Comparative study of left vertebral artery revascularization in patients with and without aberrant left vertebral anatomy.

OBJECTIVE: Left vertebral artery revascularization is indicated in surgery involving zone 2 of the aortic arch and is typically accomplished indirectly via subclavian artery revascularization. For aberrant left vertebral anatomy, direct revascularization is indicated. Our objective was to compare the outcomes of direct vertebral artery revascularization with indirect subclavian artery revascularization for treating aortic arch pathology and to identify predictors of mortality. METHODS: A retrospective cohort study was conducted at a single tertiary hospital, including patients who underwent open or endovascular vertebral artery revascularization from 2005 to 2022. Those who underwent direct vertebral revascularization were compared with those who were indirectly revascularized via subclavian artery revascularization. The outcomes of interest were a composite outcome (any of death, stroke, nerve injury, and thrombosis) and mortality. Univariate logistic regression models were fitted to quantify the strength of differences between the direct and indirect revascularization cohorts. Cox regression was used to identify mortality predictors. RESULTS: Of 143 patients who underwent vertebral artery revascularization, 21 (14.7%) had a vertebral artery originating from the aortic arch. The median length of stay was 10 days (interquartile range, 6-20 days), and demographics were similar between cohorts. The incidence of composite outcome, bypass thrombosis, and hoarseness was significantly higher in the direct group (42.9% vs 18.0%, P = .019; 33.3% vs 0.8%, P < .0001; 57.1% vs 18.0%, P < .001, respectively). The direct group was approximately three times more likely to experience the composite outcome (odds ratio, 3.41; 95% confidence interval, 1.28, 9.08); similarly, this group was approximately six times more likely to have hoarseness (odds ratio, 5.88; 95% confidence interval, 2.21, 15.62). There was no significant difference in mortality rates at 30 days, 1, 3, 5, and 10 years of follow-up. Age, length of hospital stay, and congestive heart failure were identified as predictors of higher mortality. After adjusting for these covariates, the group itself was not an independent predictor of mortality. CONCLUSIONS: Direct vertebral revascularization was associated with higher rates of composite outcome (death, stroke, nerve injury, and thrombosis), bypass thrombosis and hoarseness. Patients with aberrant vertebral anatomy are at higher risks of these complications compared with patients with standard arch anatomy. However, after adjusting for other factors, mortality rates were not significantly different between the groups.

Outcomes of abdominal aortic aneurysm repair among patients with rheumatoid arthritis.

OBJECTIVE: In the present study, we compared the outcomes of elective abdominal aortic aneurysm (AAA) repair in patients with and without rheumatoid arthritis (RA) stratified by the type of surgery. METHODS: A retrospective population-based cohort study was conducted from 2003 to 2016. Linked administrative health data from Ontario, Canada were used to identify all patients aged ≥65 years who had undergone elective open or endovascular AAA repair during the study period. Patients were identified using validated procedure and billing codes and matching using propensity scores. The primary outcome was survival. The secondary outcomes were major adverse cardiovascular events (MACE)-free survival (defined as freedom from death, myocardial infarction, and stroke), reintervention, and secondary rupture. RESULTS: Of 14,816 patients undergoing elective AAA repair, a diagnosis of RA was present for 309 (2.0%). The propensity-matched cohort included 234 pairs of RA and control patients. The matched cohort was followed up for a mean ± standard deviation of 4.93 ± 3.35 years, and the median survival was 6.76 and 7.31 years for the RA and control groups, respectively. Cox regression analysis demonstrated no statistically significant differences in the hazards for death, MACE, reintervention, or secondary rupture. Analysis of the differences in outcomes stratified by repair approach also showed no statistically significant differences in the hazards for death, MACE, reintervention, or secondary rupture. CONCLUSIONS: We found no statistically significant differences in survival, MACE, reintervention, or secondary rupture among patients with RA undergoing elective AAA repair compared with controls. Further studies are required to evaluate the impact of comorbidities and antirheumatic medications on the outcomes of elective AAA repair.

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.

A systematic review and meta-analysis of plain versus drug-eluting balloon angioplasty in the treatment of juxta-anastomotic hemodialysis arteriovenous fistula stenosis.

OBJECTIVE: Owing to the lack of comparative evidence between the endovascular technologies for arteriovenous fistula (AVF) stenosis treatments, we sought to summarize the reported data comparing the effectiveness of different endovascular approaches for the treatment of AVF stenoses at the juxta-anastomotic site. METHODS: We performed a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched from inception to June 12, 2018 for observational and randomized studies that had examined the effectiveness of AVF stenosis treatment using plain percutaneous balloon angioplasty (PTA), cutting balloon angioplasty, drug-eluting balloon (DEB) angioplasty, high-pressure balloon angioplasty, and stenting. Bias was assessed using the Newcastle-Ottawa scale for observational studies and the Cochrane Collaboration tool for randomized studies. Article screening, full-text review, assessment of bias, and data collection were conducted in duplicate, with a third reviewer to reconcile any discrepancies. We conducted a qualitative synthesis of the available evidence and a quantitative meta-analysis for the primary assisted patency outcome. The meta-analysis was conducted using Review Manager, version 5.3, using random effects models, with the I2 statistic used to assess heterogeneity. Statistical significance was set at P < .05. RESULTS: Our search yielded 3683 reports. Of these, three randomized trials and three observational studies were included. Three studies with 342 patients had described the effectiveness of high-pressure balloon angioplasty, conventional PTA, and stenting and had analyzed the data qualitatively. Three studies with 141 patients had investigated native AVF patency after DEB angioplasty and conventional PTA and were included in the meta-analysis. DEB angioplasty showed significantly greater primary assisted patency rates at 12 months after treatment compared with PTA (odds ratio, 3.66; 95% confidence interval, 1.32-10.14; I2 = 49%). No statistically significant differences were found in 6-month primary assisted patency among the treatment groups (odds ratio, 2.03; 95% confidence interval, 0.64-6.45; I2 = 50%). A total of 58 of 72 AVFs remained patent 6 months after DEB angioplasty compared with 45 of 69 at 6 months after PTA. At 12 months after treatment, 48 of 72 AVFs remained patent after DEB angioplasty compared with 23 of 69 AVFs after PTA. CONCLUSIONS: Our findings suggest DEB angioplasty is a more effective treatment option for AVF stenosis at the juxta-anastomotic site compared with PTA. Although DEB angioplasty might provide longer term patency than other endovascular treatments, further high-quality data are needed to confirm this finding.

Population-based long-term outcomes of open versus endovascular aortic repair of ruptured abdominal aortic aneurysms.

OBJECTIVE: Existing data regarding endovascular aortic repair (EVAR) of ruptured abdominal aortic aneurysm (rAAA) are conflicting in their findings. The purpose of this paper was to determine the long-term outcomes of EVAR vs open surgical repair (OSR) for treatment of rAAA. METHODS: A population-based retrospective cohort study of all patients 40 years or more that underwent OSR or EVAR of rAAA in Ontario, Canada, from 2003 to 2016 was conducted. Administrative data from the province of Ontario was used as the data source. The propensity for repair approach was calculated using a logistic regression model including all covariates and used for inverse probability of treatment weighting. Cox proportional hazards regression was conducted using the weighted cohort to determine the survival and major adverse cardiovascular event (MACE)-free survival of EVAR relative to OSR for rAAA up to 10 years after repair. RESULTS: A total of 2692 rAAA (261 EVAR [10%] and 2431 OSR [90%]) repairs were recorded from April 1, 2003, to March 31, 2016. Mean follow-up for the entire cohort was 3.4 years (standard deviation [SD], 3.9 years), with a maximum follow-up of 14.0 years. OSR patients were followed for a mean of 3.5 years (SD, 4.0 years) and maximum of 14.0 years, and EVAR patients were followed for a mean of 2.7 years (SD, 2.7 years) and a maximum of 11.4 years. Median survival was 2.7 years overall, and 2.5 and 3.7 years for OSR and EVAR patients, respectively. There were no significant baseline differences between EVAR and OSR patients after inverse probability of treatment weighting. EVAR patients were at lower hazard for all-cause mortality (hazard ratio, 0.49; 95% confidence interval, 0.37-0.65; P < .01), and MACE (hazard ratio, 0.51, 95% confidence interval, 0.40-0.66; P < .01) within 30 days of repair. There were no statistically significant differences between EVAR and OSR in the hazard for all-cause mortality or MACE from 30 days to 5 years, and 5 to 10 years. Despite this, the upfront mortality and MACE benefits of EVAR persisted for more than 4.5 years after repair. CONCLUSIONS: This population-based cohort study using administrative data from Ontario, Canada, demonstrated lower hazards for all-cause mortality and MACE within 30 days of operation in favor of EVAR, but no differences in the mid- or longer-term results. More work is needed to understand and improve the long-term outcomes of ruptured endovascular aortic aneurysm repair and ruptured open surgical repair.

Short-term outcomes of combined neuraxial and general anaesthesia versus general anaesthesia alone for elective open abdominal aortic aneurysm repair: retrospective population-based cohort study†.

BACKGROUND: Use of neuraxial anaesthesia for open abdominal aortic aneurysm repair is postulated to reduce mortality and morbidity. This study aimed to determine the 90-day outcomes after elective open abdominal aortic aneurysm repair in patients receiving combined general and neuraxial anaesthesia vs general anaesthesia alone. METHODS: A retrospective population-based cohort study was conducted from 2003 to 2016. All patients ≥40 yr old undergoing open abdominal aortic aneurysm repair were included. The propensity score was used to construct inverse probability of treatment weighted regression models to assess differences in 90-day outcomes. RESULTS: A total of 10 447 elective open abdominal aortic aneurysm repairs were identified; 9003 (86%) patients received combined general and neuraxial anaesthesia and 1444 (14%) received general anaesthesia alone. Combined anaesthesia was associated with significantly lower hazards for all-cause mortality (hazard ratio [HR]=0.47; 95% confidence interval [CI], 0.37-0.61) and major adverse cardiovascular events (HR=0.72; 95% CI, 0.60-0.86). Combined patients were at lower odds for acute kidney injury (odds ratio [OR]=0.66; 95% CI, 0.49-0.89), respiratory failure (OR=0.41; 95% CI, 0.36-0.47), and limb complications (OR=0.30; 95% CI, 0.25-0.37), with higher odds of being discharged home (OR=1.32; 95% CI, 1.15-1.51). Combined anaesthesia was also associated with significant mechanical ventilation and ICU and hospital length of stay benefits. CONCLUSIONS: Combined general and neuraxial anaesthesia in elective open abdominal aortic aneurysm repair is associated with reduced 90-day mortality and morbidity. Neuraxial anaesthesia should be considered as a routine adjunct to general anaesthesia for elective open abdominal aortic aneurysm repair.

The economic burden of inpatient diabetic foot ulcers in Toronto, Canada.

OBJECTIVE: Diabetic foot ulcer, which often leads to lower limb amputation, is a devastating complication of diabetes that is a major burden on patients and the healthcare system. The main objective of this study is to determine the economic burden of diabetic foot ulcer-related care. METHODS: We conducted a multicenter study of all diabetic foot ulcer patients admitted to general internal medicine wards at seven hospitals in the Greater Toronto Area, Canada from 2010 to 2015, using the GEMINI database. We compared the mean costs of care per patient for diabetic foot ulcer-related admissions, admissions for other diabetes-related complications, and admissions for the top five most costly general internal medicine conditions, using the Ontario Case Costing Initiative. Regression models were used to determine adjusted estimates of cost per patient. Propensity-score matched analyses were performed as sensitivity analyses. RESULTS: Our study cohort comprised of 557 diabetic foot ulcer patients; 2939 non-diabetic foot ulcer diabetes patients; and 23,656 patients with the top 5 most costly general internal medicine conditions. Diabetic foot ulcer admissions incurred the highest mean cost per patient ($22,754) when compared to admissions with non-diabetic foot ulcer diabetes ($8,350) and the top five most costly conditions ($10,169). Using adjusted linear regression, diabetic foot ulcer admissions demonstrated a 49.6% greater mean cost of care than non-diabetic foot ulcer-related diabetes admissions (95% CI 1.14-1.58), and a 25.6% greater mean cost than the top five most costly conditions (95% CI 1.17-1.34). Propensity-scored matched analyses confirmed these results. CONCLUSION: Diabetic foot ulcer patients incur significantly higher costs of care when compared to admissions with non-diabetic foot ulcer-related diabetes patients, and the top five most costly general internal medicine conditions.

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.

Knowledge gap of peripheral artery disease starts in medical school.

OBJECTIVE: Previous data suggest that physicians have suboptimal knowledge about peripheral artery disease (PAD). Our aim was to evaluate Canadian medical students' knowledge of PAD to determine if this knowledge gap exists early in medical training. METHODS: We conducted a descriptive, cross-sectional, interview-based study of graduating medical students at the University of Toronto. We used a standardized questionnaire to evaluate students' knowledge of PAD and coronary artery disease (CAD) in the following domains: clinical presentation, risk factors, preventative measures, treatment, and complications. We calculated mean (standard deviation [SD]) scores for each CAD and PAD knowledge domain and examined for differences in PAD vs CAD scores. RESULTS: Seventy-two graduating medical students participated in this study, of which females accounted for 58%. Nearly all participants reported being exposed to PAD (89%) and CAD (92%) through their medical school curriculum. Overall, medical students scored better in identifying CAD characteristics (mean [SD] score, 16.4 [2.7]) compared with PAD (mean [SD] score, 14.6 [3.2]) (P < .0001). This difference was driven by the inferior performance of students in identifying risk factors (P < .0001), preventative measures (P = .049), and complications (P < .0001) of PAD compared with CAD. Out-of-class exposure (eg, clinical rotation, research experience) had a positive impact on students knowledge of both PAD and CAD. CONCLUSIONS: Our results demonstrate suboptimal knowledge of medical graduates of both CAD and PAD. Although they share common atherosclerotic risk factors and cardiovascular complications, medical students were less likely to associate these with PAD than CAD. We recommend a comprehensive module that incorporates all presentations of atherosclerotic disorders to enhance students' understanding of these pathologies in medical schools.

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.

A systematic review and meta-analysis of the long-term outcomes of endovascular versus open repair of abdominal aortic aneurysm.

OBJECTIVE: This study synthesized the literature comparing the long-term (5-9 years) and very long-term (≥10 years) all-cause mortality, reintervention, and secondary rupture rates between endovascular aneurysm repair (EVAR) and open surgical repair (OSR) of abdominal aortic aneurysm (AAA). METHODS: MEDLINE, Embase, and CENTRAL databases were searched from inception to May 2018 for studies comparing EVAR to OSR with a minimum follow-up period of 5 years. Study selection, data abstraction, and quality assessment were conducted by two independent reviewers, with a third author resolving discrepancies. Study quality was assessed using the Cochrane and Newcastle-Ottawa scales. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects models. Heterogeneity was quantified using the I2 statistic, and publication bias was assessed using funnel plots. RESULTS: Our search yielded 3431 unique articles. Three randomized controlled trials and 68 observational studies comparing 151,092 EVAR to 148,692 OSR patients were included. Inter-rater agreement was excellent at the screening (κ = 0.78) and full-text review (κ = 0.89) stages. Overall, the risk of bias was low to moderate. For long-term outcomes, 54 studies reported all-cause mortality (n = 203,246), 23 reported reintervention (n = 157,151), and 4 reported secondary rupture (n = 150,135). EVAR was associated with higher long-term all-cause mortality (OR, 1.19; 95% CI, 1.06-1.33; P = .003, I2 = 91%), reintervention (OR, 2.12; 95% CI, 1.67-2.69; P < .00001, I2 = 96%), and secondary rupture rates (OR, 4.84; 95% CI, 2.63-8.89; P < .00001, I2 = 92%). For very long-term outcomes, 15 studies reported all-cause mortality (n = 48,721), 9 reported reintervention (n = 7511), and 1 reported secondary rupture (n = 1116). There was no mortality difference between groups, but EVAR was associated with higher reintervention (OR, 2.47; 95% CI, 1.71-3.57; P < .00001, I2 = 84%) and secondary rupture rates (OR, 8.10; 95% CI, 1.01-64.99; P = .05). Subanalysis of more recent studies, with last year of patient recruitment 2010 or after, demonstrated no long-term mortality differences between EVAR and OSR. CONCLUSIONS: EVAR is associated with higher long-term all-cause mortality, reintervention, and secondary rupture rates compared with OSR. In the very long-term, EVAR is also associated with higher reintervention and secondary rupture rates. Notably, EVAR mortality has improved over time. Vigilant long-term surveillance of EVAR patients is recommended.

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.

Perceptions of Canadian Vascular Surgeons Toward Pharmacologic Risk Reduction in Patients with Peripheral Artery Disease: 2018 Update.

BACKGROUND: Vascular surgeons have a central role in managing peripheral artery disease (PAD). This study assessed their knowledge, attitudes, and behaviors regarding pharmacologic risk reduction in PAD and results were compared to a similar 2004 survey conducted by our group. METHODS: An online questionnaire was administered to 161 active members of the Canadian Society for Vascular Surgery. RESULTS: Forty-eight participants (30%) completed the survey. Recommended targets for low-density lipoprotein cholesterol, blood pressure, and glucose were known by 52%, 38%, and 50% of vascular surgeons, respectively. Almost all participants recognized antiplatelet dosages and statin indications, but less than half could identify indications (29%) and precautions (44%) for angiotensin converting enzyme (ACE) inhibitor therapy. A majority (58%) routinely evaluate risk factors in <50% of their patients. Most vascular surgeons regularly provide risk reduction counseling, but less than 10% initiate or modify antihypertensive or ACE inhibitor therapy. Compared to 2004, knowledge of targets and indications/precautions for common cardiovascular medications and frequency of risk factor assessment have not changed. Rates of counseling for diabetes control and statin prescription have improved, but remain suboptimal. Regarding newer medications with cardiovascular benefit, less than 10% would prescribe proprotein convertase subtilisin/kexin type 9 and sodium-glucose cotransporter 2 inhibitors if they were available. The majority of vascular surgeons rate their PAD risk reduction knowledge as average and support an up-to-date Canadian PAD guideline. Most participants believe that risk reduction therapy is best provided by family physicians and internists, but also acknowledge that vascular surgeons should be well-versed in assessing and managing risk factors in PAD. CONCLUSIONS: Significant knowledge and action gaps exist among Canadian vascular surgeons with regards to pharmacologic cardiovascular risk reduction in PAD. Although there is recognition that vascular surgeons are central to the medical management of patients with PAD, few routinely evaluate risk factors and prescribe medications. There is little evidence of sufficient improvement since 2004. New educational and clinical strategies are needed to improve PAD risk reduction pharmacotherapy among Canadian vascular surgeons.

The Current Status of Lithoplasty in Vascular Calcifications: A Systematic Review.

Background. Lithoplasty is a method of alleviating vessel stenosis by using localized high-speed pressure waves to disrupt calcium deposits. A systematic review of the literature was performed to summarize the early outcomes of lithoplasty in peripheral and coronary artery disease. Methods. We searched EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials from database inception to July 2018 for original studies describing the use of lithoplasty. Study selection and data extraction were performed in duplicate, with a third author resolving discrepancies. Results. A total of 9 records were included from the 201 studies eligible for screening. In total, 211 patients with vascular calcification lesions underwent lithoplasty. The patients on average had an age of 73.2 years and had a maximum follow-up period of 5.5 months. Most lesions (72%, 152/212) were in peripheral artery beds, with the remainder occurring in coronary vessels. Lesioned vessels typically had severe calcium burden 62.6% (131/210), with an average initial stenosis of 76.6% (range, 68.1%-77.8%). After treatment, the average residual stenosis was 21.0% (range, 13.3%-26.2%), with a mean acute gain of vessel diameter of 2.5 mm. A limited number of type D dissections occurred, with a total of 2.4% (5/211) of patients requiring stent implantation. Conclusions. Recent studies suggest that lithoplasty is a promising intervention to decrease vessel stenosis in both peripheral artery disease and coronary artery disease, with minimal occurrence of major adverse events. Further research studies, with more rigorous study designs, are needed to determine the effectiveness of lithoplasty in vascular calcifications.

Association between operator specialty and outcomes after carotid artery revascularization.

OBJECTIVE: To examine the association between operator specialty and 30-day outcomes among patients undergoing carotid endarterectomy and carotid artery stenting. METHODS: We conducted a population-based, observational cohort study of all individuals who underwent carotid endarterectomy or stenting in Ontario, Canada (population, 13.6 million) between April 1, 2002, and March 1, 2015, using administrative claims databases. We stratified endarterectomy and stenting patients according to operator specialty, and followed them for 30 days after the procedure. For carotid endarterectomy, we compared outcomes between vascular surgeons and nonvascular surgeons. For carotid artery stenting, we compared outcomes between radiologists and neurosurgeons. We built multilevel multivariable logistic regression models adjusted for patient demographics, comorbidities, carotid artery symptom status, and annual institutional and operator volume to examine rates of 30-day stroke or death. RESULTS: A total of 16,544 patients were studied (n = 14,301 endarterectomy and n = 2243 stenting). Vascular surgeons performed the majority (55.7%) of carotid endarterectomy procedures, followed by neurosurgeons (21.0%), general surgeons (15.3%), and cardiac surgeons (7.9%). Radiologists (82.5%) and neurosurgeons (17.5%) performed carotid artery stenting. In the endarterectomy group, the risk of stroke or death was higher among patients treated by nonvascular surgeons (4.0%) compared with vascular surgeons (2.9%; adjusted odds ratio [OR], 1.32; 95% confidence interval [CI], 1.08-1.62; P = .008). This difference was driven by a higher rate of stroke among nonvascular surgery-treated patients (3.6%) compared with vascular surgery-treated patients (2.5%; adjusted OR, 1.38; 95% CI, 1.11-1.71). The risk of death was similar between the two groups. With respect to specific nonvascular surgery specialties, the rate of 30-day stroke or death was higher in endarterectomy patients treated by neurosurgeons (4.1%; adjusted OR, 1.27; 95% CI, 1.00-1.61) and cardiac surgeons (4.4%; adjusted OR, 1.54; 95% CI, 1.04-2.30) compared with vascular surgeons (2.9%). Patients who underwent carotid artery stenting by radiologists vs neurosurgeons experienced 30-day stroke or death at similar rates (8.0% vs 7.9%, respectively; adjusted OR, 1.07; 95% CI, 0.66-1.74; P = .79). CONCLUSIONS: The risk for periprocedural stroke or death was significantly higher among carotid endarterectomy patients treated by nonvascular surgeons (neurosurgeons and cardiac surgeons) compared with vascular surgeons. Operator specialty did not seem to have a significant effect on periprocedural outcomes among patients who underwent carotid artery stenting. These results can have implications for physician referral practices and local policies.

Renin-angiotensin system blockade does not attenuate abdominal aortic aneurysm growth, rupture rate, or perioperative mortality after elective repair.

OBJECTIVE: The objective of this study was to summarize the literature regarding the effects of renin-angiotensin system blockade (RASB) using angiotensin-converting enzyme inhibitors (ACEis) or angiotensin receptor blockers (ARBs) on human abdominal aortic aneurysm (AAA) growth, rupture, and perioperative mortality. METHODS: We conducted a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Our review protocol was registered at the International Prospective Register of Systematic Reviews (CRD42016054082). We searched the Cochrane Central Register of Controlled Trials database, MEDLINE, and Embase from inception to 2017 for studies examining the effects of ACEi or ARB treatment on AAA growth, rupture, or perioperative mortality. Review, abstraction, and quality assessment were conducted in duplicate, and a third author resolved discrepancies. We assessed study quality using the Cochrane and Newcastle-Ottawa scales. We used random-effects models to calculate pooled mean differences and odds ratios (ORs) with 95% confidence intervals (CIs). Heterogeneity was quantified using the I2 statistic. RESULTS: Our search yielded 525 articles. One randomized and seven observational studies involving 35,448 patients were included. Inter-rater agreement was excellent (κ = 0.78), and risk of bias was low to moderate. All studies investigated ACEis, three studies investigated ARBs, and two studies included a composite RASB group consisting of ACEi or ARB users. Five studies assessed AAA growth, two assessed rupture rate, and one reported 30-day mortality after elective open repair. There was no difference in AAA growth rate between RASB and control (mean difference, 0.03 mm/y; 95% CI, -0.40 to 0.46; P = .88; I2 = 60%). No protective effect of RASB (OR, 0.92; 95% CI, 0.72, 1.16; P = .47; I2 = 90%) was demonstrated for AAA rupture. Finally, RASB increased 30-day mortality in patients undergoing elective open AAA repair (OR, 5; 95% CI, 1.4, 27) according to a single well-adjusted study. CONCLUSIONS: RASB does not appear to affect AAA growth and rupture rate but increases elective perioperative mortality. The small number of heterogeneous, retrospective studies and limited long-term follow-up preclude a definitive dismissal of RASB as pharmacotherapy for AAA. Prospective, long-term data are needed to clarify the effect of RASB on AAA growth, rupture, and perioperative mortality.

Validation of abdominal aortic aneurysm repair codes in Ontario administrative data.

PURPOSE: To determine the positive predictive values (PPV) of Ontario administrative data codes for the identification of open (OSR) and endovascular (EVAR) repairs of elective (eAAA) and ruptured (rAAA) abdominal aortic aneurysms. METHODS: We randomly identified 319 eAAA and rAAA repairs at two Toronto hospitals between April 2003 and March 2015, using administrative health data in Ontario, Canada. International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) codes I71.3 and I71.4, were used to identify rAAA and eAAA patients, respectively. A blinded retrospective chart review was conducted and served as the gold standard comparator. Re-abstracted records were compared to Canadian Classification of Health Interventions (CCI) and Ontario Health Insurance Plan (OHIP) codes in the Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD) and OHIP databases. We calculated the PPV and 95% confidence intervals (95% CI) of individual and combined procedure and billing codes for elective and ruptured OSR and EVAR (eOSR, eEVAR, rOSR, and rEVAR). RESULTS: Permutation of codes allowed identification of eOSR with 95% PPV (95% CI 88, 98), eEVAR with 96% PPV (95% CI 90, 99), rOSR with 87% PPV (95% CI 79, 93) and rEVAR with 91% PPV (95% CI 59, 100). CONCLUSIONS: Diagnostic, procedure and billing code combinations allow identification of eOSR, eEVAR, rOSR and rEVAR patients in Ontario administrative data with a high degree of certainty.

Thirty-day hospital readmission and emergency department visits after vascular surgery: a Canadian prospective cohort study.

BACKGROUND: Rates of hospital readmission following surgery can serve as a marker for quality of care. The aim of this study was to establish the rates and causes of readmission and emergency department visits after vascular surgery and to understand how these patients are managed. METHODS: We conducted a prospective observational cohort study including all inpatients who underwent major vascular surgery between September 2015 and June 2016 at a tertiary vascular care centre in Toronto. Patients were followed at 30 days after discharge via telephone interview. RESULTS: We enrolled 133 patients (94 men [70.7%] and 39 women [29.3%] with a mean age of 65.3 years). The most common index admission diagnosis was peripheral artery disease (67 patients [50.4%]). At 30 days, 19 patients (14.8%) had been readmitted or had visited the emergency department, most commonly after lower extremity revascularization (19.4%). Ten patients were readmitted a mean of 16.8 days following discharge; surgical site infection was the most common cause for readmission (3 patients). The most common treatment was antimicrobial therapy (4 patients). The mean hospital length of stay was 14.4 days. Nine patients presented to the emergency department a mean of 10.6 days after discharge; 6 reported a wound issue, and most (6 of 9) were managed with oral antibiotic treatment. CONCLUSION: Early readmission/emergency department visits after lower extremity revascularization surgery in patients with peripheral artery disease are common and are often due to surgical site infection or wound-related issues. Follow-up within 7-10 days and a specialized wound care team may help reduce the occurrence of these events.

CONTEXTE: Les taux de réadmission à l'hôpital après une chirurgie peuvent servir d'indicateur de la qualité des soins. L'étude visait à déterminer les taux et les causes de réadmissions et de visites à l'urgence chez les patients ayant subi une chirurgie vasculaire et à étudier la façon dont ces patients étaient pris en charge. MÉTHODES: Nous avons mené une étude de cohorte observationnelle prospective portant sur tous les patients qui ont été hospitalisés pour une importante chirurgie vasculaire entre septembre 2015 et juin 2016 dans un centre de soins tertiaires vasculaires à Toronto. Nous avons fait un suivi téléphonique auprès de ces patients 30 jours après leur congé. RÉSULTATS: Nous avons recruté 133 patients (94 hommes [70,7 %] et 39 femmes [29,3 %] dont l'âge moyen était de 65,3 ans). Le diagnostic le plus courant à l'admission initiale était la maladie artérielle périphérique (67 patients [50,4 %]). À 30 jours, 19 patients (14,8 %) avaient été réhospitalisés ou s'étaient présentés à l'urgence; la plupart avaient initialement subi une revascularisation des membres inférieurs (19,4 %). Dix patients ont été réhospitalisés en moyenne 16,8 jours après leur congé; l'infection du site opératoire était la cause la plus courante de réadmission (3 patients). Le traitement le plus courant chez les patients réhospitalisés était le traitement antimicrobien (4 patients). La durée médiane des séjours à l'hôpital était de 14,4 jours. Neuf patients se sont présentés à l'urgence en moyenne 10,6 jours après leur congé; 6 ont signalé un problème avec leur plaie, et la majorité (6 des 9 patients) ont reçu une antibiothérapie orale. CONCLUSION: Les réadmissions ou les visites à l'urgence de patients atteints d'une maladie artérielle périphérique peu après une chirurgie de revascularisation des membres inférieurs sont courantes et souvent attribuables à une infection du site opératoire ou à des problèmes associés à la plaie. Un suivi après 7 à 10 jours ainsi que les services d'une équipe spécialisée en soin des plaies pourraient contribuer à réduire la fréquence de ce type d'événement.

Thirty-day hospital readmission and emergency department visits after vascular surgery: a Canadian prospective cohort study.

BACKGROUND: Rates of hospital readmission following surgery can serve as a marker for quality of care. The aim of this study was to establish the rates and causes of readmission and emergency department visits after vascular surgery and to understand how these patients are managed. METHODS: We conducted a prospective observational cohort study including all inpatients who underwent major vascular surgery between September 2015 and June 2016 at a tertiary vascular care centre in Toronto. Patients were followed at 30 days after discharge via telephone interview. RESULTS: We enrolled 133 patients (94 men [70.7%] and 39 women [29.3%] with a mean age of 65.3 years). The most common index admission diagnosis was peripheral artery disease (67 patients [50.4%]). At 30 days, 19 patients (14.8%) had been readmitted or had visited the emergency department, most commonly after lower extremity revascularization (19.4%). Ten patients were readmitted a mean of 16.8 days following discharge; surgical site infection was the most common cause for readmission (3 patients). The most common treatment was antimicrobial therapy (4 patients). The mean hospital length of stay was 14.4 days. Nine patients presented to the emergency department a mean of 10.6 days after discharge; 6 reported a wound issue, and most (6 of 9) were managed with oral antibiotic treatment. CONCLUSION: Early readmission/emergency department visits after lower extremity revascularization surgery in patients with peripheral artery disease are common and are often due to surgical site infection or wound-related issues. Follow-up within 7-10 days and a specialized wound care team may help reduce the occurrence of these events.

CONTEXTE: Les taux de réadmission à l'hôpital après une chirurgie peuvent servir d'indicateur de la qualité des soins. L'étude visait à déterminer les taux et les causes de réadmissions et de visites à l'urgence chez les patients ayant subi une chirurgie vasculaire et à étudier la façon dont ces patients étaient pris en charge. MÉTHODES: Nous avons mené une étude de cohorte observationnelle prospective portant sur tous les patients qui ont été hospitalisés pour une importante chirurgie vasculaire entre septembre 2015 et juin 2016 dans un centre de soins tertiaires vasculaires à Toronto. Nous avons fait un suivi téléphonique auprès de ces patients 30 jours après leur congé. RÉSULTATS: Nous avons recruté 133 patients (94 hommes [70,7 %] et 39 femmes [29,3 %] dont l'âge moyen était de 65,3 ans). Le diagnostic le plus courant à l'admission initiale était la maladie artérielle périphérique (67 patients [50,4 %]). À 30 jours, 19 patients (14,8 %) avaient été réhospitalisés ou s'étaient présentés à l'urgence; la plupart avaient initialement subi une revascularisation des membres inférieurs (19,4 %). Dix patients ont été réhospitalisés en moyenne 16,8 jours après leur congé; l'infection du site opératoire était la cause la plus courante de réadmission (3 patients). Le traitement le plus courant chez les patients réhospitalisés était le traitement antimicrobien (4 patients). La durée médiane des séjours à l'hôpital était de 14,4 jours. Neuf patients se sont présentés à l'urgence en moyenne 10,6 jours après leur congé; 6 ont signalé un problème avec leur plaie, et la majorité (6 des 9 patients) ont reçu une antibiothérapie orale. CONCLUSION: Les réadmissions ou les visites à l'urgence de patients atteints d'une maladie artérielle périphérique peu après une chirurgie de revascularisation des membres inférieurs sont courantes et souvent attribuables à une infection du site opératoire ou à des problèmes associés à la plaie. Un suivi après 7 à 10 jours ainsi que les services d'une équipe spécialisée en soin des plaies pourraient contribuer à réduire la fréquence de ce type d'événement.