included 30,813 operations (27,988 unique patients): 17,517 (57%) nondiabetic patients, 5194 patients with low-severity/controlled diabetes, and 8102 (26%) patients with poorly controlled diabetes, including 5531 (70%) treated with insulin. There were 6439 (21%) patients with high-severity HbA1c values and 1663 (5%) patients with very-high-severity HbA1c values. Those with a very high HbA1c level were more likely to be nonwhite, insulin dependent, and active smokers. Compared with nondiabetics, patients with very-high-severity HbA1c had an 81% increase in MACEs and 31% increase in MALEs, whereas patients with high-severity HbA1c only had a 49% increase in MACEs and a 12% increase in MALEs. Each one-step increase in severity category (eg, low to high to very high) was associated with an average 29% increase in the odds of MACEs and an 8% increase in the odds of MALEs. CONCLUSIONS Uncontrolled diabetes with an HbA1c value >10.0% was associated with significantly worse 30-day surgical outcomes. Patients with incrementally better glycemic control (HbA1c level of 7.0%-10.0%) did not suffer the same rate of complications, suggesting that preoperative attempts at improving diabetes management even slightly could lead to improved surgical outcomes in open infrainguinal bypass patients.
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Affiliation(s)
- Katharine L McGinigle
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Daniel G Kindell
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Paula D Strassle
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jason R Crowner
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Luigi Pascarella
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Mark A Farber
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - William A Marston
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Shipra Arya
- Department of Surgery, School of Medicine, Stanford University, Palo Alto, Calif
| | - Corey A Kalbaugh
- Department of Public Health Sciences, Clemson University, Clemson, SC
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Motta F, Parodi FE, Crowner JR, Pascarella L, McGinigle KL, Marston WA, Kibbe MR, Farber MA. Performance of Viabahn Balloon-Expandable Stent Compared With Self-expanding Covered Stents for Fenestrated-Branched Endovascular Aortic Repair. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2019.10.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Affiliation(s)
- Brooke A. Chidgey
- Department of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill
| | | | - Peggy P. McNaull
- Department of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill
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Kindell DG, Kalbaugh CA, McGinigle KL. Uncontrolled Diabetes Is Associated with Significant Increase in Limb Amputation in the 30-Day Postoperative Period after Lower Extremity Bypass. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.748] [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: 10/25/2022]
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Motta F, Crowner JR, Kalbaugh CA, Knowles M, Pascarella L, McGinigle KL, Farber MA. Stenting of superior mesenteric and celiac arteries does not increase complication rates after fenestrated-branched endovascular aneurysm repair. J Vasc Surg 2019; 70:691-701. [DOI: 10.1016/j.jvs.2018.11.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 11/13/2018] [Indexed: 11/17/2022]
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Young JC, Paul NJ, Karatas TB, Kondrasov SA, McGinigle KL, Crowner JR, Pascarella L, Farber MA, Kibbe MR, Marston WA, Kalbaugh CA. Cigarette smoking intensity informs outcomes after open revascularization for peripheral artery disease. J Vasc Surg 2019; 70:1973-1983.e5. [PMID: 31176638 DOI: 10.1016/j.jvs.2019.02.066] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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: 10/11/2018] [Accepted: 02/20/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Cigarette smoking is the leading risk factor for peripheral artery disease (PAD). Existing literature often defines smoking history in broad categories of current, former, and never smokers, which may not sufficiently identify patients at the highest risk for poor outcomes. The purpose of this study was to examine the use of more informative categorization of smoking and to determine the association with important revascularization outcomes. METHODS We conducted a retrospective review of all patients undergoing open lower extremity revascularization for symptomatic PAD, defined as claudication (Rutherford 3) or critical limb ischemia (Rutherford 4-6), during a 5-year period (2013-2017). Smoking history, demographics, and comorbidities were abstracted from electronic health records from seven hospitals within our health care system. Smoking history was defined by intensity (packs/day), duration (years), pack-year history, and cessation time. Outcomes included major adverse limb events (MALEs), death, limb loss, and amputation-free survival. Cox proportional hazards models were used to calculate hazard ratios and 95% confidence intervals (CIs) for each parameter adjusted for patients' demographics and comorbidities. Cumulative incidence is reported for outcomes at 30, 180, and 365 days of follow-up. RESULTS We identified 693 patients undergoing open lower extremity revascularization for PAD (66% critical limb ischemia; 46% diabetes). The 1-year cumulative incidence of MALEs was 29.9% (95% CI, 26.4-33.9), whereas the 1-year incidence of death was 9.8% (95% CI, 7.5-12.7). The broad classification of current and former smokers identified no statistically significant differences in any measured outcomes. Patients who smoked more than one pack/day had 1.48 (95% CI, 1.01-2.16) times increase in risk of MALEs at 1 year compared with patients who smoked one or fewer packs/day. Patients who smoked more than one pack/day also had the highest 1-year amputation incidence (12.7%). Each of the four parameters was associated with increased risk of poor outcomes, although small sample size limited the precision of our estimates. CONCLUSIONS We found that smoking intensity is particularly informative of outcomes of patients undergoing open lower extremity revascularization for symptomatic PAD. These findings lay the groundwork for future research on relevant smoking history parameters and benefits of smoking reduction and cessation for clinicians to discuss with patients and to better understand and inform patients of intervention risks and expected outcomes.
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Affiliation(s)
- Jessica C Young
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Nicole Jadue Paul
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Turkan Banu Karatas
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Sasha A Kondrasov
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Katharine L McGinigle
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jason R Crowner
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Luigi Pascarella
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Mark A Farber
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Melina R Kibbe
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - William A Marston
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Corey A Kalbaugh
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC.
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McGinigle KL, Eldrup-Jorgensen J, McCall R, Freeman NL, Pascarella L, Farber MA, Marston WA, Crowner JR. A systematic review of enhanced recovery after surgery for vascular operations. J Vasc Surg 2019; 70:629-640.e1. [PMID: 30922754 DOI: 10.1016/j.jvs.2019.01.050] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 01/05/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients undergoing vascular operations face high rates of intraoperative and postoperative complications and delayed return to baseline. Enhanced recovery after surgery (ERAS), with its aim of delivering high-quality perioperative care and accelerating recovery, appears well suited to address the needs of this population. METHODS In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we performed a systematic review to characterize the use and effectiveness of ERAS in all types of vascular and endovascular operations. We queried MEDLINE (through PubMed), Embase, Web of Science, Scopus, ProQuest Dissertations and Theses Global, Cochrane Central Register of Controlled Trials, Prospero, and Google Scholar. Two reviewers independently completed screening, review, and quality assessment. Eligible articles described the use of ERAS pathways for vascular operations from January 1, 1997, through December 7, 2017. Details regarding patients' demographics and use of the ERAS pathway or selected ERAS components were extracted. When available, results including perioperative morbidity, mortality, and in-hospital length of stay were collected. The studies with control groups that evaluated ERAS-like pathways were meta-analyzed using random-effects meta-analysis. RESULTS In the final analysis, 19 studies were included: four randomized controlled trials and 15 observational studies. By Let Evidence Guide Every New Decision (LEGEND) criteria, the two good-quality studies are randomized controlled trials that evaluated a specific part of an ERAS pathway. All other studies were considered poor quality. Meta-analysis of the five studies describing ERAS-like pathways demonstrated a reduction in length of stay by 3.5 days (P = .0012). CONCLUSIONS Based on systematic review, the use of ERAS pathways in vascular surgery is limited, and existing evidence of their feasibility and effectiveness is low quality. There is minimal poor- to moderate-quality evidence describing the use of ERAS pathways in open aortic operations. There is scarce, poor-quality evidence related to ERAS pathways in lower extremity operations and no published evidence related to ERAS pathways in endovascular operations. Although the risk of bias is high in most of the studies done to date, all of them observed improvements in length of stay, postoperative diet, and ambulation. It is reasonable to consider the implementation of ERAS pathways in the care of vascular surgery patients, specifically those undergoing open aortic operations, but many of the details will be based on limited data and extrapolation from other surgical specialties until further research is done.
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Affiliation(s)
- Katharine L McGinigle
- Department of Surgery, Division of Vascular Surgery, University of North Carolina, Chapel Hill, NC.
| | - Jens Eldrup-Jorgensen
- Department of Surgery, Division of Vascular Surgery, Maine Medical Center, Portland, Me
| | - Rebecca McCall
- Health Science Library, University of North Carolina, Chapel Hill, NC
| | - Nikki L Freeman
- Department of Statistics, University of North Carolina, Chapel Hill, NC
| | - Luigi Pascarella
- Department of Surgery, Division of Vascular Surgery, University of North Carolina, Chapel Hill, NC
| | - Mark A Farber
- Department of Surgery, Division of Vascular Surgery, University of North Carolina, Chapel Hill, NC
| | - William A Marston
- Department of Surgery, Division of Vascular Surgery, University of North Carolina, Chapel Hill, NC
| | - Jason R Crowner
- Department of Surgery, Division of Vascular Surgery, University of North Carolina, Chapel Hill, NC
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Antonescu I, McGinigle KL, Crowner JR. A case of aneurysmal dilation of a brachial artery after venous outflow resection. J Vasc Surg Cases Innov Tech 2019; 4:335-338. [PMID: 30761382 PMCID: PMC6298935 DOI: 10.1016/j.jvscit.2018.08.010] [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] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 08/29/2018] [Indexed: 11/15/2022]
Abstract
Dilation throughout the brachial artery in the setting of an arteriovenous fistula is a common occurrence, but focal aneurysmal dilation is not often visualized. Progressive enlargement of a focal arterial segment warrants intervention before negative sequelae. We present the case of a 38-year-old man with history of left upper extremity brachiocephalic fistula who had an enlarged brachial artery and progressive aneurysmal dilation of the distal aspect after ligation and excision of a dilated venous outflow component. The patient was successfully treated with resection and end-to-end reconstruction of the brachial artery, with resolution of pain and improvement in the functionality of his extremity. This case highlights the possible challenges encountered in such situations, when the anatomy is so distorted that it is difficult to clearly delineate on preoperative imaging.
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Affiliation(s)
- Ioana Antonescu
- Correspondence: Ioana Antonescu, MD, MSc, Vascular Surgery, UNCH, 3024 Burnett-Womack Bldg, Chapel Hill, NC 27599
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Motta F, Crowner JR, Kalbaugh CA, Marston WA, Pascarella L, McGinigle KL, Kibbe MR, Farber MA. Outcomes and complications after fenestrated-branched endovascular aortic repair. J Vasc Surg 2018; 70:15-22. [PMID: 30591293 DOI: 10.1016/j.jvs.2018.10.052] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [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: 05/11/2018] [Accepted: 10/01/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To report the outcomes of patients enrolled in a physician-sponsored investigational device exemption trial for endovascular treatment of complex thoracoabdominal aortic aneurysms with fenestrated and/or branched devices. METHODS This study represents a retrospective analysis of a prospectively maintained database of patients enrolled in a physician-sponsored investigational device exemption trial for endovascular treatment of complex thoracoabdominal aneurysms between July 2012 and July 2017. Subjects included high-risk patients for open repair and patients with unsuitable anatomy for either standard endovascular aneurysm repair or Zenith (Cook Medical, Bloomington, Ind) fenestrated device. Aneurysm classification was based upon Crawford classification. We included the pararenal and paravisceral aneurysms in the type IV aneurysm group, because the repair of these aneurysms usually involved treatment of all four visceral branches. The endografts implanted were custom manufactured devices or off-the-shelf devices based on the Cook Zenith platform. Variables analyzed included preoperative demographics and comorbidities, anatomic aneurysmal characteristics, procedural details, and perioperative complications. RESULTS One -hundred fifty patients with a mean age of 71 ± 7.9 years were treated; 69% were male. Tobacco use (93%) and hypertension (91%) were the most common risk factors. Fifty-seven patients (38%) had a history of previous aortic repair. The mean aneurysm diameter was 62 ± 12 mm and 14 (9%) aneurysms were associated with chronic dissection. A total of 573 visceral vessels were incorporated (celiac artery/superior mesenteric artery [287 vessels], renal arteries [275 vessels], and 11 additional vessels) and 539 were stented. The celiac artery/superior mesenteric artery received a fenestrated design in 76.1% of cases. Branch designs were used in the renal artery in 13.2%, with the remainder treated with fenestrations. Spinal cord drainage was used in 51% of patients (76/150). The mean operative time, fluoroscopy time, and estimated blood loss were 283 ± 89 minutes, 83 ± 38 minutes, and 417 ± 404 mL, respectively. There were five patients (3.3%) with intraoperative complications, resulting in one intraoperative death. The early mortality was 2.7% (4/150). Major complications included respiratory failure in 7% (10/150), stroke and myocardial infarction in 0.7% each (1/150), and paraplegia in 2.7% (4/150). Acute kidney injury occurred in 4.7% of patients (7/150), two of whom required temporary dialysis. Thirty-nine percent of patients experienced at least one complication. Early branch vessel patency was 99.8% (525/526). Survival, primary, and primary-assisted branch patency at 2 years of follow-up were 79%, 97%, and 99%, respectively. CONCLUSIONS Endovascular repair of complex aneurysms is safe and effective when performed in a high-volume center experienced in aortic disease management. Branch vessels patency and the low incidence of paraplegia and mortality support expanded use to treat most complex thoracoabdominal aortic aneurysms.
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Affiliation(s)
- Fernando Motta
- Division of Vascular Surgery, Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jason R Crowner
- Division of Vascular Surgery, Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Corey A Kalbaugh
- Division of Vascular Surgery, Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - William A Marston
- Division of Vascular Surgery, Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Luigi Pascarella
- Division of Vascular Surgery, Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Katharine L McGinigle
- Division of Vascular Surgery, Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Melina R Kibbe
- Division of Vascular Surgery, Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Mark A Farber
- Division of Vascular Surgery, Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC.
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Kalbaugh CA, Young JC, Paul NJ, McGinigle KL, Crowner J, Pascarella L, Farber MA, Kibbe MR, Marston WA. Smoking Intensity and Major Adverse Limb Events Following Infrainguinal Bypass for Symptomatic Peripheral Artery Disease. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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