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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024. [PMID: 38743805 DOI: 10.1161/cir.0000000000001251] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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Bansal A, Nanjundappa A, Raymond D, Kirksey L, Khot UN. Longitudinal trends in acute pulmonary embolism hospitalizations during the COVID-19 pandemic. Eur J Intern Med 2024; 123:148-150. [PMID: 38310010 DOI: 10.1016/j.ejim.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 01/16/2024] [Indexed: 02/05/2024]
Affiliation(s)
- Agam Bansal
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Aravinda Nanjundappa
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Daniel Raymond
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Lee Kirksey
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Umesh N Khot
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, United States.
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Sorour AA, Dehaini H, Alnahhal KI, Khalifeh A, Rowse JW, Quatromoni JG, Caputo FJ, Lyden SP, Kirksey L. Natural history of superior mesenteric artery in-stent restenosis. J Vasc Surg 2024; 79:818-825.e2. [PMID: 38128845 DOI: 10.1016/j.jvs.2023.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE Superior mesenteric artery (SMA) stenting is the preferred approach for patients with symptomatic SMA-associated chronic mesenteric ischemia (CMI). The durability of this modality is impacted by in-stent restenosis (ISR). Duplex ultrasound (DUS) and computed tomographic angiography (CTA)-measured ISR may be weakly correlated and not uniformly associated with recurrence of presenting symptoms. This study aims to analyze the association between the degree of ISR for patients with CMI and to develop a predictive model for symptom recurrence. METHODS Single center, retrospective study included all patients with CMI with SMA stents from the period of 2003 to 2020. Follow-up period analysis included patients' symptoms recurrence, DUS, CTA, and angiography. A receiver operating characteristic (ROC) analysis was used to evaluate whether peak systolic velocity (PSV) was predictive of symptom recurrence. A subgroup analysis of patients (asymptomatic and symptomatic) with SMA ISR was identified; restenosis defined by DUS with peak systolic velocity (PSV) ≥350. RESULTS The study included 186 patients with the ROC analysis obtained from 503 postoperative visits. PSV was not a predictor of symptoms return with area under the curve (AUC) = 0.49 (95% confidence interval [CI], 0.40-0.57). Agreement analysis between imaging modalities showed higher agreement between CTA and angiogram (AUC, 0.769; 95% CI, 0.688-0.849) vs CTA and DUS (AUC, 0.650; 95% CI, 0.589-0.711). The subgroup analysis of patients with ISR included 99 patients (asymptomatic n = 67; symptomatic n = 32). There was no statistical difference between median time (months) to ISR between both groups: 4.5 (asymptomatic group) and 7.6 (symptomatic group). The use of preoperative antiplatelet (86% vs 65%; P = .015) and P2Y12 receptor blockers (36% vs 13%; P = .016) was more prevalent in the asymptomatic group. There was no difference between the type or number of stents placed, stent diameter, or concomitant celiac artery intervention between both groups. CONCLUSIONS The natural history of SMA and multimodality defined ISR in CMI has not previously been described. Elevated PSV was a poor predictor of symptoms recurrence. Both asymptomatic and symptomatic patients with ISR did not differ in type of stent placed, time to ISR, or involvement of celiac artery. Antiplatelet use pre- and postoperatively appears protective against symptoms recurrence. Our findings underscore the need for long-term surveillance integrating clinical evaluation and multimodality imaging when indicated.
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Affiliation(s)
- Ahmed A Sorour
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Hassan Dehaini
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Khaled I Alnahhal
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Ali Khalifeh
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Jarrad W Rowse
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Jon G Quatromoni
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Francis J Caputo
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Sean P Lyden
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Lee Kirksey
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH; Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH.
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Fitridge R, Chuter V, Mills J, Hinchliffe R, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, Russell D, van den Berg JC, Venermo M, Schaper N. The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes and a foot ulcer. Diabetes Metab Res Rev 2024; 40:e3686. [PMID: 37726988 DOI: 10.1002/dmrr.3686] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this guideline the IWGDF, the European Society for Vascular Surgery and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development, and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.
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Affiliation(s)
- Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, New South Wales, Australia
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- San Francisco Medical Centre, University of California, San Francisco, California, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | | | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital, Bern, Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Nicolaas Schaper
- Division of Endocrinology, Department Internal Medicine, MUMC+, Maastricht, The Netherlands
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Chuter V, Schaper N, Hinchliffe R, Mills J, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, David R, van den Berg JC, Venermo M, Fitridge R. Performance of non-invasive bedside vascular testing in the prediction of wound healing or amputation among people with foot ulcers in diabetes: A systematic review. Diabetes Metab Res Rev 2024; 40:e3701. [PMID: 37493206 DOI: 10.1002/dmrr.3701] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 07/10/2023] [Indexed: 07/27/2023]
Abstract
INTRODUCTION The presence of peripheral artery disease (PAD) confers a significantly increased risk of failure to heal and major lower limb amputation for people with diabetes-related foot ulcer (DFU). Determining performance of non-invasive bedside tests for predicting likely DFU outcomes is therefore key to effective risk stratification of patients with DFU and PAD to guide management decisions. The aim of this systematic review was to determine the performance of non-invasive bedside tests for PAD to predict DFU healing, healing post-minor amputation, or need for minor or major amputation in people with diabetes and DFU or gangrene. METHODS A database search of Medline and Embase was conducted from 1980 to 30 November 2022. Prospective studies that evaluated non-invasive bedside tests in patients with diabetes, with and without PAD and foot ulceration or gangrene to predict the outcomes of DFU healing, minor amputation, and major amputation with or without revascularisation, were eligible. Included studies were required to have a minimum 6-month follow-up period and report adequate data to calculate the positive likelihood ratio (PLR) and negative likelihood ratio for the outcomes of DFU healing, and minor and major amputation. Methodological quality was assessed using the Quality in Prognosis Studies tool. RESULTS From 14,820 abstracts screened 28 prognostic studies met the inclusion criteria. The prognostic tests evaluated by the studies included: ankle-brachial index (ABI) in 9 studies; ankle pressures in 10 studies, toe-brachial index in 4 studies, toe pressure in 9 studies, transcutaneous oxygen pressure (TcPO2 ) in 7 studies, skin perfusion pressure in 5 studies, continuous wave Doppler (pedal waveforms) in 2 studies, pedal pulses in 3 studies, and ankle peak systolic velocity in 1 study. Study quality was variable. Common reasons for studies having a moderate or high risk of bias were poorly described study participation, attrition rates, and inadequate adjustment for confounders. In people with DFU, toe pressure ≥30 mmHg, TcPO2 ≥25 mmHg, and skin perfusion pressure of ≥40 mmHg were associated with a moderate to large increase in pretest probability of healing in people with DFU. Toe pressure ≥30 mmHg was associated with a moderate increase in healing post-minor amputation. An ABI using a threshold of ≥0.9 did not increase the pretest probability of DFU healing, whereas an ABI <0.5 was associated with a moderate increase in pretest probability of non-healing. Few studies investigated amputation outcomes. An ABI <0.4 demonstrated the largest increase in pretest probability of a major amputation (PLR ≥10). CONCLUSIONS Prognostic capacity of bedside testing for DFU healing and amputation is variable. A toe pressure ≥30 mmHg, TcPO2 ≥25 mmHg, and skin perfusion pressure of ≥40 mmHg are associated with a moderate to large increase in pretest probability of healing in people with DFU. There are little data available evaluating the prognostic capacity of bedside testing for healing after minor amputation or for major amputation in people with DFU. Current evidence suggests that an ABI <0.4 may be associated with a large increase in risk of major amputation. The findings of this systematic review need to be interpreted in the context of limitations of available evidence, including varying rates of revascularisation, lack of post-revascularisation bedside testing, and heterogenous subpopulations.
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Affiliation(s)
- Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Sydney, Australia
| | - Nicolaas Schaper
- Division of Endocrinology, Department of Internal Medicine, MUMC+, Maastricht, The Netherlands
| | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- San Francisco (UCSF) Medical Centre, University of California, San Francisco, California, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St. Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | | | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital, Bern, Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Chuter V, Schaper N, Mills J, Hinchliffe R, Russell D, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries MD, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, van den Berg JC, Venermo M, Fitridge R. Effectiveness of revascularisation for the ulcerated foot in patients with diabetes and peripheral artery disease: A systematic review. Diabetes Metab Res Rev 2024; 40:e3700. [PMID: 37539634 DOI: 10.1002/dmrr.3700] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 07/10/2023] [Indexed: 08/05/2023]
Abstract
INTRODUCTION Peripheral artery disease (PAD) is associated with an increased likelihood of delayed or non-healing of a diabetes-related foot ulcer, gangrene, and amputation. The selection of the most effective surgical technique for revascularisation of the lower limb in this population is challenging and there is a lack of conclusive evidence to support the choice of intervention. This systematic review aimed to determine, in people with diabetes and tissue loss, if direct revascularisation is superior to indirect revascularisation and if endovascular revascularisation is superior to open revascularisation for the outcomes of wound healing, minor or major amputation, and adverse events including mortality. METHODS Title and abstract searches of Medline, Embase, PubMed, and EBSCO were conducted from 1980 to 30th November 2022. Cohort and case-control studies and randomised controlled trials reporting comparative outcomes of direct (angiosome) revascularisation (DR) and indirect revascularisation (IR) or the comparative outcomes of endovascular revascularisation and open or hybrid revascularisation for the outcomes of healing, minor amputation, and major amputation in people with diabetes, PAD and tissue loss (including foot ulcer and/or gangrene) were eligible. Methodological quality was assessed using the Cochrane risk-of-bias tool for randomised trials, the ROBINS-I tool for non-randomised studies, and Newcastle-Ottawa Scale for observational and cohort studies where details regarding the allocation to intervention groups were not provided. RESULTS From a total 7086 abstracts retrieved, 26 studies met the inclusion criteria for the comparison of direct angiosome revascularisation (DR) and indirect revascularisation (IR), and 11 studies met the inclusion criteria for the comparison of endovascular and open revascularisation. One study was included in both comparisons. Of the included studies, 35 were observational (31 retrospective and 4 prospective cohorts) and 1 was a randomised controlled trial. Cohort study quality was variable and generally low, with common sources of bias related to heterogeneous participant populations and interventions and lack of reporting of or adjusting for confounding factors. The randomised controlled trial had a low risk of bias. For studies of DR and IR, results were variable, and it is uncertain if one technique is superior to the other for healing, prevention of minor or major amputation, or mortality. However, the majority of studies reported that a greater proportion of participants receiving DR healed compared with IR, and that IR with collaterals may have similar outcomes to DR for wound healing. For patients with diabetes, infrainguinal PAD, and an adequate great saphenous vein available for use as a bypass conduit who were deemed suitable for either surgical procedure, an open revascularisation first approach was superior to endovascular therapy to prevent a major adverse limb event or death (Hazard Ratio: 0.72; 95% CI 0.61-0.86). For other studies of open and endovascular approaches, there was generally no difference in outcomes between the interventions. CONCLUSIONS The majority of available evidence for the effectiveness of DR and IR and open and endovascular revascularisation for wound healing and prevention of minor and major amputation and adverse events including mortality in people with diabetes, PAD and tissue loss is inconclusive, and the certainty of evidence is very low. Data from one high quality randomised controlled trial supports the use of open over endovascular revascularisation to prevent a major limb event and death in people with diabetes, infrainguinal disease and tissue loss who have an adequate great saphenous vein available and who are deemed suitable for either approach.
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Affiliation(s)
- Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Sydney, Australia
| | - Nicolaas Schaper
- Division of Endocrinology, Department Internal Medicine, MUMC+, Maastricht, The Netherlands
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- San Francisco (UCSF) Medical Centre, University of California, San Francisco, California, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | - Joakim Nordanstig
- Department of Molecular and Clinical Medicine at the Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Department of Vascular Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital, Bern, Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Chuter V, Schaper N, Mills J, Hinchliffe R, Russell D, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, van den Berg JC, Venermo M, Fitridge R. Effectiveness of bedside investigations to diagnose peripheral artery disease among people with diabetes mellitus: A systematic review. Diabetes Metab Res Rev 2024; 40:e3683. [PMID: 37477087 DOI: 10.1002/dmrr.3683] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 06/19/2023] [Indexed: 07/22/2023]
Abstract
As a progressive disease process, early diagnosis and ongoing monitoring and treatment of lower limb peripheral artery disease (PAD) is critical to reduce the risk of diabetes-related foot ulcer (DFU) development, non-healing of wounds, infection and amputation, in addition to cardiovascular complications. There are a variety of non-invasive tests available to diagnose PAD at the bedside, but there is no consensus as to the most diagnostically accurate of these bedside investigations or their reliability for use as a method of ongoing monitoring. Therefore, the aim of this systematic review was to first determine the diagnostic accuracy of non-invasive bedside tests for identifying PAD compared to an imaging reference test and second to determine the intra- and inter-rater reliability of non-invasive bedside tests in adults with diabetes. A database search of Medline and Embase was conducted from 1980 to 30 November 2022. Prospective and retrospective investigations of the diagnostic accuracy of bedside testing in people with diabetes using an imaging reference standard and reliability studies of bedside testing techniques conducted in people with diabetes were eligible. Included studies of diagnostic accuracy were required to report adequate data to calculate the positive likelihood ratio (PLR) and negative likelihood ratio (NLR) which were the primary endpoints. The quality appraisal was conducted using the Quality Assessment of Diagnostic Accuracy Studies and Quality Appraisal of Reliability quality appraisal tools. From a total of 8517 abstracts retrieved, 40 studies met the inclusion criteria for the diagnostic accuracy component of the review and seven studies met the inclusion criteria for the reliability component of the review. Most studies investigated the diagnostic accuracy of ankle -brachial index (ABI) (N = 38). In people with and without DFU, PLRs ranged from 1.69 to 19.9 and NLRs from 0.29 to 0.84 indicating an ABI <0.9 increases the likelihood of disease (but the extent of the increase ranges from a small to large amount) and an ABI within the normal range (≥0.90 and <1.3) does not exclude PAD. For toe-brachial index (TBI), a threshold of <0.70 has a moderate ability to rule PAD in and out; however, this is based on limited evidence. Similarly, a small number of studies indicate that one or more monophasic Doppler waveforms in the pedal arteries is associated with the presence of PAD, whereas tri- or biphasic waveform suggests that PAD is less likely. Several forms of bedside testing may also be useful as adjunct tests and 7 studies were identified that investigated the reliability of bedside tests including ABI, toe pressure, TBI, transcutaneous oxygen pressure (TcPO2 ) and pulse palpation. Inter-rater reliability was poor for pulse palpation and moderate for TcPO2. The ABI, toe pressure and TBI may have good inter- and intra-rater reliability, but margins of error are wide, requiring a large change in the measurement for it to be considered a true change rather than error. There is currently no single bedside test or a combination of bedside tests that has been shown to have superior diagnostic accuracy for PAD in people with diabetes with or without DFU. However, an ABI <0.9 or >1.3, TBI of <0.70, and absent or monophasic pedal Doppler waveforms are useful to identify the presence of disease. The ability of the tests to exclude disease is variable and although reliability may be acceptable, evidence of error in the measurements means test results that are within normal limits should be considered with caution and in the context of other vascular assessment findings (e.g., pedal pulse palpation and clinical signs) and progress of DFU healing.
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Affiliation(s)
- Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Sydney, Australia
| | - Nicolaas Schaper
- Division of Endocrinology, Department of Internal Medicine, MUMC+, Maastricht, The Netherlands
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- University of California, San Francisco (UCSF) Medical Centre, San Francisco, California, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital Bern Switzerland, Bern, Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Wu VS, Caputo FJ, Quatromoni JG, Kirksey L, Lyden SP, Rowse JW. Association between socioeconomic deprivation and presentation with a ruptured abdominal aortic aneurysm. J Vasc Surg 2024; 79:44-54. [PMID: 37657685 DOI: 10.1016/j.jvs.2023.08.127] [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: 05/31/2023] [Revised: 08/14/2023] [Accepted: 08/26/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVE Given the ongoing nature of research in the social determinants space and urges to improve United States Preventive Services Task Force screening efforts for abdominal aortic aneurysms (AAAs), this project aims to characterize the association between the level of socioeconomic deprivation, rurality, and ruptured AAA (rAAA) presentation across the United States. METHODS We queried the Vascular Quality Initiative registry (2010-2019) for patients with AAAs. The area deprivation index (ADI) is an index from 1 to 100 used to capture socioeconomic status. ADI was grouped into quintiles, with the most deprived regions being quintile 5 and having the highest ADI index. Multivariable logistic regression assessed the association between ADI, rurality, and rAAA presentation overall and before age 65. RESULTS Of the 82,909 patients included, 11,458 patients (14%) resided in the most socioeconomically deprived regions, and 18,083 patients (22%) lived in rural regions. Overall, 6831 patients (8.2%) experienced an rAAA, with 4696 patients (69%) residing in the three most deprived quintiles. Most patients underwent endovascular repair (n = 67,933; 82%), followed by open repair (n = 14,976; 18%). On multivariable analysis, residence in the most socioeconomically deprived region was associated with a near 1.5-fold increased odds of presenting with an rAAA compared with a residence in the least deprived regions (odds ratio [OR], 1.46; 95% confidence interval [CI], 1.31-1.63; P < .001), whereas urban residence was associated with a decreased odds to present with an rAAA compared with rural residence (OR, 0.84; 95% CI, 0.79-0.89; P < .001). When stratifying the study population by the United States Preventive Services Task Force recommended age for AAA screening (65 years old), 14,147 patients (17%) were under 65. Of those under 65, 1381 patients (9.8%) experienced a rAAA, and 9955 patients (71%) resided in the three most deprived quintiles. Residence in the most socioeconomically deprived region was associated with an increased odds of presenting with an rAAA compared with residence in the least deprived region (OR, 1.31; 95% CI, 1.01-1.69; P = .042). However, there were no significant associations between rural residence and increased rAAA presentation among individuals under 65 (OR, 1.07; 95% CI, 0.93-1.23; P = .36). CONCLUSIONS Among all patients in this study, patients residing in highly socioeconomically deprived or rural regions were more likely to present with an rAAA, but among those under 65, only residence in a socioeconomically deprived area was associated with increased odds of rAAA presentation. Understanding the effects of socioeconomic deprivation on rAAA presentation can identify at-risk populations for early AAA screening before rupture.
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Affiliation(s)
- Victoria S Wu
- Case Western Reserve University School of Medicine, Cleveland, OH.
| | - Francis J Caputo
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Jon G Quatromoni
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Lee Kirksey
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Sean P Lyden
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Jarrad W Rowse
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH
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9
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Secemsky EA, Giri J, Brodmann M, Gouëffic Y, Fu W, Greenberg-Worisek AJ, Jaff MR, Kirksey L, Kohi MP. Implementing methods in the ELEGANCE registry to increase diversity in clinical research. J Vasc Surg 2024; 79:136-145.e3. [PMID: 37742734 DOI: 10.1016/j.jvs.2023.08.131] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/19/2023] [Accepted: 08/03/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVE Women and underrepresented minorities (URMs) who are at an increased risk of presenting with severe peripheral artery disease (PAD) and have different responses to treatment compared with non-Hispanic White males yet are underrepresented in PAD research. METHODS ELEGANCE is a global, prospective, multi-center, post-market registry of PAD patients treated with drug-eluting device that aims to enroll at least 40% women and 40% URMs. The study design incorporates strategies to increase enrollment of women and URMs. Inclusion criteria are age ≥18 years and treatment with any commercially available Boston Scientific Corporation drug-eluting device marketed for peripheral vasculature lesions; exclusion criterion is life expectancy <1 year. RESULTS Of 750 patients currently enrolled (951 lesions) across 39 sites, 324 (43.2%) are female and 350 (47.3%) are URMs (21.6% Black, 11.2% Asian, 8.5% Hispanic/Latino, and 5.3% other). Rutherford classification is distributed differently between sexes (P = .019). Treatment indication differs among race/ethnicity groups (P = .003). Chronic limb-threatening ischemia was higher for Black (38.3%) and Hispanic/Latino (28.1%) patients compared with non-Hispanic White (21.8%) and Asian patients (21.4%). De-novo stenosis was higher in Asian patients (92.3%) compared with Black, non-Hispanic White, and Hispanic/Latino patients (72.2%, 68.7%, and 77.8%, respectively; P < .001). Mean lesion length was longest for Black patients (162.7 mm), then non-Hispanic White (135.2 mm), Asian (134.8 mm), and Hispanic/Latino patients (128.1 mm; P = .008). CONCLUSIONS Analyses of data from the ELEGANCE registry show that differences exist in baseline disease characteristics by sex and race/ethnicity; these may be the result of other underlying factors, including time to diagnosis, burden of undermanaged comorbidities, and access to care.
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Affiliation(s)
- Eric A Secemsky
- Department of Vascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
| | - Jay Giri
- Department of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Yann Gouëffic
- Vascular Center, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Weiguo Fu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | | | - Michael R Jaff
- Peripheral Interventions, Boston Scientific Corporation, Marlborough, MA
| | - Lee Kirksey
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, OH
| | - Maureen P Kohi
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
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10
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Secemsky EA, Kirksey L, Quiroga E, King CM, Martinson M, Hasegawa JT, West NEJ, Wadhera RK. Impact of Intensity of Vascular Care Preceding Major Amputation Among Patients With Chronic Limb-Threatening Ischemia. Circ Cardiovasc Interv 2024; 17:e012798. [PMID: 38152880 DOI: 10.1161/circinterventions.122.012798] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 09/22/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Lower-limb amputation rates in patients with chronic limb-threatening ischemia vary across the United States, with marked disparities in amputation rates by gender, race, and income status. We evaluated the association of patient, hospital, and geographic characteristics with the intensity of vascular care received the year before a major lower-limb amputation and how intensity of care associates with outcomes after amputation. METHODS Using Medicare claims data (2016-2019), beneficiaries diagnosed with chronic limb-threatening ischemia who underwent a major lower-limb amputation were identified. We examined patient, hospital, and geographic characteristics associated with the intensity of vascular care received the year before amputation. Secondary objectives evaluated all-cause mortality and adverse events following amputation. RESULTS Of 33 036 total Medicare beneficiaries undergoing major amputation, 7885 (23.9%) were due to chronic limb-threatening ischemia; of these, 4988 (63.3%) received low-intensity and 2897 (36.7%) received high-intensity vascular care. Mean age, 76.6 years; women, 38.9%; Black adults, 24.5%; and of low income, 35.2%. After multivariable adjustment, those of low income (odds ratio, 0.65 [95% CI, 0.58-0.72]; P<0.001), and to a lesser extent, men (odds ratio, 0.89 [95% CI, 0.81-0.98]; P=0.019), and those who received care at a safety-net hospital (odds ratio, 0.87 [95% CI, 0.78-0.97]; P=0.012) were most likely to receive low intensity of care before amputation. High-intensity care was associated with a lower risk of all-cause mortality 2 years following amputation (hazard ratio, 0.79 [95% CI, 0.74-0.85]; P<0.001). CONCLUSIONS Patients who were of low-income status, and to a lesser extent, men, or those cared for at safety-net hospitals were most likely to receive low-intensity vascular care. Low-intensity care was associated with worse long-term event-free survival. These data emphasize the continued disparities that exist in contemporary vascular practice.
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Affiliation(s)
- Eric A Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (E.A.S., R.K.W.)
| | - Lee Kirksey
- Department of Vascular Surgery, Cleveland Clinic, OH (L.K.)
| | - Elina Quiroga
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle (E.Q.)
| | - Claire M King
- Abbott Vascular, Santa Clara, CA (C.M.K., J.T.H., N.E.J.W.)
| | | | | | - Nick E J West
- Abbott Vascular, Santa Clara, CA (C.M.K., J.T.H., N.E.J.W.)
| | - Rishi K Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (E.A.S., R.K.W.)
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11
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Baffoe-Bonnie H, Alnahhal KI, Englund K, Baker ME, Kirksey L. A case series of image-guided percutaneous drainage of abdominal aortic graft infection as bridge therapy. Vascular 2023:17085381231214318. [PMID: 38031998 DOI: 10.1177/17085381231214318] [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: 12/01/2023]
Abstract
INTRODUCTION Aortic graft infection (AGI) is a rare complication following endovascular aneurysm repair and is associated with substantial morbidity and mortality. The traditional management of AGI is intravenous antibiotic therapy and surgical explantation. In this case series, percutaneous drainage was used as a bridge therapy in the treatment of AGI. METHODS We report two cases, 78-year-old male and 57-year-old female, in whom image-guided percutaneous drainage was used to treat AGI in two contrasting contexts. Informed consent was obtained from both cases/relatives for publication. RESULTS Both cases underwent successful percutaneous drainage of AGI utilized as a bridge therapy before definitive surgical reconstruction and graft explantation. Each patient had a different outcome. In the first case, the patient's comorbidities and severe disease state could not be overcome, resulting in his death. The second patient benefitted from the percutaneous drainage by allowing her more time ameliorate her malnutrition before definitive surgery. CONCLUSION Data on the outcomes of percutaneous drainage of AGI is limited. The successful procedure described in this case series emphasizes the need to conduct more research to evaluate the safety and efficacy of this treatment approach before the surgical explantation.
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Affiliation(s)
| | - Khaled I Alnahhal
- Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland, OH, USA
| | - Kristin Englund
- Department of Infectious Disease, Cleveland Clinic, Cleveland, OH, USA
| | - Mark E Baker
- Abdominal Imaging Section, Imaging Institute and Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Lee Kirksey
- Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland, OH, USA
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12
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Fitridge R, Chuter V, Mills J, Hinchliffe R, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, Russell D, van den Berg JC, Venermo M, Schaper N. The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes mellitus and a foot ulcer. J Vasc Surg 2023; 78:1101-1131. [PMID: 37724985 DOI: 10.1016/j.jvs.2023.07.020] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis, and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this updated guideline, the IWGDF, the European Society for Vascular Surgery, and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.
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Affiliation(s)
- Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital Adelaide, Australia.
| | - Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Australia
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- University of California, San Francisco Medical Centre, CA, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | | | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital Bern Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Nicolaas Schaper
- Division of Endocrinology, Dept. Internal Medicine, MUMC+, The Netherlands
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13
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Laczynski DJ, Gallop J, Sicard GA, Sidawy AN, Rowse JW, Lyden SP, Smolock CJ, Kirksey L, Quatromoni JG, Caputo FJ. Benchmarking a Center of Excellence in Vascular Surgery: Using Acute Physiology and Chronic Health Evaluation II to Validate Outcomes in a Tertiary Care Institute. Vasc Endovascular Surg 2023; 57:856-862. [PMID: 37295071 DOI: 10.1177/15385744231183744] [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: 06/12/2023]
Abstract
OBJECTIVE The Society of Vascular Surgery (SVS) has made it a top priority to implement verification of vascular "centers of excellence". Our institutional aortic network was established in 2008 in order to standardize care of patients with suspected acute aortic pathology. The implementation and success of this program has been previously reported. We sought to use our experience as a benchmark for which to develop prognostic modeling to quantify clinical status upon admission and help predict outcomes. Our objective was to validate the Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system using a cohort of aortic emergencies transferred by an organized transfer network. METHOD This was a retrospective, single institution review of patients transferred through an institutional aortic network for acute aortic pathology from 2017-2018. Demographics, comorbidities, aortic diagnosis, APACHE II score, as well as 30-day mortality were recorded. Associations with 30-day mortality were evaluated using two-sample t-tests, ANOVA models, Pearson chi-square tests and Fisher exact tests. Receiver operating characteristic (ROC) curves were fit overall and by pathology to predict 30-day mortality by Apache II total score. RESULTS There were 395 consecutive transfers were identified. The mean age was 64.7 years. Diagnoses included Type A Dissection (n = 134), Type B (n = 81), Aortic Aneurysm (n = 122), and PAU/IMH (n = 27). Mean APACHE II score on arrival was 12. Overall there were 53 deaths (13.4%) in the cohort. Patients that died had significantly higher Apache II total scores (11.3 vs 16.5, P < .001). The area under the receiver operator characteristic (ROC) curve (AUC) was .66 for the full cohort, indicating a poor clinical prediction test. CONCLUSION APACHE II score is a poor predictor of 30-day mortality in a large transfer network accepting all aortic emergencies. The authors believe further refining a prognostic model for diverse population will not only help in predicting outcomes but to objectively quantify illness severity in order to have a basis for comparison among institutions and verification of "centers of excellence".
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Affiliation(s)
- D J Laczynski
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - J Gallop
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - G A Sicard
- Division of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - A N Sidawy
- Division of Vascular Surgery, Department of Surgery, George Washington University, Washington, DC, USA
| | - J W Rowse
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - S P Lyden
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - C J Smolock
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - L Kirksey
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - J G Quatromoni
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - F J Caputo
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
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14
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Alnahhal KI, Sorour AA, Lyden SP, Caputo FJ, Park WM, Rowse JW, Quatromoni JG, Khalifeh A, Dehaini H, Bena JF, Kirksey L. Management of patients with chronic mesenteric ischemia across three consecutive eras. J Vasc Surg 2023; 78:1228-1238.e1. [PMID: 37399971 DOI: 10.1016/j.jvs.2023.06.021] [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: 05/01/2023] [Revised: 06/23/2023] [Accepted: 06/25/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Endovascular intervention (EI) is the most commonly used modality for chronic mesenteric ischemia (CMI). Since the inception of this technique, numerous publications have reported the associated clinical outcomes. However, no publication has reported the comparative outcomes over a period of time in which both the stent platform and adjunctive medical therapy have evolved. This study aims to assess the impact of the concomitant evolution of both the endovascular approach and optimal guideline-directed medical therapy (GDMT) on CMI outcomes over three consecutive time eras. METHODS A retrospective review at a quaternary center from January 2003 to August 2020 was performed to identify patients who underwent EIs for CMI. The patients were divided into three groups based on the date of intervention: early (2003-2009), mid (2010-2014), and late (2015-2020). At least one angioplasty/stent was performed for the superior mesenteric artery (SMA) and/or celiac artery. The patients' short- and mid-term outcomes were compared between the groups. Univariable and multivariable Cox proportional hazard models were also conducted to evaluate the clinical predictors for primary patency loss in SMA only subgroup. RESULTS A total of 278 patients were included (early, 74; mid, 95; late, 109). The overall mean age was 71 years, and 70% were females. High technical success (early, 98.6%; mid, 100%; late, 100%; P = .27) and immediate resolution of symptoms (early, 86.3%; mid, 93.7%; late, 90.8%; P = .27) were noted over the three eras. In both the celiac artery and SMA cohorts, the use of bare metal stents (BMS) declined over time (early, 99.0%; mid, 90.3%; late, 65.5%; P < .001) with a proportionate increase in covered stents (CS) (early, 0.99%; mid, 9.7%; late, 28.9%; P < .001). The use of postoperative antiplatelet and statins has increased over time (early, 89.2%; mid, 97.9%; late, 99.1%; P = .003) and (early, 47%; mid, 68%; late, 81%; P = .001), respectively. In the SMA stent-only cohort, no significant differences were noted in primary patency rates between BMS and CS (hazard ratio, 0.95; 95% confidence interval, 0.26-2.87; P = .94). High-intensity preoperative statins were associated with fewer primary patency loss events compared to none/low- or moderate-intensity statins (hazard ratio, 0.30; 95% confidence interval, 0.11-0.72; P = .014). CONCLUSIONS Consistent outcomes were observed for CMI EIs across three consecutive eras. In the SMA stent-only cohort, no statistically significant difference in early primary patency was noted for CS and BMS, making the use of CS at additional cost controversial and possibly not cost effective. Notably, the preoperative high-intensity statins were associated with improved SMA primary patency. These findings demonstrate the importance of guideline-directed medical therapy as an essential adjunct to EI in the treatment of CMI.
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Affiliation(s)
- Khaled I Alnahhal
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Ahmed A Sorour
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Sean P Lyden
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Francis J Caputo
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Woosup M Park
- Division of Vascular Surgery, Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH
| | - Jarrad W Rowse
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Jon G Quatromoni
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Ali Khalifeh
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Hassan Dehaini
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - James F Bena
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Lee Kirksey
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH.
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15
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Fitridge R, Chuter V, Mills J, Hinchliffe R, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, Russell D, van den Berg JC, Venermo M, Schaper N. The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot Ulcer. Eur J Vasc Endovasc Surg 2023:S1078-5884(23)00586-5. [PMID: 37724984 DOI: 10.1016/j.ejvs.2023.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis, and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this updated guideline, the IWGDF, the European Society for Vascular Surgery, and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.
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Affiliation(s)
- Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital Adelaide, Australia.
| | - Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Australia
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- University of California, San Francisco Medical Centre, CA, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | | | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital Bern Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Nicolaas Schaper
- Division of Endocrinology, Dept. Internal Medicine, MUMC+, The Netherlands
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16
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Allison MA, Armstrong DG, Goodney PP, Hamburg NM, Kirksey L, Lancaster KJ, Mena-Hurtado CI, Misra S, Treat-Jacobson DJ, White Solaru KT. Health Disparities in Peripheral Artery Disease: A Scientific Statement From the American Heart Association. Circulation 2023; 148:286-296. [PMID: 37317860 DOI: 10.1161/cir.0000000000001153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Peripheral artery disease (PAD) affects 200 million individuals worldwide. In the United States, certain demographic groups experience a disproportionately higher prevalence and clinical effect of PAD. The social and clinical effect of PAD includes higher rates of individual disability, depression, minor and major limb amputation along with cardiovascular and cerebrovascular events. The reasons behind the inequitable burden of PAD and inequitable delivery of care are both multifactorial and complex in nature, including systemic and structural inequity that exists within our society. Herein, we present an overview statement of the myriad variables that contribute to PAD disparities and conclude with a summary of potential novel solutions.
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Julien HM, Wang Y, Curtis JP, Johnston-Cox H, Eberly LA, Wang GJ, Nathan AS, Fanaroff AC, Khatana SAM, Groeneveld PW, Secemsky EA, Eneanya ND, Vora AN, Kobayashi T, Barbery C, Chery G, Kohi M, Kirksey L, Armstrong EJ, Jaff MR, Giri J. Racial Differences in Presentation and Outcomes After Peripheral Arterial Interventions: Insights From the NCDR-PVI Registry. Circ Cardiovasc Interv 2023; 16:e011485. [PMID: 37339237 DOI: 10.1161/circinterventions.121.011485] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 05/03/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND We assess the rates of device use and outcomes by race among patients undergoing lower extremity peripheral arterial intervention using the American College of Cardiology National Cardiovascular Data Registry-Peripheral Vascular Intervention (PVI) registry. METHODS Patients who underwent PVI between April 2014 and March 2019 were included. Socioeconomic status was evaluated using the Distressed Community Index score for patients' zip codes. Multivariable logistic regression was used to assess factors associated with utilization of drug-eluting technologies, intravascular imaging, and atherectomy. Among patients with Centers for Medicare and Medicaid Services data, we compared 1-year mortality, rates of amputation, and repeat revascularizations. RESULTS Of 63 150 study cases, 55 719 (88.2%) were performed in White patients and 7431 (11.8%) in Black patients. Black patients were younger (67.9 versus 70.0 years), had higher rates of hypertension (94.4% versus 89.5%), diabetes (63.0% versus 46.2%), less likely to be able to walk 200 m (29.1% versus 24.8%), and higher Distressed Community Index scores (65.1 versus 50.6). Black patients were provided drug-eluting technologies at a higher rate (adjusted odds ratio, 1.14 [95% CI, 1.06-1.23]) with no difference in atherectomy (adjusted odds ratio, 0.98 [95% CI, 0.91-1.05]) or intravascular imaging (adjusted odds ratio, 1.03 [95% CI, 0.88-1.22]) use. Black patients experienced a lower rate of acute kidney injury (adjusted odds ratio, 0.79 [95% CI, 0.72-0.88]). In Centers for Medicare and Medicaid Services-linked analyses of 7429 cases (11.8%), Black patients were significantly less likely to have surgical (adjusted hazard ratio, 0.40 [95% CI, 0.17-0.96]) or repeat PVI revascularization (adjusted hazard ratio, 0.42 [95% CI, 0.30-0.59]) at 1 year compared with White patients. There was no difference in mortality (adjusted hazard ratio [0.8-1.4]) or major amputation (adjusted hazard ratio, 2.5 [95% CI, 0.8-7.6]) between Black and White patients. CONCLUSIONS Black patients presenting for PVI were younger, had higher prevalence of comorbidities and lower socioeconomic status. After adjustment, Black patients were less likely to have surgical or repeat PVI revascularization after the index PVI procedure.
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Affiliation(s)
- Howard M Julien
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
- Center for Health Equity Research and Promotion, Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA (H.M.J., P.W.G., S.A.M.K.)
- Penn Cardiovascular Center for Health Equity and Social Justice, Philadelphia (H.M.J., L.A.E.)
| | - Yongfei Wang
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (Y.W., J.P.C.)
- Center of Outcome Research and Evaluation Yale New Haven Health System, CT (Y.W., J.P.C.)
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (Y.W., J.P.C.)
- Center of Outcome Research and Evaluation Yale New Haven Health System, CT (Y.W., J.P.C.)
| | - Hillary Johnston-Cox
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
| | - Lauren A Eberly
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
- Penn Cardiovascular Center for Health Equity and Social Justice, Philadelphia (H.M.J., L.A.E.)
| | - Grace J Wang
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
| | - Ashwin S Nathan
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
| | - Alexander C Fanaroff
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
| | - Sameed Ahmed M Khatana
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
- Center for Health Equity Research and Promotion, Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA (H.M.J., P.W.G., S.A.M.K.)
| | - Peter W Groeneveld
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
- Center for Health Equity Research and Promotion, Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA (H.M.J., P.W.G., S.A.M.K.)
| | - Eric A Secemsky
- Department of Medicine, Harvard Medical School, Boston, MA (E.A.S.)
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (E.A.S.)
| | - Nwamaka D Eneanya
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia (N.D.E.)
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (N.D.E.)
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (N.D.E.)
| | - Amit N Vora
- University of Pittsburgh Medical Center-Pinnacle, Wormleysburg, PA (A.N.V.)
| | - Taisei Kobayashi
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
| | - Carlos Barbery
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
| | - Godefroy Chery
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
| | - Maureen Kohi
- Department of Radiology, University of North Carolina School of Medicine, Chapel Hill (M.K.)
| | - Lee Kirksey
- Division of Vascular Surgery, Cleveland Clinic, OH (L.K.)
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO (E.J.A.)
- University of Colorado School of Medicine, Aurora (E.J.A.)
| | - Michael R Jaff
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston (M.R.J.)
| | - Jay Giri
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
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Alnahhal KI, Lyden SP, Caputo FJ, Sorour AA, Rowe VL, Colglazier JJ, Smith BK, Shames ML, Kirksey L. The USMLE® STEP 1 Pass or Fail Era of the Vascular Surgery Residency Application Process: Implications for Structural Bias and Recommendations. Ann Vasc Surg 2023:S0890-5096(23)00239-X. [PMID: 37120072 DOI: 10.1016/j.avsg.2023.04.018] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 05/01/2023]
Abstract
MOTIVES BEHIND THE SHIFT USMLE® STEP 1 score reporting has been changed to a binary pass/fail format since January 26, 2022. The motives behind this change were (1) the questionable validity of using USMLE® STEP 1 as a screening tool during the candidate selection process and (2) the negative impact of using standardized examination scores as an initial gatekeeping threshold for the underrepresented in medicine (URiM) candidates applying to GME programs, given their generally lower mean standardized exams scores compared to non-URiM students. The USMLE® administrators justified this change as a tactic to enhance the overall educational experience for all students and to increase the representation of URiM groups. Moreover, they advised the program directors (PDs) to give more attention to other important qualities and components such as the applicant's personality traits, leadership roles and other extracurricular accomplishments, as part of a holistic evaluation strategy. IMPACT OF USMLE® STEP 1 PASS/FAIL: At this early stage, it is unclear how this change will impact Vascular Surgery Integrated residency (VSIR) programs. Several questions are outstanding, most importantly, how VSIR PDs will evaluate applicants absent the variable which heretofore was the primary screening tool. Our previously published survey showed that VSIR PDs will move their attention to other measures such as USMLE® STEP 2CK and letters of recommendation during the VSIR selection process. Furthermore, more emphasis on subjective measures such as the applicant's medical school rank and extracurricular student activities is expected. Given the expected higher weight of USMLE® STEP 2CK in the selection process than ever, many anticipate that medical students will dedicate more of their limited time to its preparation at the expense of both clinical and non-clinical activities. Potentially leaving less time to explore specialty pathways and to determine whether VS is the appropriate career for them. A FRAMEWORK FOR CANDIDATE EVALUATION The critical juncture in the VSIR candidate evaluation paradigm presents an opportunity to thoughtfully transform the process via current (Standardized Letter of Recommendation, USMLE® STEP 2CK, and clinical research) and future (Emotional Intelligence, Structure Interview and Personality Assessment) measures which constitute a framework to follow in the USMLE® STEP 1 pass/fail era.
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Affiliation(s)
- Khaled I Alnahhal
- Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland
| | - Sean P Lyden
- Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland
| | - Francis J Caputo
- Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland
| | - Ahmed A Sorour
- Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland
| | - Vincent L Rowe
- Division of Vascular and Endovascular Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles
| | - Jill J Colglazier
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester
| | - Brigitte K Smith
- Department of Surgery, Division of Vascular Surgery, University of Utah, Salt Lake City
| | - Murray L Shames
- Division of Vascular Surgery, University of South Florida School of Medicine, Tampa
| | - Lee Kirksey
- Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland.
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19
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Alnahhal KI, Williams DB, Kirksey L. Surgical creation of lower extremity fistula and grafts. Cardiovasc Diagn Ther 2023; 13:156-161. [PMID: 36864969 PMCID: PMC9971307 DOI: 10.21037/cdt-22-549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 12/23/2022] [Indexed: 02/18/2023]
Abstract
Lower limb vascular access (LLVA) should be considered for patients in whom upper extremity access has been exhausted. The decisional process around vascular access (VA) site selection should incorporate a patient centered approach that aligns with End Stage Kidney Disease life-plan as recently described in proffered in 2019 Vascular Access Guidelines. The current surgical approaches to LLVA can be divided into two main groups: (A) autologous arteriovenous fistulas (AVFs); (B) synthetic arteriovenous grafts (AVGs). The autologous AVFs include both the femoral vein (FV) and great saphenous vein (GSV) transpositions, while prosthetic AVGs in the thigh position are appropriate for certain patient subtypes. Good durability has been described for autogenous FV transposition as well as AVGs with both demonstrating acceptable primary and secondary patency rates. Major complications such as steal syndrome, limb edema, and bleeding and minor complications such as wound-related infection, hematoma and delayed wound healing have been noted. LLVA is commonly reserved for the patient in whom the only alternative VA may be a tunneled catheter with its attendant morbidity. In this clinical circumstance, successful LLVA has the opportunity to be a life-saving surgical therapy when successfully performed. We describe a thoughtful approach that focuses on patient selection to optimize success and mitigate complications associated with LLVA.
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Affiliation(s)
- Khaled I Alnahhal
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - D'Andre B Williams
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Lee Kirksey
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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20
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Alnahhal KI, Rowse J, Kirksey L. The challenging surgical vascular access creation. Cardiovasc Diagn Ther 2023; 13:162-172. [PMID: 36864962 PMCID: PMC9971302 DOI: 10.21037/cdt-22-560] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/06/2023] [Indexed: 02/16/2023]
Abstract
With the increasing life expectancy of patients with end-stage kidney disease, the creation and maintenance of hemodialysis vascular access are becoming more challenging. A comprehensive patient evaluation including a complete history, physical examination, and ultrasonographic vessel assessment is the foundation of the clinical evaluation. A patient-centered approach acknowledges the myriad of factors that impact the selection of optimal access for the distinct clinical and social circumstance of each patient. An interdisciplinary team approach involving various healthcare providers in all stages of hemodialysis access creation is important and associated with better outcomes. While patency is considered the most important parameter in most vascular reconstructive scenarios, the ultimate determinant of success in vascular access for hemodialysis is a circuit that allows consistent and uninterrupted delivery of the prescribed hemodialysis. The best conduit is one that is superficial, easily identified, straight, and of a large caliber. Individual patient factors and skill level of the cannulating technician also play a crucial role in the initial success and maintenance of vascular access. Special attention should be considered in dealing with more challenging groups such as the elderly population where the newest vascular access guidance from The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative will be transformative. The current guidelines recommend monitoring the vascular access by regular physical and clinical assessments, however, inadequate evidence is available to support routine ultrasonographic surveillance for improving access patency.
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Affiliation(s)
- Khaled I Alnahhal
- Department of Vascular Surgery, Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jarrad Rowse
- Department of Vascular Surgery, Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Lee Kirksey
- Department of Vascular Surgery, Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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21
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Alnahhal KI, Rowse J, Kirksey L. Management of concomitant central venous disease. Cardiovasc Diagn Ther 2023; 13:291-298. [PMID: 36864954 PMCID: PMC9971306 DOI: 10.21037/cdt-22-570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 02/06/2023] [Indexed: 02/18/2023]
Abstract
Symptomatic central venous disease (CVD) is a significant common problem in patients with end-stage renal disease given its adverse impact on hemodialysis (HD) vascular access (VA). The current mainstay management is percutaneous transluminal angioplasty (PTA) with or without stenting which is typically reserved for unsatisfactory angioplasty or more challenging lesions. Despite factors such as target vein diameters and lengths and vessel tortuosity that may determine the choice of bare-metal versus covered stents (CS), current scientific literature is pointing out the superiority of the latter one. Alternative management options such as hemodialysis reliable outflow (HeRO) graft showed favorable results in terms of high patency rates and fewer infections, however, complications such as a steal syndrome and, to a lesser extent, graft migration and separation are major concerns. The surgical reconstruction approaches such as bypass, patch venoplasty, or chest wall arteriovenous graft with or without endovascular interventions as a hybrid procedure are still viable options and may be considered. However, further long-term investigations are needed to highlight the comparative outcomes of these approaches. Open surgery might be an alternative before proceeding to more unfavorable approaches such as lower extremity vascular access (LEVA). The appropriate therapy should be selected based upon a patient-centered interdisciplinary discussion utilizing the locally available expertise in the area of VA creation and maintenance.
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Affiliation(s)
- Khaled I Alnahhal
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jarrad Rowse
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Lee Kirksey
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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Alnahhal KI, Dehaini H, Sorour AA, Vyas P, Chumakova M, Bena J, Kirksey L. Predictors for Distal Revascularization Following Femoral Endarterectomy in Chronic Limb-Threatening Ischemia Patients. Vasc Endovascular Surg 2023:15385744231154084. [PMID: 36849162 DOI: 10.1177/15385744231154084] [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: 03/01/2023]
Abstract
OBJECTIVE This study aims to identify the clinical variables which are predictive for the benefit of concomitant distal revascularization (DR) to prevent Chronic limb-threatening ischemia (CLTI) progression and the need for major limb amputation. METHODS This is a retrospective cohort study of patients who presented with lower limb ischemia and required at least femoral endarterectomy (FEA), recruited over a period of 15 years (2002-2016). The patient cohort was divided into three groups based on the type of intervention: A (FEA alone), B (FEA + catheter-based intervention/(CBI)), and C (FEA + surgical bypass (SB)). The primary endpoint was to identify independent predictors for the use of concomitant DR (CBI or SB). Secondary endpoints were amputation rate, length of stay, mortality rate, postoperative ankle-brachial index and complications, readmission rate, re-intervention rate, resolution of symptoms and wound status. RESULTS A total of 400 patients were included, 68.0% were males. Most presenting limbs were at Rutherford class (RC) III and WIfI stage 2, with an ankle-brachial index (ABI) of .47 ± .21 and a TASC II class C lesion. No significant differences were found in the primary-assisted and secondary patency rates between the three groups (P > .05, in all). In the multivariate analyses, clinical variables associated with DR were hyperlipidemia (hazard ratio (HR) 2.1-2.2), TASC II D (HR 2.62), Rutherford class 4 (HR 2.3) and 5 (HR 3.7), as well as WIfI stage ≥3 (HR 1.48). CONCLUSIONS Femoral endarterectomy is sufficient to treat intermittent claudication. However, patients in whom rest pain, tissue loss or TASC II D anatomic lesion severity are present may benefit from concomitant distal revascularization. Taking into consideration the overall assessment of operative risk factors for each individual patient, proceduralists should have a lower threshold for performing early or concomitant distal revascularization to reduce CLTI progression including additional tissue loss and/or major limb amputation.
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Affiliation(s)
- Khaled I Alnahhal
- 2569 Department of Vascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, OH, USA
| | - Hassan Dehaini
- 2569 Department of Vascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, OH, USA
| | - Ahmed A Sorour
- 2569 Department of Vascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, OH, USA
| | - Priyam Vyas
- 2569 Department of Vascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, OH, USA
| | - Maryana Chumakova
- 2569 Department of Vascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, OH, USA
| | - James Bena
- 2569 Department of Vascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, OH, USA
| | - Lee Kirksey
- 2569 Department of Vascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, OH, USA
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Murea M, Gardezi AI, Goldman MP, Hicks CW, Lee T, Middleton JP, Shingarev R, Vachharajani TJ, Woo K, Abdelnour LM, Bennett KM, Geetha D, Kirksey L, Southerland KW, Young CJ, Brown WM, Bahnson J, Chen H, Allon M. Study protocol of a randomized controlled trial of fistula vs. graft arteriovenous vascular access in older adults with end-stage kidney disease on hemodialysis: the AV access trial. BMC Nephrol 2023; 24:43. [PMID: 36829135 PMCID: PMC9960188 DOI: 10.1186/s12882-023-03086-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 02/13/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND Treatment of end-stage kidney disease (ESKD) with hemodialysis requires surgical creation of an arteriovenous (AV) vascular access-fistula (AVF) or graft (AVG)-to avoid (or limit) the use of a central venous catheter (CVC). AVFs have long been considered the first-line vascular access option, with AVGs as second best. Recent studies have suggested that, in older adults, AVGs may be a better strategy than AVFs. Lacking evidence from well-powered randomized clinical trials, integration of these results into clinical decision making is challenging. The main objective of the AV Access Study is to compare, between the two types of AV access, clinical outcomes that are important to patients, physicians, and policy makers. METHODS This is a prospective, multicenter, randomized controlled trial in adults ≥ 60 years old receiving chronic hemodialysis via a CVC. Eligible participants must have co-existing cardiovascular disease, peripheral arterial disease, and/or diabetes mellitus; and vascular anatomy suitable for placement of either type of AV access. Participants are randomized, in a 1:1 ratio, to a strategy of AVG or AVF creation. An estimated 262 participants will be recruited across 7 healthcare systems, with average follow-up of 2 years. Questionnaires will be administered at baseline and semi-annually. The primary outcome is the rate of CVC-free days per 100 patient-days. The primary safety outcome is the cumulative incidence of vascular access (CVC or AV access)-related severe infections-defined as access infections that lead to hospitalization or death. Secondary outcomes include access-related healthcare costs and patients' experiences with vascular access care between the two treatment groups. DISCUSSION In the absence of studies using robust and unbiased research methodology to address vascular access care for hemodialysis patients, clinical decisions are limited to inferences from observational studies. The goal of the AV Access Study is to generate evidence to optimize vascular access care, based on objective, age-specific criteria, while incorporating goals of care and patient preference for vascular access type in clinical decision-making. TRIAL REGISTRATION This study is being conducted in accordance with the tenets of the Helsinki Declaration, and has been approved by the central institutional review board (IRB) of Wake Forest University Health Sciences (approval number: 00069593) and local IRB of each participating clinical center; and was registered on Nov 27, 2020, at ClinicalTrials.gov (NCT04646226).
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA. .,Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - Ali I Gardezi
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Mathew P Goldman
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston- Salem, NC, USA
| | - Caitlin W Hicks
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, 600 N Wolfe St, Halsted 668, Baltimore, MD, USA
| | - Timmy Lee
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.,Division of Nephrology, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - John P Middleton
- Division of Nephrology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Roman Shingarev
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Tushar J Vachharajani
- Department of Kidney Medicine, Glickman Urological & Kidney Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Karen Woo
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Lama M Abdelnour
- Department of Medicine, Division of Nephrology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Kyla M Bennett
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Lee Kirksey
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Kevin W Southerland
- Division of Vascular & Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Carlton J Young
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - William M Brown
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Judy Bahnson
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Haiying Chen
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Michael Allon
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA. .,Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
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Elbadawi A, Elgendy IY, Joseph D, Eze-Nliam C, Rampersad P, Ouma G, Bhandari R, Kirksey L, Chaudhury P, Chung MK, Kalra A, Mehta N, Bartholomew JR, Sahai A, Svensson LG, Cameron SJ. Racial Differences and In-Hospital Outcomes Among Hospitalized Patients with COVID-19. J Racial Ethn Health Disparities 2022; 9:2011-2018. [PMID: 34506011 PMCID: PMC8432274 DOI: 10.1007/s40615-021-01140-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE There is a paucity of data on how race affects the clinical presentation and short-term outcome among hospitalized patients with SARS-CoV-2, the 2019 coronavirus (COVID-19). METHODS Hospitalized patients ≥ 18 years, testing positive for COVID-19 from March 13, 2020 to May 13, 2020 in a United States (U.S.) integrated healthcare system with multiple facilities in two states were evaluated. We documented racial differences in clinical presentation, disposition, and in-hospital outcomes for hospitalized patients with COIVD-19. Multivariable regression analysis was utilized to evaluate independent predictors of outcomes by race. RESULTS During the study period, 3678 patients tested positive for COVID-19, among which 866 were hospitalized (55.4% self-identified as Caucasian, 29.5% as Black, 3.3% as Hispanics, and 4.7% as other racial groups). Hospitalization rates were highest for Black patients (36.6%), followed by other (28.3%), Caucasian patients (24.4%), then Hispanic patients (10.7%) (p < 0.001). Caucasian patients were older, and with more comorbidities. Absolute lymphocyte count was lowest among Caucasian patients. Multivariable regression analysis revealed that compared to Caucasians, there was no significant difference in in-hospital mortality among Black patients (adjusted odds ratio [OR] 0.53; 95% confidence interval [CI] 0.26-1.09; p = 0.08) or other races (adjusted OR 1.62; 95% CI 0.80-3.27; p = 0.18). Black and Hispanic patients were admitted less frequently to the intensive care unit (ICU), and Black patients were less likely to require pressor support or hemodialysis (HD) compared with Caucasians. CONCLUSIONS This observational analysis of a large integrated healthcare system early in the pandemic revealed that patients with COVID-19 did exhibit some racial variations in clinical presentation, laboratory data, and requirements for advanced monitoring and cardiopulmonary support, but these nuances did not dramatically alter in-hospital outcomes.
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Affiliation(s)
- Ayman Elbadawi
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
- Department of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Islam Y Elgendy
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Douglas Joseph
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Chete Eze-Nliam
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Penelope Rampersad
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Geoffrey Ouma
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rohan Bhandari
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Cardiovascular and Metabolic Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Lee Kirksey
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Pulkit Chaudhury
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mina K Chung
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Cardiovascular and Metabolic Sciences, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Ankur Kalra
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Neil Mehta
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - John R Bartholomew
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Aditya Sahai
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Lars G Svensson
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Cardiovascular and Metabolic Sciences, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Scott J Cameron
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.
- Department of Cardiovascular and Metabolic Sciences, Cleveland Clinic, Cleveland, OH, USA.
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA.
- Department of Hematology, Taussig Cancer Institute, Cleveland, OH, USA.
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Cleveland Clinic Foundation, J3-5, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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Sohail MA, Sedor J, Kirksey L, Blaha SC, Hofmann H. Unilateral atrophic kidney in a 45-year-old woman. Cleve Clin J Med 2022; 89:465-471. [PMID: 35914930 DOI: 10.3949/ccjm.89a.21015] [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] [Indexed: 11/14/2022]
Affiliation(s)
- Mohammad A Sohail
- Internal Medicine Residency Program, Cleveland Clinic, Cleveland, OH
| | - John Sedor
- Department of Kidney Medicine, Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, OH; Glickman Urology & Kidney Institute, Cleveland Clinic, Cleveland, OH; Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Lee Kirksey
- Vice Chairman, Department of Vascular Surgery, Walter W. Buckley Endowed Chair, Co-Director of The Multicultural Center, Sydell and Arnold Miller Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Steven C Blaha
- Emergency Services Institute, Cleveland Clinic, Cleveland, OH
| | - Heather Hofmann
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH
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Sorour AA, Kirksey L, Caputo FJ, Dehaini H, Rowe VL, Colglazier JJ, Smith BK, Shames ML, Lyden SP. Vascular Surgery Integrated Resident Selection Criteria in the Step 1 Pass/Fail Era: A National Survey of Program Directors. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.03.075] [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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Dehaini H, Kirksey L, Sorour AA, Caputo FJ, Smolock CJ, Lyden SP. Hybrid Leg Revascularization: Remote Endarterectomy and Deep Vein Bypass to Posterior Tibial Artery. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.03.546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Penuela MJ, Bryd H, Steenberge SP, Quatromoni JG, Rowse JW, Kirksey L, Caputo FJ, Lyden SP, Smolock CJ. Stable Treatment and Outcomes Over a Decade of Increasingly Complex Urgent Abdominal Aortic Aneurysm Presentation. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.03.547] [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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Scierka LE, Mena-Hurtado C, Shishehbor MH, Spertus JA, Nagpal S, Babrowski T, Bunte MC, Politano A, Humphries M, Chung J, Kirksey L, Alabi O, Soukas P, Parikh S, Faizer R, Fitridge R, Provance J, Romain G, McMillan N, Stone N, Scott K, Fuss C, Pacheco CM, Gosch K, Harper-Brooks A, Smolderen KG. The shifting care and outcomes for patients with endangered limbs - Critical limb ischemia (SCOPE-CLI) registry overview of study design and rationale. Int J Cardiol Heart Vasc 2022; 39:100971. [PMID: 35198727 PMCID: PMC8850321 DOI: 10.1016/j.ijcha.2022.100971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/26/2022] [Accepted: 02/02/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Critical limb ischemia (CLI), the most severe form of peripheral artery disease, is associated with pain, poor wound healing, high rates of amputation, and mortality (>20% at 1 year). Little is known about the processes of care, patients' preferences, or outcomes, as seen from patients' perspectives. The SCOPE-CLI study was co-designed with patients to holistically document patient characteristics, treatment preferences, patterns of care, and patient-centered outcomes for CLI. METHODS This 11-center prospective observational registry will enroll and interview 816 patients from multispecialty, interdisciplinary vascular centers in the United States and Australia. Patients will be followed up at 1, 2, 6, and 12 months regarding their psychosocial factors and health status. Hospitalizations, interventions, and outcomes will be captured for 12 months with vital status extending to 5 years. Pilot data were collected between January and July of 2021 from 3 centers. RESULTS A total of 70 patients have been enrolled. The mean age was 68.4 ± 11.3 years, 31.4% were female, and 20.0% were African American. CONCLUSIONS SCOPE-CLI is uniquely co-designed with patients who have CLI to capture the care experiences, treatment preferences, and health status outcomes of this vulnerable population and will provide much needed information to understand and address gaps in the quality of CLI care and outcomes.ClinicalTrials.gov identifier (NCT Number): NCT04710563 https://clinicaltrials.gov/ct2/show/NCT04710563.
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Affiliation(s)
- Lindsey E. Scierka
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | - Carlos Mena-Hurtado
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | - Mehdi H. Shishehbor
- Case Western University School of Medicine/Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH, United States
| | - John A. Spertus
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Sameer Nagpal
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | | | - Matthew C. Bunte
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Amani Politano
- Oregon Health & Science University, Portland, OR, United States
| | | | - Jayer Chung
- Baylor College of Medicine, Houston, TX, United States
| | - Lee Kirksey
- Cleveland Clinic, Cleveland, OH, United States
| | | | | | - Sahil Parikh
- Columbia University – Presbyterian, New York, NY, United States
| | - Rumi Faizer
- University of Minnesota, Minneapolis, MN, United States
| | - Robert Fitridge
- Discipline of Surgery, The University of Adelaide, Adelaide, Australia
| | - Jeremy Provance
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | - Gaëlle Romain
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | - Neil McMillan
- Discipline of Surgery, The University of Adelaide, Adelaide, Australia
| | - Nancy Stone
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Kate Scott
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Christine Fuss
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Christina M. Pacheco
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Kensey Gosch
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Avis Harper-Brooks
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | - Kim G. Smolderen
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
- Yale University, Department of Psychiatry, New Haven, CT, United States
- Corresponding author at: 789 Howard Avenue, New Haven, CT 06519, United States.
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Beck CJ, Germano E, Artis AS, Kirksey L, Smolock CJ, Lyden SP, Bakaeen FG, Menon V, Roselli EE, Farivar BS. Outcomes and role of peripheral revascularization in type A aortic dissection (TAAD) presenting with acute lower extremity ischemia. Eur J Vasc Endovasc Surg 2022. [DOI: 10.1016/j.ejvs.2022.01.024] [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: 11/03/2022]
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Sorour AA, Kirksey L. Bilateral retropharyngeal internal carotid artery ‘kissing carotids’. Eur Heart J Case Rep 2021; 5:ytab390. [PMID: 34926982 PMCID: PMC8672654 DOI: 10.1093/ehjcr/ytab390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/05/2021] [Accepted: 09/13/2021] [Indexed: 11/13/2022]
Affiliation(s)
- Ahmed A Sorour
- Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Desk H3-521-2, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Lee Kirksey
- Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Desk H3-521-2, 9500 Euclid Avenue, Cleveland, OH 44195, USA
- Walter W. Buckley Endowed Chair, Department of Vascular Surgery, Cleveland Clinic, Desk H3-521-2, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Smith AH, Beach JM, Dash S, Rowse J, Parodi FE, Kirksey L, Caputo FJ, Lyden SP, Smolock CJ. Comparison of Aortobifemoral Bypass to Aortoiliac Stenting with Bifurcation Reconstruction for TASC II D Aortoiliac Occlusive Disease. Ann Vasc Surg 2021; 82:120-130. [PMID: 34788703 DOI: 10.1016/j.avsg.2021.10.040] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 10/09/2021] [Accepted: 10/11/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Long-segment stenting of the infrarenal aorta and bilateral iliac arteries, with or without femoral endarterectomy for diffuse disease, has been adopted for treatment of severe aortoiliac occlusive disease (AIOD). The objective of this study was to compare outcomes of this reconstruction, termed aortoiliac stenting with bifurcation reconstruction (AISBR), to aortobifemoral bypass (ABF) in patients with comparable TASC II D lesions. METHODS This is a single-center, retrospective review of patients treated with ABF or AISBR for comparable TASC II D lesions between 2010 and 2018. ABF patients were included only if they were deemed anatomic candidates also for AISBR after review of preoperative imaging. Patients treated for acute limb ischemia and bypass graft infection were excluded. Statistics included Fisher exact test, Kaplan-Meier analysis, and Cox proportional hazards regression. RESULTS There were 24 ABF and 75 AISBR included in the study. The primary indication for treatment was claudication in 55 (55.6%) patients, rest pain in 28 (28.3%), and tissue loss in 16 (16.2%). Patients undergoing AISBR were more likely to be female. Femoral endarterectomies were performed in 37/75 (49.3%) AISBR and 14/24 (58.3%) ABF (p=0.44). AISBR were performed percutaneously in 34/75 (45.1%). No AISBR required conversion to ABF. Intraoperative blood loss, procedure time and hospital length of stay (LOS) were significantly less for AISBR compared to ABF. Surgical site infections (SSI) were less common in patients undergoing AISBR (AISBR: 6/75 (8.0%) vs. ABF: 9/24 (37.5%), (p<0.01). One AISBR and two ABF developed late SSI >30 days postoperatively. The reductions in blood loss, LOS and SSI remained significant after excluding percutaneous AISBR from the analysis. Five-year primary patency was 50.8% (95% CI: 33.3, 68.4%) for AISBR and 88.1% (72.7, 100.0%) for ABF (p=0.04). Five-year survival was 76.5% (95% CI: 63.6, 89.5) for AISBR and 100% (95% CI: 100.0, 100.0) for ABF (p = 0.07). Five-year primary assisted patency, secondary patency, freedom from reintervention and major adverse limb events did not differ significantly between groups. CONCLUSIONS AISBR is a viable option for management of TASC II D AIOD, with lower morbidity and acceptable durability when compared to traditional ABF.
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Affiliation(s)
- Andrew H Smith
- Aortic Center and Heart Vascular and Thoracic Institute, Department of Vascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195
| | - Jocelyn M Beach
- Department of Vascular Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756
| | - Siddhartha Dash
- Aortic Center and Heart Vascular and Thoracic Institute, Department of Vascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195
| | - Jarrad Rowse
- Aortic Center and Heart Vascular and Thoracic Institute, Department of Vascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195
| | - Frederico E Parodi
- Division of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC 27599
| | - Lee Kirksey
- Aortic Center and Heart Vascular and Thoracic Institute, Department of Vascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195
| | - Francis J Caputo
- Aortic Center and Heart Vascular and Thoracic Institute, Department of Vascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195
| | - Sean P Lyden
- Aortic Center and Heart Vascular and Thoracic Institute, Department of Vascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195
| | - Christopher J Smolock
- Aortic Center and Heart Vascular and Thoracic Institute, Department of Vascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195.
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Beck C, Pickney C, Caputo F, Glover K, Rowse J, Quatromoni J, Kirksey L, Lyden S, Smolock C. Effect of an Abdominal Aortic Aneurysm Appropriateness Dashboard on Clinical Practice. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Sorour A, Kirksey L, Laczynski DJ, Hoell NG, Kalahasti V, Smolock CJ, Lyden SP, Caputo FJ. Racial Disparities in Presentation and Short-term Outcome in Patients With Acute Type B Aortic Dissection. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.07.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Beck CJ, Germano E, Artis AS, Kirksey L, Smolock CJ, Lyden SP, Bakaeen FG, Menon V, Roselli EE, Farivar BS. Outcomes and role of peripheral revascularization in type A aortic dissection (TAAD) presenting with acute lower extremity ischemia. J Vasc Surg 2021; 75:495-503.e5. [PMID: 34500026 DOI: 10.1016/j.jvs.2021.08.050] [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: 02/02/2021] [Accepted: 08/01/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Limited data exists on management and outcomes of patients presenting with type A aortic dissection (TAAD) and acute lower extremity ischemia (ALI). The role of limb-related revascularization and optimal treatment strategy remains undefined. The objective of this study was to analyze dissection characteristics, treatment modalities, and outcomes of patients undergoing proximal aortic repair for TAAD with ALI. METHODS Consecutive patients who underwent proximal aortic repair for TAAD were identified from a prospectively maintained database. Clinical data, imaging, operative details, and outcomes of patients with TAAD and ALI were retrospectively analyzed. Kaplan-Meier methodology was used to estimate overall and amputation-free survival. Log-rank tests were used to compare overall curves. Predictors of revascularization and in-hospital mortality were determined using multivariable logistic regression analysis. RESULTS From 2010 to 2018, 463 patients with TAAD underwent proximal aortic repair. A total of 81 patients (17%) presented with ALI; 48% (39/81) with isolated ALI, and 52% (42/81) with ALI and renovisceral malperfusion. Thirty percent (24/81) required revascularization in addition to proximal aortic repair. Revascularization strategies involved endovascular (46%; 11/24), open (33%; 8/24), and hybrid (21%; 5/24) interventions. The major amputation rate was 4% (3/81), and in-hospital mortality was 21% (17/81). Amputation-free survival was significantly lower in patients requiring revascularization compared with those who did not (log-rank P = .023). Overall survival did not significantly differ between the two groups (log-rank P = .095). Overall survival was significantly lower in patients with concomitant ALI and renovisceral malperfusion compared with those with isolated ALI (log-rank P = .0017). Distal extent of dissection flap into zone 11 (odds ratio [OR], 5.65; 95% confidence interval [CI], 1.58-20.2; P = .008) and partial/complete thrombosis of any iliac artery (OR, 3.94; 95% CI, 1.23-12.6; P = .021) were associated with increased risk of requiring an additional revascularization procedure. True lumen collapse at level of renovisceral aorta (OR, 8.84; 95% CI, 1.74-44.9; P = .0086) was associated with increased risk of in-hospital mortality. CONCLUSIONS ALI resolves after proximal aortic repair of TAAD in most cases. Distal extent of aortic dissection into zone 11 and iliac thrombosis are risk factors for additional peripheral revascularization. True lumen collapse at the renovisceral aorta and TAAD with concomitant ALI and renovisceral malperfusion portends a poor prognosis. A multi-disciplinary team approach to manage these patients who present with ascending aortic dissection and distal malperfusion may improve outcomes in this complex population.
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Affiliation(s)
- Cassandra J Beck
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Emidio Germano
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Amanda S Artis
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lee Kirksey
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Sean P Lyden
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Venu Menon
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Behzad S Farivar
- Division of Vascular & Endovascular Surgery, University of Virginia, Charlottesville, Va; Aortic Center, University of Virginia Medical Center, Charlottesville, Va.
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Steenberge SP, Smolock CJ, Caputo FJ, Rowse JW, Quatromoni J, Kirksey L, Lyden SP. Natural History and Growth Rates of Isolated Common Iliac Artery Aneurysms. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.455] [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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Kirksey L, Sorour AA, Rowse JW, Quatromoni J, Smolock CJ, Caputo FJ, Lyden SP. Dialysis Access: Axillary Artery to Vein Loop Chest Wall Bridge Graft. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Kirksey L, Sorour AA, Duson S, Osman MF, Downing LJ, Ayman A, Rowe V. Black Vascular Surgeons Survey: Who Are They? Where Are They? Who Do They Treat? J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.414] [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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Abstract
Attaining equity in vaccination distribution is a moral and ethical goal that ensures all members of our community are properly cared for. We suggest a comprehensive approach that involves allocating community resources based on local economic, demographic, and COVID-19 infection data, removing technology barriers by staffing vaccine appointment call-in centers, distributing vaccines based on objective factors (eg, household density) rather than on a "first come, first served" basis, and creating pop-up vaccination sites at trusted community organizations such as federally qualified healthcare centers, churches, libraries, and barber/beauty shops. Until every community is safe, no community will be safe.
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Affiliation(s)
- Lee Kirksey
- Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH; Walter W. Buckley Endowed Chair, Department of Vascular Surgery, Cleveland Clinic, Cleveland, OH
| | - Adam J Milam
- Fellow, Anesthesiology Institute, Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Caleb W Curry
- Case Western Reserve University, Undergraduate Studies, Cleveland, OH
| | - Ahmed A Sorour
- Research Fellow, Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
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40
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Ghulam Q, Bredahl K, Eiberg J, Bal L, van Sambeek MR, Kirksey L, Kilaru S, Taudorf M, Rouet L, Collet-Billon A, Kawashima T, Entrekin R, Sillesen H. Three-dimensional ultrasound is a reliable alternative in endovascular aortic repair surveillance. J Vasc Surg 2021; 74:979-987. [PMID: 33684470 DOI: 10.1016/j.jvs.2021.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 02/18/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Three-dimensional ultrasound (3D-US) has already demonstrated improved reproducibility with a high degree of agreement (intermodality variability), reproducibility (interoperator variability), and repeatability (intraoperator variability) compared with conventional two-dimensional ultrasound (2D-US) when estimating the maximum diameter of native abdominal aortic aneurysms (AAAs). The aim of the present study was, in a clinical, multicenter setting, to evaluate the accuracy of 3D-US with aneurysm model quantification software (3D-US abdominal aortic aneurysm [AAA] model) for endovascular aortic aneurysm repair (EVAR) sac diameter assessment vs that of computed tomography angiography (CTA) and 2D-US. METHODS A total of 182 patients who had undergone EVAR from April 2016 to December 2017 and were compliant with a standardized EVAR surveillance program were enrolled from five different vascular centers (Rigshospitalet, Copenhagen, Denmark; Catharina Ziekenhuis, Eindhoven, Netherlands; L'hospital de la Timone, Paris, France; Cleveland Clinic, Cleveland, Ohio; and The Christ Hospital, Cincinnati, Ohio) in four countries. All image acquisitions were performed at the local sites (ie, 2D-US, 3D-US, CTA). Only the 2D-US and CTA readings were performed both locally and centrally. All images were read centrally by the US and CTA core laboratory. Anonymized image data were read in a randomized and blinded manner. RESULTS The sample used to estimate the accuracy of the 3D-US AAA model and 2D-US included 164 patients and 177 patients, respectively. The Bland-Altman analysis revealed that the mean difference between CTA and 3D-US was -2.43 mm (95% confidence interval [CI], -5.20 to 0.14; P = .07) with a lower and upper limit of agreement of -8.9 mm (95% CI, -9.3 to -8.4) and 2.7 mm (95% CI, 2.3-3.2), respectively. For 2D-US and CTA, the mean difference was -3.62 mm (95% CI, -6.14 to -1.10; P = .002), with a lower and upper limit of agreement of -10.3 mm (95% CI, -10.8 to -9.8) and 2.5 mm (95% CI, 2-2.9), respectively. CONCLUSIONS The 3D-US AAA model showed no significant difference compared with CTA for measuring the anteroposterior diameter, indicating less bias for 3D-US compared with 2D-US. Thus, 3D-US with AAA model software is a viable modality for anteroposterior diameter assessment for surveillance after EVAR.
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Affiliation(s)
- Qasam Ghulam
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark.
| | - Kim Bredahl
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jonas Eiberg
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Copenhagen Academy of Medical Education and Simulation, Copenhagen, Denmark
| | - Laurence Bal
- Le Centre Aorte Timone, Department of Cardiovascular Surgery, Hospital de la Timone, Marseille, France
| | - Marc R van Sambeek
- Department of Vascular Surgery, Catharina Ziekenhuis, Eindhoven, Netherlands; Department of Cardiovascular Biomechanics, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Lee Kirksey
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Sashi Kilaru
- Department of Vascular Surgery, The Christ Hospital, Cincinnati, Ohio
| | | | - Laurence Rouet
- Philips Research Medisys, Suresnes, Philips Ultrasound, Bothell, Wash
| | | | - Toana Kawashima
- Regulatory and Clinical Affairs, Philips Ultrasound, Bothell, Wash
| | - Robert Entrekin
- Ultrasound Clinical Science, Philips Ultrasound, Bothell, Wash
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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41
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Lim S, Alarhayem AQ, Rowse JW, Caputo FJ, Smolock CJ, Lyden SP, Kirksey L, Hardy DM. Thoracic outlet decompression for subclavian venous stenosis after ipsilateral hemodialysis access creation. J Vasc Surg Venous Lymphat Disord 2021; 9:1473-1478. [PMID: 33676044 DOI: 10.1016/j.jvsv.2021.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/12/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Central venous stenosis is one of the most challenging complications in patients requiring hemodialysis. Venous thoracic outlet syndrome is an underappreciated cause of central venous stenosis in patients requiring dialysis that can result in failed percutaneous intervention and loss of a functioning dialysis access. Limited data exist about the safety and outcomes of first rib resection in patients requiring hemodialysis, and the results have been confounded by the various surgical approaches used. The purpose of the present study was to evaluate the safety, operative outcomes, and patency of the existing dialysis access after transaxillary thoracic outlet decompression. METHODS A retrospective medical record review was performed from January 2008 to December 2019 of patients who had undergone thoracic outlet decompression for subclavian vein stenosis with ipsilateral upper extremity hemodialysis access. The baseline characteristics and comorbidities were reviewed. The operative and postoperative course were evaluated. The survival and patency rates were analyzed using the life-table method and Kaplan-Meier curve. RESULTS A total of 18 extremities in 18 patients were identified. Their mean age was 59 ± 11 years, and 89% were men. A total of 13 fistulas and 5 grafts were included. All patients had undergone repair via a transaxillary approach. First rib resection, anterior scalenectomy, and circumferential venolysis were performed in all 18 patients. The mean operative time was 99 ± 19 minutes, with an estimated blood loss of 78 ± 66 mL. The median length of stay was 2 days. No patient had died at 30 days. The survival rate at 1 year was 83%. The primary, primary-assisted, and secondary patency at 1 year were 42%, 69%, and 93%, respectively. CONCLUSION Thoracic outlet decompression via the transaxillary approach is a technically feasible and safe operation in patients with ipsilateral upper extremity hemodialysis access. Patients with threatened dialysis access due to subclavian vein stenosis should be carefully evaluated for possible extrinsic compression at the costoclavicular junction. These patients might benefit from transaxillary first rib resection, scalenectomy, and venolysis.
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Affiliation(s)
- Sungho Lim
- Department of Vascular Surgery, Sydell and Arnold Miller Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Abdul Q Alarhayem
- Department of Vascular Surgery, Sydell and Arnold Miller Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jarrad W Rowse
- Department of Vascular Surgery, Sydell and Arnold Miller Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Francis J Caputo
- Department of Vascular Surgery, Sydell and Arnold Miller Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Christopher J Smolock
- Department of Vascular Surgery, Sydell and Arnold Miller Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Sean P Lyden
- Department of Vascular Surgery, Sydell and Arnold Miller Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lee Kirksey
- Department of Vascular Surgery, Sydell and Arnold Miller Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - David M Hardy
- Department of Vascular Surgery, Sydell and Arnold Miller Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
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Abstract
Minority groups continue to suffer disproportionately from COVID-19's impact, with Blacks and Hispanics three times more likely to die from the disease than their White counterparts. The COVID-19 vaccine roll out has the potential to provide relief to these most adversely impacted communities. However, historic mistrust within racial minority communities threatens to derail the effective implementation of a vaccination program. The origin of this mistrust is multifactorial. Current day experience with structural racism and research abuses like Tuskegee Study collectively influence our perception of biased healthcare system. We outline issues and propose solutions that must be addressed to achieve a successful vaccination agenda. Mishandling of public expectations at any point may lead to an avalanche of vaccine opposition which might be unrecoverable.
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Affiliation(s)
- Lee Kirksey
- Walter W. Buckley Endowed Chair, Department of Vascular Surgery, Cleveland Clinic, Cleveland, OH, USA.
| | - Ahmed A Sorour
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Charles Modlin
- Department of Urology, Cleveland Clinic, Cleveland, OH, USA
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Batagini NC, Constantin BD, Kirksey L, Vallentsits Estenssoro AE, Puech-Leão P, De Luccia N, Simão da Silva E. Natural History of Splanchnic Artery Aneurysms. Ann Vasc Surg 2020; 73:290-295. [PMID: 33346122 DOI: 10.1016/j.avsg.2020.10.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 10/15/2020] [Accepted: 10/25/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Splanchnic artery aneurysms (SAAs) represent a rare and potential life-threatening disease with a documented incidence of 0.1-2.0%. The risk of rupture and the diameter to recommend surgery are still controversial. The purpose of this study was to review surveillance computed tomography scans (CTs) at a high-volume institution in order to better define the natural history of the SAA. METHODS Between January 2000 and February 2019, all SAAs patients in follow-up at a single center institution were selected for analysis. CTs from patients managed nonoperatively and CTs before surgery from patients submitted to surgery were studied. The first CTs were used to determine aneurysm size, morphology, and anatomic characteristics, and the last CTs performed during nonoperative follow-up were used to compare the diameter with the previous CTs. Primary endpoint included growth rate for all SAAs location, and secondary endpoint included the clinical or anatomical characteristic associated with a faster growth rate. RESULTS In total, 116 consecutive patients were identified with SAAs and 74 patients with 87 SAAs who had at least 2 CTs during follow-up were analyzed. From those 74 patients, 12 were submitted to surgery and only their preoperative CTs were analyzed. The SAAs' locations were: splenic (55.4%), hepatic (12.2%), superior mesenteric artery (17.6%), celiac trunk (27.0%), gastric and gastroepiploic arteries (1.4%), pancreaticoduodenal and gastroduodenal arteries (4.1%). The median follow-up for all patients was 46.7 months (±35.3), and the median of growth for all aneurysms was 0.63 mm/year (±2.19). Only the splenic aneurysms presented growth with statistic significance of 1.08 mm per/year (±1.99) (P < 0.001). Only portal hypertension showed statistically significance to splenic aneurysm growth (P = 0.002). Multivariate analysis for variables associated with splenic aneurysm growth ≥1 mm/year showed that portal hypertension was the only variable with statistical significance (P < 0.01, IC 95% 2.0-186.9, β = 19.5). CONCLUSIONS Although longer-term follow-up and larger sample size are needed to better understand the natural history of SAAs, the majority of SAAs tends to remain stable in size through follow-up. Portal hypertension was the only risk factor found for true splenic aneurysm growth, and so those patients must have a closer follow-up.
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Affiliation(s)
- Nayara Cioffi Batagini
- Vascular and Endovascular Division, Surgery Department, Hospital das Clinicas - LIM 02, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil.
| | - Bruno Donegá Constantin
- Vascular and Endovascular Division, Surgery Department, Hospital das Clinicas - LIM 02, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Lee Kirksey
- Vascular and Endovascular Division, Vascular and Endovascular Surgery Departament, The Cleveland Clínic, Cleveland, OH
| | - Andre Echaime Vallentsits Estenssoro
- Vascular and Endovascular Division, Surgery Department, Hospital das Clinicas - LIM 02, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Pedro Puech-Leão
- Vascular and Endovascular Division, Surgery Department, Hospital das Clinicas - LIM 02, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Nelson De Luccia
- Vascular and Endovascular Division, Surgery Department, Hospital das Clinicas - LIM 02, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Erasmo Simão da Silva
- Vascular and Endovascular Division, Surgery Department, Hospital das Clinicas - LIM 02, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil
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Alarhayem A, Morrow K, Caputo F, Hardy D, Kirksey L, Lyden S, Rowse J, Smolock C. The Natural History of Common Carotid Artery Occlusive Disease. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.08.108] [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: 10/23/2022]
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45
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Rowse J, Harris D, Hardy D, Kirksey L, Smolock C, Lyden S, Caputo F. Optimal Timing of Surveillance Ultrasound in Small Aortic Aneurysms. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.06.079] [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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Tucker DL, Perry J, Bock A, Douglas A, Albert C, Kirksey L, Zhen-Yu Tong M. Left ventricular assist device implantation with axillary-axillary outflow graft. JTCVS Tech 2020; 4:197-199. [PMID: 34318011 PMCID: PMC8303080 DOI: 10.1016/j.xjtc.2020.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 07/29/2020] [Accepted: 08/10/2020] [Indexed: 11/26/2022] Open
Affiliation(s)
| | - John Perry
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ashley Bock
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Aaron Douglas
- Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Chonyang Albert
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Lee Kirksey
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Michael Zhen-Yu Tong
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
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Kirksey L, Tucker DL, Taylor E, White Solaru KT, Modlin CS. Pandemic Superimposed on Epidemic: Covid-19 Disparities in Black Americans. J Natl Med Assoc 2020; 113:39-42. [PMID: 32747313 PMCID: PMC7395612 DOI: 10.1016/j.jnma.2020.07.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/02/2020] [Accepted: 07/05/2020] [Indexed: 11/28/2022]
Abstract
Health and healthcare disparities are variances in the health of a population or the care rendered to a population. Disparities result in a disproportionately higher prevalence of disease or lower standard of care provided to the index group. Multiple theories exist regarding the genesis of this disturbing finding. The COVID-19 pandemic has had the unfortunate effect of amplifying health inequity in vulnerable populations. African Americans, who make up approximately 12% of the US population are reportedly being diagnosed with COVID-19 and dying at disproportionately higher rates. Viewed holistically, multiple factors are contributing to the perfect storm: 1) Limited availability of public testing, 2) A dramatic increase in low wage worker unemployment/health insurance loss especially in the service sector of the economy, 3) High rates of preexisting chronic disease states/reduced access to early healthcare and 4) Individual provider and structural healthcare system bias. Indeed, COVID-19 represents a pandemic superimposed on a historic epidemic of racial health inequity and healthcare disparities. Therapeutic solutions are not expected in the near term. Thus, identifying the genesis and magnitude of COVID-19's impact on African American communities is the requisite first step toward crafting an immediate well designed response. The mid and long term approach should incorporate population health based tactics and strategies.
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Affiliation(s)
- Lee Kirksey
- Walter W. Buckley Endowed Chair, Sydell and Arnold Miller Heart and Vascular Institute, Cleveland Clinic Main Campus, Cleveland, OH, 44195, USA.
| | - Dominique L Tucker
- Case Western Reserve University School of Medicine, Health Education Campus, Cleveland, OH, 44106, USA
| | - Eddie Taylor
- Chairmen, The Presidents Council of Cleveland, USA
| | - Khendi T White Solaru
- Department of Cardiovascular Medicine, Harrington Heart and Vascular Institute, University Hospitals Cleveland, Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA
| | - Charles S Modlin
- Section of Renal Transplantation, Department of Urology, Glickman Urological Institute, Cleveland Clinic Main Campus, Cleveland, OH 44195, USA
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McLennan G, Vachharajani T, Kirksey L. Abstract No. 442 Inpatient screening for endovascular arteriovenous fistula: the good, the bad, and the ugly. . . J Vasc Interv Radiol 2020. [DOI: 10.1016/j.jvir.2019.12.503] [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] Open
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49
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Droz NM, Lyden SP, Bena J, Smolock CJ, Hardy D, Farivar BS, Kirksey L, Caputo FJ. Carotid Endarterectomy Remains Safe in High-Risk Patients. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Vachharajani TJ, Kirksey L, McLennan G. Endovascular Bypass for Thoracic Vein Occlusion: An Innovative Technique for Hemodialysis Vascular Access. Am J Kidney Dis 2020; 75:468-470. [PMID: 32046863 DOI: 10.1053/j.ajkd.2019.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 12/13/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Tushar J Vachharajani
- Glickman Urological & Kidney Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University and Cleveland Clinic Foundation, Cleveland, OH.
| | - Lee Kirksey
- Heart and Vascular Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University and Cleveland Clinic Foundation, Cleveland, OH
| | - Gordon McLennan
- Department of Biomedical Engineering, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University and Cleveland Clinic Foundation, Cleveland, OH; Section of Vascular and Interventional Radiology, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University and Cleveland Clinic Foundation, Cleveland, OH
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