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Walsh JP, Hentschel DM, Sharma G, Lotto CE, Ozaki CK. Contemporary Strategies to Promote Dialysis Access Fistula Maturation. Vasc Endovascular Surg 2022; 56:590-594. [PMID: 35574704 DOI: 10.1177/15385744211037834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: The inability of a newly created arteriovenous fistula to support hemodialysis due to non-maturation results in increased complications secondary to catheter dependence. Methods: In view of the highly variable approaches by providers with heterogenous backgrounds (general surgery, vascular surgery, interventional radiology and interventional nephrology, urology, transplant surgery, etc.) we sought to describe a collection of algorithms that have functioned well in our hands to manage this challenging clinical problem and guide trainees and practicing clinicians alike.Results: Physical examination along with selective duplex ultrasound and fistulogram can identify most pathologies underlying non-maturation.Conclusion: Both endovascular and open techniques can be employed to optimize maturation rates in this complex population.
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Affiliation(s)
- Jillian P Walsh
- 1861Division of Vascular and Endovascular Surgery, Brigham & Women's Hospital, Boston, MA, USA
| | - Dirk M Hentschel
- Brigham Health, Renal Division, 1861Brigham & Women's Faulkner Hospital, Boston, MA, USA
| | - Gaurav Sharma
- 1861Division of Vascular and Endovascular Surgery, Brigham & Women's Hospital, Boston, MA, USA
| | - Christine E Lotto
- Division of Vascular and Endovascular Surgery, Capital Health Medical Center, Pennington, NJ, USA
| | - Charles Keith Ozaki
- 1861Division of Vascular and Endovascular Surgery, Brigham & Women's Hospital, Boston, MA, USA
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Sharma G, Madenci AL, Wanis KN, Comment LA, Lotto CE, Shah SK, Ozaki CK, Subramanian SV, Eldrup-Jorgensen J, Belkin M. Association and interplay of surgeon and hospital volume with mortality after open abdominal aortic aneurysm repair in the modern era. J Vasc Surg 2020; 73:1593-1602.e7. [PMID: 32976969 DOI: 10.1016/j.jvs.2020.07.108] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 07/30/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Operative volume has been used as a marker of quality. Research from previous decades has suggested minimum open abdominal aortic aneurysm (AAA) repair volume requirements for surgeons of 9 to 13 open AAA repairs annually and for hospitals of 18 open AAA repairs annually to purportedly achieve acceptable results. Given concerns regarding the decreased frequency of open repairs in the endovascular era, we examined the association of surgeon and hospital volume with the 30- and 90-day mortality in the Vascular Quality Initiative (VQI) registry. METHODS Patients who had undergone elective open AAA repair from 2013 to 2018 were identified in the VQI registry. We performed a cross-sectional evaluation of the association between the average hospital and surgeon volume and 30-day postoperative mortality using a hierarchical Bayesian model. Cross-level interactions were permitted, and random surgeon- and hospital-level intercepts were used to account for clustering. The mortality results were adjusted by standardizing to the observed distribution of relevant covariates in the overall cohort. The outcomes were compared to the Society for Vascular Surgery guidelines recommended criteria of <5% perioperative mortality. RESULTS A total of 3078 patients had undergone elective open AAA repair by 520 surgeons at 128 hospitals. The 30- and 90-day risks of postoperative mortality were 4.1% (n = 126) and 5.4% (n = 166), respectively. The mean surgeon volume and hospital volume both correlated inversely with the 30-day mortality. Averaged across all patients and hospitals, we found a 96% probability that surgeons who performed an average of four or more repairs per year achieved <5% 30-day mortality. Substantial interplay was present between surgeon volume and hospital volume. For example, at lower volume hospitals performing an average of five repairs annually, <5% 30-day mortality would be expected 69% of the time for surgeons performing an average of three operations annually. In contrast, at higher volume hospitals performing an average of 40 repairs annually, a <5% 30-day mortality would be expected 96% of the time for surgeons performing an average of three operations annually. As hospital volume increased, a diminishing difference occurred in 30-day mortality between lower and higher volume surgeons. Likewise, as surgeon volume increased, a diminishing difference was found in 30-day mortality between the lower and higher volume hospitals. CONCLUSIONS Surgeons and hospitals in the VQI registry achieved mortality outcomes of <5% (Society for Vascular Surgery guidelines), with an average surgeon volume that was substantially lower compared with previous reports. Furthermore, when considering the development of minimal surgeon volume guidelines, it is important to contextualize the outcomes within the hospital volumes.
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Affiliation(s)
- Gaurav Sharma
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center, Harvard Medical School, Boston, Mass
| | - Arin L Madenci
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center, Harvard Medical School, Boston, Mass; Harvard T.H. Chan School of Public Health, Boston, Mass
| | | | | | - Christine E Lotto
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center, Harvard Medical School, Boston, Mass
| | - Samir K Shah
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center, Harvard Medical School, Boston, Mass; Harvard T.H. Chan School of Public Health, Boston, Mass
| | - C Keith Ozaki
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center, Harvard Medical School, Boston, Mass
| | | | | | - Michael Belkin
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center, Harvard Medical School, Boston, Mass.
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Lotto CE, Sharma G, Walsh JP, Shah SK, Nguyen LL, Ozaki CK, Menard MT, Belkin M. The impact of combined iliac occlusive disease and aortic aneurysm on open surgical repair. J Vasc Surg 2019; 71:2021-2028.e1. [PMID: 31727458 DOI: 10.1016/j.jvs.2019.08.249] [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: 02/06/2019] [Accepted: 08/11/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Severe aortoiliac occlusive disease is a relative contraindication for endovascular aneurysm repair, owing to an association with high stent graft-related complication and reintervention rates in this population. Open AAA repair requiring aortofemoral bypass (AFB), however, may represent a unique population with differing outcomes from standard open repair. We sought to compare the demographic and procedural characteristics, as well as outcomes of patients undergoing standard intra-abdominal repairs (STD) versus those requiring AFB. METHODS Using a prospectively maintained database, we retrospectively identified patients who underwent open AAA repair from 1994 to 2017. A total of 1087 consecutive cases were performed consisting of 981 STD (681 tube graft, 300 aortoiliac) and 106 AFB cases. Demographics, procedural data, postoperative complications, and long-term survival were analyzed. RESULTS The AFB cohort had more women (39.0 vs 22.8%; P = .001) and higher rates of hypertension (81.1 vs 69.8%; P = .015), chronic obstructive pulmonary disease (28.3 vs 17.4%; P = .006), and smoking (50.9 vs 36%; P = .002). The AFB group had smaller mean aortic (5.22 vs 5.77 cm; P = .001) and graft (17.08 vs 18.2 mm; P = .001) diameters. Proximal clamp position and blood loss were equivalent, although total anesthesia time was longer (295 vs 234 minutes; P = .001) in the AFB cohort. Overall 30-day postoperative morbidity (38.7 vs 24.8%; P = .002) was higher in the AFB group. Specifically, postoperative renal insufficiency (8.2 vs 3.4%; P = .032), wound infection (5.7 vs 1.2%; P = .005), and hematoma/seroma (5.7 vs 1.2%; P = .003) were more likely. Hospital length of stay was longer for AFB (11.9 vs 9.9 days; P = .007). The 30-day mortality (0.9% AFB vs 1.8% STD; P = .50) and major morbidity (17 vs 11.5%; P = .10) did not differ. Reintervention rate within 30 days of the initial surgery (12.3 vs 4.6; P = .001) and overall (33 vs 18.9%; P = .001) was higher in the AFB group. Long-term survival was lower in the AFB group (5-year survival: 63.1% AFB vs 71.9% STD; hazard ratio 0.76, log-rank P = .047). Multivariate regression analysis identified age, comorbid conditions, and aneurysm characteristics-rather than repair type-as independent predictors of 30-day reintervention and mortality at 5 years. CONCLUSIONS Patients requiring AFB for AAA owing to associated iliac occlusive disease have more preoperative comorbidities, postoperative complications, a longer length of stay, reintervention rates and shorter 5-year survival. Patient and aneurysm characteristics rather than surgical repair type appear to be responsible for these differences. Nevertheless, 30-day mortality and major morbidity were comparable, making AFB an attractive alternative to endovascular aneurysm repair in patients with advanced iliac occlusive disease.
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Affiliation(s)
- Christine E Lotto
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center/Harvard Medical School, Boston, Mass
| | - Gaurav Sharma
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center/Harvard Medical School, Boston, Mass
| | - Jillian P Walsh
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center/Harvard Medical School, Boston, Mass
| | - Samir K Shah
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center/Harvard Medical School, Boston, Mass
| | - Louis L Nguyen
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center/Harvard Medical School, Boston, Mass
| | - C Keith Ozaki
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center/Harvard Medical School, Boston, Mass
| | - Matthew T Menard
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center/Harvard Medical School, Boston, Mass
| | - Michael Belkin
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center/Harvard Medical School, Boston, Mass.
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Blackwood SL, O'Leary JJ, Scully RE, Lotto CE, Nguyen LL, Gravereaux EC, Menard MT, Ozaki CK, Gates JD, Belkin M. Emergency intraoperative vascular surgery consultations at a tertiary academic center. J Vasc Surg 2019; 71:967-978. [PMID: 31515177 DOI: 10.1016/j.jvs.2019.05.064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 12/12/2018] [Accepted: 05/29/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Vascular surgeons are frequently called on to provide emergency assistance to surgical colleagues. Whereas previous studies have included elective preoperative vascular consultations, we sought to characterize the breadth of assistance provided during unplanned intraoperative consultations at a single tertiary academic center. METHODS We queried our institutional billing department during a 15-year period and reviewed the records (January 1, 2002-December 31, 2016) and identified unanticipated unplanned vascular surgery intraoperative consultations from all surgical services. Patients' demographics and comorbidities were recorded along with the consulting services, type of index operation, reasons for vascular consultation, regions of anatomic interventions, type of vascular interventions performed, and outcomes achieved. RESULTS There were 419 emergency intraoperative consultations identified. Patients were 51% male, with an average age of 57 years and body mass index of 28.3 kg/m2. The most frequently consulting subspecialties included surgical oncology (n = 139 [33.2%]), cardiac surgery (n = 82 [19.6%]), and orthopedics (n = 44 [10.5%]). Index cases were elective/nonurgent (n = 324 [77.3%]), urgent (n = 27 [6.4%]), and emergent (n = 68 [16.2%]), with a majority involving tumor resection (n = 240 [57.3%]). The primary reasons for vascular consultation were revascularization (n = 213 [50.8%]), control of bleeding (n = 132 [31.5%]), assistance with dissection or exposure (n = 46 [11%]), embolic protection (n = 24 [5.7%]), and other (n = 4 [1.1%]). The primary blood vessel and anatomic field of intervention were categorized. Most cases (n = 264 [63%]) included preservation of blood flow, including primary arterial repair (n = 181 [43.2%]), patch angioplasty (n = 83 [19.8%]), bypass (n = 63 [15%]), and thrombectomy (n = 38 [9.1%]). Postoperative mean length of stay was 15 days, with 30-day and 1-year mortality of 7.2% and 26.5%. CONCLUSIONS Vascular surgeons are called on to provide unplanned open surgical consultations for a wide variety of specialties over wide-ranging anatomic regions, employing a variety of skills and techniques. This study testifies to the essential services supplied to hospitals and our surgical colleagues along with the broad skills and training necessary for modern vascular surgeons.
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Affiliation(s)
- Stuart L Blackwood
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass.
| | - James J O'Leary
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Rebecca E Scully
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Christine E Lotto
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Louis L Nguyen
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Edwin C Gravereaux
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Matthew T Menard
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | - C Keith Ozaki
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | | | - Michael Belkin
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
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Lotto CE, Shah S, Nguyen L, Blackwood SL, Ozaki CK, Menard MT, Belkin M. NESVS3. The Impact of Combined Iliac Occlusive Disease and Aortic Aneurysm on Open Surgical Repair. J Vasc Surg 2018. [DOI: 10.1016/j.jvs.2018.06.107] [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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Blackwood SL, O'Leary JJ, Lotto CE, Shah SK, Nguyen LL, Gravereaux EC, Menard MT, Ozaki CK, Gates JD, Belkin M. NESVS8. Emergency Intraoperative Vascular Surgery Consultations at a Tertiary Academic Center. J Vasc Surg 2018. [DOI: 10.1016/j.jvs.2018.06.112] [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: 10/28/2022]
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Macarak EJ, Lotto CE, Koganti D, Jin X, Wermuth PJ, Olsson AK, Montgomery M, Rosenbloom J. Trametinib prevents mesothelial-mesenchymal transition and ameliorates abdominal adhesion formation. J Surg Res 2018; 227:198-210. [DOI: 10.1016/j.jss.2018.02.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 01/11/2018] [Accepted: 02/13/2018] [Indexed: 12/13/2022]
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Koganti D, Lotto CE, Macarak E, Jin X, Olsson AK, Rosenbloom J. Trametinib Prevents Mesothelial-Mesenchymal Transition and Ameliorates Abdominal Adhesion Formation. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.788] [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: 10/18/2022]
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