Socioeconomic "Distressed Communities Index" Improves Surgical Risk-adjustment.

OBJECTIVE: We hypothesize the Distressed Communities Index (DCI), a composite socioeconomic ranking by ZIP code, will predict risk-adjusted outcomes after surgery. SUMMARY OF BACKGROUND DATA: Socioeconomic status affects surgical outcomes; however, the American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) database does not account for these factors. METHODS: All ACS NSQIP patients (17,228) undergoing surgery (2005 to 2015) at a large academic institution were paired with the DCI, which accounts for unemployment, education level, poverty rate, median income, business growth, and housing vacancies. Developed by the Economic Innovation Group, DCI scores range from 0 (no distress) to 100 (severe distress). Multivariable regressions were used to evaluate ACS NSQIP predicted risk-adjusted effect of DCI on outcomes and inflation-adjusted hospital cost. RESULTS: A total of 4522 (26.2%) patients came from severely distressed communities (top quartile). These patients had higher rates of medical comorbidities, transfer from outside hospital, emergency status, and higher ACS NSQIP predicted risk scores (all P < 0.05). In addition, these patients had greater resource utilization, increased postoperative complications, and higher short- and long-term mortality (all P < 0.05). Risk-adjustment with multivariate regression demonstrated that DCI independently predicts postoperative complications (odds ratio 1.1, P = 0.01) even after accounting for ACS NSQIP predicted risk score. Furthermore, DCI independently predicted inflation-adjusted cost (+$978/quartile, P < 0.0001) after risk adjustment. CONCLUSIONS: The DCI, an established metric for socioeconomic distress, improves ACS NSQIP risk-adjustment to predict outcomes and hospital cost. These findings highlight the impact of socioeconomic status on surgical outcomes and should be integrated into ACS NSQIP risk models.

Lower extremity bypass and endovascular intervention for critical limb ischemia fail to meet Society for Vascular Surgery's objective performance goals for limb-related outcomes in a contemporary national cohort.

OBJECTIVE: In 2009, the Society for Vascular Surgery (SVS) developed objective performance goals (OPGs) to define the therapeutic benchmarks in critical limb ischemia (CLI) based on outcomes from randomized trials of lower extremity bypass (LEB). Current performance relative to these benchmarks in both LEB and infrainguinal endovascular intervention (IEI) remains unknown. The objective of this study was to determine whether LEB and IEI performed for CLI in a contemporary national cohort met OPG 30-day safety thresholds. METHODS: SVS OPG criteria were applied to 11,043 revascularizations for CLI performed from 2011 to 2015 in the National Surgical Quality Improvement Program (NSQIP) vascular targeted modules. Primary 30-day safety OPGs including major adverse cardiovascular events (MACEs), major adverse limb events (MALEs), and amputation were calculated for the NSQIP LEB (n = 3833) and IEI (n = 3526) cohorts as well as for subgroups at "high anatomic risk" (infrapopliteal revascularization) and "high clinical risk" (age >80 years and tissue loss). These were compared with SVS OPG benchmarks using χ2 comparisons. RESULTS: Compared with the SVS OPG cohort, both the NSQIP LEB and IEI cohorts had fewer patients at high anatomic risk (LEB, 51%; IEI, 27%; SVS OPG, 60%; both P < .0001). The LEB cohort had fewer patients with high clinical risk than the SVS OPG cohort (LEB, 11%; SVS OPG, 16%; P < .0001). The 30-day MALE was significantly higher in the NSQIP LEB (9.0% [8.7%-9.2%]) and IEI (9.7% [9.4%-10.0%]) cohorts compared with the SVS OPG cohort (6.1% [4.7%-9.0%]; both P ≤ .007), including significantly higher rates of amputation. MACE was significantly lower in the NSQIP LEB (4.2% [4.1%-4.3%]) and IEI (3.1% [3.0%-3.2%]) cohorts compared with the SVS OPG cohort (6.1% [4.7%-8.1%]; both P ≤ .013). Among patients at high anatomic risk, 30-day MALE was significantly higher after LEB (9.5% [9.1%-9.8%]) and IEI (11.1% [10.4-11.8%]) compared with the SVS OPG cohort (6.1% [4.2%-8.6%]; P ≤ .002). Among patients with high clinical risk, IEI was associated with lower MACE compared with the SVS OPG cohort, with similar limb-related outcomes. CONCLUSIONS: In contemporary real-world practice, LEB and IEI for CLI failed to meet SVS OPG limb-related 30-day safety benchmarks for the entire CLI cohort as well as for the patients at high anatomic risk. Additional investigation using SVS OPGs as consistent end points is required to determine why limb-related outcomes after revascularization for CLI remain suboptimal. LEB and IEI surpassed OPG benchmarks for 30-day cardiovascular morbidity and mortality. OPGs for cardiovascular morbidity in patients undergoing revascularization for CLI deserve re-evaluation using contemporary data.

Resident-Specific Morbidity Reduced Following ACS NSQIP Data-Driven Quality Program.

BACKGROUND: The Accreditation Council for Graduate Medical Education Milestone Project for general surgery provided a more robust method for developing and tracking residents' competence. This framework enhanced systematic and progressive development of residents' competencies in surgical quality improvement. STUDY DESIGN: A 22-month interactive, educational program based on resident-specific surgical outcomes data culminated in a quality improvement project for postgraduate year 4 surgery residents. Self- assessment, quality knowledge test, and resident-specific American College of Surgeons National Surgical Quality Improvement Program Quality In-Training Initiative morbidity were compared before and after the intervention. RESULTS: Quality in-training initiative morbidity decreased from 25% (82/325) to 18% (93/517), p = 0.015 despite residents performing more complex cases. All participants achieved level 4 competency (4/4) within the general surgery milestones improvement of care, practice-based learning and improvement competency. Institutional American College of Surgeons National Surgical Quality Improvement Program general surgery morbidity improved from the ninth to the sixth decile. Quality assessment and improvement self-assessment postintervention scores (M = 23.80, SD = 4.97) were not significantly higher than preintervention scores (M = 19.20, SD = 5.26), p = 0.061. Quality Improvement Knowledge Application Tool postintervention test scores (M = 17.4, SD = 4.88), were not significantly higher than pretest scores (M = 13.2, SD = 1.92), p = 0.12. CONCLUSION: Sharing validated resident-specific clinical data with participants was associated with improved surgical outcomes. Participating fourth year surgical residents achieved the highest score, a level 4, in the practice based learning and improvement competency of the improvement of care practice domain and observed significantly reduced surgical morbidity for cases in which they participated.

Retrograde pedal access technique for revascularization of infrainguinal arterial occlusive disease.

PURPOSE: To evaluate limb salvage after recanalization of lower extremity arteries using retrograde pedal access in patients with critical limb ischemia (CLI). MATERIALS AND METHODS: A retrospective review was performed of all patients in whom retrograde pedal arterial access was used for recanalization of infrainguinal occlusive disease between September 2002 and January 2013. Treatment was performed in 99 limbs in 92 patients (64 men and 28 women; median age, 71.6 y; range, 44-91 y) with CLI and no appropriate venous conduit for surgical bypass. Treated limbs were classified as Rutherford class 5 or 6 in 88% and class 4 in 12%. Retrograde and antegrade accesses were combined when occlusions could not be crossed from the antegrade direction. The treated occlusive segments were limited to the femoropopliteal arteries in 22% of procedures, runoff arteries in 32%, or both segments in 46%. Technical success was defined as successful crossing of the lesion and achievement of inline flow to the pedal vessel. Kaplan-Meier analysis was performed to determine limb salvage rate. RESULTS: Technical success was achieved in 88 of 99 (89%) treated limbs. Stents were placed for suboptimal angioplasty results in 41 of 88 (47%) successfully treated limbs. Major complications occurred in 8 of 99 (8%) procedures, 3 of which resulted in periprocedural mortality. Median follow-up was 8 months (mean, 17 mo; range, 1-98 mo). The limb salvage rate for technically successful cases was 74% at 6 months, 64% at 12 months, and 55% at 24 months. CONCLUSIONS: Retrograde pedal access is a viable revascularization technique for achieving limb salvage in patients with CLI.

Predictors of false lumen thrombosis in type B aortic dissection treated with TEVAR.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) offers a less invasive treatment option in type B aortic dissection (TBAD) patients and its value has been demonstrated in acute and chronic dissection patients. Total false lumen thrombosis (FLT) is associated with better long-term outcome in these patients, however, this is not obtained in all patients. The purpose of this study was to investigate predictors of FLT. METHODS: We retrospectively investigated patients who underwent TEVAR for a type B dissection in a large referral center between 2005 and 2012. All patients with a CT angiogram (CTA) obtained preoperatively, postoperatively and after one year of follow-up were selected for analysis. Volume measurements and several morphologic characteristics were analyzed for all scans using Aquarius iNtuition software (TeraRecon, San Mateo, Calif, USA). Multivariate logistic regression analyses were used to study the influence of these characteristics on FLT. RESULTS: Of 132 patients that received TEVAR for an aortic dissection, 43 patients (mean age, 60.3±14.2; 30 male) met our inclusion criteria, of whom 16 (37%) developed full FLT after 1 yr of follow-up. Multivariate logistic regression showed that side branch involvement [odds ratio (OR), 0.03; 95% confidence interval (CI), 0.00-0.92; P=0.045] and a total patent false lumen (FL) at presentation (OR, 0.01; 95% CI, 0.00-0.58; P=0.027) were associated with decreased complete FLT. Volumetric data showed significantly more reduction of the thoracic false lumen in FLT patients compared with non-FLT (-52.3% vs. -32.4%; P=0.043) and also a tendency of less volume increase in the abdominal segment (-5.0±37.5 vs. 21.8±44.3; P=0.052). CONCLUSIONS: Patients admitted with type B dissection and branch vessel involvement or a patent entry tear after TEVAR are less likely to develop FLT and aortic remodeling during follow-up. These findings suggest that these patients may require a more extensive procedure and more intensive follow-up to prevent long-term complications.

Hybrid repair of aortic arch aneurysm.

Hybrid repair of thoracic aortic aneurysm has been used with increasing frequency over the past decade, as indications for endovascular therapy have continued to expand. Hybrid techniques may avoid and limit the morbidity and mortality associated with sternotomy or thoracotomy, mechanical circulatory support, and hypothermic arrest. We present the case of a patient with extensive aortic aneurysmal disease initially needing open ascending aortic and subsequent thoracoabdominal repair. However, owing to continued enlargement of the aortic arch, hybrid extrathoracic, extra-anatomic complete aortic arch debranching and transcatheter endografting was ultimately pursued with favorable midterm results.