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1.
J Vasc Surg ; 2024 Jun 27.
Artículo en Inglés | MEDLINE | ID: mdl-38944400

RESUMEN

OBJECTIVES: The frequency of atherectomy in lower extremity arterial disease has increased substantially over the past several years, specifically in the office-based laboratory (OBL) setting, yet the efficacy compared to other interventions and the consequences of distal embolization remain unknown. Embolic Protection Devices (EPD) have been used at varying rates depending on physician and practice setting. Previous studies have described lesion characteristics to consider when weighing the benefits and drawbacks associated with device usage. Our study focuses on the use of atherectomy and EPD in femoropopliteal arterial disease to better characterize resource usage trends and postoperative outcomes in the inpatient and OBL interventional settings. METHODS: We conducted a retrospective analysis on endovascular interventions performed for femoral-popliteal occlusive disease that were entered into the Vascular Quality Initiative (VQI) data registry between 2017-2021. A 1:1 greedy-match, adjusted analysis based on inpatient or OBL location of procedure was utilized to compare the groups. Hierarchical logistical regression with selective use of principal component analysis was utilized to further explore the differences in EPD usage and immediate postoperative outcomes. A proportional hazard model was used to demonstrate differences in reintervention rates up to two years postoperatively between patients who underwent atherectomy in the inpatient vs OBL treatment setting. RESULTS: 2,849 matched pairs were included in the final analysis. In our cohort, there was 22% EPD usage overall, 40% in the hospital setting and 4.4% in the OBL setting (p<0.001). Among the patients with available follow-up information, OBL intervention setting increased probability of reintervention by 18% at 2 years postoperatively compared to the inpatient setting, however there was no difference associated with EPD placement and rate of reintervention. CONCLUSIONS: Use of EPD in the OBL setting compared to the hospital setting is dramatically decreased, however, no increased incidence of postoperative complications was seen compared to procedures performed in the hospital setting when controlling for patient and lesion characteristics. Patients with available follow-up data were more likely to undergo ipsilateral reintervention between 6 months and 2 years postoperatively if atherectomy was done in the OBL setting. Dedicated studies are encouraged to ensure patient safety, effective resource allocation, and long-term efficacy of OBL atherectomy as an ever-growing number of peripheral arterial procedures are transitioned to the OBL setting.

2.
J Vasc Surg ; 2024 May 29.
Artículo en Inglés | MEDLINE | ID: mdl-38821432

RESUMEN

OBJECTIVE: Postoperative outcomes following carotid revascularization are understudied in Asian patients. We aimed to assess whether disease severity and postoperative outcomes following carotid revascularization differ between Asian and White patients, and whether this varies with Asian procedure density. METHODS: We analyzed the Vascular Quality Initiative Carotid Endarterectomy and Carotid Artery Stenting datasets from 2003 to 2021. Regions were divided into tertiles based on Asian procedure density. Propensity scores were used to match Asian and White patients based on patient factors and procedure type. The primary outcome variable was a collapsed composite of in-hospital ipsilateral stroke/death/myocardial infarction. χ2 tests were used to assess association between Asian race and disease severity, center and surgeon volume, and 1-year outcomes. Logistic and Cox regressions were performed between the matched cohorts. RESULTS: A total of 1766 Asian and 159,608 White patients underwent carotid revascularization, and we identified 2704 patients (1352 Asian and 1352 White) in the matched cohorts. Among propensity matched patients, all-comer Asian patients more commonly had >80% ipsilateral stenosis (63% vs 52%; P < .001) and a moderate/severe preoperative Rankin score (7.6% vs 5.1%; P = .007). The rate of in-hospital stroke/death/myocardial infarction was higher in Asian patients (2.6% vs 1.3%; P = .012), and this disparity was more pronounced in the lowest tertile of Asian procedure density (4.3% vs 0.5%; P < .001). Logistic regression in the propensity-matched cohort demonstrated Asian race was associated with lower odds of intervention at highest volume centers (odds ratio [OR], 0.3; 95% confidence interval [CI], 0.2-0.3; P < .001) and by highest volume surgeons (OR, 0.3; 95% CI, 0.3-0.4; P < .001). Asian race was associated with higher odds of in-hospital stroke/death/myocardial infarction (OR, 2.0; 95% CI, 1.1-3.8; P = .031), and there was a significant interaction between Asian procedure density and the relationship between Asian race and this outcome (interaction P = .001). After accounting for center and surgeon volume, the association of Asian race and the composite outcome was mitigated (OR, 1.5; 95% CI, 0.7-3.3; P = .300). Cox regression between the matched cohorts demonstrated that Asian race was associated with lower 1-year mortality (hazard ratio, 0.5; 95% CI, 0.3-0.7; P = .001) and higher risk of 1-year reintervention (hazard ratio, 16; 95% CI, 1.8-142; P = .013). CONCLUSIONS: Asian patients are more likely to present with a higher degree of carotid stenosis, higher preoperative risk, and experience worse perioperative outcomes. The association of Asian race with perioperative stroke/death/myocardial infarction varies with Asian procedure density and is also confounded by center and surgeon volume. These results highlight the importance of understanding referral patterns and cultural effects on outcomes disparities in Asian patients.

3.
J Vasc Surg ; 78(1): 175-183.e3, 2023 07.
Artículo en Inglés | MEDLINE | ID: mdl-36889608

RESUMEN

OBJECTIVE: The nature of peripheral arterial disease and postoperative outcomes are understudied in Asian patients. We aimed to determine if there are disparities in disease severity at the time of presentation and postoperative outcomes with regard to Asian race. METHODS: We analyzed the Society for Vascular Surgery Vascular Quality Initiative Peripheral Vascular Intervention dataset from 2017 to 2021, which includes endovascular lower extremity interventions. Propensity scores were used to match White and Asian patients based on age, sex, comorbidities, ambulatory/functional status, and intervention level. Differences were examined with regard to Asian race across all patients in the United States, Canada, and Singapore, and separately in the United States and Canada only. The primary outcome was emergent intervention. We also examined differences in severity of disease and postoperative outcomes. RESULTS: A total of 80,312 White and 1689 Asian patients underwent peripheral vascular intervention. After propensity score matching, we identified 1669 matched pairs of patients across all centers including Singapore and 1072 matched pairs in the United States and Canada only. Among the matched cohort consisting of all centers, Asian patients had a higher rate of emergent intervention to prevent limb loss (5.6% vs 1.7%, P < .001). The majority of Asian patients presented with chronic limb threatening ischemia at a higher rate than White patients within the cohort including Singapore (71% vs 66%, P = .005). Within both propensity-matched cohorts, the rate of in-hospital death was higher in Asian patients (all centers: 3.1% vs 1.2%, P < .001; United States and Canada only: 2.1% vs 0.8%, P = .010). Logistic regression demonstrated greater odds of emergent intervention in Asian patients from all centers including Singapore (odds ratio [OR], 3.3; 95% confidence interval [CI], 2.2-5.1, P < .001) but not in the United States and Canada only (OR, 1.4; 95% CI, 0.8-2.8, P = .261). In addition, Asian patients had greater odds of in-hospital death in both matched cohorts (all centers: OR, 2.6; 95% CI, 1.5-4.4, P < .001; United States and Canada: OR, 2.5; 95% CI, 1.1-5.8, P = .026). Asian race was associated with a greater risk of loss of primary patency at 18 months (all centers: hazard ratio, 1.5; CI, 1.2-1.8, P = .001; United States and Canada only: hazard ratio, 1.5; CI, 1.2-1.9, P = .002). CONCLUSIONS: Asian patients are more likely to present with advanced peripheral arterial disease and undergo emergent intervention to prevent limb loss, in addition to having worse postoperative outcomes and long-term patency. These results highlight the need for improved screening and postoperative follow-up in this understudied population.


Asunto(s)
Procedimientos Endovasculares , Enfermedad Arterial Periférica , Humanos , Estados Unidos/epidemiología , Mortalidad Hospitalaria , Resultado del Tratamiento , Recuperación del Miembro , Factores de Riesgo , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/cirugía , Estudios Retrospectivos , Procedimientos Endovasculares/efectos adversos , Isquemia
4.
J Vasc Surg ; 77(3): 818-826.e1, 2023 03.
Artículo en Inglés | MEDLINE | ID: mdl-36257345

RESUMEN

OBJECTIVE: Underinsured patients can experience worse preoperative medical optimization. We aimed to determine whether insurance status was associated with carotid endarterectomy (CEA) urgency and postoperative outcomes. METHODS: We analyzed the Society for Vascular Surgery Vascular Quality Initiative Carotid Endarterectomy dataset from January 2012 to January 2021. Univariable and multivariable methods were used to analyze the differences across the insurance types for the primary outcome variable: CEA urgency. The analyses were limited to patients aged <65 years to minimize age confounding across insurers. We also examined differences in preoperative medical optimization and symptomatic disease and postoperative outcomes. A secondary analysis was performed to examine the effect of CEA urgency on the postoperative outcomes. RESULTS: A total of 27,331 patients had undergone first-time CEA. Of these patients, 4600 (17%) had Medicare, 3440 (13%) had Medicaid, 17,917 (65%) had commercial insurance, and 1374 (5%) were uninsured. The Medicaid and uninsured patients had higher rates of urgent operation compared with Medicare (20.0% and 34.7% vs 14.4%; P < .001), with no differences in the commercial group vs the Medicare group. Additionally, Medicaid and uninsured patients had lower rates of aspirin, statin, and/or antiplatelet use (93.6% and 93.5% vs 95.8%; P < .001) and higher rates of symptomatic disease (42.1% and 57.6% vs 36.2%; P < .001) compared with Medicare patients. The rate of perioperative stroke/death was higher for the Medicaid and uninsured patients than for the Medicare patients (1.63% and 1.89% vs 1.02%; P = .017 and P = .01, respectively), with no differences in the commercial group. Multivariable analysis demonstrated that compared with Medicare, Medicaid and uninsured status were associated with increased odds of an urgent operation (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.1-1.5; and OR, 2.3; 95% CI, 2.0-2.7, respectively), symptomatic disease (OR, 1.2; 95% CI, 1.1-1.4; and OR, 2.2; 95% CI, 1.9-2.5, respectively), and perioperative stroke/death (OR, 1.6; 95% CI, 1.1-2.4; and OR, 1.8; 95% CI, 1.1-3.0, respectively) and a decreased odds of aspirin, statin, and/or antiplatelet use (OR, 0.71; 95% CI, 0.6-0.9; and OR, 0.76; 95% CI, 0.6-0.99, respectively). Additionally, the rates of perioperative stroke/death were higher for patients who had required urgent surgery compared with elective surgery (2.8% vs 1.0%; P < .001). Multivariable analysis demonstrated increased odds of perioperative stroke/death for patients who had required urgent surgery (OR, 2.4; 95% CI, 1.9-3.1). CONCLUSIONS: Medicaid and uninsured patients were more likely to require urgent CEA, in part because of poor preoperative medical optimization. Additionally, urgent operation was independently associated with worse postoperative outcomes. These results highlight the need for improved preoperative follow-up for underinsured populations.


Asunto(s)
Estenosis Carotídea , Endarterectomía Carotidea , Inhibidores de Hidroximetilglutaril-CoA Reductasas , Accidente Cerebrovascular , Humanos , Anciano , Estados Unidos , Endarterectomía Carotidea/efectos adversos , Factores de Riesgo , Medicare , Accidente Cerebrovascular/etiología , Aspirina , Cobertura del Seguro , Resultado del Tratamiento , Estudios Retrospectivos , Estenosis Carotídea/cirugía , Medición de Riesgo
5.
J Vasc Surg ; 75(2): 680-686, 2022 02.
Artículo en Inglés | MEDLINE | ID: mdl-34478809

RESUMEN

OBJECTIVE: The contemporary medicolegal environment has been linked to procedure overuse, health care variation, and higher costs. For physicians accused of malpractice, there is also a personal toll. The objective of this study was to evaluate the prevalence of and risk factors for involvement in medical malpractice lawsuits among United States vascular surgeons, and to examine the association between these allegations with surgeon wellness. METHODS: In 2018, the Society of Vascular Surgery (SVS) Wellness Task Force conducted a confidential survey of active members using a validated burnout assessment (Maslach Burnout Index) embedded into a questionnaire. This survey included questions related to medical errors and malpractice litigation. De-identified demographic, personal, and practice-related characteristics were assessed in respondents who reported malpractice allegations in the preceding 2 years, then compared with those without recent medicolegal litigation. Risk factors for malpractice allegations were identified (χ2, Kruskal-Wallis tests), and the association between malpractice allegations with wellness was examined. Multivariate logistic regression models were developed to identify independent risk factors for malpractice accusations. RESULTS: Of 2905 active SVS members, 871 responses from practicing vascular surgeons were analyzed. A total of 161 (18.5%) were named in a malpractice lawsuit within 2 years. Malpractice allegations were significantly associated with surgeon burnout (odds ratio, 1.47; 95% confidence interval, 1.01-2.15; P = .041), but not with self-reported depression or suicidal ideation. The nature of malpractice claims included procedural errors (23.1%), failure to treat (18.8%), and error/delay in diagnosis (16.9%). Twenty percent of claims were settled prior to trial, and 19% were dismissed. Defendant vascular surgeons reported a "fair" resolution in 26.4% of closed cases. By unadjusted analysis, factors significantly associated with recent malpractice claims included mean age (51.7 ± 10.0 vs 49.3 ± 11.2 years; P = .0044) and mean years in practice (18.0 ± 10.7 vs 15.2 ± 11.8; P = .0007). Multivariate analysis revealed independent variables associated with malpractice allegations, including on-call frequency (P = .0178), recent medical errors (P = .0189), and male surgeons (P = .045). CONCLUSIONS: Malpractice allegations are common for vascular surgeons and are significantly associated with surgeon burnout. Nearly 20% of survey respondents reported being named in a lawsuit within the preceding 2 years. Our findings underscore the need for SVS initiatives to provide counseling and peer support for vascular surgeons facing litigation.


Asunto(s)
Agotamiento Profesional/epidemiología , Mala Praxis/legislación & jurisprudencia , Medición de Riesgo/métodos , Cirujanos/legislación & jurisprudencia , Procedimientos Quirúrgicos Vasculares/psicología , Adulto , Anciano , Agotamiento Profesional/psicología , Femenino , Estudios de Seguimiento , Humanos , Consentimiento Informado/legislación & jurisprudencia , Masculino , Persona de Mediana Edad , Prevalencia , Estudios Retrospectivos , Factores de Riesgo , Cirujanos/psicología , Encuestas y Cuestionarios , Estados Unidos/epidemiología
6.
Kidney Med ; 3(6): 1091-1094, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-34939019

RESUMEN

Kidney replacement therapy is required in up to one-third of patients after left ventricular assist device (LVAD) placement. A subset of these patients requires long-term maintenance hemodialysis and therefore needs durable vascular access but the ideal access in such patients has not been established. We present a series of 3 patients in whom arteriovenous grafts (AVGs) were successfully used for long-term kidney replacement therapy after LVAD placement. The maximum time from AVG placement to first successful AVG use was 40 days, and the longest AVG use duration was more than 2 years. 2 patients required AVG excision due to infection but both had successful placement of a second AVG. Total time on kidney replacement therapy was 993, 1,055, and 956 days for the 3 cases, of which dialysis catheter use was required for only 23%, 6.5%, and 27%, respectively. These cases suggest that AVG placement is a viable option for dialysis access in patients with LVADs.

7.
J Vasc Surg ; 74(4): 1309-1316.e2, 2021 10.
Artículo en Inglés | MEDLINE | ID: mdl-34186164

RESUMEN

OBJECTIVE: Patients without adequate outpatient follow-up often present requiring emergency hemodialysis and then undergo permanent dialysis access placement at a later time. We sought to examine the relationship between type of insurance and whether a patient was already on dialysis at time of surgery. METHODS: The Vascular Quality Initiative Hemodialysis Access registry was queried for all adult patients undergoing first time permanent hemodialysis access between January 2015 and September 2019. Patient and procedural characteristics were examined in patients split by private insurance-Medicare more than 65 years of age, Medicare less than 65 years of age, and Medicaid. The primary outcome was whether patients were on dialysis at the time of surgery. RESULTS: There were 19,307 adult patients that underwent first time placement of an arteriovenous fistula or graft. Of these patients, 9729 (50%) had Medicare, 7179 (37%) had private insurance, and 2399 (12%) had Medicaid. The patients with Medicare were subgrouped by age with 2968 (31%) being less than 65 years of age and 6761 (69%) being more than 65 years of age. Patients with Medicare and less than 65 were the most likely to be on dialysis at the time of surgical access placement at 67%, whereas 59% of Medicaid patients were on dialysis, and 53% each group of patients with Medicare and more than 65 years of age and private insurance were on dialysis. After adjustment for patient characteristics, patients with Medicare who were less than 65 and more than 65 years of age were both significantly more likely to be on dialysis at time of surgery compared with private insurance with odds ratio (OR) of 1.64 (95% confidence interval [CI], 1.49-1.80; P < .001) and an OR of 1.11 (95% CI, 1.03-1.20; P = .007), respectively. After adjustment, patients with Medicaid were no longer significantly more likely to be on dialysis. Secondary outcomes demonstrated, after adjustment, no difference in the association between a surgical fistula vs graft in any insurance groups; however, patients with Medicare and who were less than 65 years of age were more likely to have a nonradial artery used for anastomosis with an OR of 1.18 (95% CI, 1.04-1.34; P = .011). CONCLUSIONS: Certain types of insurance are correlated with being on dialysis at the time of access placement. Although associations were seen between insurance type and surgical access characteristics, these were associations predominantly insignificant when patient demographics and status of dialysis were controlled for. These potential gaps in care represent an area for improvement that deserves further exploration.


Asunto(s)
Derivación Arteriovenosa Quirúrgica , Implantación de Prótesis Vascular , Seguro de Salud , Fallo Renal Crónico/terapia , Diálisis Renal , Tiempo de Tratamiento , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Fallo Renal Crónico/diagnóstico , Fallo Renal Crónico/epidemiología , Masculino , Medicaid , Medicare , Persona de Mediana Edad , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiología
8.
Ann Surg Open ; 2(1): e040, 2021 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-37638243

RESUMEN

Objectives: To understand the impact that video telehealth has on outpatient visit volume and reimbursement as a method of maintaining care. Background: As the coronavirus disease 2019 (COVID-19) spread across the United States starting in 2020, it caused numerous areas of medicine and healthcare to reexamine how we provide care to patients across all disciplines. One method clinicians used to rapidly adapt to these transformed settings was video telehealth, which was previously rarely used. Methods: This retrospective review examined outpatient volume and reimbursement data of a large, academic department of surgery. The study reviewed data during 2 time periods: pre-COVID-19 (February 1, 2020, to March 15, 2020) and COVID-19 (March 16, 2020, to April 30, 2020). Results: During the period of February 1 to April 30, 13,193 outpatient visits were analyzed. The pre-COVID-19 group contained 9041 (68.5%) visits, whereas the COVID-19 group contained 4152 (31.4%) visits. All divisions noted a drop in visit volume from pre-COVID-19 compared with COVID-19. There was rapid adoption of video telehealth during COVID-19, which made up most patient visits during that time (61.3%). We also found that video telehealth led to significant reimbursements while also allowing patients in numerous states to receive care. Conclusions: Previously, video telehealth was used by clinicians in a small portion of outpatient visits. However, safety concerns surrounding COVID-19 forced multiple changes to the way care is provided. Although outpatient volume at our center was less than that before the pandemic, video telehealth was rapidly adopted by providers and allowed for safe and effective outpatient care to patients in a high number of states while still being reimbursed at a high rate.

10.
Artif Organs ; 41(1): 11-16, 2017 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-28093811

RESUMEN

Lower-extremity ischemia is a significant complication in children on femoral venoarterial extracorporeal membrane oxygenation (VA ECMO). Our institution currently routinely uses distal perfusion catheters (DPCs) in all femoral arterial cannulations in attempts to reduce ischemia. We performed a single-center, retrospective review of pediatric patients supported with femoral VA ECMO from January 2005 to November 2015. The outcomes of patients with prophylactic DPC placement at cannulation (prophylactic DPC) were compared to a historical group with DPCs placed in response only to clinically evident ischemic changes (reactive DPC). Ischemic complication requiring invasive intervention (fasciotomy or amputation) was the primary outcome. Twenty-nine patients underwent a total of 31 femoral arterial cannulations, 17 with prophylactic DPC and 14 with reactive DPC. Ischemic complications requiring invasive intervention developed in 2 of 17 (12%) prophylactic DPC patients versus 4 of 14 (29%) reactive DPC. In the reactive DPC group, 7 of 14 (50%) had ischemic changes postcannulation, six underwent DPC placement, and three out of six of these patients still required invasive intervention. One of the seven patients had ischemic changes, did not undergo DPC, and required amputation. While a greater percentage of patients in the prophylactic group was cannulated during extracorporeal cardiopulmonary resuscitation (ECPR), statistical significance was not otherwise demonstrated. We demonstrate feasibility of superficial femoral artery (SFA) access in pediatric patients. We note fewer ischemic complications with prophylactic DPC placement, and observe that salvaging a limb with a reactive DPC was only successful 50% of the time. Although there was no statistical difference in the primary outcome between the two groups, limitations and confounding factors include small sample size and a greater percentage of patients in the prophylactic DPC group cannulated with ECPR in progress.


Asunto(s)
Cateterismo Periférico/métodos , Oxigenación por Membrana Extracorpórea/efectos adversos , Arteria Femoral/cirugía , Isquemia/etiología , Isquemia/prevención & control , Pierna/irrigación sanguínea , Adolescente , Adulto , Niño , Preescolar , Femenino , Humanos , Isquemia/terapia , Masculino , Perfusión/métodos , Estudios Retrospectivos , Resultado del Tratamiento , Adulto Joven
11.
Am J Orthop (Belle Mead NJ) ; 45(5): 314-8, 2016.
Artículo en Inglés | MEDLINE | ID: mdl-27552456

RESUMEN

Orthopedic surgeons commonly encounter patients with lumbar radiculopathy. These patients typically seek treatment for lower back or buttock pain radiating down the leg. It can be challenging to differentiate between orthopedic, neurologic, and vascular causes of leg pain, such as peripheral artery disease (PAD), especially aortoiliac PAD, which can present with hip, buttock, and thigh pain. To our knowledge, this is the first report on a series of patients with thigh pain initially diagnosed as radiculopathy who underwent unproductive diagnostic tests and procedures, and ultimately were given delayed diagnoses of aortoiliac PAD.


Asunto(s)
Enfermedad Arterial Periférica/diagnóstico , Radiculopatía/diagnóstico , Anciano , Anciano de 80 o más Años , Angioplastia , Diagnóstico Diferencial , Femenino , Humanos , Masculino , Enfermedad Arterial Periférica/cirugía , Examen Físico , Pulso Arterial , Stents , Resultado del Tratamiento
12.
J Vasc Surg ; 61(3): 703-12.e1, 2015 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-25720929

RESUMEN

OBJECTIVE: Despite improvements in endovascular therapy for lower extremity arterial disease, open surgical revascularization is still required when the disease is extensive. Although autogenous vein is the conduit of choice for open femoropopliteal bypass, prosthetic grafts can be an acceptable alternative when adequate vein is not available. The FUSION BIOLINE heparin-coated vascular graft (Maquet Endovascular, Wayne, NJ) was developed to improve the patency rate associated with standard prosthetic grafts. The current study, the FINEST Trial (Comparison of Safety and Primary Patency Between the FUSION BIOLINE Heparin-Coated Vascular Graft and EXXCEL Soft ePTFE), was designed to assess the clinical outcome of heparin-coated and standard vascular grafts in a prospective, randomized, controlled, multicenter trial. METHODS: During a 25-month period ending in June 2012, 209 eligible patients scheduled to undergo elective prosthetic femoral to above-knee or below-knee popliteal bypass were randomized to receive a standard expanded polytetrafluoroethylene (ePTFE) graft or the heparin-coated FUSION BIOLINE vascular graft. Among 203 patients in the efficacy analysis, claudication was the presenting symptom in 147 (72.4%), and the site of the distal anastomosis was at the above-knee level in 174 (85.7%). Grafts were assessed by duplex ultrasound imaging and ankle-brachial indices performed postoperatively at discharge and at 30 days, 6 months, and 12 months. The primary efficacy end point was primary patency of the study graft. The primary safety end point was the composite of major adverse events and periprocedural death. Secondary end points included the time to hemostasis of bleeding at the anastomotic suture hole and primary assisted and secondary patency. RESULTS: The primary patency rates at 6 months were 86.4% for the FUSION BIOLINE heparin-coated vascular graft group compared with 70.0% for the standard ePTFE group, a difference of 16.4% (95% confidence interval, 2.7%-29.9%; P = .006), and the respective rates at 12 months were 76.5% and 67.0% (95% confidence interval, -4.8% to 23.0%; P = .05). The mean time to hemostasis of bleeding at the suture hole was 3.5 minutes in the FUSION BIOLINE group and 11.0 minutes in the standard ePTFE group (P < .0001). Major adverse events were significantly lower in the FUSION BIOLINE group, occurring in 17.1%, compared with 30.7% in the standard ePTFE group (P = .033), principally a result of a lower rate of major graft reinterventions through 12 months in the FUSION BIOLINE group (16.2% vs 30.7%). CONCLUSIONS: Data from this randomized multicenter study demonstrated improved midterm patency, less bleeding at the suture hole, and lower major adverse events with the FUSION BIOLINE heparin-coated vascular graft compared with standard ePTFE grafts. Although the ultimate long-term benefit of the graft cannot be ascertained with the data currently available, the utility of the FUSION BIOLINE vascular graft appears promising.


Asunto(s)
Anticoagulantes/administración & dosificación , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Materiales Biocompatibles Revestidos , Arteria Femoral/cirugía , Heparina/administración & dosificación , Extremidad Inferior/irrigación sanguínea , Enfermedad Arterial Periférica/cirugía , Politetrafluoroetileno , Arteria Poplítea/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Índice Tobillo Braquial , Implantación de Prótesis Vascular/efectos adversos , Constricción Patológica , Procedimientos Quirúrgicos Electivos , Femenino , Arteria Femoral/fisiopatología , Oclusión de Injerto Vascular/etiología , Oclusión de Injerto Vascular/fisiopatología , Oclusión de Injerto Vascular/prevención & control , Humanos , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/fisiopatología , Arteria Poplítea/fisiopatología , Hemorragia Posoperatoria/etiología , Hemorragia Posoperatoria/prevención & control , Estudios Prospectivos , Diseño de Prótesis , Factores de Tiempo , Resultado del Tratamiento , Ultrasonografía Doppler Dúplex , Estados Unidos , Grado de Desobstrucción Vascular
13.
Ann Vasc Surg ; 29(3): 443-6, 2015 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-25463339

RESUMEN

BACKGROUND: The external carotid artery (ECA) can be an important collateral for cerebral perfusion in the presence of severe internal carotid artery (ICA) disease. ICA stenting that covers the ECA origin may put the ECA at increased risk of stenosis. Our objective was to determine the rate of ECA stenosis secondary to ICA stenting, determine predictive factors, and describe any subsequent associated symptoms. METHODS: We retrospectively reviewed clinical data on all ICA stents crossing the origin of the ECA placed by vascular surgeons at our institution. We analyzed patient demographics, comorbidities, stent type and sizes, as well as medication profile to determine predictors of ECA stenosis. RESULTS: Between 2005 and 2013, there were 72 (out of 119 total ICA stenting) patients (mean age 71, 68% male) who underwent placement of ICA stents that also crossed the origin of the ECA. Six patients (8.3%) had a significantly increased ECA stenosis postprocedure. There were no occlusions. All patients with ECA stenosis maintained patency of their ICA stent and were asymptomatic. Age, gender, comorbidities, stent type and size, and medication profile were not associated with ECA stenosis after stenting. CONCLUSIONS: ECA stenosis after ICA stenting covering the ECA origin is uncommon and not clinically significant in patients with patent ICA stents. The clinical significance of concurrent ECA and ICA stenosis after stenting is unclear as it is not captured here. The potential for ECA stenosis should not deter stenting across the ECA origin if necessary. Patient and stent factors are not predictive of ECA stenosis.


Asunto(s)
Angioplastia/efectos adversos , Angioplastia/instrumentación , Arteria Carótida Común , Arteria Carótida Externa , Arteria Carótida Interna , Estenosis Carotídea/terapia , Stents , Anciano , Anciano de 80 o más Años , Arteria Carótida Común/fisiopatología , Arteria Carótida Externa/fisiopatología , Arteria Carótida Interna/fisiopatología , Estenosis Carotídea/diagnóstico , Estenosis Carotídea/fisiopatología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Ciudad de Nueva York , Recurrencia , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción Vascular
14.
J Neurosurg ; 120(6): 1458-64, 2014 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-24605842

RESUMEN

OBJECT: Ventriculoatrial (VA) shunting is rarely used for patients with normal-pressure hydrocephalus (NPH), likely due to surgeon technical preference and case reports indicating cardiopulmonary complications. However, these complications have typically been limited to adults in whom VA shunts had been placed when they were children. Few studies have directly compared VA shunting to ventriculoperitoneal (VP) shunting in cases of NPH. METHODS: The authors retrospectively analyzed all NPH patients treated by a single surgeon at their center from January 2002 through December 2011. Thirty patients were treated with VA shunts (14 male) and 157 with VP shunts (86 male). The patients' mean age (± SD) at surgery was 73.7 ± 9.4 years for VA shunting and 76.0 ± 8.2 years for VP shunting; the median durations of follow-up were 42.0 months (IQR 19.2-63.6 months) and 34.2 months (IQR 15.8-67.5), respectively. Statistical analysis was performed using chi-square tests and Wilcoxon rank-sum tests. RESULTS: Perioperative and postoperative complications for VA and VP shunting cohorts, respectively, included distal revision (2.7% vs 6.6%, p = 0.45), proximal revision (2.7% vs 2.5%, p = 0.97), and postoperative seizure (2.7% vs 1.5%, p = 0.62). Shunt drainage-related subdural hematomas/hygromas developed in 8.1%/27.0% of VA shunt-treated patients versus 6.6%/26.4% of VP shunt-treated patients (p = 0.76/0.98) and were nearly always successfully managed with programmable-valve adjustment. Symptomatic intracerebral hemorrhage (1.5%) and shunt infection (2.0%) were only observed in those who underwent VP shunting. Of note, no cardiovascular complications were observed in any patient, and there were no cases of distal occlusion of the VA shunt. CONCLUSIONS: The authors found no significant differences in complication rates between VA and VP shunting, and VA shunting was not associated with any cardiopulmonary complications. Thus, in the authors' experience, VA shunting is at least as safe as VP shunting for treating NPH.


Asunto(s)
Ventrículos Cerebrales/cirugía , Atrios Cardíacos/cirugía , Hidrocéfalo Normotenso/fisiopatología , Hidrocéfalo Normotenso/cirugía , Presión Intracraneal/fisiología , Derivación Ventriculoperitoneal/métodos , Anciano , Anciano de 80 o más Años , Anastomosis Quirúrgica/métodos , Hemorragia Cerebral/epidemiología , Femenino , Hematoma/epidemiología , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Infección de la Herida Quirúrgica/epidemiología , Resultado del Tratamiento
15.
Ann Vasc Surg ; 28(5): 1266-70, 2014 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-24355161

RESUMEN

BACKGROUND: Adrenal venous sampling (AVS) is used to distinguish between bilateral idiopathic hyperplasia and a functional adrenal tumor in patients with hyperaldosteronism. Successful sampling from both adrenal veins is necessary for lateralization and may require more than 1 procedure. AVS has traditionally been performed by interventional radiologists; however, our goal was to examine the outcomes when performed by a vascular surgeon. METHODS: All patients with a diagnosis of hyperaldosteronism were referred for AVS regardless of imaging findings. Cortisol and aldosterone levels were measured in blood samples from both adrenal veins. Postoperative analysis of intraoperative laboratory values before and after cosyntropin administration determined successful cannulation and sampling of each vein. RESULTS: Between 2007 and 2012, 53 patients underwent AVS by one vascular surgeon. The average age was 54 and 63% were men. Our success rate increased with experience, because during the earlier years (2007-2010) primary and secondary success rates were 58% and 68%, respectively compared with later years (2011-2012) when primary and secondary success rates were 82% and 95%, respectively (P<0.05). Results of AVS altered localization of disease compared with what had been anticipated based on preoperative imaging and thus influenced surgical decision making in 47% of cases. CONCLUSIONS: AVS is an important procedure in the work up of hyperaldosteronism to help identify and localize metabolically active tumors. It is an additional area in medicine where a vascular surgeon can lend expertise. Success with the procedure improves with experience and should be performed by high volume surgeons.


Asunto(s)
Glándulas Suprarrenales/irrigación sanguínea , Competencia Clínica , Hiperaldosteronismo/diagnóstico , Cirujanos/normas , Venas/patología , Diagnóstico Diferencial , Femenino , Estudios de Seguimiento , Humanos , Hiperplasia/patología , Masculino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Estudios Retrospectivos , Venas/cirugía
16.
Ann Vasc Surg ; 28(4): 964-9, 2014 May.
Artículo en Inglés | MEDLINE | ID: mdl-24370501

RESUMEN

BACKGROUND: Race and insurance status are seen as potential barriers to health care access and maintenance. Our goal was to see how these, as well as other patient and procedural characteristics, affected our populations' upper extremity vascular access outcomes. METHODS: We retrospectively reviewed 601 vascular access patients from 2004 through 2012 in our urban university hospital. We recorded patient demographics, insurance status, comorbidities, and complications. Primary outcomes were reintervention, long-term mortality, and transplantation. RESULTS: Median age was 62 ± 15.8 years, and 58% were male. Most operations were arteriovenous fistulas (66%). The majority of patients identified themselves as Hispanic (50%), followed by white (22%), and black (19%). Most patients had Medicare only (42%), 31% had private insurance, and 27% had Medicaid as their insurance. Black/African American patients were more likely to receive an arteriovenous graft (AVG) compared with white and Hispanic patients (44% vs. 28% and 33%, P < 0.05). White patients were significantly older (68) than Hispanics (61) or blacks (58). Freedom from reintervention at 5 years was 55% with previous tunneled catheter use predictive. Mortality at 5 years was 35% and predicted by age, AVG placement, white race, and not receiving a kidney transplant. Predictors of not receiving a transplant included older age, lower albumin, AVG placement, and coronary artery disease. CONCLUSIONS: There were no disparities with insurance status in long-term outcomes in our population. Race was not a factor for reintervention or transplantation; however, black/African American patients were more likely have an AVG placed, and white patients had a lower long-term survival after access placement.


Asunto(s)
Derivación Arteriovenosa Quirúrgica , Implantación de Prótesis Vascular , Accesibilidad a los Servicios de Salud , Disparidades en el Estado de Salud , Cobertura del Seguro , Seguro de Salud , Grupos Raciales , Diálisis Renal , Extremidad Superior/irrigación sanguínea , Factores de Edad , Anciano , Derivación Arteriovenosa Quirúrgica/efectos adversos , Derivación Arteriovenosa Quirúrgica/economía , Derivación Arteriovenosa Quirúrgica/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/economía , Implantación de Prótesis Vascular/mortalidad , Cateterismo Venoso Central , Comorbilidad , Femenino , Accesibilidad a los Servicios de Salud/economía , Hospitales Universitarios , Humanos , Cobertura del Seguro/economía , Seguro de Salud/economía , Trasplante de Riñón , Masculino , Medicaid , Medicare , Persona de Mediana Edad , Sector Privado , Diálisis Renal/efectos adversos , Diálisis Renal/economía , Diálisis Renal/mortalidad , Estudios Retrospectivos , Centros de Atención Terciaria , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiología , Salud Urbana
17.
Stroke ; 44(4): 1150-2, 2013 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-23404722

RESUMEN

BACKGROUND AND PURPOSE: Statins are neuroprotective in a variety of experimental models of cerebral injury. We sought to determine whether patients taking statins before asymptomatic carotid endarterectomy exhibit a lower incidence of neurological injury (clinical stroke and cognitive dysfunction). METHODS: A total of 328 patients with asymptomatic carotid stenosis scheduled for elective carotid endarterectomy consented to participate in this observational study of perioperative neurological injury. RESULTS: Patients taking statins had a lower incidence of clinical stroke (0.0% vs 3.1%; P=0.02) and cognitive dysfunction (11.0% vs 20.2%; P=0.03). In a multivariate regression model, statin use was significantly associated with decreased odds of cognitive dysfunction (odds ratio, 0.51 [95% CI, 0.27-0.96]; P=0.04). CONCLUSIONS: Preoperative statin use was associated with less neurological injury after asymptomatic carotid endarterectomy. These observations suggest that it may be possible to further reduce the perioperative morbidity of carotid endarterectomy. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00597883.


Asunto(s)
Estenosis Carotídea/complicaciones , Estenosis Carotídea/tratamiento farmacológico , Endarterectomía Carotidea/efectos adversos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Anciano , Encéfalo/patología , Cognición , Trastornos del Conocimiento/complicaciones , Trastornos del Conocimiento/diagnóstico , Humanos , Persona de Mediana Edad , Análisis Multivariante , Enfermedades del Sistema Nervioso/complicaciones , Enfermedades del Sistema Nervioso/prevención & control , Oportunidad Relativa , Factores de Riesgo , Resultado del Tratamiento
18.
J Vasc Surg ; 54(4): 1067-73, 2011 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-21971092

RESUMEN

BACKGROUND: Digital subtraction angiography (DSA) is the gold standard for diagnosing lower extremity (LE) arterial lesions. However, duplex ultrasound (DUS) is a widely used, safe, and noninvasive method of detecting LE lesions. The purpose of this study was to establish DUS criteria for detecting and grading de novo stenotic lesions in the femoropopliteal arterial segment. METHODS: A prospective database was established including all patients who underwent LE endovascular interventions between 2004 and 2009. Patients with de novo stenotic lesions in the femoropopliteal segment were selected. DUS and DSA data pairs ≤30 days apart were analyzed. Peak systolic velocity (PSV; cm/s), velocity ratio (Vr), and DSA stenosis were noted. Linear regression and receiver operator characteristic (ROC) curves were used. RESULTS: Two hundred seventy-five lesions in 200 patients were analyzed. Indications were claudication (50.5%), rest pain (12.5%), and tissue loss (37.0%). Mean time interval between DUS and DSA was 24 days. Both PSV (R = .80, R(2) = .641; P < .001) and Vr (R = .73, R(2) = .546; P < .001) showed strong correlation with the degree of angiographic stenosis. ROC analysis showed that to detect ≥70% stenosis, a PSV of 200 cm/s had 89.2% sensitivity and 89.7% specificity, and a Vr of 2.0 had 88.7% sensitivity and 90.2% specificity. Similarly, to differentiate between <50% and ≥50% stenosis, PSV of 150 cm/s and Vr of 1.5 were highly specific and predictive. Combining PSV 200 cm/s and Vr 2.0 for ≥70% stenosis gave 79.0% sensitivity, 99.0% specificity, 99.0% positive predictive value, and 85.0% negative predictive value. CONCLUSION: DUS shows a strong agreement with angiography and has good accuracy in detecting femoropopliteal lesions. We propose DUS criteria of PSV 200 cm/s and Vr 2.0 to differentiate between <70% and ≥70% de novo stenosis in the femoropopliteal arterial segment.


Asunto(s)
Arteriopatías Oclusivas/diagnóstico por imagen , Arteria Femoral/diagnóstico por imagen , Arteria Poplítea/diagnóstico por imagen , Ultrasonografía Doppler Dúplex , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Angiografía de Substracción Digital , Índice Tobillo Braquial , Arteriopatías Oclusivas/fisiopatología , Velocidad del Flujo Sanguíneo , Constricción Patológica , Femenino , Arteria Femoral/fisiopatología , Humanos , Modelos Lineales , Masculino , Persona de Mediana Edad , Ciudad de Nueva York , Arteria Poplítea/fisiopatología , Valor Predictivo de las Pruebas , Curva ROC , Flujo Sanguíneo Regional , Estudios Retrospectivos , Sensibilidad y Especificidad , Índice de Severidad de la Enfermedad
20.
Semin Vasc Surg ; 24(1): 31-5, 2011 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-21718930

RESUMEN

Innominate and subclavian artery lesions run a wide spectrum of disease manifestation and treatment options. Since the first surgical treatment, multiple variances have been attempted with the desire to maintain high long-term patency rates while reducing perioperative morbidity and mortality. The advent of endovascular procedures in the 1970s provided the opportunity to seek alternative treatment options, but the fear of serious neurologic sequela stalled the adoption of these new techniques. The advancement in endovascular techniques and technology, along with proven clinical success and decreased morbidity and mortality, has led to their adoption as the first-line treatment.


Asunto(s)
Arteriopatías Oclusivas/terapia , Tronco Braquiocefálico/cirugía , Procedimientos Endovasculares , Síndrome del Robo de la Subclavia/terapia , Procedimientos Quirúrgicos Vasculares , Arteriopatías Oclusivas/fisiopatología , Arteriopatías Oclusivas/cirugía , Tronco Braquiocefálico/fisiopatología , Procedimientos Endovasculares/efectos adversos , Humanos , Síndrome del Robo de la Subclavia/fisiopatología , Síndrome del Robo de la Subclavia/cirugía , Resultado del Tratamiento , Grado de Desobstrucción Vascular , Procedimientos Quirúrgicos Vasculares/efectos adversos
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