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OBJECTIVE: Examine the association between sex, race, ethnicity, and family income, and the intersectionality between these identities, and sustained or cultivated paths in surgery in medical school. METHODS: This retrospective cohort study examines US medical students who matriculated in academic years 2014-2015 and 2015-2016. Data were provided by the Association of American Medical Colleges, including self-reported sex, race, ethnicity, family income, interest in surgery at matriculation, and successful placement into a surgical residency at graduation. This study examined 2 outcomes: (1) sustained path in surgery between matriculation and graduation for students who entered medical school with an interest in surgery and (2) cultivated path in surgery for students who entered medical school not initially interested in surgery and who applied to and were successfully placed into a surgical residency at graduation. RESULTS: Among the 5074 students who reported interest in surgery at matriculation, 2108 (41.5%) had sustained path in surgery. Compared to male students, female students were significantly less likely to have sustained path in surgery [adjusted relative risk (aRR): 0.92 (0.85-0.98)], while Asian (aRR: 0.82, 95% CI: 0.74-0.91), Hispanic (aRR: 0.70, 95% CI: 0.59-0.83), and low-income (aRR: 0.85, 95% CI: 0.78-0.92) students were less likely to have a sustained path in surgery compared to their peers. Among the 17,586 students who reported an initial interest in a nonsurgical specialty, 1869 (10.6%) were placed into a surgical residency at graduation. Female students, regardless of race/ethnic identity and income, were significantly less likely to have cultivated paths in surgery compared to male students, with underrepresented in medicine female students reporting the lowest rates. CONCLUSIONS AND RELEVANCE: This study demonstrates the significant disparity in sustained and cultivated paths in surgery during undergraduate medical education. Innovative transformation of the surgical learning environment to promote surgical identity development and belonging for females, underrepresented in medicine, and low-income students is essential to diversify the surgical workforce.
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Educación de Pregrado en Medicina , Estudiantes de Medicina , Femenino , Humanos , Masculino , Etnicidad , Estudios Retrospectivos , Clase Social , Grupos Raciales , Distribución por SexoRESUMEN
Clinical failure of arteriovenous neointimal hyperplasia (NIH) fistulae (AVF) is frequently due to juxta-anastomotic NIH (JANIH). Although the mouse AVF model recapitulates human AVF maturation, previous studies focused on the outflow vein distal to the anastomosis. We hypothesized that the juxta-anastomotic area (JAA) has increased NIH compared with the outflow vein. AVF was created in C57BL/6 mice without or with chronic kidney disease (CKD). Temporal and spatial changes of the JAA were examined using histology and immunofluorescence. Computational techniques were used to model the AVF. RNA-seq and bioinformatic analyses were performed to compare the JAA with the outflow vein. The jugular vein to carotid artery AVF model was created in Wistar rats. The neointima in the JAA shows increased volume compared with the outflow vein. Computational modeling shows an increased volume of disturbed flow at the JAA compared with the outflow vein. Endothelial cells are immediately lost from the wall contralateral to the fistula exit, followed by thrombus formation and JANIH. Gene Ontology (GO) enrichment analysis of the 1,862 differentially expressed genes (DEG) between the JANIH and the outflow vein identified 525 overexpressed genes. The rat jugular vein to carotid artery AVF showed changes similar to the mouse AVF. Disturbed flow through the JAA correlates with rapid endothelial cell loss, thrombus formation, and JANIH; late endothelialization of the JAA channel correlates with late AVF patency. Early thrombus formation in the JAA may influence the later development of JANIH.NEW & NOTEWORTHY Disturbed flow and focal endothelial cell loss in the juxta-anastomotic area of the mouse AVF colocalizes with acute thrombus formation followed by late neointimal hyperplasia. Differential flow patterns between the juxta-anastomotic area and the outflow vein correlate with differential expression of genes regulating coagulation, proliferation, collagen metabolism, and the immune response. The rat jugular vein to carotid artery AVF model shows changes similar to the mouse AVF model.
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Derivación Arteriovenosa Quirúrgica , Hiperplasia , Venas Yugulares , Ratones Endogámicos C57BL , Neointima , Ratas Wistar , Trombosis , Animales , Trombosis/fisiopatología , Trombosis/patología , Trombosis/genética , Trombosis/etiología , Trombosis/metabolismo , Masculino , Venas Yugulares/metabolismo , Venas Yugulares/patología , Venas Yugulares/fisiopatología , Modelos Animales de Enfermedad , Arterias Carótidas/patología , Arterias Carótidas/fisiopatología , Arterias Carótidas/metabolismo , Arterias Carótidas/cirugía , Ratones , Ratas , Flujo Sanguíneo Regional , Endotelio Vascular/metabolismo , Endotelio Vascular/fisiopatología , Endotelio Vascular/patología , Insuficiencia Renal Crónica/patología , Insuficiencia Renal Crónica/fisiopatología , Insuficiencia Renal Crónica/genética , Insuficiencia Renal Crónica/metabolismo , Células Endoteliales/metabolismo , Células Endoteliales/patologíaRESUMEN
OBJECTIVE: Patients with intermittent claudication (IC) from peripheral arterial disease (PAD) have significant improvement with supervised exercise therapy (SET). However, many patients have progressive disease that will ultimately require revascularization. We sought to determine whether the anatomic patterns of PAD were associated with response to SET. METHODS: We prospectively enrolled patients with IC at the West Haven, Connecticut Veterans Health Administration between June 2019 and June 2022. Patients were classified based on the level of their arterial disease with >50% obstruction. SET failure was defined as progressive symptoms or development of critical limb-threatening ischemia (CLTI) requiring revascularization. RESULTS: Thirty-eight patients with PAD were included. Thirteen patients (34.2%) had significant common femoral artery (CFA) disease, and 25 (65.8%) had non-CFA disease. Over a median follow-up of 1407 days, 11 patients (84.6%) with CFA disease failed SET as compared with three patients (12.0%) with non-CFA disease (P < .001). Patients with CFA disease were more likely to develop CLTI (46.2% vs 4.0%; P = .001) and have persistent symptoms (38.5% vs 8.0%; P = .02). Patients with CFA disease had significantly lower post-SET ankle-brachial index (0.58 ± 0.14 vs 0.77 ± 0.19; P = .03). In multivariate analysis, the only variable associated with SET failure was CFA disease location (odds ratio, 68.75; 95% confidence interval, 5.05-936.44; P = .001). CONCLUSIONS: Patients with IC from high-grade CFA atherosclerosis are overwhelmingly likely to fail SET, potentially identifying a subset of patients who benefit from upfront revascularization.
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Aterosclerosis , Enfermedad Arterial Periférica , Humanos , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/terapia , Claudicación Intermitente/diagnóstico , Claudicación Intermitente/terapia , Procedimientos Quirúrgicos Vasculares , Terapia por Ejercicio/efectos adversos , Resultado del Tratamiento , Isquemia , Factores de RiesgoRESUMEN
OBJECTIVE: The optimal management of patients with asymptomatic carotid stenosis (AsxCS) is enduringly controversial. We updated our 2021 Expert Review and Position Statement, focusing on recent advances in the diagnosis and management of patients with AsxCS. METHODS: A systematic review of the literature was performed up to August 1, 2023, using PubMed/PubMed Central, EMBASE and Scopus. The following keywords were used in various combinations: "asymptomatic carotid stenosis," "carotid endarterectomy" (CEA), "carotid artery stenting" (CAS), and "transcarotid artery revascularization" (TCAR). Areas covered included (i) improvements in best medical treatment (BMT) for patients with AsxCS and declining stroke risk, (ii) technological advances in surgical/endovascular skills/techniques and outcomes, (iii) risk factors, clinical/imaging characteristics and risk prediction models for the identification of high-risk AsxCS patient subgroups, and (iv) the association between cognitive dysfunction and AsxCS. RESULTS: BMT is essential for all patients with AsxCS, regardless of whether they will eventually be offered CEA, CAS, or TCAR. Specific patient subgroups at high risk for stroke despite BMT should be considered for a carotid revascularization procedure. These patients include those with severe (≥80%) AsxCS, transcranial Doppler-detected microemboli, plaque echolucency on Duplex ultrasound examination, silent infarcts on brain computed tomography or magnetic resonance angiography scans, decreased cerebrovascular reserve, increased size of juxtaluminal hypoechoic area, AsxCS progression, carotid plaque ulceration, and intraplaque hemorrhage. Treatment of patients with AsxCS should be individualized, taking into consideration individual patient preferences and needs, clinical and imaging characteristics, and cultural, ethnic, and social factors. Solid evidence supporting or refuting an association between AsxCS and cognitive dysfunction is lacking. CONCLUSIONS: The optimal management of patients with AsxCS should include BMT for all individuals and a prophylactic carotid revascularization procedure (CEA, CAS, or TCAR) for some asymptomatic patient subgroups, additionally taking into consideration individual patient needs and preference, clinical and imaging characteristics, social and cultural factors, and the available stroke risk prediction models. Future studies should investigate the association between AsxCS with cognitive function and the role of carotid revascularization procedures in the progression or reversal of cognitive dysfunction.
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Estenosis Carotídea , Endarterectomía Carotidea , Procedimientos Endovasculares , Accidente Cerebrovascular , Humanos , Estenosis Carotídea/complicaciones , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/cirugía , Medición de Riesgo , Resultado del Tratamiento , Endarterectomía Carotidea/efectos adversos , Factores de Riesgo , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/prevención & control , Procedimientos Endovasculares/efectos adversos , Stents/efectos adversos , Estudios RetrospectivosRESUMEN
OBJECTIVE: Despite the publication of various national/international guidelines, several questions concerning the management of patients with asymptomatic (AsxCS) and symptomatic (SxCS) carotid stenosis remain unanswered. The aim of this international, multi-specialty, expert-based Delphi Consensus document was to address these issues to help clinicians make decisions when guidelines are unclear. METHODS: Fourteen controversial topics were identified. A three-round Delphi Consensus process was performed including 61 experts. The aim of Round 1 was to investigate the differing views and opinions regarding these unresolved topics. In Round 2, clarifications were asked from each participant. In Round 3, the questionnaire was resent to all participants for their final vote. Consensus was reached when ≥75% of experts agreed on a specific response. RESULTS: Most experts agreed that: (1) the current periprocedural/in-hospital stroke/death thresholds for performing a carotid intervention should be lowered from 6% to 4% in patients with SxCS and from 3% to 2% in patients with AsxCS; (2) the time threshold for a patient being considered "recently symptomatic" should be reduced from the current definition of "6 months" to 3 months or less; (3) 80% to 99% AsxCS carries a higher risk of stroke compared with 60% to 79% AsxCS; (4) factors beyond the grade of stenosis and symptoms should be added to the indications for revascularization in AsxCS patients (eg, plaque features of vulnerability and silent infarctions on brain computed tomography scans); and (5) shunting should be used selectively, rather than always or never. Consensus could not be reached on the remaining topics due to conflicting, inadequate, or controversial evidence. CONCLUSIONS: The present international, multi-specialty expert-based Delphi Consensus document attempted to provide responses to several unanswered/unresolved issues. However, consensus could not be achieved on some topics, highlighting areas requiring future research.
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Estenosis Carotídea , Accidente Cerebrovascular , Humanos , Estenosis Carotídea/diagnóstico , Estenosis Carotídea/diagnóstico por imagen , Consenso , Técnica Delphi , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/etiología , Constricción PatológicaRESUMEN
The Wound Healing Society guidelines for the treatment of arterial insufficiency ulcers were originally published in 2006, with the last update in 2014. These guidelines provided recommendations, along with their respective levels of evidence, on seven categories: diagnosis, surgery, infection control, wound bed preparation, dressings, adjuvant therapy and long-term maintenance. Over the last 9 years, additional literature regarding these aspects of arterial ulcer management has been published. An advisory panel comprised of academicians, clinicians and researchers was chosen to update the 2014 guidelines. Members included vascular surgeons, internists, plastic surgeons, anaesthesiologists, emergency medicine physicians and dermatologists, all with expertise in wound healing. The goal of this article is to evaluate relevant new findings upon which an updated version of the guidelines will be based.
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BACKGROUND: Peripheral arterial disease (PAD) is associated with reduced muscle mass and quality, but the effects of leg ischemia caused by PAD on muscle quality remain poorly understood. The purpose of this study was to evaluate leg muscle mass and muscle quality in patients with intermittent claudication due to PAD using bioelectrical impedance analysis (BIA). METHODS: One hundred forty-one patients with intermittent claudication due to PAD who visited Tokyo Medical University Hospital from April 2019 to April 2020 were retrospectively analyzed. Leg ischemia was assessed using ankle-brachial pressure index (ABI). The skeletal muscle mass (SMM) assessed leg muscle mass, while the phase angle (PhA) assessed leg muscle quality using BIA. RESULTS: A total of 282 legs in 141 patients were included in the analysis. Leg PhA and SMM showed a decreasing trend according to the severity of leg ischemia (borderline/no ischemia: 2.80 ± 0.50 kg/m2, 4.38 ± 0.94°; mild ischemia: 2.83 ± 0.49 kg/m2, 4.33 ± 1.03°; moderate/severe ischemia: 2.50 ± 0.40 kg/m2, 3.89 ± 0. 88°; P < 0.001 and P = 0.020, respectively). The ABI was moderately correlated with leg SMM (B = 0.347, ß = 0.134, P < 0.001) and leg PhA (B = 0.577, ß = 0.111, P = 0.013) after adjustment for all significant covariates. Leg PhA was moderately correlated with leg SMM (r = 0.318, P < 0.001). CONCLUSIONS: Leg ischemia, especially when moderate or severe, has an adverse effect on both muscle mass and quality in the lower extremities and is associated with skeletal muscle myopathy.
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Índice Tobillo Braquial , Impedancia Eléctrica , Claudicación Intermitente , Músculo Esquelético , Enfermedad Arterial Periférica , Humanos , Claudicación Intermitente/fisiopatología , Claudicación Intermitente/diagnóstico , Enfermedad Arterial Periférica/fisiopatología , Enfermedad Arterial Periférica/complicaciones , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/diagnóstico por imagen , Masculino , Anciano , Femenino , Músculo Esquelético/irrigación sanguínea , Músculo Esquelético/fisiopatología , Estudios Retrospectivos , Persona de Mediana Edad , Anciano de 80 o más Años , Índice de Severidad de la Enfermedad , Valor Predictivo de las Pruebas , Sarcopenia/fisiopatología , Sarcopenia/diagnóstico , Isquemia/fisiopatología , Isquemia/diagnóstico , Fuerza MuscularRESUMEN
Peripheral artery disease is a major atherosclerotic disease that is associated with poor outcomes such as limb loss, cardiovascular morbidity, and death. Artificial intelligence (AI) has seen increasing integration in medicine, and its various applications can optimize the care of peripheral artery disease (PAD) patients in diagnosis, predicting patient outcomes, and imaging interpretation. In this review, we introduce various AI applications such as natural language processing, supervised machine learning, and deep learning, and we analyze the current literature in which these algorithms have been applied to PAD.
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Procesamiento de Lenguaje Natural , Enfermedad Arterial Periférica , Valor Predictivo de las Pruebas , Humanos , Enfermedad Arterial Periférica/terapia , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/fisiopatología , Aprendizaje Profundo , Aprendizaje Automático Supervisado , Diagnóstico por Computador , Toma de Decisiones Clínicas , Pronóstico , Inteligencia Artificial , Técnicas de Apoyo para la DecisiónRESUMEN
OBJECTIVES: Antiplatelet therapy is an essential element in the management of patients with arterial vascular disease. In peripheral arterial disease (PAD), dual antiplatelet therapy (DAPT), primarily clopidogrel and aspirin, is routinely prescribed following intervention. There is sparse data regarding the need for DAPT, the appropriate duration, or the heterogeneity of treatment effects for antiplatelet regimens across patients, leading to potential uncertainty and heterogeneity around treatment practices. An example of heterogeneity of treatment effects is a patients' metabolizer status for the use of clopidogrel. The aim of the study was to (1) assess clinicians' knowledge of and attitudes toward managing patients with CYP2C19 mutations, (2) identify barriers to implementation of CYP2C19 testing and management policies, and (3) reach consensus for CYP2C19 testing and management strategies for patients with PAD who undergo peripheral vascular interventions (PVI). METHODS: A modified Delphi method was used to establish consensus amongst PAD interventionalists around CYP2C19 testing. All practicing Yale New Haven Hospital PAD interventionalists with backgrounds in interventional cardiology, vascular surgery, or interventional radiology were approached by email for participation. Round 1 included the collection of baseline demographic questions, knowledge questions, and three statements for consensus. Knowledge questions were rated on a 0-10 Likert scale with the following anchors: 0 ("Not at all"), 5 ("Neutral), and 10 ("Very Much"). Participants were asked to rate the importance of the three consensus statements on a 9-point Likert scale from 1 ("Strongly Disagree") to 10 ("Strongly Agree"). In Round 2, participants were shown the same consensus statements, the median response of the group from the previous round, and their previous answers. Participants were instructed to revise their rating using the results from the previous round. This process was repeated for Round 3. RESULTS: Of the 28 experts invited to participate, 13 agreed (46%). Participants were predominantly male (92.3%) and white (61.5%) with representation from interventional cardiology (46.2%) and vascular surgery (53.8%). Most participants reported more than 10+ years in practice (61.5%). PAD interventionalists felt they would benefit from more education regarding CYP2C19 mutations (median score 8.0, interquartile range 5.0-8.5). They indicated some familiarity with CYP2C19 mutations (7.0, 6.0-9.5) but did not feel strongly that CYP2C19 was important to their practice (6.0, 5.5-7.5). In each round, the median responses for the three consensus statements were 5, 6, and 9, respectively. With each successive round the interquartile range narrowed indicative of evolving consensus but did not reach the prespecified interquartile range for consensus of 1 for any of the statements. CONCLUSIONS: PAD interventionalists practicing at an academic health system recognize the heterogenous response of their patients to clopidogrel therapy but are unsure when to leverage genetic testing to improve outcomes for their patients. Our study identified gaps regarding PAD interventionalists' knowledge, perceived barriers, and attitudes toward CYP2C19 testing in PAD. This information highlights the need for randomized data on genetic testing for clopidogrel responsiveness in peripheral vascular disease following intervention to help guide antiplatelet management.
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BACKGROUND: There is uncertainty whether elderly patients with symptomatic carotid stenosis have higher rates of adverse events following carotid endarterectomy. In trials, recurrent stroke risk on medical therapy alone increased with age, whereas operative stroke risk was not related. Few octogenarians were included in trials and there has been no systematic analysis of all study types. We aimed to evaluate the safety of carotid endarterectomy in symptomatic elderly patients, particularly in octogenarians. METHODS: We did a systematic review and meta-analysis of studies (from January 1, 1980 through March 1, 2022) reporting post carotid endarterectomy risk of stroke, myocardial infarction, and death in patients with symptomatic carotid stenosis. We included observational studies and interventional arms of randomized trials if the outcome rates (or the raw data to calculate these) were provided. Individual patient data from 4 prospective cohorts enabled multivariate analysis. RESULTS: Of 47 studies (107 587 patients), risk of perioperative stroke was 2.04% (1.94-2.14) in octogenarians (390 strokes/19 101 patients) and 1.85% (1.75-1.95) in nonoctogenarians (1395/75 537); P=0.046. Perioperative death was 1.09% (0.94-1.25) in octogenarians (203/18 702) and 0.53% (0.48-0.59) in nonoctogenarians (392/73 327); P<0.001. Per 5-year age increment, a linear increase in perioperative stroke, myocardial infarction, and death were observed; P=0.04 to 0.002. However, during the last 3 decades, perioperative stroke±death has declined significantly in octogenarians (7.78% [5.58-10.55] before year 2000 to 2.80% [2.56-3.04] after 2010); P<0.001. In Individual patient data multivariate-analysis (5111 patients), age ≥85 years was independently associated with perioperative stroke (P<0.001) and death (P=0.005). Yet, survival was similar for octogenarians versus nonoctogenarians at 1-year (95.0% [93.2-96.5] versus 97.5% [96.4-98.6]; P=0.08), as was 5-year stroke risk (11.93% [9.98-14.16]) versus 12.78% [11.65-13.61]; P=0.24). CONCLUSIONS: We found a modest increase in perioperative risk with age in symptomatic patients undergoing carotid endarterectomy. As stroke risk increases with age when on medical therapy alone, our findings support selective urgent intervention in symptomatic elderly patients.
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Estenosis Carotídea , Endarterectomía Carotidea , Infarto del Miocardio , Accidente Cerebrovascular , Anciano de 80 o más Años , Humanos , Anciano , Endarterectomía Carotidea/efectos adversos , Estenosis Carotídea/cirugía , Constricción Patológica/complicaciones , Estudios Prospectivos , Factores de Riesgo , Resultado del Tratamiento , Accidente Cerebrovascular/etiología , Infarto del Miocardio/etiologíaRESUMEN
Arteriovenous fistulae (AVF) fail to mature more frequently in female patients compared with male patients, leading to inferior outcomes and decreased utilization. Since our mouse AVF model recapitulates sex differences in human AVF maturation, we hypothesized that sex hormones mediate these differences during AVF maturation. C57BL/6 mice (9-11 wk) were treated with aortocaval AVF surgery and/or gonadectomy. AVF hemodynamics were measured via ultrasound (days 0-21). Blood was collected for FACS and tissue for immunofluorescence and ELISA (days 3 and 7); wall thickness was assessed by histology (day 21). Inferior vena cava shear stress was higher in male mice (P = 0.0028) after gonadectomy, and they had increased wall thickness (22.0 ± 1.8 vs. 12.7 ± 1.2 µm; P < 0.0001). Conversely, female mice had decreased wall thickness (6.8 ± 0.6 vs. 15.3 ± 0.9 µm; P = 0.0002). Intact female mice had higher proportions of circulating CD3+ T cells on day 3 (P = 0.0043), CD4+ (P = 0.0003) and CD8+ T cells (P = 0.005) on day 7, and CD11b+ monocytes on day 3 (P = 0.0046). After gonadectomy, these differences disappeared. In intact female mice, CD3+ T cells (P = 0.025), CD4+ T cells (P = 0.0178), CD8+ T cells (P = 0.0571), and CD68+ macrophages (P = 0.0078) increased in the fistula wall on days 3 and 7. This disappeared after gonadectomy. Furthermore, female mice had higher IL-10 (P = 0.0217) and TNF-α (P = 0.0417) levels in their AVF walls than male mice. Sex hormones mediate AVF maturation, suggesting that hormone receptor signaling may be a target to improve AVF maturation.NEW & NOTEWORTHY After arteriovenous fistula creation, females have lower rates of maturation and higher rates of failure than males. In a mouse model of venous adaptation that recapitulates human fistula maturation, sex hormones may be mechanisms of the sexual dimorphism: testosterone is associated with reduced shear stress, whereas estrogen is associated with increased immune cell recruitment. Modulating sex hormones or downstream effectors suggests sex-specific therapies and could address disparities in sex differences in clinical outcomes.
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Fístula Arteriovenosa , Derivación Arteriovenosa Quirúrgica , Humanos , Masculino , Femenino , Ratones , Animales , Linfocitos T CD8-positivos , Maduración Sexual , Ratones Endogámicos C57BL , Derivación Arteriovenosa Quirúrgica/efectos adversos , Modelos Animales de Enfermedad , Testosterona , Inmunidad , Diálisis RenalRESUMEN
OBJECTIVE: Patients with chronic kidney disease (CKD) who undergo peripheral vascular interventions (PVI) with iodinated contrast are at higher risk of post-contrast acute kidney injury (PC-AKI). Carbon dioxide (CO2) angiography can reduce iodinated contrast volume usage in this patient population, but its impact on PC-AKI has not been studied. We hypothesize that CO2 angiography is associated with a decrease in PC-AKI in patients with advanced CKD. METHODS: The Vascular Quality Initiative PVI dataset from 2010 to 2021 was reviewed. Only patients with advanced CKD (estimated glomular filtration rate <45 ml/min/1.73 m2) treated for peripheral arterial disease were included. Propensity matching and multivariate logistic regression based on demographics, comorbidities, CKD stage, and indications were used to compare the outcomes of patients treated with and without CO2. RESULTS: There were 20,706 PVIs performed in patients with advanced CKD, and only 22% utilized CO2 angiography. Compared with patients treated without CO2, patients who underwent CO2 angiography were younger and less likely to be women or White, and more likely to have poor renal function, diabetes, cardiac comorbidities, and present with tissue loss. Propensity matching yielded well-matched groups with 4472 patients in each group. The procedural details after matching demonstrated 50% reduction in the volume of contrast used (32±33 vs 65±48 mL; P < .01). PVI with CO2 angiography was associated with lower rates of PC-AKI (3.9% vs 4.8%; P = .03) and cardiac complications (2.1% vs 2.9%; P = .03) without a significant difference in technical failure or major/minor amputations. Low contrast volumes (≤50 mL for CKD3, ≤20 mL for CKD4, and ≤9 mL for CKD5) are associated with reduced risk of PC-AKI (hazard ratio, 0.59; P < .01). CONCLUSIONS: CO2 angiography reduces iodinated contrast volume usage during PVI and is associated with decreased cardiac complications and PC-AKI. CO2 angiography is underutilized and should be considered for patients with advanced CKD who require endovascular therapy.
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Lesión Renal Aguda , Insuficiencia Renal Crónica , Humanos , Femenino , Masculino , Dióxido de Carbono/efectos adversos , Resultado del Tratamiento , Riñón/fisiología , Angiografía/efectos adversos , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/diagnóstico , Insuficiencia Renal Crónica/terapia , Medios de Contraste/efectos adversos , Lesión Renal Aguda/inducido químicamente , Lesión Renal Aguda/diagnóstico , Factores de Riesgo , Estudios RetrospectivosRESUMEN
OBJECTIVE: The aim of this study was to evaluate safety and efficacy of thoracic endovascular aortic repair (TEVAR) for acute Stanford type B aortic dissection (TBAD) with retrograde type A intramural hematoma (TAIMH). METHODS: Patients with acute TBAD with retrograde TAIMH treated with TEVAR between January 1, 2014, to March 31, 2022, were retrospectively reviewed. Aortic diameter and distance were measured using the 3D Slicer image computing platform. Patients' characteristics, procedural, in-hospital and follow-up data, and aortic remodeling were analyzed. RESULTS: Fifty-two patients (average age, 52.6 years; 42 males [80.8%]) were included. The median interval from symptom onset to TEVAR was 11 days (interquartile range, 7.0-16.8 days). The maximal diameter of the ascending aorta (AA) was <50 mm, and the hematoma thickness in the AA was ≤10 mm in all patients. Both the in-hospital and 30-day mortality rates were 0%. The 30-day complication rate was 11.5%. The overall cumulative survival rates were 100% at 1 year, 97.1% at 3 years, and 92.6% at 5 years. Four of 52 patients (7.7%) developed retrograde type A aortic dissection at 10 days to 4 months postoperatively, and one of 52 patients (1.9%) developed an isolated AA dissection 4 months postoperatively; these five patients were treated and alive at late follow-up in March 2022. The rates of cumulative freedom from thoracic aortic re-intervention were 93.7% at 1 year and 90.7% at 5 years. Positive AA remodeling was observed in 92.3% (48/52) of patients during follow-up. The maximal diameter of AA (mean ± standard error of mean) at admission was 42.7 ± 0.8 mm, which decreased to 39.5 ± 0.9 mm at last follow-up. The maximal AA hematoma thickness at admission was 7.6 ± 0.3 mm, which reduced to 2.2 ± 0.9 mm at last follow-up. CONCLUSIONS: For selected patients of acute Stanford TBAD with retrograde TAIMH, endovascular repair may be a safe, effective, and durable alternative treatment, if the maximum diameter of the AA is <50 mm and the intramural hematoma thickness in the AA is ≤10 mm.
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Aneurisma de la Aorta Torácica , Disección Aórtica , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Masculino , Humanos , Persona de Mediana Edad , Reparación Endovascular de Aneurismas , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/etiología , Implantación de Prótesis Vascular/efectos adversos , Estudios Retrospectivos , Procedimientos Endovasculares/efectos adversos , Resultado del Tratamiento , Factores de Tiempo , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/cirugía , Hematoma/diagnóstico por imagen , Hematoma/etiología , Hematoma/cirugíaRESUMEN
OBJECTIVE: Endovascular popliteal artery aneurysm (PAA) repair has acceptable outcomes compared with open repair for elective therapy. Endovascular repair for urgent PAA causing acute limb ischemia (ALI) has not been well-studied. This project compares outcomes of urgent endovascular and open repair of PAA with ALI. METHODS: The Vascular Quality Initiative database for peripheral vascular interventions (PVIs) and infrainguinal bypass were reviewed for PAAs with ALI from 2010 to 2021. Only patients entered as having symptoms of ALI in the PVI module and ALI as indication in the infrainguinal bypass module were included. In addition, patients undergoing elective treatment were excluded and the sample analyzed was restricted to patients undergoing urgent and emergent open and endovascular repair. Patient demographics and comorbidities as well as procedural details were compared between the two groups. Perioperative complications up to 30 days were compared as well as long-term outcomes including major amputation and mortality at 1 year. RESULTS: Urgent PAA repair for ALI constituted 10.5% (n = 571) of all PAAs. Most urgent repairs were open (80.6%; n = 460) with 19.4% (n = 111) endovascular. The proportion of endovascular repair significantly increased from 16.7% in 2010 to 85.7% in 2021. Patients undergoing endovascular repair were older (71.2 ± 12.5 vs 68.0 ± 11.8; P = .011) than patients undergoing open repair. They were also more likely to have coronary artery disease (32.4% vs 21.7%; P = .006). Open PAA repair was associated with more bleeding complications (20.8% vs 2.7%; P < .001), longer postoperative length of stay (8.1 ± 9.3 days vs 4.9 ± 5.6 days; P < .001), and less likelihood of discharge to home (64.9% vs 70.3%; P = .051). Perioperative major amputation rate was 7.5% with no difference between the two treatment strategies up to 1 year. However, patients receiving endovascular repair had higher inpatient (1.1% vs 0%; P < .001), 30-day (6.3% vs 0.4%; P < .001), and 1-year (16.5% vs 8.4%; P = .02) mortality. Multivariable regression analysis suggested that endovascular repair was possibly associated with increased 30-day mortality, but not 1-year mortality. CONCLUSIONS: Endovascular PAA has exponentially increased from 2010 to 2021. Endovascular repair is associated with decreased complications and hospital length of stay. The increased perioperative mortality seen in this group is likely due to selection bias.
Asunto(s)
Aneurisma , Arteriopatías Oclusivas , Procedimientos Endovasculares , Enfermedades Vasculares Periféricas , Aneurisma de la Arteria Poplítea , Humanos , Factores de Riesgo , Procedimientos Endovasculares/efectos adversos , Resultado del Tratamiento , Aneurisma/complicaciones , Aneurisma/diagnóstico por imagen , Aneurisma/cirugía , Isquemia/diagnóstico por imagen , Isquemia/etiología , Isquemia/cirugía , Arteriopatías Oclusivas/cirugía , Enfermedades Vasculares Periféricas/cirugía , Estudios Retrospectivos , Arteria Poplítea/diagnóstico por imagen , Arteria Poplítea/cirugía , Recuperación del Miembro/efectos adversosRESUMEN
BACKGROUND: An increased prevalence of thoracic aortic aneurysms (TAA) has been demonstrated in patients with simple renal cysts (SRC); patients with SRC have a less elastic aortic wall than those without SRC. The purpose of this study was to evaluate aneurysm sac shrinkage after thoracic endovascular aortic repair (TEVAR) for true TAA in patients with and without SRC. METHODS: One hundred three patients with true aneurysms of the thoracic aorta who underwent TEVAR at our university hospital from November 2013 to December 2021 were included in this study. Aneurysm sac size was compared between that on baseline preoperative computed tomography and that on postoperative computed tomography scans at 1 year. A change in aneurysm sac size ≥5 mm was considered to be significant, whether due to expansion or shrinkage. RESULTS: The patients were divided into two groups: those with SRC (46 patients [45%]) and those without SRC (57 patients [55%]). At 1 year, there was a significant difference in the proportion of aneurysm sac shrinkage between patients with SRC and those without SRC (23.9% vs 59.6%; P < .001). Patients with SRC showed significantly less aneurysm sac shrinkage than those without SRC (-1.8 ± 5.6 mm vs -5.1 ± 6.6 mm; P = .009). Univariable and multivariable analyses showed that the initial sac diameter (odds ratio, 1.08; 95% confidence interval, 1.03-1.14; P = .002) and the presence of SRC (odds ratio, 0.15; 95% confidence interval, 0.06-0.40; P < .001) were positively and negatively associated with aneurysm sac shrinkage after TEVAR, respectively. CONCLUSIONS: The presence of a SRC was independently associated with failure of aneurysm sac shrinkage after TEVAR for true TAA. This suggests that the presence of a SRC may be a predictor for the failure of aneurysm sac shrinkage after TEVAR.
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Aneurisma de la Aorta Torácica , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Enfermedades Renales Quísticas , Humanos , Reparación Endovascular de Aneurismas , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/métodos , Resultado del Tratamiento , Factores de Riesgo , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/métodos , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/cirugía , Estudios RetrospectivosRESUMEN
BACKGROUND: Arteriovenous fistulae (AVF) are the gold standard for vascular access for hemodialysis. Although the vein must thicken and dilate for successful hemodialysis, excessive wall thickness leads to stenosis causing AVF failure. Since TGF-ß (transforming growth factor-beta) regulates ECM (extracellular matrix) deposition and smooth muscle cell (SMC) proliferation-critical components of wall thickness-we hypothesized that disruption of TGF-ß signaling prevents excessive wall thickening during venous remodeling. METHODS: A mouse aortocaval fistula model was used. SB431542-an inhibitor of TGF-ß receptor I-was encapsulated in nanoparticles and applied to the AVF adventitia in C57BL/6J mice. Alternatively, AVFs were created in mice with conditional disruption of TGF-ß receptors in either SMCs or endothelial cells. Doppler ultrasound was performed serially to confirm patency and to measure vessel diameters. AVFs were harvested at predetermined time points for histological and immunofluorescence analyses. RESULTS: Inhibition of TGF-ß signaling with SB431542-containing nanoparticles significantly reduced p-Smad2-positive cells in the AVF wall during the early maturation phase (days 7-21) and was associated with decreased AVF wall thickness that showed both decreased collagen density and decreased SMC proliferation. SMC-specific TGF-ß signaling disruption decreased collagen density but not SMC proliferation or wall thickness. Endothelial cell-specific TGF-ß signaling disruption decreased both collagen density and SMC proliferation in the AVF wall and was associated with reduced wall thickness, increased outward remodeling, and improved AVF patency. CONCLUSIONS: Endothelial cell-targeted TGF-ß inhibition may be a translational strategy to improve AVF patency.
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Fístula Arteriovenosa , Derivación Arteriovenosa Quirúrgica , Animales , Colágeno , Modelos Animales de Enfermedad , Células Endoteliales , Ratones , Ratones Endogámicos C57BL , Factor de Crecimiento Transformador beta , Factores de Crecimiento Transformadores , Remodelación Vascular/fisiologíaRESUMEN
INTRODUCTION: Evaluation of limb hemodynamics using the ankle-brachial index (ABI) may be difficult due to skin lesions, extensive necrosis, and obesity, such as commonly present in patients with diabetes with chronic limb-threatening ischemia (CLTI). We hypothesized that the pedal acceleration time (PAT) correlates with ABI and Wound, Ischemia, and foot Infection (WIfI) scores in patients with diabetes to serve as a new modality to accurately stage CLTI. METHODS: A single-center, cross-sectional study included patients with and without diabetes > 18 years with CLTI. Limbs were categorized in three grades of ischemia based on the ABI (ABI < 0.8, < 0.6, and < 0.4) and in two classes based on WIfI stages of amputation risk. Receiver operator characteristic (ROC) curves were used to determine PAT sensitivity, specificity, and accuracy to predict lower-limb ischemia. RESULTS: A total of 141 patients (67 nondiabetic and 74 diabetic) and 198 lower limbs (94 nondiabetic and 104 diabetic) met the inclusion criteria. In patients without diabetes, the accuracy of PAT for detecting an ABI < 0.8 was 85%; for detecting an ABI < 0.6 was 85%; and for detecting an ABI < 0.4 was 87%. In patients with diabetes, the accuracy of PAT in detecting an ABI < 0.8 was 91%; for detecting an ABI < 0.6 was 79%; and for detecting an ABI < 0.4 was 88%. In patients without diabetes, the accuracy for detecting WIfI stages of moderate and high amputation risk was 77% and for patients with diabetes was also 77%. CONCLUSIONS: PAT shows high correlation with the ABI as well as with the WIfI stages of amputation risk and the grades of ischemia, with high accuracy.
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Diabetes Mellitus , Enfermedad Arterial Periférica , Humanos , Estudios Transversales , Factores de Riesgo , Resultado del Tratamiento , Recuperación del Miembro , Estudios Retrospectivos , Isquemia , Medición de RiesgoRESUMEN
BACKGROUND: Vascular malformations are rare diseases and treatment remains controversial. Sclerotherapy is accepted as a minimally invasive treatment with good results; however, some patients do not report good response to sclerotherapy, and it is not clear which variables influence treatment outcome, preventing optimal patient selection. We hypothesized that large diameter lesions have reduced efficacy and satisfaction with sclerotherapy. Therefore, we prospectively evaluated the clinical response of low-flow vascular malformations treated with 1% polidocanol foam sclerotherapy and determined the correlation of symptom improvement with clinical variables. METHODS: Prospective cohort study of patients with symptomatic low flow vascular malformations treated at the Hospital das Clínicas between December 2016 and November 2018. Lesions were classified according to location, extension, diameter, type of vessels, margins, and symptoms. Sclerotherapy was performed by direct injection of 1% polidocanol foam, with a maximum volume of 10 ml per session. Symptom improvement was evaluated using the visual analog scale and patient-reported quality of life was assessed by the Short-form 6 dimensions (SF-6D) questionnaire. Follow-up was performed every 3 months after treatment. RESULTS: Forty lesions were treated in 38 patients, with 19 women and 19 men; median age was 20.5 years (range 4 months to 63 years). Most lesions (80%) were venous, and most commonly in the lower limbs (47.5%); 27.5% were superficial, 35% were deep, and 37.5% affected both compartments. The most common clinical presentations were deformity (95%), pain (78%), and functional limitation (58%); deep compartment lesions were more associated with functional limitation (69% vs. 27%; P = 0.030). Fifty-three per cent of lesions were >10 cm and were associated with increased numbers of psychosocial symptoms (P = 0.038). Two-hundred and forty-two sessions of sclerotherapy were performed, with 6 mean treatments per lesion (range 1-15). The mean follow-up time was 23 months (range 2-23 months). The most common complications were pain and local edema, without any major complications; some patients reported symptom recurrence (15% pain, 10% deformity, and 12% functional limitation). Sclerotherapy was associated with significant improvement of all symptoms (P < 0.001). However, lesions >10 cm were associated with poor improvement in deformity (P = 0.003). Quality of life improved for most patients (60%) and treatment satisfaction was high (82%). CONCLUSIONS: Treatment of low-flow vascular malformations with 1% polidocanol foam is safe and effective; sclerotherapy improves symptoms and quality of life. Large diameter lesions (>10 cm) are associated with increased treatment failure. A small percentage of patients reported recurrent symptoms and require other modalities for successful treatment.
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Escleroterapia , Malformaciones Vasculares , Masculino , Humanos , Femenino , Lactante , Escleroterapia/efectos adversos , Escleroterapia/métodos , Polidocanol/efectos adversos , Soluciones Esclerosantes/efectos adversos , Estudios Prospectivos , Calidad de Vida , Resultado del Tratamiento , Estudios Retrospectivos , Malformaciones Vasculares/terapia , Malformaciones Vasculares/tratamiento farmacológico , Dolor/etiologíaRESUMEN
BACKGROUND: Arteriovenous fistulae mature less frequently in women than in men, leading to inferior patency and decreased fistula utilization in women. We hypothesized that both anatomic and physiologic sex differences explain reduced maturation. METHODS: The electronic medical records of patients who had a primary arteriovenous fistula created from 2016 to 2021 at a single center were reviewed; sample size was determined using a power calculation. Postoperative ultrasound and laboratory tests were obtained at least 4 weeks after fistula creation. Primary unassisted fistula maturation was determined up to 4 years postprocedure. RESULTS: A total of 28 women and 28 men with a brachial-cephalic fistula were analyzed. The inflow brachial artery diameter was smaller in women than in men, both preoperatively (4.2 ± 0.9 vs. 4.9 ± 1.0 mm, P = 0.008) and postoperatively (4.8 ± 0.8 vs. 5.3 ± 0.9 mm, P = 0.039). Despite similar preoperative brachial artery peak systolic velocity, women had significantly lower postoperative arterial velocity (P = 0.027). Fistula flow was reduced in women, particularly in the midhumerus (747.0 ± 570.4 vs. 1,117.1 ± 471.3 cc/min, P = 0.003). Percentages of neutrophils and lymphocytes were similar among women and men 6 weeks after fistula creation. However, women had reduced monocytes (8.5 ± 2.0 vs. 10.0 ± 2.6%, P = 0.0168). Among 28 men, 24 of 28 (85.7%) achieved unassisted maturation, whereas only 15 of 28 (53.6%) women had fistulae that matured without intervention. Secondary analysis using logistic regression suggested that postoperative arterial diameter was associated with maturation in men, while postoperative monocyte percentage was associated with maturation in women. CONCLUSIONS: Sex differences during arteriovenous fistula maturation are present in arterial diameter and velocity, suggesting that both anatomic and physiologic differences in arterial inflow contribute to sex differences in fistula maturation. In men, postoperative arterial diameter is correlated with maturation, whereas in women, the significantly lower proportion of circulating monocytes suggests a role for the immune response in fistula maturation.
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Fístula Arteriovenosa , Derivación Arteriovenosa Quirúrgica , Humanos , Femenino , Masculino , Derivación Arteriovenosa Quirúrgica/efectos adversos , Derivación Arteriovenosa Quirúrgica/métodos , Monocitos , Resultado del Tratamiento , Diálisis Renal/métodos , Arteria Braquial/diagnóstico por imagen , Arteria Braquial/cirugía , Grado de Desobstrucción Vascular , Estudios RetrospectivosRESUMEN
BACKGROUND: The aim of the study was to determine the change in skeletal muscle mass over time by bioelectrical impedance analysis (BIA) in patients with peripheral artery disease (PAD). METHODS: Patients with symptomatic PAD visiting Tokyo Medical University Hospital between January 2018 and October 2020 were retrospectively analyzed. PAD was diagnosed based on ankle brachial pressure index (ABI) < 0.9 with either leg and confirmed by duplex scan and/or computed tomography angiography as needed. Patients undergoing endovascular treatment, surgery, or supervised exercise therapy were excluded before and during the study period. Skeletal muscle mass of the extremities was measured using BIA. The sum of skeletal muscle masses in the arms and legs was calculated as skeletal muscle mass index (SMI). Patients were scheduled to undergo BIA at an interval of 1 year. RESULTS: Of 119 patients, 72 patients were included in the study. All patients were ambulatory and had symptoms of intermittent claudication (Fontaine's stage II). SMI significantly decreased from 6.98 ± 1.30 at baseline to 6.83 ± 1.29 at 1-year follow-up. Individual skeletal muscle mass of the ischemic leg was significantly reduced after 1 year, but not in the nonischemic leg. A decrease in SMI (defined as SMI ≥0.1 kg/m2 per year) was independently associated with low ABI. The optimal cut-off value of ABI for the decrease in SMI was 0.72. CONCLUSIONS: These results suggest that lower limb ischemia due to PAD, especially if ABI is < 0.72 or less, may result in a decrease in skeletal muscle mass that affects health and physical function.