Clinical Effectiveness and Resource Utilization of Surgery versus Endovascular Therapy for Chronic Limb-Threatening Ischemia.

BACKGROUND: The clinical effectiveness of surgical versus endovascular therapy for chronic limb-threatening ischemia (CLTI) continues to be debated, and the resources required for each therapy are unclear. METHODS: Systematic review of randomized controlled trials (RCTs) and observational studies comparing surgery with endovascular therapy for CLTI, which reported clinical effectiveness and resource utilization. Short-term and long-term clinical outcomes were examined. RESULTS: The search yielded 4,231 titles, of which 17 publications met our inclusion criteria. Five publications were all from 1 RCT, and 12 publications were observational studies. In the RCT, the surgical approach had greater resource use in the first year (total hospital days across all admissions for surgery versus angioplasty: 46.14 ± 53.87 vs. 36.35 ± 51.39; P < 0.001; also true for days in high-dependency and intensive therapy units), but differences were not statistically significant in subsequent years. All-cause mortality presented a nonsignificant difference favoring angioplasty in the first 2 years (adjusted hazard ratio [aHR], 1.27; 95% confidence interval [95% CI], 0.75-2.15), but after 2 years, it favored surgical treatment (aHR, 0.34; 95% CI, 0.17-0.71). The observational studies reported short-term effectiveness and resource utilization favoring endovascular therapy, but most differences were not statistically significant. Long-term outcomes were more mixed; in particular, mortality outcomes generally favored surgery, although concluding that cause and effect is not possible as endovascularly treated patients tended to be older and may have had a shorter life expectancy regardless of therapy. CONCLUSIONS: The clinical effectiveness and resource utilization of surgery compared with endovascular therapy for CLTI is not known with certainty and will not be known until ongoing trials report results. It is likely that findings will vary by the time horizon, where initial outcomes and utilization tend to favor endovascular interventions, but long-term outcomes favor surgical revascularization.

Early Outcomes of Routine Delayed Shunting in Carotid Endarterectomy for Asymptomatic Patients.

OBJECTIVE/BACKGROUND: The aim was to evaluate early outcomes of carotid endarterectomy (CEA) in asymptomatic patients using a standardised technique based on routine shunting after rapid plaque removal ("delayed"). METHODS: A retrospective review of all asymptomatic patients who underwent CEA during a 10 year single centre experience (January 2007-December 2016) was performed. The technique was based on rapid endarterectomy with distal intimal edge visualisation, followed by routine shunt insertion; subsequent time spent on the manoeuvre and closure were completed under shunting. Primary endpoints were relevant neurological complication rate (RNCR) and death within 30 days. To better identify any difference related to changes in medical therapy, anaesthetic management, and different operators over time, patients were divided into group A (underwent CEA in the first 5 year period) and group B (underwent CEA during the second 5 year period). Univariate analysis of factors associated with RNCR was performed. Operator experience (seniority), expertise (CEA volume per year), and time period were incorporated. RESULTS: In total, 1745 patients matched the inclusion criteria and were enrolled. Altogether, 147 (8.9%) had contemporary contralateral stenosis ≥70% and 58 (3.5%) had contralateral internal carotid artery chronic occlusion. No patient died peri-operatively; major myocardial infarction occurred in 19 patients (1.1%). Overall, peri-operative RNCR was 0.6% (major stroke: n = 6 [0.4%]; minor stroke: n = 4 [0.2%]). RNCR distribution was maintained equally comparing group A and B (0.8% vs. 0.4%; p = 0.17). No differences were found in RNCR when comparing operator experience (p = 0.88) and expertise (p = 0.93). Univariable analysis found diabetes as the only clinical factor influencing RNCR (odds ratio 3.79, 95% confidence interval 1.06-13.50; p = 0.04); none of the other factors, such as time period, operator experience, and expertise, reached statistical significance. CONCLUSIONS: Routine delayed shunting associated with standardisation of the technique seems to be a safe and effective technique and contributes to maintaining the RNCR < 1% over time and independently from operators and other clinical factors.

Development and Validation of a Novel Literature-Based Method to Identify Disparity-Sensitive Surgical Quality Metrics.

BACKGROUND: Disparity in surgical care impedes the delivery of uniformly high-quality care. Metrics that quantify disparity in care can help identify areas for needed intervention. A literature-based Disparity-Sensitive Score (DSS) system for surgical care was adapted by the Metrics for Equitable Access and Care in Surgery (MEASUR) group. The alignment between the MEASUR DSS and Delphi ratings of an expert advisory panel (EAP) regarding the disparity sensitivity of surgical quality metrics was assessed. STUDY DESIGN: Using DSS criteria MEASUR co-investigators scored 534 surgical metrics which were subsequently rated by the EAP. All scores were converted to a 9-point scale. Agreement between the new measurement technique (ie DSS) and an established subjective technique (ie importance and validity ratings) were assessed using the Bland-Altman method, adjusting for the linear relationship between the paired difference and the paired average. The limit of agreement (LOA) was set at 1.96 SD (95%). RESULTS: The percentage of DSS scores inside the LOA was 96.8% (LOA, 0.02 points) for the importance rating and 94.6% (LOA, 1.5 points) for the validity rating. In comparison, 94.4% of the 2 subjective EAP ratings were inside the LOA (0.7 points). CONCLUSIONS: Applying the MEASUR DSS criteria using available literature allowed for identification of disparity-sensitive surgical metrics. The results suggest that this literature-based method of selecting quality metrics may be comparable to more complex consensus-based Delphi methods. In fields with robust literature, literature-based composite scores may be used to select quality metrics rather than assembling consensus panels.

Perioperative and Long-Term Outcomes of Robot-Assisted Partial Nephrectomy: A Systematic Review.

BACKGROUND: Adoption of the robotic surgical platform for small renal cancers has rapidly expanded, but its utility compared to other approaches has not been established. The objective of this review is to assess perioperative and long-term oncologic and functional outcomes of robot-assisted partial nephrectomy (RAPN) compared to laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN). METHODS: A search in PubMed, Embase, and Cochrane (2010-2019) was conducted. Of 3877 articles screened, 7 observational studies were included. RESULTS: RAPN was associated with 24-50 mL less intraoperative blood loss compared to LPN and 39-84 mL less than OPN. RAPN also demonstrated trends of other postoperative benefits, such as shorter length of stay and fewer major complications. Several studies reported better long-term functional kidney outcomes, but these findings were inconsistent. Recurrence and cancer-specific survival (CSS) were similar across groups. While RAPN had a 5-year CSS of 90.1%-97.9%, LPN and OPN had survival rates of 85.9%-86.9% and 88.5-96.3% respectively. CONCLUSIONS: RAPN may be associated with a lower estimated blood loss and comparable long-term outcomes when compared to other surgical approaches. However, additional randomized or propensity matched studies are warranted to fully assess long-term functional kidney and oncologic outcomes.