Do patients actually understand? An evaluation of the informed consent process for endoscopic procedures in rural Uganda.

INTRODUCTION: Improving surgical access in low- and middle-income countries is vital for the 5 billion people who lack safe surgical care. Tailoring a culturally sensitive approach to consent is essential for patient comprehension and comfort, thereby alleviating the effects of resource constraints and advancing equitable care. This study examines the consenting process for endoscopy at Kyabirwa Surgical Center in Kyabirwa, Jinja, Uganda, to assess patients' knowledge and attitudes as a potential barrier to participating in endoscopic procedures. METHODS: All adult upper endoscopy (EGD) and colonoscopy patients were recruited to participate in a survey of their demographics, knowledge, and attitudes toward their procedure. All patients received a standard consultation explaining the procedure and its risks and benefits. RESULTS: 75 patients were included; median age was 54 years and 56% (n = 42) were women. 92% (n = 69) of patients had never had an endoscopy before and 73% (n = 55) of patients were scheduled for an EGD while the remaining 27% (n = 20) were scheduled for a colonoscopy. Most patients 80% (n = 60) had a basic understanding of what an endoscopy is and 87% (n = 65) its diagnostic purpose. Few patients 15% (n = 11) knew of the most common side effects or if they would have a surgical scar 27% (n = 20). Overall, 46.7% (n = 35) of patients were moderately or severely fearful of getting an endoscopy. Additionally, 45.3% (n = 34) of patients were moderately or severely fearful of receiving anesthesia during their endoscopic procedure. Despite this fear, most patients 85.3% (n = 64) stated that they understood the benefits of the procedure either very well or extremely well. CONCLUSIONS: Most patients understood the role that an endoscopic procedure plays in their care and its potential benefits. Despite this, many patients continued to have high levels of fear associated with both the endoscopic procedure and with receiving anesthesia during their procedure. Future patient education should focus on addressing patients' fears and the risks of undergoing an endoscopy, which may improve the utilization of surgical services.

Collaborative international partnership: Enabling the development of a state-of-the-art minimally invasive surgical center in rural Uganda through telementoring.

BACKGROUND: Access to minimally invasive surgery (MIS) is limited in Sub-Saharan African countries. In 2019, the Mount Sinai Department of Surgery in New York collaborated with local Ugandans to construct the Kyabirwa Surgical Center (KSC), an independent, replicable, self-sustaining ambulatory surgical center in Uganda. We developed a focused MIS training program using a combination of in-person training and supervised telementoring. We present the results of our initial MIS telementoring experience. METHODS: We worked jointly with Ugandan staff to construct the KSC in the rural province of Jinja. A solar-powered backup battery system ensured continuous power availability. Underground fiber optic cables were installed to provide stable high-speed Internet. The local Ugandan general surgeon (JOD) underwent a mini-fellowship in MIS and then trained extensively using the Fundamentals of Laparoscopic Surgery program. After a weeklong in-person session to train the Ugandan OR team, JOD performed laparoscopic cases with telementoring, which was conducted remotely by surgeons in New York via audiovisual feeds from the KSC OR. RESULTS: From October 2021 to February 2024, JOD performed 61 telementored laparoscopic operations at KSC including 37 appendectomies and 24 cholecystectomies. Feedback was provided regarding patient positioning, port placement, surgical technique, instrument use, and critical steps of the operation. There were no intra-operative complications. Postoperatively, field medical workers visited patients at home to collect follow-up information. Two superficial wound infections (3.3%) were reported in the short-term follow-up. CONCLUSION: Telementoring can be safely implemented to assist surgeons in previously underserved areas to provide advanced laparoscopic surgical care to the local patient population.

Use of Spinal Anesthesia during Thoracic Endovascular Aortic Repair.

BACKGROUND: The purpose of this study was to assess outcomes after spinal anesthesia (SA) versus general anesthesia (GA) in patients undergoing thoracic endograft placement and to evaluate the adjunctive use of cerebrospinal fluid drainage (CSFD) placement. METHODS: A single-center retrospective review of patients that underwent thoracic endograft placement from 2001 to 2019 was performed. Patients were stratified based on the type of anesthesia they received: GA, SA or epidural, GA with CSFD, and SA with CSFD. Primary outcomes included 30-day mortality and length of stay (LOS). Baseline characteristics were analyzed with Student's t-test and Pearson's chi-squared test. Multivariate logistic regression analysis was performed to identify risk factors for 30-day mortality and longer LOS. RESULTS: A total of 333 patients underwent thoracic endograft placement; 104 patients received SA, 180 patients received GA, 30 patients received GA and CSFD, and 19 patients received SA and CSFD. Of the total patients, 16.2% underwent thoracic endograft placement for type B aortic dissection, 3.3% for type A aortic dissection, and 12.3% for penetrating ulcer. The mean age of the study population was 68.7 years old. Patients undergoing SA were older with a mean age of 73.4 years versus 64.7 years for patients undergoing GA (P < 0.001). Spinal anesthesia (SA) was preferred in patients at high risk for GA (>75 years old: 52.9% vs. 33.3%, P < 0.001; renal comorbidities: 20.6% vs. 10.6%, P = 0.03, and current smokers: 26.7% vs. 9.6%, P < 0.001). Length of stay (LOS) was decreased in the SA group (4.29 days vs. 9.70 days, P < 0.001). There was a lower incidence of spinal cord ischemia in the SA group (1.0% vs. 2.2%, P = 0.44), as well as significantly decreased 30-day mortality (0% vs. 5.6%, P = 0.01), reintervention (19.2% vs. 26.8%, P = 0.02), and return to the operating room (6.8% vs. 12.7%, P = 0.02). Of the 19 patients that had SA + CSFD, there were no signs and symptoms of spinal cord ischemia and decreased incidence of perioperative complications (0% vs. 33.3%, P = 0.01). There was no difference in the risk for intraoperative complications, neurologic complications, or 30-day mortality between GA + CSFD patients versus SA + CSFD patients. Age >75 (P = 0.002), intraoperative complications (P < 0.001), and perioperative complications (P = 0.02) were associated with increased mortality after thoracic endograft placement per multivariate logistic regression analysis. CONCLUSIONS: Spinal anesthesia (SA) in select high-risk patients was associated with reduced 30-day mortality, neurologic complications, and LOS compared to GA. The concurrent use of spinal drainage and SA had satisfactory results compared to spinal drainage and GA.

Body Mass Index Impacts Indication But Not Outcomes of Thoracic Endovascular Aortic Repair.

BACKGROUND: There are limited studies looking at thoracic endovascular aortic repair (TEVAR) outcomes in obese and overweight patients. Our objective was to determine the rate of complications, reintervention, and short-term mortality in normal weight, overweight, and obese patients undergoing TEVAR. METHODS: Patients undergoing TEVAR at a large tertiary hospital from October 2007 to January 2020 were analyzed. Patients were stratified into 3 cohorts based on body mass index (BMI): normal (18.5-25 kg/m2), overweight (25-30 kg/m2), and obese (>30 kg/m2). Primary outcomes were 30-day and 1-year survival. Intraoperative, in-hospital, and postdischarge complications were assessed as secondary outcomes using the Clavian-Dindo classification system. In addition, reinterventions associated with the index TEVAR procedure as a secondary outcome. RESULTS: Among 204 patients fitting the study criteria, we identified 65 with normal BMI, 78 overweight, and 61 obese patients. Obese patients were younger than the overweight and normal BMI patients (mean age 62.2 vs. 66.7 vs. 70.7, respectively, P = 0.003). In terms of TEVAR indication, the obese cohort had the highest percentage of patients with type B aortic dissection (36.4%), while the normal BMI cohort had the higher proportion of patients undergoing TEVAR for isolated thoracic aortic aneurysm (63.9%). Intraoperative complications did not significantly differ between cohorts. Postoperatively, in-hospital complications, postdischarge complications and 30-day return to the operative room did not differ significantly between study cohorts. Odds of reintervention did not differ significantly between cohorts, both on univariate and multivariate analysis. Log-rank test of Kaplan Meier analysis revealed no difference in reintervention-free survival (P = 0.22). Thirty-day mortality and 1-year overall survival were similar across cohorts. Both univariate and multivariate logarithmic regression revealed no difference in likelihood of 30-day mortality between the obese and normal cohort. CONCLUSIONS: There were no measurable differences in complications, reinterventions, or mortality, suggesting that vascular surgeons can perform TEVAR across a spectrum of BMI without compromising outcomes.

Technological Advances to Address the Challenging Abdominal Aortic Aneurysm Neck.

There have been significant technologic advances in endovascular aortic therapies since the introduction of conventional infrarenal endovascular aortic aneurysm repair (EVAR). These advances have sought to address the weaknesses of conventional EVAR- particularly the difficult or "hostile" infrarenal aortic aneurysm neck. We review anatomical features that create a hostile neck and the most recent advancements to overcome these limitations. EndoAnchors replicate open suture fixation to seal endograft to aortic tissue and have been shown to be useful as a prophylactic measure in short, angulated necks as well as therapeutic for type Ia endoleaks. Fenestrated EVAR (FEVAR) devices such as the Z-fen (Cook Medical, Bloomington, IN, USA) raises the seal zone to the suprarenal segment while maintaining renal perfusion. Finally, multibranch aortic grafts such as the Thoracoabdominal Branch Endoprosthesis (Tambe; W. L. Gore & Associates, Flagstaff, AZ, USA) raise the seal zone above the visceral segment and can be used off the shelf with promising results.

Remote training and teleproctoring in gastrointestinal endoscopy for practicing surgeon in rural Uganda.

BACKGROUND: There is a significant, unmet need for endoscopy services in rural Uganda. With limited diagnostic and therapeutic interventions, patients in these communities often present with advanced disease. Practicing surgeons must continually adapt to new techniques to meet the needs of their patient populations. Here, we present a remotely proctored endoscopy training program for a surgeon practicing in an area devoid of endoscopic capabilities. METHODS: This was a retrospective case series conducted between February 2020 and December 2022 at Kyabirwa Surgical Center (KSC). After a 1-week in-person training camp, one surgeon performed endoscopy under guidance of a remote proctor. Patient data and outcomes were collected retrospectively. RESULTS: The previously endoscopic naïve practicing Ugandan surgeon was remotely proctored for 139 endoscopic cases and he subsequently independently performed 167 diagnostic colonoscopies and 425 upper endoscopies. Therapeutic endoscopy was conducted under remote guidance after proficiency in diagnostic endoscopy. A total of 43 therapeutic procedures were performed, including 29 esophageal stent placements, 5 variceal bandings, and 9 foreign body retrievals. All procedures were completed without complication. CONCLUSION: Our center developed a remotely proctored endoscopy program that allowed for training of practicing surgeons in an area lacking endoscopic services. Despite its limitations, remotely proctored endoscopy serves as a unique but highly valuable method of expanding access to endoscopy, particularly in areas that lack adequate training opportunities.

The Venous Thrombectomy Armamentarium: An Expanding World.

Acute deep venous thrombosis (DVT) is a common and important public health problem. It affects more than 350,000 people in the United States annually and has a substantial economic impact. Without adequate treatment, there is significant risk of development of post-thrombotic syndrome (PTS) resulting in patient morbidity, worse quality of life, and costly long-term medical care. Over the past decade, the treatment algorithm for patients with acute DVT has significantly changed. Prior to 2008, the treatment recommendation for patients with acute DVT was limited to anticoagulation and conservative management. In 2008, national clinical practice guidelines were updated to include interventional strategies such as surgical- and catheter-based techniques for the treatment of acute DVT. Early strategies for debulking of extensive acute DVT primarily consisted of open surgical thrombectomy and administration of thrombolytics. In the intervening period, a plethora of advanced endovascular techniques and technologies have been developed which reduced the morbidity of operative intervention and risks of hemorrhage associated with thrombolysis. This review will focus on the novel technologies commercially available for management of acute DVT, denoting unique features inherent to each device. This expanded armamentarium gives vascular surgeons and proceduralists the opportunity to individualize their treatment approach to the specific patient's anatomy, lesion, and history.

Follow-up after acute thrombotic events following COVID-19 infection.

OBJECTIVE: COVID-19 infection results in a hypercoagulable state predisposing patients to thrombotic events. We report the 3- and 6-month follow-up of 27 patients who experienced acute arterial thrombotic events in the setting of COVID-19 infection. METHODS: Data were prospectively collected and maintained for all vascular surgery consultations in the Mount Sinai Health System from patients who presented between March 16 and May 5, 2020. RESULTS: Twenty-seven patients experienced arterial thrombotic events. The average length of stay was 13.3 ± 15.4 days. Fourteen patients were treated with open surgical intervention, six were treated with endovascular intervention, and seven were treated with anticoagulation only. At 3-month follow-up, 11 patients (40.7%) were deceased. Nine patients who expired did so during the initial hospital stay. The 3-month cumulative primary patency rate for all interventions was 72.2%, and the 3-month primary patency rates for open surgical and endovascular interventions were 66.7 and 83.3, respectively. There were 9 (33.3%) readmissions within 3 months. Six-month follow-up was available in 25 (92.6%) patients. At 6-month follow-up, 12 (48.0%) patients were deceased, and the cumulative primary patency rate was 61.9%. The 6-month primary patency rates of open surgical and endovascular interventions were 66.7% and 55.6%, respectively. The limb-salvage rate at both 3 and 6 months was 89.2%. CONCLUSIONS: Patients with COVID-19 infections who experienced thrombotic events saw high complication and mortality rates with relatively low patency rates.

Endovascular techniques in the treatment of extracranial carotid artery aneurysms.

OBJECTIVE: Carotid artery aneurysms and pseudoaneurysms (extracranial carotid artery aneurysm [ECCAs]) are relatively rare. The gold standard treatment has historically been open repair; however, there is increasing evidence of successful treatment of ECCAs with endovascular techniques. Our study examines the evolving experience with endovascular management of ECCAs at a tertiary care center. METHODS: We performed a retrospective analysis of patients with ECCAs who underwent endovascular interventions at a single institution from 2010 to 2020. With increasing experience, the techniques evolved from covered stents to stent-assisted coil embolization and finally to braided stents and overlapping closed cell stents. RESULTS: There were 18 ECCAs in 17 patients treated with endovascular modalities. The average age was 65.9 years. There were 11 males (64.7%). Seven aneurysms (38.9%) were symptomatic: three patients had painless pulsatile masses, three patients had painful pulsatile masses, and one had transient ischemia attacks. Two (11.1%) were treated with covered stents, 2 (11.1%) were treated with stent-assisted embolization, 2 (11.1%) were treated with flow-diverting braided stents, 10 (55.6%) were treated with overlapping bare metal stents, and 2 (11.1%) were treated with embolization or ligation alone. Technical success was achieved in all patients. The mean duration of follow up was 338 days (range, 8-3039 days). No perioperative or postoperative complications were encountered, including no neurologic deficits and no embolic events. All patients were discharged on postoperative day 1 or 2. All 16 stents (100%) retained vessel patency on follow-up imaging and exclusion of ECCAs was confirmed on postprocedure surveillance imaging. CONCLUSIONS: Endovascular modalities for the management of ECCAs have evolved with experience. Our study suggests that endovascular management is technically feasible as well as clinically effective and suggests an algorithm for navigating the various treatment modalities.

Neutrophil-to-Lymphocyte Ratio Associated With Adverse Events After Endovascular Aneurysm Repair (EVAR).

BACKGROUND: The blood neutrophil-to-lymphocyte ratio (NLR) is a surrogate biomarker of systemic inflammation with important prognostic significance in multiple disease processes, including cardiovascular diseases. It is inexpensive, widely available, and may be related to the outcomes of patients after surgery. We aimed to investigate the possible association of NLR with the outcomes of patients following endovascular aneurysm repair (EVAR). METHODS: This single-center, retrospective study of a prospectively maintained database evaluated 777 patients with a diagnosed abdominal aortic aneurysm (AAA) who underwent EVAR and were longitudinally followed between 2001 and 2017. NLR was defined as the ratio of absolute neutrophil count to absolute lymphocyte count. The mortality and reinterventions were used to evaluate outcomes using the appropriate univariate models, and the effect of clinical variables on NLR was further investigated using multivariate modelling. RESULTS: The median NLR for all patients was 3 IQR [2.2 - 4.6]. A cut-off point of 3.6 was uncovered in a training set of 388 patients using the maximally ranked statistic method. Patients with NLR < 3.6 had significantly improved mortality rates (P< 0.0001) in the training set, and results were internally validated in a testing set of 389 patients (P = 0.042). Multivariate analysis revealed that high NLR (HR 1.4 95% CI [1.0 - 2.0]; P< 0.05) remained an independent predictor of mortality in a multivariate analysis controlling for characteristics such as comorbidities, age, and maximal aortic diameter. 5-year mortality and 30-day, 1-year and 5-year reinterventions were all higher in the high NLR group. CONCLUSION: High NLR was significantly associated with higher rates of death at 5 years as well as higher rates of reinterventions at 30 days, 1 year and 5 years. We also suggest that an internally validated cut-off point of NLR >3.6 may be clinically important to help segregate patients into high and low NLR categories. It remains unclear whether NLR is directly linked to adverse events post-EVAR or whether it is a surrogate for an inflammatory state that predisposes patients to higher risk of death or reinterventions.

Decreased Abdominal Aortic Aneurysm Size Following EVAR in Patients With CT Evidence of Subclinical Thoracic Aortic Dissection.

BACKGROUND: Aneurysm sac regression following endovascular repair (EVAR) of an abdominal aortic aneurysm (AAA) is an established indicator of surgical success. However, even with a completely excluded aneurysm, the degree of aortic sac regression may vary. This study evaluates the relationship between aneurysm sac regression after EVAR and the presence of morphological features in the thoracic aorta that can be associated with a subclinical aortic dissection, termed dissection morphology in this study. METHODS: Patients who underwent EVAR to repair an infrarenal aortic aneurysm at Mount Sinai Hospital between 1996 and 2017 with a postoperative CT scan and a 3-year follow-up scan available for analysis were included in the study. Patients with a type I or type III endoleak were not included. The thoracic aorta was evaluated for dissection morphology on CT scan, which included the presence of aortic dissection, penetrating aortic ulcers, and intramural hematomas. AAA sac regression after EVAR was compared between patients with dissection morphology (n = 157) and patients without those characteristics (n = 141). An independent investigator performed the CT analysis and was blinded to the degree of sac regression. RESULTS: Demographics and comorbid clinical conditions were compared between patients with and without dissection morphology. There were no significant differences in age, gender, smoking habits, or cardiovascular conditions. The median AAA diameter after EVAR, over the course of the study, in patients with dissection morphology decreased by 11.30 mm (-17.20, -3.60) compared to a median change of 0.30 mm (-8.60, 8.60) in patients without dissection morphology features (p < 0.001). Patients with dissection morphology also had fewer type II endoleaks in postoperative follow-up scans (22.9% vs. 53.9%, p < 0.001). Additionally, patients with dissection morphology had longer EVAR operative times (192.00 min [167.25, 230.00] vs.174.00 min [150.00, 215.00], p = 0.004). AAA-related mortality after 3 years was not significantly different between the 2 groups (p = 1.0). CONCLUSIONS: The presence of imaging features consistent with dissection morphology in the thoracic aorta correlated with greater AAA sac regression and fewer type II endoleaks after EVAR. Assessing these imaging features in patients undergoing EVAR may be useful in understanding aneurysm behavior in terms of aneurysm growth, risk of rupture, and outcomes following endovascular surgery. Identifying differential rates of aneurysm sac regression may have implications regarding the role of subclinical dissections in the etiology of AAA development.

Defining Types and Determining Risk Factors for Vascular Surgery Readmissions.

BACKGROUND: Vascular surgery patients typically have numerous comorbidities, which puts them at higher risk for postoperative readmissions. This study aims to investigate the risk factors for and appropriately categorize the various types of vascular surgery readmissions. METHODS: Nine hundred seventy-two patients were retrospectively reviewed. Readmissions were classified into 3 separate groups: readmissions that occurred between 0 and 30 days (30-day readmissions), 31-90 days (3-month readmissions), and 91-365 days (1-year readmissions). Each readmission was then assigned to 1 of the 4 categories based on whether they were related to the index procedure and whether they were planned. Univariate tests were performed for demographic variables based on their type of readmission, and logistic regressions were then performed to identify predictors of each unplanned, related readmissions. RESULTS: The overall 30-day readmission rate was 21.9% (n = 213). The unplanned, related readmission cohort (n = 83) had the highest readmission rate of 8.5%. The related, planned readmission rate was 5.9% (n = 58), while the unrelated, unplanned readmission rate was 5.6% (n = 55). In contrast, the overall 1-year readmission rate was 40.0% (n = 389), with the largest category being unplanned, unrelated readmissions at 19.7% (n = 191). The unplanned, related readmission rate was 8.7% (n = 85), whereas the planned, related readmission rate was 5.7% (n = 55). Compared with other types of readmissions, unplanned, related readmissions tended to affect patients who were younger, had poor glycemic control, and had higher body mass indexes (BMIs). Multivariate predictors of unplanned, related readmissions were poor glycemic control at 3 months (odds ratio [OR]: 2.16, P = 0.03), and BMI at 30 days (OR: 1.06, P = 0.04) and 1 year (OR: 1.05, P = 0.04). CONCLUSIONS: Readmissions have varying risk factors depending on their category; targeting glycemic control and obesity may reduce unplanned, related readmissions.

Femoral Access for Iliac Branched Endoprosthesis Deployment in Patients with a Prior Bifurcated Aortic Stent Graft.

This series describes an innovative technique to deploy iliac branched endoprostheses (IBEs) in patients with preexisting endovascular aneurysm repair (EVAR). It demonstrates an alternative approach that may be preferred when brachial access is anatomically challenging or when access site complications are of concern. We detail a technique that uses transfemoral access to bring IBE device components up and over an infrarenal endograft bifurcation and into proper position. This series suggests that endovascular specialists should consider the advantages and disadvantages of a transfemoral approach when selecting the best method of repairing a patient's iliac artery aneurysm after prior EVAR.

The Transradial Approach for Lower Extremity Vascular Intervention.

Simultaneous technological advancements in both imaging as well as devices have resulted in an expansion of endovascular options for vascular access. In particular, radial access has traditionally been more favored for coronary interventions; its use in the aortoiliac and lower extremity vasculature has been constrained by the length of devices and the size of sheaths required. However, with increasing catheter shaft lengths, in addition to new thin-walled sheaths allowing for downsizing, the ability to perform transradial interventions on infrainguinal and infrageniculate vessels has been more readily facilitated. In this review, we analyze the potential for transradial therapies in the treatment of peripheral arterial disease (PAD).

Vascular surgeon-hospitalist comanagement improves in-hospital mortality at the expense of increased in-hospital cost.

OBJECTIVE: We have shown that vascular surgeon- hospitalist co management resulted in improved in-hospital mortality rates. We now aim to assess the impact of the hospitalist co management service (HCS) on healthcare cost. METHODS: A total of 1558 patients were divided into three cohorts and compared: 516 in 2012, 525 in 2013, and 517 in 2014. The HCS began in January 2013. Data were standardized for six vascular surgeons that were present 2012-2014. New attendings were excluded. Ten hospitalists participated. Case mix index (CMI), contribution margin, total hospital charges (THCs), length of stay (LOS), actual direct costs (ADCs), and actual variable indirect costs (AVICs) were compared. Analysis of variance with post-hoc tests, t-tests, and linear regressions were performed. RESULTS: THC rose by a mean difference of $14,578.31 between 2012 and 2014 (P < .001) with a significant difference found between all groups during the study period (P = .0004). ADC increased more than AVIC; however, both significantly increased over time (P = .0002 and P = .014, respectively). A mean $3326.63 increase in ADC was observed from 2012 to 2014 (P < .0001). AVIC only increased by an average $392.86 during the study period (P = .01). This increased cost was observed in the context of a higher CMI and longer LOS. CMI increased from 2.25 in 2012 to 2.53 in 2014 (P = .006). LOS increased by a mean 1.02 days between 2012 and 2014 (P = .016), and significantly during the study period overall (P = .018). After adjusting for CMI, LOS increases by only 0.61 days between 2012 and 2014 (P = .07). In a final regression model, THC is independently predicted by comanagement, CMI, and LOS. After adjusting for CMI and LOS, the increase in THC because of comanagement (2012 vs 2014) accounts for only $4073.08 of the total increase (P < .001). During this time, 30-day readmission rates decreased by ∼7% (P = .005), while related 30-day readmission rates decreased by ∼2% (P = .32). Physician contribution margin remained unchanged over the 3-year period (P = .76). The most prevalent diagnosis-related group was consistent across all years. Variation in the principal diagnosis code was observed with the prevalence of circulatory disorders because of type II diabetes replacing atherosclerosis with gangrene as the most prevalent diagnosis in 2013 and 2014 compared with 2012. CONCLUSIONS: In-hospital cost is significantly higher since the start of the HCS. This surge may relate to increased CMI, LOS, and improved coding. This increase in cost may be justified as we have observed sustained reduction in in-hospital mortality and slightly improved readmission rates.

An anatomic risk model to screen post endovascular aneurysm repair patients for aneurysm sac enlargement.

BACKGROUND: Follow-up computed tomography angiography (CTA) scans add considerable postimplantation costs to endovascular aneurysm repairs (EVARs) of abdominal aortic aneurysms (AAAs). By building a risk model, we hope to identify patients at low risk for aneurysm sac enlargement to minimize unnecessary CTAs. METHODS: 895 consecutive patients who underwent EVAR for AAA were reviewed, of which 556 met inclusion criteria. A Probit model was created for aneurysm sac enlargement, with preoperative aneurysm morphology, patient demographics, and operative details as variables. RESULTS: Our final model included 287 patients and had a sensitivity of 100%, a specificity of 68.9%, and an accuracy of 70.4%. Ninety-nine (35%) of patients were assigned to the high-risk group, whereas 188 (65%) of patients were assigned to the low-risk group. Notably, regarding anatomic variables, our model reported that age, pulmonary comorbidities, aortic neck diameter, iliac artery length, and aneurysms were independent predictors of post-EVAR sac enlargement. With the exception of age, all statistically significant variables were qualitatively supported by prior literature. With regards to secondary outcomes, the high-risk group had significantly higher proportions of AAA-related deaths (5.1% versus 1.1%, P = 0.037) and Type 1 endoleaks (9.1% versus 3.2%, P = 0.033). CONCLUSIONS: Our model is a decent predictor of patients at low risk for post AAA EVAR aneurysm sac enlargement and associated complications. With additional validation and refinement, it could be applied to practices to cut down on the overall need for postimplantation CTA.

The Protective Effects of Diabetes Mellitus on Post-EVAR AAA Growth and Reinterventions.

BACKGROUND: This study aims to investigate the effect of diabetes on post-endovascular aneurysm repairs (EVARs) of abdominal aortic aneurysms (AAAs). METHODS: A total of 1,479 consecutive patients who underwent AAA EVAR were reviewed. The cohorts were divided based on their diabetes status and compared. Preoperative demographic and comorbidity data were analyzed using the t-test and chi-squared test, whereas post-EVAR outcomes were analyzed using Probit multivariate model, followed by Kaplan-Meier survival curve and Cox regression. RESULTS: Of our 1,479 patients, 993 met inclusion criteria. One hundred eighty-three were diabetics (18.4%) compared with 810 nondiabetics (81.6%). Coronary artery disease (CAD; diabetics: 70.49%, nondiabetics: 60.76%, P = 0.014) and hypertension (HTN; diabetics: 90.16%, nondiabetics: 79.46%, P = 0.0008) were the only comorbidities analyzed, including follow-up length, which had any significant differences between the diabetic and nondiabetic groups. Probit multivariate analysis using a combined cohort follow-up mean of 51 months showed a significant decrease in aneurysm sac enlargement in diabetic patients (diabetics: 13.11%, nondiabetics: 19.43%, model estimate: 0.3058; 95% confidence interval [CI]: 0.0486-0.5629, Pr > ChiSq = 0.0198) and trended toward significantly fewer reinterventions (diabetics: 23.50%, nondiabetics: 28.41%, model estimate: 0.1990; 95% CI: -0.0262 to 0.4243, Pr > ChiSq = 0.0833). In the Cox regressions, diabetes had a significant protective factor on reinterventions (hazard ratio [HR]: 0.697, Pr > ChiSq = 0.0151), and was trending toward significance for aneurysm sac enlargement (HR: 0.750, Pr > ChiSq = 0.1961). There was no significant difference across diabetic status in any other outcomes, including mortality and endoleak occurrence. CONCLUSIONS: Although a higher proportion of diabetic patients present with HTN and CAD, they have decreased long-term rates of aneurysm sac enlargement after EVAR. As a result, this cohort trends toward a lower need for reintervention after EVAR.

Hemodialysis Vascular Access: Rising Costs as a Surrogate Marker for Patency and Function of Arteriovenous Fistulas.

BACKGROUND: Establishment and maintenance of vascular access for hemodialysis is life-sustaining for patients needing renal-replacement therapy. Arteriovenous fistulas (AVFs) are the preferred type of access, but the costs associated with creation and maintenance are poorly characterized, especially with respect to patient characteristics. METHODS: A prospectively maintained registry has been established at The Mount Sinai Hospital for patients undergoing access procedures since 2007. We studied 163 patients undergoing successfully placed and cannulated AVFs as their first permanent ipsilateral access and for whom 3-year follow-up was available, including 18 patients with failed contralateral AVFs. Records were analyzed for institutional inpatient and outpatient procedures related to access maturation, imaging, catheter-related procedures, and revisions. We determined hospital costs for 3 AVF locations, assessing the contribution of various factors to variation in costs and patency. RESULTS: The median first-year cost of patent AVFs was $8,662, with $4,754 attributable to initial creation. For fistulas remaining patent for at least 3 years, median cumulative 36-month costs were $11,639, with $1,343 attributable to imaging and $10,478 to creation and interventions. Fistulas with patent lifetimes of 19-30 months (3.7%) had median cumulative costs of $26,035. Those with patent lifetimes of 6 months or shorter (6.7%) had median cumulative costs of $17,526. Right-sided fistulas were associated with 41% higher 1-year costs and 38% higher 3-year costs when compared with left-sided fistulas. Human Immunodeficiency Virus (HIV) status and prior history of complex contralateral access were also associated with higher 1-year and 3-year costs. CONCLUSIONS: Hemodialysis access maintenance contributes significantly to the healthcare burden of renal disease. Our data suggest that particular patient characteristics factor into patency and costs. Short-term mounting costs associated with AVF maintenance may portend poor long-term patency. Rising healthcare costs cannot be easily controlled without understanding the clinical factors driving them.

The Use of Branched Endografts for the Aortic Arch in the Endovascular Era.

The endovascular realm has steadily increased its footing in the treatment of the aorta and all of its territories since the foundational case in 1990 by Parodi. The aortic arch, however, continues to be one of the last bastions for treatment via open surgery, which remains the gold standard. Significant comorbidity and prior cardiac surgery prevent open surgery from being the only preferred option, allowing novel endovascular procedures to be considered. Since 1999, more advanced endovascular systems have been created by companies such as Cook Medical, Bolton Medical, Medtronic, Endospan, Gore Medical, and, recently, Kawasumi. The unique shape and angulation of the aortic arch often require the use of custom-made grafts, though arch reconstruction may also include in situ or back-table physician alterations to off-the-shelf devices. The goal of branched endografts is to exclude the aneurysm, while maintaining flow to supra-aortic trunk vessels. Technical success and device durability are limited by the physical constraints of the aortic arch, though greater experience may yield better patient outcomes. Typically, the initial stent-graft (SG) is introduced and deployed into the arch first. Bridging SG are then inserted via axillary or carotid access. Most often, the bridging SG extends from the innominate branch to the distal innominate, and from the left carotid branch to the left common carotid. The major concern is that manipulation of catheters and wires, both within the carotid arteries and aortic arch, create the potential for emboli leading to stroke and paraplegia. The development of endovascular-only techniques for aortic arch pathology will only increase with the aging population of the United States and associated accumulation of comorbidities, making open surgery too grave of a risk.

Hybrid Repair Techniques for Complex Aneurysms and Dissections Involving the Aortic Arch and Thoracic Aorta.

Aortic aneurysms involving the ascending aorta, aortic arch, and descending thoracic aorta have been a challenging entity to surgically treat for over 60 years. Despite the mortality of the disease, early open surgical procedures also had significant morbidity and mortality. The inherent risk in treating multiple anatomic segments simultaneously led to the innovation of the staged elephant trunk (ET) approach by Borst in 1983. To avoid the thoracotomy and associated complications related to the second stage of the procedure, an endovascular completion paradigm was begun by Volodos in 1991. This theoretical hybrid technique combinined shorter and less elaborate open supra-aortic trunk debranching with less invasive endovascular exclusion and has grown since then in terms of different approaches and case volume. The rise of thoracic endovascular aortic repair (TEVAR) combined with debranching bypass has allowed certain lesions to be treated without a large scale intrathoracic open surgical procedure. The complexity and extensiveness of certain lesions, however, has necessitated a hybrid approach such as the frozen elephant trunk (FET) and the standard ET with second stage TEVAR. The former has been used to treat multifocal degenerative aneurysms, chronic dissections with aneurysm, and acute extensive dissections. After conventional proximal aortic replacement, a stent-graft (SG) is delivered antegrade through the transected arch where it is sutured proximally and then "frozen" distally via endovascular means. The FET has the advantage of avoiding a second stage, but potentially introduces a greater rate of spinal cord ischemia compared to the standard elephant trunk. Improvements on the FET procedure have included the development of more advanced hybrid SG such as the Vascutek® Thoraflex™ Hybrid graft (Vascutek Ltd, Scotland, UK), which consists of a distal en,dograft sealed to a proximal four-branched Vascutek Gelweave™ Vascutek Ltd, Scotland, UK) and incorporated sewing collar. While open surgery continues to be a component of complex aortic arch aneurysms, the development of hybrid devices that can bridge the gap between open and endovascular surgery will continue to flourish.