Quality of Life in Patients With Chronic Limb-Threatening Ischemia Treated With Revascularization.

BACKGROUND: In the BEST-CLI trial (Best Endovascular Versus Best Surgical Therapy for Patients With Chronic Limb-Threatening Ischemia), a prespecified secondary objective was to assess the effects of revascularization strategy on health-related quality of life (HRQoL). METHODS: Patients with chronic limb-threatening ischemia were randomized to surgical bypass (Bypass) or endovascular intervention (Endo) in 2 parallel trials. Cohort 1 included patients with single-segment great saphenous vein; cohort 2 included those lacking suitable single-segment great saphenous vein. HRQoL was assessed over the trial duration using Vascular Quality-of-Life (VascuQoL), European Quality-of-Life-5D (EQ-5D), the Short Form-12 (SF-12) Physical Component Summary (SF-12 PCS), SF-12 Mental Component Summary (SF-12 MCS), Utility Index Score (SF-6D R2), and numeric rating scales of pain. HRQoL was summarized by cohort and compared within and between groups using mixed-model linear regression. RESULTS: A total of 1193 and 335 patients in cohorts 1 and 2 with a mean follow-up of 2.9 and 2.0 years, respectively, were analyzed. In cohort 1, HRQoL significantly improved from baseline to follow-up for both groups across all measures. For example, mean (SD) VascuQoL scores were 3.0 (1.3) and 3.0 (1.2) for Bypass and Endo at baseline and 4.7 (1.4) and 4.8 (1.5) over follow-up. There were significant group differences favoring Endo when assessed with VascuQoL (difference, -0.14 [95% CI, -0.25 to -0.02]; P=0.02), SF-12 MCS (difference, -1.03 [95% CI, -1.89 to -0.18]; P=0.02), SF-6D R2 (difference, -0.01 [95% CI, -0.02 to -0.001]; P=0.03), numeric rating scale pain at present (difference, 0.26 [95% CI, 0.03 to 0.49]; P=0.03), usual level during previous week (difference, 0.26 [95% CI, 0.04 to 0.48]; P=0.02), and worst level during previous week (difference, 0.29 [95% CI, 0.02 to 0.56]; P=0.04). There was no difference between treatment arms on the basis of EQ-5D (difference, -0.01 [95% CI, -0.03 to 0.004]; P=0.12) or SF-12 PCS (difference, -0.41 [95% CI, -1.2 to 0.37]; P=0.31). In cohort 2, HRQoL also significantly improved from baseline to the end of follow-up for both groups based on all measures, but there were no differences between Bypass and Endo on any measure. CONCLUSIONS: Among patients with chronic limb-threatening ischemia deemed eligible for either Bypass or Endo, revascularization resulted in significant and clinically meaningful improvements in HRQoL. In patients with an available single-segment great saphenous vein for bypass, but not among those without one, Endo was statistically superior on some HRQoL measures; however, these differences were below the threshold of clinically meaningful difference.

The role of sealants for achieving anastomotic hemostasis in vascular surgery.

BACKGROUND: During vascular interventions, connections that link arteries, veins, or synthetic grafts, which are known as an 'anastomosis', may be necessary. Vascular anastomoses can bleed from the needle holes that result from the creation of the anastomoses. Various surgical options are available for achieving hemostasis, or the stopping of bleeding, including the application of sealants directly onto the bleeding vessels or tissues. Sealants are designed for use in vascular surgery as adjuncts when conventional interventions are ineffective and are applied directly by the surgeon to seal bleeding anastomoses. Despite the availability of several different types of sealants, the evidence for the clinical efficacy of these hemostatic adjuncts has not been definitively established in vascular surgery patients. OBJECTIVES: To evaluate the benefits and harms of sealants as adjuncts for achieving anastomotic site hemostasis in patients undergoing vascular surgery. SEARCH METHODS: The Cochrane Vascular Information Specialist conducted systematic searches of the following databases: the Cochrane Vascular Specialised Register via the Cochrane Register of Studies; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE via Ovid; Embase via Ovid ; and CINAHL via EBSCO. We also searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform for clinical trials. Reference lists of included trials and relevant reviews were also searched. The latest search date was 6 March 2023. SELECTION CRITERIA: We included randomized controlled trials that compared fibrin or synthetic sealant use with alternative interventions (e.g. manual compression, reversal of anticoagulation) for achieving anastomotic-site hemostasis in vascular surgery procedures. We included participants who underwent the creation of an anastomosis during vascular surgery. We excluded non-vascular surgery patients. DATA COLLECTION AND ANALYSIS: We have used standard Cochrane methods. Our primary outcomes were time to hemostasis, failure of hemostatic intervention, and intraoperative blood loss. Our secondary outcomes were operating time, death from bleeding complications up to 30 days, postoperative bleeding up to 30 days, unplanned return to the operating room for bleeding complications management up to 30 days, quality of life, and adverse events. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS: We found 24 randomized controlled trials that included a total of 2376 participants who met the inclusion criteria. All trials compared sealant use with standard care controls, including oxidized cellulose, gelatin sponge, and manual compression. All trials were at high risk of performance bias, detection bias, and other sources of bias. We downgraded the certainty of evidence for risk of bias concerns, inconsistency, imprecision and possible publication bias. Combining data on time to hemostasis showed that sealant use may reduce the mean time to hemostasis compared to control (mean difference (MD) -230.09 seconds, 95% confidence interval (CI) -329.24 to -130.94; P < 0.00001; 7 studies, 498 participants; low-certainty evidence). Combining data on failure of hemostatic intervention showed that sealant use may reduce the rate of failure compared to control, but the evidence is very uncertain (risk ratio (RR) 0.46, 95% CI 0.35 to 0.61; P < 0.00001; 17 studies, 2120 participants; very low-certainty evidence). We did not detect any clear differences between the sealant and control groups for intraoperative blood loss (MD -32.69 mL, 95% CI -96.21 to 30.83; P = 0.31; 3 studies, 266 participants; low-certainty evidence); operating time (MD -18.72 minutes, 95% CI -40.18 to 2.73; P = 0.09; 4 studies, 436 participants; low-certainty evidence); postoperative bleeding (RR 0.78, 95% CI 0.59 to 1.04; P = 0.09; 9 studies, 1216 participants; low-certainty evidence), or unplanned return to the operating room (RR 0.27, 95% CI 0.04 to 1.69; P = 0.16; 8 studies, 721 participants; low-certainty evidence). No studies reported death from bleeding or quality of life outcomes. AUTHORS' CONCLUSIONS: Based on meta-analysis of 24 trials with 2376 participants, our review demonstrated that sealant use for achieving anastomotic hemostasis in vascular surgery patients may result in reduced time to hemostasis, and may reduce rates of hemostatic intervention failure, although the evidence is very uncertain, when compared to standard controls. Our analysis showed there may be no differences in intraoperative blood loss, operating time, postoperative bleeding up to 30 days, and unplanned return to the operating room for bleeding complications up to 30 days. Deaths and quality of life could not be analyzed. Limitations include the risk of bias in all studies. Our review has demonstrated that using sealants may reduce the time required to achieve hemostasis and the rate of hemostatic failure. However, a significant risk of bias was identified in the included studies, and future trials are needed to provide unbiased data and address other considerations such as cost-effectiveness and adverse events with sealant use.

Distal Adjuncts for High-Risk Lower Extremity Bypasses.

BACKGROUND: This review will discuss the use of distal adjuncts for improving graft patency in high-risk lower extremity bypasses. METHODS: Factors that contribute to the increased risk of failure in high-risk lower extremity bypasses, such as the use of nonautogenous conduits, the creation of bypasses to very distal arterial targets, and bypasses in patients with significant tibial arterial disease, will be discussed. RESULTS: The use of surgical techniques such as creating venous cuffs, venous patches, and arteriovenous fistulas have been shown to improve the patency of high-risk bypasses. CONCLUSIONS: Despite the increased risk of failure, the use of surgical adjuncts such as cuffs, patches, and arteriovenous fistulas can improve the patency rates of high-risk lower extremity bypasses.

YouTube as a source of education in perioperative anesthesia for patients and trainees: a systematic review.

BACKGROUND: Online video sharing platforms like YouTube (Google LLC, San Bruno, CA, USA) have become a substantial source of health information. We sought to conduct a systematic review of studies assessing the overall quality of perioperative anesthesia videos on YouTube. METHODS: We searched Embase, MEDLINE, and Ovid for articles published from database inception to 1 May 2023. We included primary studies evaluating YouTube videos as a source of information regarding perioperative anesthesia. We excluded studies not published in English and studies assessing acute or chronic pain. Studies were screened and data were extracted in duplicate by two reviewers. We appraised the quality of studies according to the social media framework published in the literature. We used descriptive statistics to report the results using mean, standard deviation, range, and n/total N (%). RESULTS: Among 8,908 citations, we identified 14 studies that examined 796 videos with 59.7 hr of content and 47.5 million views. Among the 14 studies that evaluated the video content quality, 17 different quality assessment tools were used, only three of which were externally validated (Global Quality Score, modified DISCERN score, and JAMA score). Per global assessment rating of video quality, 11/13 (85%) studies concluded the overall video quality as poor. CONCLUSIONS: Overall, the educational content quality of YouTube videos evaluated in the literature accessible as an educational resource regarding perioperative anesthesia was poor. While these videos are in demand, their impact on patient and trainee education remains unclear. A standardized methodology for evaluating online videos is merited to improve future reporting. A peer-reviewed approach to online open-access videos is needed to support patient and trainee education in anesthesia. STUDY REGISTRATION: Open Science Framework ( https://osf.io/ajse9 ); first posted, 1 May 2023.

RéSUMé: CONTEXTE: Les plateformes de partage de vidéos en ligne comme YouTube (Google LLC, San Bruno, CA, États-Unis) sont devenues une source importante d'informations sur la santé. Nous avons cherché à réaliser une revue systématique des études évaluant la qualité globale des vidéos d'anesthésie périopératoire sur YouTube. MéTHODE: Nous avons recherché des articles dans Embase, MEDLINE et Ovid publiés depuis la création de ces bases de données jusqu'au 1er mai 2023. Nous avons inclus des études primaires évaluant les vidéos YouTube comme source d'information sur l'anesthésie périopératoire. Nous avons exclu les études publiées dans une langue autre que l'anglais et les études évaluant la douleur aiguë ou chronique. Les études ont été examinées et les données ont été extraites en double par deux personnes. Nous avons évalué la qualité des études selon le cadre des médias sociaux publié dans la littérature. Nous avons utilisé des statistiques descriptives pour rapporter les résultats en utilisant la moyenne, l'écart type, la plage et n/total N (%). RéSULTATS: Parmi 8908 citations, nous avons identifié 14 études qui ont examiné 796 vidéos avec 59,7 heures de contenu et 47,5 millions de vues. Parmi les 14 études qui ont évalué la qualité du contenu vidéo, 17 outils d'évaluation de la qualité différents ont été utilisés, dont seulement trois ont été validés en externe (Score Global Quality, score DISCERN modifié et score JAMA). Selon l'évaluation globale de la qualité des vidéos, 11 études sur 13 (85 %) ont conclu que la qualité globale des vidéos était médiocre. CONCLUSION: Dans l'ensemble, la qualité du contenu éducatif des vidéos YouTube évaluées dans la littérature accessible en tant que ressource éducative concernant l'anesthésie périopératoire était médiocre. Bien que ces vidéos soient très demandées, leur impact sur la formation de la patientèle et des stagiaires reste incertain. Une méthodologie normalisée d'évaluation des vidéos en ligne est nécessaire pour améliorer les évaluations futures. Une approche évaluée par les pairs pour les vidéos en libre accès en ligne est nécessaire pour soutenir la formation de la patientèle et des stagiaires en anesthésie. ENREGISTREMENT DE L'éTUDE: Open Science Framework ( https://osf.io/ajse9 ); première publication le 1er mai 2023.

Evaluating YouTube as a Source of Education for Patients Undergoing Surgery: A Systematic Review.

OBJECTIVE: The objective of this systematic review is to characterize the peer-reviewed literature investigating YouTube as a source of patient education for patients undergoing surgery. SUMMARY BACKGROUND DATA: YouTube is the largest online video sharing platform and has become a substantial source of health information that patients are likely to access before surgery, yet there has been no systematic assessment of peer-reviewed studies. A comprehensive literature search was conducted using EMBASE, MEDLINE, and Ovid HealthStar from inception through to December of 2021. METHODS: All primary studies evaluating YouTube as a source of patient education relating to surgical procedures (general, cardiac, urology, otolaryngology, plastic, vascular) were included. Study screening and data extraction occurred in duplicate with two reviewers. Characteristics extracted included video length, view count, upload source, overall video educational quality, and quality of individual studies. RESULTS: Among 6,453 citations, 56 studies were identified that examined 6,797 videos with 547 hours of content and 1.39 billion views. There were 49 studies that evaluated the educational quality of the videos. A total of 43 quality assessment tools were used, with each study using a mean of 1.90 assessment tools. Per the global rating for assessments, 34/49 studies (69%) concluded that the overall quality of educational content was poor. CONCLUSIONS: While the impact of non-peer-reviewed YouTube videos on patient knowledge for surgery is unclear, the large amount of online content suggests that they are in demand. The overall educational content of these videos is poor, however, and there is substantial heterogeneity in the quality assessment tools used in their evaluation. A peer-reviewed and standardized approach to online education with video content is needed to better support patients.

Health utility in community-dwelling adults with dysvascular lower limb loss.

PURPOSE: Adults with dysvascular lower extremity amputation (LEA) experience a large number of secondary health conditions yet there is a gap in the literature on health utility scores for this population. A health utility score relates to a person's state of well-being, and is a single metric anchored at 0 (death) and 1 (perfect health). This study aimed to provide a descriptive account of health utility scores in community-dwelling adults with dysvascular LEA. METHODS: Participants were adults with dysvascular LEA who were 3 months post-amputation. Data collected included socio-demographic characteristics, the Special Interest Group in Amputee Medicine (SIGAM) grades, the dysvascular conditions scale (DCS), which is a scale developed for this study, and the Short Form-36 (SF-36). SF-6D health utility scores were derived from the SF-36 using a software algorithm. Participants were grouped into low-impact and high-impact groups based on self-reported severity of symptoms using the DCS. Health utility scores were compared between the low-impact and high-impact groups using independent t-tests. RESULTS: A total of 231 participants were enrolled in the study. The mean SF-6D health utility score was 0.689 (0.127). A significant association was found between health utility score and SIGAM grade (p < 0.001, η2 = .09). Health utility was positively associated with age (r = 0.137, p = 0.037) and months post-amputation (r = 0.141, p = 0.032), and negatively associated with DCS severity (r = -0.526, p < 0.001). Health utility scores were lower for participants in the DCS high-impact groups for conditions such as diabetes mellitus, phantom limb pain, musculoskeletal pain, back pain, psychological distress, depression, vision problems, and other pain. CONCLUSION: Cost-utility analyses rely on health utility estimates and our findings provide data for future economic evaluations that may assist policy makers in evidence informed allocation of healthcare resources for this population.

Association Between Hospital Postoperative Troponin Use and Patient Outcomes After Vascular Surgery.

BACKGROUND: Acute myocardial injury after noncardiac surgery, which is most often symptomatically silent, is associated with increased mortality and morbidity. However, it is not known if routine postoperative troponin testing will affect patient outcomes. METHODS: We assembled a cohort of patients who underwent carotid endarterectomy or abdominal aortic aneurysm repair in Ontario, Canada, from 2010 to 2017. Hospitals were categorized into high, medium, and low troponin testing intensity based on the proportion of patients who received postoperative troponin testing. Cox proportional hazards modeling was used to assess the association between hospital-specific testing intensity and 30-day and 1-year major adverse cardiovascular events (MACEs) while adjusting for patient-, surgery-, and hospital-level factors. RESULTS: The cohort consisted of 18,467 patients from 17 hospitals. Mean age was 72 years, and 74.0% were men. Rates of postoperative troponin testing were 77.5%, 35.8%, and 21.6% in the high-, medium-, and low-testing intensity hospitals, respectively. At 30 days, 5.3%, 5.3%, and 6.5% of patients in high-, medium-, and low-testing intensity hospitals experienced MACE, respectively. Higher troponin testing rate was associated with lower adjusted hazard ratios (HRs) for MACE at 30 days (0.94; 95% confidence interval [CI], 0.89-0.98) and at 1 year (0.97; 95% CI, 0.94-0.99) for each 10% increase in hospital troponin rate. Hospitals with high-testing intensity had higher rates of postoperative cardiology referrals, cardiovascular testing, and rates of new cardiovascular prescriptions. CONCLUSIONS: Patients undergoing vascular surgery at hospitals with higher postoperative troponin testing intensity experienced fewer adverse outcomes than patients who had surgery at hospitals with lower testing intensity.

General versus loco-regional anesthesia for endovascular aortic aneurysm repair.

BACKGROUND: Aortic aneurysms occur when the aorta, the body's largest artery, grows in size, and can occur in the thoracic or abdominal aorta. The approaches to repair aortic aneurysms include directly exposing the aorta and replacing the diseased segment via open repair, or endovascular repair. Endovascular repair uses fluoroscopic-guidance to access the aorta and deliver a device to exclude the aneurysmal aortic segment without requiring a large surgical incision. Endovascular repair can be performed under a general anesthetic, during which the unconscious patient is paralyzed and reliant on an anesthetic machine to maintain the airway and provide oxygen to the lungs, or a loco-regional anesethetic, for which medications are administered to provide the person with sufficient sedation and pain control without requiring a general anesthetic. While people undergoing general anesthesia are more likely to remain still during surgery and have a well-controlled airway in the event of unanticipated complications, loco-regional anesthesia is associated with fewer postoperative complications in some studies. It remains unclear which anesthetic technique is associated with better outcomes following the endovascular repair of aortic aneurysms. OBJECTIVES: To evaluate the benefits and harms of general anesthesia compared to loco-regional anesthesia for endovascular aortic aneurysm repair. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search was 11 March 2022. SELECTION CRITERIA: We searched for all randomized controlled trials that assessed the effects of general anesthesia compared to loco-regional anesthesia for endovascular aortic aneurysm repairs. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were: all-cause mortality, length of hospital stay, length of intensive care unit stay. Our secondary outcomes were: incidence of endoleaks, requirement for re-intervention, incidence of myocardial infarction, quality of life, incidence of respiratory complications, incidence of pulmonary embolism, incidence of deep vein thrombosis, and length of procedure. We planned to use GRADE methodology to assess the certainty of evidence for each outcome. MAIN RESULTS: We found no studies, published or ongoing, that met our inclusion criteria. AUTHORS' CONCLUSIONS: We did not identify any randomized controlled trials that compared general versus loco-regional anesthesia for endovascular aortic aneurysm repair. There is currently insufficient high-quality evidence to determine the benefits or harms of either anesthetic approach during endovascular aortic aneurysm repair. Well-designed prospective randomized trials with relevant clinical outcomes are needed to adequately address this.

Geographical socioeconomic disadvantage is associated with adverse outcomes following major amputation in diabetic patients.

OBJECTIVE: Socioeconomic disadvantage is a known predictor of adverse outcomes and amputation in patients with diabetes. However, its association with outcomes after major amputation has not been described. Here, we aimed to determine the association of geographic socioeconomic disadvantage with 30-day readmission and 1-year reamputation rates among patients with diabetes undergoing major amputation. METHODS: Patients from the Maryland Health Services Cost Review Commission Database who underwent major lower extremity amputation with a concurrent diagnosis of diabetes mellitus between 2015 and 2017 were stratified by socioeconomic disadvantage as determined by the area deprivation index (ADI) (ADI1 [least deprived] to ADI4 [most deprived]). The primary outcomes were rates of 30-day readmission and 1-year reamputation, evaluated using multivariable logistic regression models and Kaplan-Meier survival analyses. RESULTS: A total of 910 patients were evaluated (66.0% male, 49.2% Black), including 30.9% ADI1 (least deprived), 28.6% ADI2, 19.1% ADI3, and 21.2% ADI4 (most deprived). After adjusting for differences in baseline demographic and clinical factors, the odds of 30-day readmission was similar among ADI groups (P > .05 for all). Independent predictors of 30-day readmission included female sex (odds ratio [OR], 1.45), Medicare insurance (vs private insurance; OR, 1.76), and peripheral artery disease (OR, 1.49) (P < .05 for all). The odds of 1-year reamputation was significantly greater among ADI4 (vs ADI1; OR, 1.74), those with a readmission for stump complication or infection/sepsis (OR, 2.65), and those with CHF (OR, 1.53) or PAD (OR, 1.59) (P < .05 for all). CONCLUSIONS: Geographic socioeconomic disadvantage is independently associated with 1-year reamputation, but not 30-day readmission, among Maryland patients undergoing a major amputation for diabetes. A directed approach at improving postoperative management of chronic disease progression in socioeconomically deprived patients may be beneficial to reducing long-term morbidity in this high-risk group.

A survey of Canadian surgeons on the indications for home care nursing following vascular surgery.

Background: Recent evidence suggests that home care nursing is variably prescribed after vascular surgery, and may reduce emergency department visits and hospital readmissions. We therefore sought to characterize the indications for home care nursing following vascular surgery from the surgeon's perspective. Methods: An online survey was distributed to the 141 members of the Canadian Society for Vascular Surgery with questions related to home care nursing after carotid endarterectomy (CEA), endovascular aortic aneurysm repair (EVAR), open abdominal aortic aneurysm (AAA) repair and open or hybrid revascularization for peripheral arterial disease (PAD). We included all questionnaires in our analysis; the frequency denominator changes according to the number of respondents who completed each survey item. Results: There were 46 survey respondents (33% of 141) from across the country. A total of 28 (62% of 45) worked in a teaching hospital. Home care nursing was routinely prescribed by 5%, 10%, 31% and 41% of respondents following CEA, EVAR, open AAA repair and open or hybrid revascularization for PAD, respectively. Across all procedure types, the same procedure-related criteria were most often deemed to warrant a prescription for home care nursing: surgical site infection, wound complications (e.g., open wound, lymphatic leak) and use of negative-pressure wound therapy. Across all procedure types, lack of social support, physical frailty and cognitive impairment were most frequently identified as patient-specific considerations for prescribing home care nursing. Few respondents reported restrictions or standards that informed their prescribing practice. Conclusion: Most surgeon respondents agreed on the indications for home care nursing after vascular surgery. However, evidence-based standards to guide patient selection for home care nursing after vascular surgery are needed.

Contexte: Selon des données récentes, les soins infirmiers à domicile sont prescrits aléatoirement après la chirurgie vasculaire, et pourraient réduire les consultations aux urgences et les réhospitalisations. Nous avons donc voulu caractériser les indications des soins infirmiers à domicile après la chirurgie vasculaire, du point de vue des chirurgiens. Méthodes: Nous avons transmis un sondage en ligne aux 141 membres de la Société canadienne de chirurgie vasculaire (SCCV); les questions portaient sur les soins infirmiers à domicile après l'endartériectomie carotidienne, la réparation endovasculaire de l'anévrisme de l'aorte, la réparation chirurgicale de l'anévrisme de l'aorte abdominale (AAA) et la revascularisation chirurgicale ou hybride de la maladie artérielle périphérique (MAP). Nous avons inclus tous les questionnaires dans notre analyse; le dénominateur de fréquence change en fonction du nombre de répondants qui ont répondu à chaque élément du sondage. Résultats: Quarante-six chirurgiens des quatre coins du pays ont répondu (33 % des 141 membres de la SCCV). En tout, 28 (62 % des of 45) travaillaient dans un établissement universitaire. Les soins infirmiers à domicile étaient prescrits d'emblée par 5 %, 10 %, 31 % et 41 % des répondants suite à l'endartériectomie carotidienne, la réparation endovasculaire de l'anévrisme de l'aorte, la chirurgie pour AAA et la revascularisation chirurgicale ou hybride de la MPA, respectivement. Pour tous les types d'interventions, les mêmes critères liés aux interventions ont semblé justifier la prescription de soins infirmiers à domicile : infection de plaie, complications au niveau de la plaie (p. ex., plaie ouverte, plaie exsudative) et traitement de plaie par pression négative. Pour tous les types d'intervention, l'absence de soutien social, la fragilité physique et le déclin cognitif ont le plus souvent été identifiés parmi les critères spécifiques aux patients pour la prescription de soins infirmiers à domicile. Peu de répondants ont mentionné de possibles restrictions ou normes sur lesquelles fonder leurs habitudes de prescription à ce chapitre. Conclusion: La plupart des chirurgiens participants se sont entendus sur les indications des soins infirmiers à domicile après la chirurgie vasculaire. Il faudrait toutefois établir des normes fondées sur des données probantes pour guider la sélection des patients candidats aux soins infirmiers à domicile après la chirurgie vasculaire.

Evaluating Quality Metrics and Cost After Discharge: A Population-based Cohort Study of Value in Health Care Following Elective Major Vascular Surgery.

BACKGROUND: Early readmission to hospital after surgery is an omnipresent quality metric across surgical fields. We sought to understand the relative importance of hospital readmission among all health services received after hospital discharge. OBJECTIVE: The aim of this study was to characterize 30-day postdischarge cost and risk of an emergency department (ED) visit, readmission, or death after hospitalization for elective major vascular surgery. METHODS: This is a population-based retrospective cohort study of patients who underwent elective major vascular surgery - carotid endarterectomy, EVAR, open AAA repair, bypass for lower extremity peripheral arterial disease - in Ontario, Canada, between 2004 and 2015. The outcomes of interest included quality metrics - ED visit, readmission, death - and cost to the Ministry of Health, within 30 days of discharge. Costs after discharge included those attributable to hospital readmission, ED visits, rehab, physician billing, outpatient nursing and allied health care, medications, interventions, and tests. Multivariable regression models characterized the association of pre-discharge characteristics with the above-mentioned postdischarge quality metrics and cost. RESULTS: A total of 30,752 patients were identified. Within 30 days of discharge, 2588 (8.4%) patients were readmitted to hospital and 13 patients died (0.04%). Another 4145 (13.5%) patients visited an ED without requiring admission. Across all patients, over half of 30-day postdischarge costs were attributable to outpatient care. Patients at an increased risk of an ED visit, readmission, or death within 30 days of discharge differed from those patients with relatively higher 30-day costs. CONCLUSION: Events occurring outside the hospital setting should be integral to the evaluation of quality of care and cost after hospitalization for major vascular surgery.

Optimization of rifampin coating on covered Dacron endovascular stent grafts for infected aortic aneurysms.

OBJECTIVE: In the treatment of an infected aorta, open repair and replacement with a rifampin-impregnated Dacron vascular graft decrease the risk of prosthetic graft infections, with several protocols available in the literature. We hypothesize that the same holds true for endovascular aneurysm repair, and after studying and optimizing rifampin solution concentration and incubation period to maximize the coating process of rifampin on Dacron endovascular stent grafts (ESGs), we propose a rapid real-time perioperative protocol. METHODS: Several prepared rifampin solutions, including a negative control solution, were used to coat multiple triplicate sets of Dacron endovascular aortic stent grafts at different but set incubation periods. Rifampin elution from the grafts was studied by spectroscopic analysis. Once an optimized solution concentration and incubation time were determined, the elution of rifampin over time from the graft and the graft's surface characteristics were studied by ultraviolet-visible spectroscopy and atomic force microscopy. RESULTS: All coated ESGs with any concentration of prepared rifampin solution, regardless of incubation time, immediately demonstrated a visible bright orange discoloration and subsequently after elution procedures returned to the original noncolored state. At the 25-minute incubation time (standard flush), there was no statistical difference in the amount of rifampin coated to the ESGs with 10-mg/mL, 30-mg/mL, and 60-mg/mL solutions (0.06 ± 0.01, 0.07 ± 0.05, and 0.044 ± 0.01, respectively; P > .05). This was also true for a 10-minute incubation time (express flush) of 10-mg/mL and 60-mg/mL rifampin solution concentrations (0.04 ± 0.007 and 0.066 ± 0.014, respectively; P = .22). The elution-over-time of coated rifampin ESG, although not statistically significant, did seem to plateau and to reach a steady state by 50 hours and was confirmed by surface characteristics using atomic force microscopy. CONCLUSIONS: Having studied two variables of rifampin coating techniques to Dacron ESGs, the authors propose a rapid real-time perioperative coating protocol by using a 10-mg/mL rifampin solution for a 10-minute incubation period. As rifampin loosely binds to Dacron ESGs by weak intermolecular forces, a rifampin-coated ESG would need to be inserted in a timely fashion to treat the diseased aorta and to deliver its antibiotic affect. A rapid perioperative coating protocol followed by immediate deployment makes our proposed technique especially useful in an urgent and unstable clinical scenario.

A systematic review of nonoperative management in blunt thoracic aortic injury.

OBJECTIVE: The objective was to characterize the growing body of literature regarding nonoperative management of blunt thoracic aortic injury (BTAI). METHODS: A systematic search of MedLine, Embase, and Cochrane Central was completed to identify original articles reporting injury characteristics and outcomes in patients with BTAI managed nonoperatively during their index hospitalization. Article title and abstract screening, full-text review, and data abstraction were performed in duplicate, with discrepancies resolved by a third reviewer. The quality of each study was evaluated using the Oxford Centre for Evidence-Based Levels of Evidence. RESULTS: Of 2162 identified studies, 74 were included and reported on 8606 patients with BTAI who were managed nonoperatively between 1970 and 2016. Only one study was prospective. The median nonoperative sample size per study was 11 patients. The characterization of aortic injury grade differed across studies. Follow-up varied widely from 1 day to 118 months. Injury healing or improvement on follow-up imaging occurred in 34% (226 of 673 patients; reported in 37 studies), most often in the context of grade I intimal injury. Injury progression or requirement for a thoracic endovascular aneurysm repair for injury progression was 7.6% (66 of 873 patients; reported in 46 studies). A total of 37 studies reported aortic-related death, with an overall rate of 4.5% (37 of 827 patients) and a rate of 1% in grade I and II injuries (1 of 153 patients) and 18% in grade III and IV (9 of 50 patients). CONCLUSIONS: An increasing number of reports support nonoperative management of grade I intimal injury, consistent with Society for Vascular Surgery guidelines. However, a retrospective interpretation of the determinants of management, heterogeneous injury characterization, and variable follow-up remain major limitations to the informed use of nonoperative management across all BTAI grades.

Population-based secular trends in lower-extremity amputation for diabetes and peripheral artery disease.

BACKGROUND: The evolving clinical burden of limb loss secondary to diabetes and peripheral artery disease remains poorly characterized. We sought to examine secular trends in the rate of lower-extremity amputations related to diabetes, peripheral artery disease or both. METHODS: We included all individuals aged 40 years and older who underwent lower-extremity amputations related to diabetes or peripheral artery disease in Ontario, Canada (2005-2016). We identified patients and amputations through deterministic linkage of administrative health databases. Quarterly rates (per 100 000 individuals aged ≥ 40 yr) of any (major or minor) amputation and of major amputations alone were calculated. We used time-series analyses with exponential smoothing models to characterize secular trends and forecast 2 years forward in time. RESULTS: A total of 20 062 patients underwent any lower-extremity amputation, of which 12 786 (63.7%) underwent a major (above ankle) amputation. Diabetes was present in 81.8%, peripheral artery disease in 93.8%, and both diabetes and peripheral artery disease in 75.6%. The rate of any amputation initially declined from 9.88 to 8.62 per 100 000 between Q2 of 2005 and Q4 of 2010, but increased again by Q1 of 2016 to 10.0 per 100 000 (p = 0.003). We observed a significant increase in the rate of any amputation among patients with diabetes, peripheral artery disease, and both diabetes and peripheral artery disease. Major amputations did not significantly change among patients with diabetes, peripheral artery disease or both. INTERPRETATION: Lower-extremity amputations related to diabetes, peripheral artery disease or both have increased over the last decade. These data support renewed efforts to prevent and decrease the burden of limb loss.

Drug-eluting balloon angioplasty versus uncoated balloon angioplasty for the treatment of in-stent restenosis of the femoropopliteal arteries.

BACKGROUND: Stents are placed in the femoropopliteal arteries for numerous reasons, such as atherosclerotic disease, the need for dissection, and perforation of the arteries, and can become stenosed with the passage of time. When a stent develops a flow-limiting stenosis, this process is known as "in-stent stenosis." It is thought that in-stent restenosis is caused by a process known as "intimal hyperplasia" rather than by the progression of atherosclerotic disease. Management of in-stent restenosis may include performing balloon angioplasty, deploying another stent within the stenosed stent to force it open, and creating a bypass to deliver blood around the stent. The role of drug-eluting technologies, such as drug-eluting balloons (DEBs), in the management of in-stent restenosis is unclear. Drug-eluting balloons might function by coating the inside of stenosed stents with cytotoxic chemicals such as paclitaxel and by inhibiting the hyperplastic processes responsible for in-stent restenosis. It is important to perform this systematic review to evaluate the efficacy of DEB because of the potential for increased expenses associated with DEBs over uncoated balloon angioplasty, also known as plain old balloon angioplasty (POBA). OBJECTIVES: To assess the safety and efficacy of DEBs compared with uncoated balloon angioplasty in people with in-stent restenosis of the femoropopliteal arteries as assessed by criteria such as amputation-free survival, vessel patency, target lesion revascularization, binary restenosis rate, and death. We define "in-stent restenosis" as 50% or greater narrowing of a previously stented vessel by duplex ultrasound or angiography. SEARCH METHODS: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to November 28, 2017. Review authors also undertook reference checking to identify additional studies. SELECTION CRITERIA: We included all randomized controlled trials that compared DEBs versus uncoated balloon angioplasty for treatment of in-stent restenosis in the femoropopliteal arteries. DATA COLLECTION AND ANALYSIS: Two review authors (AK, WA) independently selected appropriate trials and performed data extraction, assessment of trial quality, and data analysis. The senior review author (AD) adjudicated any disagreements. MAIN RESULTS: Three trials that randomized a combined total of 263 participants met the review inclusion criteria. All three trials examined the treatment of symptomatic in-stent restenosis within the femoropopliteal arteries. These trials were carried out in Germany and Austria and used paclitaxel as the agent in the drug-eluting balloons. Two of the three trials were industry sponsored. Two companies manufactured the drug-eluting balloons (Eurocor, Bonn, Germany; Medtronic, Fridley, Minnesota, USA). The trials examined both anatomical and clinical endpoints. We noted heterogeneity in the frequency of bailout stenting deployment between studies as well as in the dosage of paclitaxel applied by the DEBs. Using GRADE assessment criteria, we determined that the certainty of evidence presented was very low for the outcomes of amputation, target lesion revascularization, binary restenosis, death, and improvement of one or more Rutherford categories. Most participants were followed up to 12 months, but one trial followed participants for up to 24 months.Trial results show no difference in the incidence of amputation between DEBs and uncoated balloon angioplasty. DEBs showed better outcomes for up to 24 months for target lesion revascularization (odds ratio (OR) 0.05, 95% confidence Interval (CI) 0.00 to 0.92 at six months; OR 0.24, 95% CI 0.08 to 0.70 at 24 months) and at six and 12 months for binary restenosis (OR 0.28, 95% CI 0.14 to 0.56 at six months; OR 0.34, 95% CI 0.15 to 0.76 at 12 months). Participants treated with DEBs also showed improvement of one or more Rutherford categories at six and 12 months (OR 1.81, 95% CI 1.02 to 3.21 at six months; OR 2.08, 95% CI 1.13 to 3.83 at 12 months). Data show no clear differences in death between DEBs and uncoated balloon angioplasty. Data were insufficient for subgroup or sensitivity analyses to be conducted. AUTHORS' CONCLUSIONS: Based on a meta-analysis of three trials with 263 participants, evidence suggests an advantage for DEBs compared with uncoated balloon angioplasty for anatomical endpoints such as target lesion revascularization (TLR) and binary restenosis, and for one clinical endpoint - improvement in Rutherford category post intervention for up to 24 months. However, the certainty of evidence for all these outcomes is very low due to the small number of included studies and participants and the high risk of bias in study design. Adequately powered and carefully constructed randomized controlled trials are needed to adequately investigate the role of drug-eluting technologies in the management of in-stent restenosis.

Peripheral artery disease among Indigenous Canadians: What do we know?

Indigenous Canadians experience a disproportionate burden of chronic atherosclerotic diseases, including peripheral artery disease (PAD). Despite an estimated prevalence of 800 000 patients with PAD in Canada, the burden of the disease among Indigenous Canadians is unclear. Available evidence suggests that this population has a higher prevalence of several major risk factors associated with PAD (diabetes, smoking and kidney disease). Unique socioeconomic, geographic and systemic obstacles affecting Indigenous Canadians' health and health care access may worsen chronic disease outcomes. Little is known about the cardiovascular and limb outcomes of Indigenous peoples with PAD. A novel approach via multidisciplinary vascular health teams engaging Indigenous communities in a culturally competent manner may potentially provide optimal vascular care to this population. Further research into the prevalence and outcomes of PAD among Indigenous Canadians is necessary to define the problem and allow development of more ffective initiatives to alleviate the disease burden in this marginalized group.

Au Canada, les membres des communautés autochtones sont affectés de manière disproportionnée par les maladies athéroscléreuses chroniques, y compris par l'artériopathie périphérique (AP). Malgré une prévalence estimée de 800 000 patients atteints d'AP au Canada, on ignore quel est le fardeau de la maladie chez les membres des communautés autochtones. Selon les données accessibles, cette population présente une prévalence plus élevée de plusieurs facteurs de risque majeurs associé à l'AP (diabète, tabagisme et maladie rénale). Certains obstacles socioéconomiques, géographiques et systémiques particuliers nuisent aussi à leur santé et leur compliquent l'accès aux soins de santé, ce qui pourrait aggraver les répercussions des maladies chroniques. On en sait peu sur l'issue des problèmes cardiovasculaires et circulatoires périphériques chez les membres des communautés autochtones touchés par l'AP. Une approche nouvelle, impliquant les communautés concernées et offerte de manière culturellement compétente par des uipes de santé vasculaire multidisciplinaires, serait propice à la prestation de soins vasculaires optimaux. Il faudra approfondir la recherche sur la prévalence et l'issue de l'AP chez les membres des communautés autochtones pour cerner le problème et permettre la mise en place d'initiatives plus efficaces afin d'alléger le fardeau de la maladie dans ce groupe marginalisé.

Using Texting for Clinical Communication in Surgery: A Survey of Academic Staff Surgeons.

BACKGROUND: Text messaging has become ubiquitous and is being increasingly used within the health care system. The purpose of this study was to understand texting practices for clinical communication among staff surgeons at a large academic institution. METHODS: Staff surgeons in 4 subspecialties (vascular, plastics, urology, and general surgery) were surveyed electronically. RESULTS: A total of 62 surgeons from general surgery (n = 33), vascular surgery (n = 6), plastic surgery (n = 13), and urology (n = 10) completed the study (response rate 30%). When conveying urgent patient-related information, staff surgeons preferred directly calling other staff surgeons (61.5%) and trainees (58.8%). When discussing routine patient information, staff surgeons used email to reach other staff surgeons (54.9%) but preferred texting (62.7%) for trainees. The majority of participants used texting because it is fast (65.4%), convenient (69.2%) and allows transmitting information to multiple recipients simultaneously (63.5%). Most felt that texting enhances patient care (71.5%); however, only half believed that it enhanced trainees' educational experiences. The majority believed that texting identifiable patient information breaches patient confidentiality. CONCLUSIONS: Our data showed high adoption of text messaging for clinical communication among surgeons, particularly with trainees. The majority of surgeons acknowledge security concerns inherent in texting for patient care. Existing mobile communication platforms fail to meet the needs of academic surgeons. Further research should include guidelines related to texting in clinical practice, educational implications of texting, and technologies to better meet the needs of clinicians working in an academic surgical settings.

Combined Coil Embolization and Foam Sclerotherapy for the Management of Varicose Veins.

BACKGROUND: We propose a novel technique for endovenous treatment of varicose veins (VVs) using combined coil embolization and foam sclerotherapy of the great saphenous vein (GSV). METHODS: A retrospective case-series analysis on patients undergoing fluoroscopically guided coil embolization of the GSV and foam sclerotherapy of the GSV and below-knee varices at a single Canadian center. RESULTS: Twenty-two patients underwent the procedure on 23 legs. Most patients (78.3%) presented for follow-up 57.2 ± 21.9 days postoperatively. Doppler studies demonstrated complete GSV occlusion in all patients. While 3 patients (13.6%) noted skin discoloration overlying the treated VVs, none complained of pain on follow-up or developed leg numbness, deep vein thrombosis, or pulmonary emboli. CONCLUSIONS: Coil embolization and foam sclerotherapy are a novel and effective treatment for VVs that uses existing and readily available angiographic equipment.

Development of a Limb-Preservation Program.

In the global scenario, as the prevalence of renal failure and diabetes increases, healing and limb preservation assume increasing clinical importance for patients and healthcare systems. Unfortunately, there continues to be variation in the care delivered to patients at risk of losing a limb based on geography, race, socioeconomic status, and insurance status. There are also a variety of therapeutic approaches to patients with limb-threatening ischemia; 25% undergo primary amputation, 25% undergo medical therapy, and only 50% undergo any attempt at revascularization. Nearly 50% of patients undergoing major amputation have not had a simple diagnostic arteriogram to assess the possibility of limb preservation. The Society of Vascular Surgery and the American Podiatric Medical Association have recognized the benefits of a multidisciplinary approach to limb preservation. Benefits to the patient include rapid assessment, improved healing, and enhanced revascularization. Advantages for the providers include the ability to efficiently manage complex patients with help from the appropriate specialties, an increase in referrals, enhanced identity of the institution, and clinical research and trials. Such a program requires the coordinated effort of physicians, nurses, allied health professionals, and administrators dedicated to the preservation of functional limbs. Beneficial components include identifiable space, a vascular laboratory, hyperbaric oxygen therapy, and protocol-driven care involving diagnostic and therapeutic modalities such as endovascular revascularization, open bypass, and soft tissue reconstruction. Prosthetic expertise is also important to maintain function in those patients for whom amputation is appropriate. But, the key to a program is cooperation and communication among the participants who have a passion for limb preservation. Video Journal Club 'Cappuccino with Claudio Ronco' at http://www.karger.com/?doi=452746.

Avulsion injury to the profunda femoris artery after total hip arthroplasty.

Vascular injuries are a rare complication of total hip arthroplasty (THA). We describe the case of 71-year-old man who underwent an elective left THA and developed a pseudoaneurysm from an avulsion injury to the first branch of the profunda femoris artery. The patient underwent urgent open primary repair of the pseudoaneurysm and recovered without any complications. This case demonstrates the importance of assessing for vascular injuries after THA and of educating patients about the associated signs and symptoms.