RESUMEN
OBJECTIVE/BACKGROUND: Over the past decade, multidisciplinary "toe and flow" programs have gained great popularity, with proven benefits in limb salvage. Many vascular surgeons have incorporated podiatrists into their practices. The viability of this practice model requires close partnership, hospital support, and financial sustainability. We intend to examine the economic values of podiatrists in a busy safety-net hospital in the Southwest United States. METHODS: An administrative database that captured monthly operating room (OR) cases, clinic encounters, in-patient volume, and total work relative value units (wRVUs) in an established limb salvage program in a tertiary referral center were examined. The practice has a diverse patient population with >30% of minority patients. During a period of 3 years, there was a significant change in the number of podiatrists (from 1 to 4) within the program, whereas the clinical full-time employees for vascular surgeons remained relatively stable. RESULTS: The limb salvage program experienced >100% of growth in total OR volumes, clinic encounters, and total wRVUs over a period of 4 years. A total of 35,591 patients were evaluated in a multidisciplinary limb salvage clinic, and 5535 procedures were performed. The initial growth of clinic volume and operative volume (P < .01) were attributed by the addition of vascular surgeons in year one. However, recruitment of podiatrists to the program significantly increased clinic and OR volume by an additional 60% and >40%, respectively (P < .01) in the past 3 years. With equal number of surgeons, podiatry contributed 40% of total wRVUs generated by the entire program in 2019. Despite the fact that that most of the foot and ankle procedures that were regularly performed by vascular surgeons were shifted to the podiatrists, vascular surgeons continued to experience an incremental increase in operative volume and >10% of increase in wRVUs. CONCLUSIONS: This study shows that the value of close collaboration between podiatry and vascular in a limb salvage program extends beyond a patient's clinical outcome. A financial advantage of including podiatrists in a vascular surgery practice is clearly demonstrated.
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Recuperación del Miembro/métodos , Grupo de Atención al Paciente/economía , Podiatría/economía , Pautas de la Práctica en Medicina/economía , Cirujanos/economía , Amputación Quirúrgica/estadística & datos numéricos , Análisis Costo-Beneficio , Humanos , Colaboración Intersectorial , Recuperación del Miembro/economía , Extremidad Inferior/irrigación sanguínea , Extremidad Inferior/cirugía , Grupo de Atención al Paciente/organización & administración , Podiatría/organización & administración , Pautas de la Práctica en Medicina/organización & administración , Estudios Retrospectivos , Cirujanos/organización & administraciónRESUMEN
BACKGROUND: Frailty syndrome confers a greater risk of morbidity and mortality after operative interventions. The aim of the present study was to assess the effect of frailty on the outcomes after carotid interventions, including both carotid endarterectomy (CEA) and carotid artery stenting (CAS). METHODS: We performed an 8-year (2005-2012) retrospective analysis of the National Surgery Quality and Improvement Program database, including patients who had undergone CEA or CAS for carotid artery stenosis. A modified frailty index score was calculated. Frail status was defined as a modified frailty index score of ≥0.27. The outcome measures were inpatient complications, mortality, failure to rescue (FTR), hospital length of stay, and 30-day readmissions. Multivariable regression analysis was performed to study the association between frailty and the perioperative outcomes. RESULTS: The data from 37,875 patients were included. Of the 37,875 patients, 95.7% had undergone CEA, and 27.3% of the patients were frail (27% of the CEA and 26% of the CAS groups had qualified as frail). Overall, 11.7% of the patients had experienced complications, 2.2% had died, and 6.7% had been readmitted after discharge. On regression analysis, after controlling for age, gender, albumin level, type of surgery, and American Society of Anesthesiologists class, frail status was an independent predictor of complications (23.5% vs 7.2%; P < .001), mortality (5.2% vs 1.1%; P = .02), FTR (12.1% vs 4.7%; P = .02), and 30-day readmissions (14.9% vs 3.7%; P = .03). On subanalysis of the patients who had undergone CAS, no association was found between frail status and the occurrence of complications (odds ratio [OR], 1.5; 95% confidence interval [CI], 0.8-3.2), mortality (OR, 1.2; 95% CI, 0.6-2.7), FTR (OR, 0.9; 95% CI, 0.4-2.3), and 30-day readmission rate (OR, 1.1; 95% CI, 0.5-3.1). CONCLUSIONS: Frailty syndrome was associated with morbidity and mortality among patients undergoing surgical interventions for carotid stenosis. In the present study, frailty was associated with significant mortality and morbidity for those who had undergone CEA but not for those who had undergone CAS. However, the present study was not designed to determine the optimal treatment of frail patients. Incorporating frailty status into the treatment algorithm (CEA vs CAS) might provide a more accurate risk assessment and improve patient outcomes.
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Estenosis Carotídea/cirugía , Endarterectomía Carotidea , Procedimientos Endovasculares , Anciano Frágil , Fragilidad/diagnóstico , Factores de Edad , Anciano , Anciano de 80 o más Años , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/mortalidad , Bases de Datos Factuales , Endarterectomía Carotidea/efectos adversos , Endarterectomía Carotidea/mortalidad , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Fracaso de Rescate en Atención a la Salud , Femenino , Fragilidad/mortalidad , Estado de Salud , Mortalidad Hospitalaria , Humanos , Pacientes Internos , Tiempo de Internación , Masculino , Readmisión del Paciente , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/terapia , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Stents , Factores de Tiempo , Resultado del Tratamiento , Estados UnidosRESUMEN
BACKGROUND: Available methods for determining outcomes in vascular surgery patients are often subjective or not applicable in nonambulatory patients. The purpose of the present study was to assess the association between vascular surgery outcomes and a previously validated upper-extremity function (UEF) method, which incorporates wearable motion sensors for the physical frailty assessment. MATERIALS AND METHODS: Patients (≥50 y old) undergoing vascular surgery were recruited. Participants performed the 20-s UEF test, which involved rapid elbow flexion. This technology quantifies physical frailty features including slowness, weakness, exhaustion, and flexibility, which allows grouping individuals into nonfrail, prefrail, and frail categories. Surgical outcomes included length of hospital stay, discharged disposition, and 30-d mortality, complications, readmission, and reintervention(s). Associations between outcomes and frailty were assessed using nominal logistic regression models, adjusted for age, gender, body mass index, and wound classification. RESULTS: Thirty-seven participants were recruited: eight nonfrail (age = 62.0 ± 10.6); 22 prefrail (age = 65.6 ± 11.6); and seven frail (age = 68.0 ± 8.0). Significant associations were observed between frailty and length of hospital stay (three times longer among frail participants, P = 0.03), mortality after surgery (two incidents among frail participants, P < 0.01), and adverse discharge disposition (all nonfrail patients were discharged home, whereas only 43% of frail patients discharged home, P = 0.01). CONCLUSIONS: This is the first study to validate the utility of UEF among patients undergoing any vascular surgery. Findings suggest that UEF may provide an objective and simple approach for assessing frailty to predict adverse events after vascular surgery, especially for nonambulatory patients.
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Codo/fisiopatología , Fragilidad/diagnóstico , Complicaciones Posoperatorias/epidemiología , Procedimientos Quirúrgicos Vasculares/efectos adversos , Dispositivos Electrónicos Vestibles , Anciano , Femenino , Fragilidad/complicaciones , Fragilidad/fisiopatología , Mortalidad Hospitalaria , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Estudios Prospectivos , Reoperación/estadística & datos numéricos , Medición de Riesgo/métodos , Factores de Riesgo , Factores de TiempoRESUMEN
BACKGROUND: Frailty syndrome is an established predictor of adverse outcomes after carotid surgery. Recently, a modified 5-factor National Surgical Quality Improvement Program frailty index has been used; however, its utility in vascular procedures is unclear. The aim of our study was to compare the 5-factor modified frailty index (mFI-5) with the 11-factor modified frailty index (mFI-11) regarding value and predictive ability for mortality, postoperative infection, and unplanned 30-day readmission. METHODS: The mFI was calculated by dividing the number of factors present for a patient by the number of available factors for which there were no missing data. Spearman rho test was used to assess the correlation between the mFI-5 and mFI-11. Predictive models, using both unadjusted and adjusted logistic regressions, were created for each outcome for carotid endarterectomy using 2005-2012 National Surgical Quality Improvement Program data, the last year all mFI-11 variables existed. RESULTS: A total of 36,000 patients were included with mean age of 74.6 ± 5.9 years, complication rate of 10.7%, mortality rate of 3.1%, and readmission rate of 6.2%. Correlation between mFI-5 and mFI-11 was above 0.9 across all outcomes for patients. mFI-5 had strong predictive ability for mortality, postoperative complications, and 30-day readmission. CONCLUSIONS: The mFI-5 and mFI-11 are equally effective predictors of postoperative outcomes in patients undergoing carotid endarterectomy. mFI-5 is a strong predictor of postoperative complications, mortality, and 30-day readmission.
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Enfermedades de las Arterias Carótidas/cirugía , Técnicas de Apoyo para la Decisión , Endarterectomía Carotidea , Anciano Frágil , Fragilidad/diagnóstico , Anciano , Anciano de 80 o más Años , Enfermedades de las Arterias Carótidas/diagnóstico , Enfermedades de las Arterias Carótidas/mortalidad , Toma de Decisiones Clínicas , Comorbilidad , Bases de Datos Factuales , Endarterectomía Carotidea/efectos adversos , Endarterectomía Carotidea/mortalidad , Femenino , Fragilidad/mortalidad , Estado de Salud , Humanos , Masculino , Readmisión del Paciente , Selección de Paciente , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Infección de la Herida Quirúrgica/epidemiología , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Traumatic superior mesenteric vein (SMV) injury is rare, and the ideal treatment is controversial. We compared the outcomes of ligation versus repair of SMV injury using the National Trauma Databank. MATERIALS AND METHODS: All adult patients who suffered from traumatic SMV injury were identified from the National Trauma Databank (2002-2014) by International Classification of Diseases (ICD) codes. Patients were stratified by treatment modality into no repair, ligation, and surgical repair using ICD procedure codes. Patient characteristics were compared between ligation and surgical repair groups using the Kruskal-Wallis test for continuous variables and Fisher's exact test for categorical variables. Outcomes, including mortality, rates of small bowel resection, length of stay (LOS), and ventilation days were compared using logistic regression. RESULTS: Among 952 patients with SMV injury, 192 patients (20.2%) had ligation, 428 (50%) underwent surgical repair, and 332 patients (34.9%) had neither repair nor ligation of the SMV. Overall hospital mortality was 32%. Age, gender, injury severity score (ISS), and Glasgow Coma Scale (GCS) were similar between groups that underwent ligation and surgical repair. Although the mortality rate (29.4% versus 36.5%, P = 0.20) and bowel resection rate (4% versus 3%, P = 0.12) were similar, patients who underwent repair had significantly longer hospital LOS (19.4 ± 24.8 versus15.2 ± 24.4 d, P < 0.001) and ICU LOS (13 ± 17.1 versus 9.3 ± 11.8 d, P = 0.02) compared to ligation. Similar results were observed in multivariable analysis when adjusted for race, associated vascular injuries, and other associated injuries. CONCLUSIONS: In patients with traumatic SMV injury, surgical repair does not appear to confer a significant survival advantage over ligation and can be associated with greater LOS and ICU LOS. Ligation may be an acceptable option for management of a traumatic SMV injury, especially when surgical repair cannot be performed, without compromising patient mortality or bowel resection rates.
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Unidades de Cuidados Intensivos/estadística & datos numéricos , Ligadura/efectos adversos , Venas Mesentéricas/lesiones , Procedimientos Quirúrgicos Vasculares/efectos adversos , Lesiones del Sistema Vascular/cirugía , Adulto , Bases de Datos Factuales , Femenino , Escala de Coma de Glasgow , Mortalidad Hospitalaria , Humanos , Puntaje de Gravedad del Traumatismo , Tiempo de Internación/estadística & datos numéricos , Ligadura/estadística & datos numéricos , Masculino , Venas Mesentéricas/cirugía , Persona de Mediana Edad , Estudios Prospectivos , Estudios Retrospectivos , Factores de Riesgo , Análisis de Supervivencia , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/estadística & datos numéricos , Lesiones del Sistema Vascular/diagnóstico , Lesiones del Sistema Vascular/mortalidad , Adulto JovenRESUMEN
OBJECTIVE: Duplex ultrasound (DU) surveillance (DUS) criteria for vein graft stenosis and thresholds for reintervention are well established. The natural history of DU-detected stenosis and the threshold criteria for reintervention in patients undergoing endovascular therapy (EVT) of the femoropopliteal system have yet to be determined. We report an analysis of routine DUS after infrainguinal EVT. METHODS: Consecutive patients undergoing EVT of the superficial femoral artery (SFA) or popliteal artery were prospectively enrolled in a DUS protocol (≤1 week after intervention, then at 3, 6, and 12 months thereafter). Peak systolic velocity (PSV) and velocity ratio (Vr) were used to categorize the treated artery: normal was PSV <200 cm/s and Vr <2, moderate stenosis was PSV = 200-300 cm/s or Vr = 2-3, and severe stenosis was PSV >300 cm/s or Vr >3. Reinterventions were generally performed for persistent or recurrent symptoms, allowing us to analyze the natural history of DU-detected lesions and to perform sensitivity and specificity analysis for DUS criteria predictive of failure. RESULTS: Ninety-four limbs (85 patients) underwent EVT for SFA-popliteal disease and were prospectively enrolled in a DUS protocol. The initial scans were normal in 61 limbs (65%), and serial DU results remained normal in 38 (62%). In 17 limbs (28%), progressive stenoses were detected during surveillance. The rate of thrombosis in this subgroup was 10%. Moderate stenoses were detected in 28 (30%) limbs at initial scans; of these, 39% resolved or stabilized, 47% progressed to severe, and occlusions developed in 14%. Five (5%) limbs harbored severe stenoses on initial scans, and 80% of lesions resolved or stabilized. Progression to occlusion occurred in one limb (20%). The last DUS showed 25 limbs harbored severe stenoses; of these, 13 (52%) were in symptomatic patients and thus required reintervention regardless of DU findings. Eleven limbs (11%) eventually occluded. Sensitivity and specificity of DUS to predict occlusion were 88% and 60%, respectively. CONCLUSIONS: DUS does not reliably predict arterial occlusion after EVT. Stenosis after EVT appears to have a different natural history than restenosis after vein graft bypass. EVT patients are more likely to have severe stenosis when they present with recurrent symptoms, in contrast to vein graft patients, who commonly have occluded grafts when they present with recurrent symptoms. The potential impact of routine DU-directed reintervention in patients after EVT is questionable. The natural history of DU-detected stenosis after femoropopliteal endovascular therapy suggests questionable clinical utility of routine DUS.
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Angioplastia , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/terapia , Arteria Femoral/diagnóstico por imagen , Arteria Poplítea/diagnóstico por imagen , Ultrasonografía Doppler Dúplex , Anciano , Anciano de 80 o más Años , Angioplastia/efectos adversos , Arizona , Arteriopatías Oclusivas/fisiopatología , Velocidad del Flujo Sanguíneo , Constricción Patológica , Femenino , Arteria Femoral/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Arteria Poplítea/fisiopatología , Valor Predictivo de las Pruebas , Recurrencia , Flujo Sanguíneo Regional , Estudios Retrospectivos , Sensibilidad y Especificidad , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
OBJECTIVE: This study aimed to quantify the impact of an integrated diabetic foot surgical service on outcomes and changes in surgical volume and focus. METHODS: We abstracted registry data from 48 consecutive months at a single institution, evaluating all patients with diabetic foot complications requiring surgery or vascular intervention, and compared outcomes in the 24 months before and after integrating podiatric surgery with vascular surgical limb-salvage service. RESULTS: The service performed 2923 operations; 790 (27.0%) were related to treatment of diabetic foot complications in 374 patients. Of these, 502 were classified as non-vascular diabetic foot surgery and 288 were vascular interventions. Urgent surgery was significantly reduced after team implementation (77.7% vs 48.5%, p < 0.0001; OR = 3.7, 95% CI: 2.4-5.5). The high/low amputation ratio decreased from 0.35 to 0.27 due to an increase in low-level (midfoot) amputations (8.2% vs 26.1%, p < 0.0001; OR = 4.0, 95% CI: 2.0-83.3). A 45.7% reduction in below-knee amputations was realized with a stable above-knee/below-knee amputation ratio (0.73-0.81). One-third of patients required vascular intervention. Vascular reconstructions increased 44.1% following institution of the team. Initial revascularization was endovascular in 70.6% of patients. Repeat endovascular intervention or conversion to open bypass was required in 37.1% of these patients, almost double the reintervention rate of those receiving open bypass first (18.9%). CONCLUSIONS: Interdisciplinary diabetic foot surgery teams may significantly impact surgery type, with greater focus on proactive and preventive, rather than reactive and ablative, procedures. Although endovascular limb-sparing procedures have become increasingly applicable, open bypass remains critical to success.
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Pie Diabético/cirugía , Recuperación del Miembro , Evaluación de Procesos y Resultados en Atención de Salud , Grupo de Atención al Paciente , Podiatría , Amputación Quirúrgica , Complicaciones de la Diabetes/cirugía , Procedimientos Endovasculares , Pie/cirugía , Humanos , Reoperación , Procedimientos Quirúrgicos Vasculares/estadística & datos numéricosRESUMEN
The duration that renal parenchyma will tolerate ischemia has continued to be debated. We have reported the cases of three patients who had undergone revascularization procedures with successful return of baseline renal function after prolonged renal artery occlusion of 14 days to 3 months. These cases highlight that aggressive revascularization can lead to successful renal salvage in selected patients. We examined the characteristics of these patients and those of others in the literature and reviewed the factors favoring recovery.
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OBJECTIVES: Preoperative duplex ultrasound mapping of veins and arteries has been widely advocated to maximize the creation of native arteriovenous fistula (AVF) for hemodialysis access, but reliable diameter criteria have not been established. We sought to determine patient and anatomic variables predictive of fistula maturation in patients receiving their initial permanent hemodialysis access. METHODS: All patients undergoing dialysis access creation from January 2003 to June 2007 were retrospectively reviewed. We analyzed fistula type and functional maturation rates (Society for Vascular Surgery [SVS] reporting standards) based on patient characteristics and findings on physical examination, preoperative vein mapping studies, or venography. Maturation and patency rates were determined by Kaplan Meier analysis. The following factors were analyzed: age, race, gender, body-mass index (BMI), fistula site, preoperative duplex vein diameter, diabetes, hyperlipidemia, HTN, prior central catheter placement, HIV, and history of IV drug abuse. RESULTS: From January 2003 to June 2007, 298 vascular access procedures were performed. One hundred ninety-five (65%) were initial hemodialysis access procedures, among which a native AVF was created in 185 (95%); 158 patients with posterior radiocephalic AVF (PRCAVF, n = 24), wrist radiocephalic AVF (WRCAVF, n = 72), or brachiocephalic AVF (BCAVF, n = 62) had adequate follow-up and were included in the analysis. PRCAVF, WRCAVF, and BCAVF had 54%, 66%, and 81% maturation rates, respectively. Both the type of fistula type (P = .032) and vein size (P = .002) significantly affected maturation by univariate analysis. In contrast, by multivariate logistic regression analysis, vein diameter was the sole independent predictor of fistula functional maturation (P = .002). CONCLUSION: In this series of 158 patients undergoing initial hemodialysis access creation, native AVF creation was performed in 95%. In contrast to previous reports, age, gender, diabetes, and BMI had no significant effect on functional maturation. By multivariate logistic regression analysis, vein diameter was the sole independent predictor of functional fistula maturation.
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Derivación Arteriovenosa Quirúrgica , Diálisis Renal , Extremidad Superior/irrigación sanguínea , Grado de Desobstrucción Vascular , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Derivación Arteriovenosa Quirúrgica/efectos adversos , Niño , Femenino , Humanos , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Insuficiencia del Tratamiento , Resultado del Tratamiento , Ultrasonografía Doppler Dúplex , Venas/diagnóstico por imagen , Venas/fisiopatología , Venas/cirugía , Adulto JovenRESUMEN
AAA repair in renal transplant recipients has generated a variety of methods of managing the allograft. Endovascular techniques have been successfully employed in this patient population. Due to inherent limitations of present endovascular methods, occasional stent-graft excision must be performed. We present a case of aortic stent-graft excision in a renal transplant recipient using a pump-oxygenator to maintain allograft perfusion.
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Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Remoción de Dispositivos , Trasplante de Riñón , Stents , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/fisiopatología , Aortografía/métodos , Embolización Terapéutica , Humanos , Masculino , Persona de Mediana Edad , Oxigenadores , Perfusión/instrumentación , Diseño de Prótesis , Falla de Prótesis , Circulación Renal , Reoperación , Tomografía Computarizada por Rayos X , Trasplante Homólogo , Insuficiencia del TratamientoRESUMEN
A 78 year-old male with multiple serious medical comorbidities was diagnosed with a pseudoaneurysm of the proximal superficial femoral artery. He had undergone successful superficial femoral artery (SFA) stenting for limb salvage four months previously and a Duplex ultrasound had confirmed adequacy of the endovascular procedure two months after its execution. This was successfully treated with placement of a covered-stent at the proximal SFA and a balloon-expandable stent at the origin of the deep femoral artery. Unfortunately the patient expired six weeks after the last endovascular intervention, likely due to procedural-unrelated causes. We postulate delayed stent erosion of a proximal atherosclerotic SFA, causing the pseudoaneurysm. This is the first report of such a case in the literature.
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Aneurisma Falso/etiología , Angioplastia , Arteriopatías Oclusivas/cirugía , Arteria Femoral/cirugía , Stents/efectos adversos , Anciano , Aneurisma Falso/diagnóstico por imagen , Arteria Femoral/diagnóstico por imagen , Humanos , Masculino , Complicaciones Posoperatorias , RadiografíaRESUMEN
A potential problem during endovascular aortic aneurysm repair (EVAR) or open repair in renal allograft patients is ischemia of the transplanted kidney. In this study, kidney transplant patients who underwent aortic aneurysm repair in our institution were added to similar cases extracted from the literature to represent the basis of this work. Comparisons between patients treated with open surgery versus EVAR were performed in terms of renal function. In the EVAR group, most aneurysms were infrarenal, and 84% were treated with modular bifurcated devices. Protective kidney allograft perfusion measures were not used. The pre- and postoperative Cr was 1.69 and 1.73 mg/dL, respectively (P = .412). All EVAR patients had good outcomes. Complications included 8 endoleaks and 1 limb ischemia case. Three patients died from aortic repair-unrelated reasons. In the open group, the pre-and postoperative Cr was 1.45 and 1.37 mg/dL, respectively (P = .055). Most cases were infrarenal and mostly treated by aortobiiliac bypasses. In 16%, no adjuvant allograft perfusion was provided. In the rest, temporary axillofemoral bypasses were used most often. Most outcomes were favorable (57%). Reported procedural-related complications included arterial embolism, wound infection, and pneumonia. Deaths were reported in 5 occasions (none allograft failure dependent). No differences in Cr between EVAR and open techniques (P = .13) were seen. Aneurysm repair in kidney transplant recipients is associated with excellent renal preservation. Adverse outcomes were all allograft failure independent in both groups. EVAR without special allograft protection measures seems to be equally effective as open surgery with or without adjuvant kidney transplant perfusion.
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Aneurisma de la Aorta/cirugía , Aneurisma Ilíaco/cirugía , Isquemia/prevención & control , Trasplante de Riñón , Riñón/irrigación sanguínea , Procedimientos Quirúrgicos Vasculares , Adulto , Anciano , Aneurisma de la Aorta/diagnóstico por imagen , Aneurisma de la Aorta/mortalidad , Femenino , Humanos , Aneurisma Ilíaco/diagnóstico por imagen , Aneurisma Ilíaco/mortalidad , Isquemia/etiología , Isquemia/fisiopatología , Riñón/fisiopatología , Riñón/cirugía , Pruebas de Función Renal , Masculino , Persona de Mediana Edad , Radiografía , Trasplante Homólogo , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/mortalidadRESUMEN
Antiphospholipid syndrome is a diagnosis with the clinical manifestations of thromboses in the presence of an antiphospholipid antibody. A 25-year-old man with a history of deep venous thrombosis, pulmonary emboli, and myocardial infarction, and receiving long-term anticoagulation with warfarin, all due to primary antiphospholipid syndrome, presented with blue toe syndrome from a primary superficial femoral artery thrombus. He was anticoagulated with fondaparinux in addition to dipyridamole and aspirin perioperatively. The area of thrombus was resected and reconstructed using a cephalic vein interposition graft. This report reviews antiphospholipid syndrome and identifies potential questions and problems relating to a rare clinical presentation.
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Síndrome Antifosfolípido/complicaciones , Arteriopatías Oclusivas/complicaciones , Síndrome del Dedo Azul/etiología , Arteria Femoral , Trombectomía/métodos , Trombosis/cirugía , Adulto , Síndrome Antifosfolípido/diagnóstico , Síndrome Antifosfolípido/tratamiento farmacológico , Arteriopatías Oclusivas/diagnóstico , Síndrome del Dedo Azul/terapia , Estudios de Seguimiento , Humanos , Masculino , Radiografía , Procedimientos de Cirugía Plástica/métodos , Medición de Riesgo , Índice de Severidad de la Enfermedad , Trombosis/diagnóstico por imagen , Resultado del Tratamiento , Warfarina/uso terapéuticoRESUMEN
Outcome analysis is increasingly being used to develop health-care policy and direct patient referral. For example, the Leapfrog Group health-care quality initiative has proposed "evidence-based hospital" referral criteria for specific procedures including elective abdominal aortic aneurysm repair (AAA-R). These criteria include an annual hospital AAA operative volume exceeding 50 cases and provision of intensive care unit (ICU) care by board-certified intensivists. Outcomes after AAA-R are reportedly influenced by presentation (intact vs. ruptured), operative approach (endovascular vs. open, transperitoneal vs. retroperitoneal), surgeon subspecialty, case volume (hospital and surgeon), and provision of postoperative care by an intensivist. The purpose of this study was to compare our single-center results with those of high-volume centers to assess the validity of the concept that surrogate markers, such as case volume or intensivist involvement, can be used to estimate procedural outcome. A retrospective review was performed of AAA-Rs at one low-volume academic medical center from January 1994 to March 2005. Demographic data, aneurysm diameter and location, operative indications, and repair approach were documented. Postoperative complications, mortality rates, and hospital and ICU length of stay (LOS) were noted and compared to established benchmarks. During the study period, 270 patients underwent AAA-R (annual mean = 27 hospital cases and 13.4 cases/attending vascular surgeon). ICU care was provided by a dedicated vascular surgery service without routine intensivist involvement. Open, elective, infrarenal AAA-R was performed in 161 patients (60%), with a 2.5% hospital mortality rate (30-day, 3.1%). Thirty-three (12%) patients underwent elective endovascular aneurysm repair (EVAR), with no mortality. Both ICU (3.7 vs. 1.4 days, p = 0.03) and hospital (9.2 vs. 2.8 days, p = 0.002) LOS were significantly reduced after EVAR compared to open repair. Hospital LOS was significantly lower after open retroperitoneal repair compared to transperitoneal repair (6.1 vs. 10.3 days, p = 0.001). Thirty-five patients (13%) underwent ruptured AAA-R, with only 34.3% mortality (in-hospital and 30-day). Forty-one patients (15%) underwent repair of complex aortic aneurysms, with 14.1% mortality. There are increasing societal and economic pressures to direct patient referrals to "centers of excellence" for specific surgical procedures. Although our institution meets neither of the Leapfrog Group's proposed criteria, our mortality and LOS for both intact and ruptured infrarenal AAA-R are equivalent or superior to published benchmarks for high-volume hospitals. Individual institutional outcome results such as these suggest that patient referral and care should be based upon actual, carefully verified outcome data rather than utilization of surrogate markers such as case volume and subspecialist involvement in postoperative care.
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Aneurisma de la Aorta Abdominal/cirugía , Rotura de la Aorta/cirugía , Benchmarking , Procedimientos Quirúrgicos Vasculares/estadística & datos numéricos , Centros Médicos Académicos/estadística & datos numéricos , Anciano , Aneurisma de la Aorta Abdominal/mortalidad , Aneurisma de la Aorta Abdominal/patología , Rotura de la Aorta/mortalidad , Rotura de la Aorta/patología , Arizona/epidemiología , Competencia Clínica/estadística & datos numéricos , Cuidados Críticos/estadística & datos numéricos , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Tratamiento de Urgencia/estadística & datos numéricos , Femenino , Mortalidad Hospitalaria , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Complicaciones Posoperatorias/epidemiología , Derivación y Consulta , Reproducibilidad de los Resultados , Estudios Retrospectivos , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/normas , Recursos Humanos , Carga de Trabajo/estadística & datos numéricosRESUMEN
Soft tissue coverage of distal medial ankle wounds is a challenging problem in orthopedic surgery because of the limited local tissues and prominent instrumentation. Traditionally, these wounds required free tissue transfer to achieve suitable coverage and subsequent bony union. To better respect the reconstructive ladder and to avoid the inherent difficulty of free flap coverage, rotational flaps have been used to cover these wounds. Both sural fasciocutaneous flaps and rotational fasciocutaneous perforator (propeller) flaps have been described for distal medial soft tissue coverage. The authors performed a retrospective chart review of patients who underwent distal medial leg coverage with the use of either sural flaps or rotational fasciocutaneous perforator flaps. The authors identified 14 patients by Current Procedural Terminology code who met the study criteria. The average age and degree of medical comorbidities were comparable in the 2 groups. The authors reviewed their medical records to evaluate fracture healing, flap size, complications, and return to normal shoe wear. All 7 sural flaps healed without incident, with underlying fracture healing. Of the 7 perforator flaps, 6 healed without incident, with underlying fracture healing. One perforator-based flap was complicated by superficial tip necrosis and went on to heal with local wound care. All patients returned to normal shoe wear. Both sural artery rotational flaps and posterior tibial artery-based rotational flaps are viable options for coverage of the distal medial leg. Coverage can be achieved reliably without microsurgery, anticoagulation, or monitoring in the intensive care unit.
Asunto(s)
Traumatismos de la Pierna/cirugía , Colgajos Quirúrgicos , Adulto , Anciano , Tobillo/cirugía , Femenino , Humanos , Pierna/cirugía , Traumatismos de la Pierna/fisiopatología , Masculino , Microcirugia/métodos , Persona de Mediana Edad , Colgajo Perforante , Procedimientos de Cirugía Plástica/métodos , Estudios Retrospectivos , Cicatrización de Heridas/fisiologíaRESUMEN
The optimal extent-of-disease evaluation for patients with clinically suspected melanoma recurrence is not known. The available modalities are numerous and many are expensive. We documented the extent of work-up carried out by plastic surgeons when their patients with melanoma develop clinical recurrence. A custom-designed questionnaire was mailed to a random sample (n=3,032) of the 4,320 members of the American Society of Plastic and Reconstructive Surgeons (ASPRS). Subjects were asked which specific laboratory tests and imaging studies they would order for a patient with initial T2N0M0 disease treated with curative intent who later presented with either regional nodal metastases or pulmonary metastases. We measured the variability in practice patterns among surgeons and estimated the effects of physician age, U.S. census region, health maintenance organization (HMO) penetration rates, and type of recurrence (regional versus systemic) on work-up intensity. Of the 1,142 questionnaires completed (38%), 395 (35%) were evaluable. Non-evaluability was usually due to lack of melanoma patient follow-up in surgeons' practices. Lesion biopsy, chest X-ray, complete blood count, liver function tests, and computed tomography were frequently used, but there was no consensus for most modalities. More tests, particularly computed tomography, were utilized for evaluating systemic recurrence than for regional recurrence (p<0.05). The intensity of work-up differed significantly (p<0.05) by surgeon age for three diagnostic tests but not by U.S. census region or HMO penetration rate. This is the first empirical data on this subject from a large sample of an international society of highly credentialed experts. The lack of consensus for most tests in current practice is presumably due to multiple factors, including the lack of evidence supporting any particular strategy.
Asunto(s)
Melanoma/diagnóstico , Recurrencia Local de Neoplasia/diagnóstico , Pautas de la Práctica en Medicina , Cirugía Plástica , Adulto , Factores de Edad , Anciano , Biopsia , Recuento de Células Sanguíneas , Sistemas Prepagos de Salud , Humanos , Melanoma/patología , Melanoma/cirugía , Persona de Mediana Edad , Recurrencia Local de Neoplasia/patología , Recurrencia Local de Neoplasia/cirugía , Estadificación de Neoplasias , Radiografía Torácica , Encuestas y Cuestionarios , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: We investigated whether geographic determinants could account for variation in posttreatment melanoma surveillance intensity among plastic surgeons. METHODS: A custom-designed questionnaire was mailed to U.S. and non-U.S. members of the American Society of Plastic and Reconstructive Surgeons (ASPRS). Subjects were asked how they use 14 specific follow-up modalities during years 1 to 5 and 10 following primary treatment for patients with cutaneous melanoma. Repeated-measures analysis of variance was used to compare practice patterns by TNM stage, year postsurgery, U.S. census region, metropolitan statistical area (MSA), and managed care organization (MCO) penetration rate. RESULTS: Of the 1,142 respondents, 395 were evaluable. Those who did not perform melanoma surgery or follow-up were excluded. Correlation analysis showed that mean follow-up intensity for the modalities surveyed was highly correlated across TNM stages and years postsurgery. Within MSAs, only chest radiograph utilization varied significantly. The pattern of testing varied significantly by geographic region for seven modalities (office visit, computed tomography scan of the brain and chest/abdomen, alpha-fetoprotein level, 5S-cysteinyl dopa level, abdominal ultrasonogram, bone scan); in each of these, utilization by non-U.S. surgeons exceeded utilization in any U.S. census region. The pattern of testing varied significantly by MCO penetration rate for chest radiograph (greater utilization in the lowest MCO penetration rate areas) and 5S-cysteinyl dopa level (greater utilization in the highest MCO penetration rate areas). CONCLUSIONS: The intensity of posttreatment surveillance recommended by ASPRS members caring for patients with cutaneous melanoma varies markedly. This analysis provides the first evidence that geographic factors significantly affect the surveillance strategies of clinicians following patients with cutaneous melanoma. Variation by census region was most prominent, although the size of detected differences was small.
Asunto(s)
Continuidad de la Atención al Paciente/estadística & datos numéricos , Melanoma/terapia , Pautas de la Práctica en Medicina/estadística & datos numéricos , Neoplasias Cutáneas/terapia , Cirugía Plástica , Censos , Geografía , Humanos , Tamizaje Masivo/estadística & datos numéricos , Análisis de Área Pequeña , Encuestas y Cuestionarios , Estados Unidos , Salud UrbanaRESUMEN
AIMS: To describe a case of simultaneous medial and lateral soft tissue coverage for exposed orthopaedic implants in the setting of revision fixation of a non-united ankle fracture. This was achieved using a sural flap as well as a propeller flap. METHODS: Case report. RESULTS: Both the sural and posterior tibial artery based rotational propeller flap healed without incident. The underlying fracture healed successfully and the patient returned to normal shoe wear. CONCLUSIONS: The sural flap in conjunction with the posterior tibial artery based rotational flap is effective in providing simultaneous medial and lateral soft tissue coverage to the ankle.
RESUMEN
Vascular involvement in the setting of neurofibromatosis type 1(NF1) has been well described. However, the coexistence of NF1 with vertebral artery (VA) aneurysms and arteriovenous fistulae (AVFs) is a rare occurrence. A 60-year-old female with NF1 and other severe comorbidities presented with acute respiratory insufficiency caused by a ruptured large VA aneurysm and an associated AVF that required emergent intubation and eventual repair through endovascular techniques that resolved her symptoms. A detailed description of this case and a comprehensive review of the literature are also presented.