Impact of Care Fragmentation after Major Lower Extremity Amputation.

BACKGROUND: Care fragmentation (CF) is a known risk factor for unplanned readmission, morbidity, and mortality after surgery. The goal of this study was to evaluate the impact of CF on outcomes of major lower extremity amputation for peripheral vascular disease. METHODS: Health-care Cost and Utilization Project Database for NY (2016) and MD/FL (2016-2017) were queried using International Classification of Diseases 10thedition to identify patients who underwent above the knee-, through the knee-, and below the knee-amputation for peripheral vascular disease. Patients with CF were identified as those with admissions to ≥2 hospitals during the study period. We compared the postamputation outcomes of mortality, readmission rate, length of stay (LOS) and hospital charges. RESULTS: We identified a total of 13,749 encounters of 2,742 patients who underwent major lower extremity amputations. There were 1,624 (59.2%) patients with CF. Patients with CF were younger (68.4 years old vs. 69.7 years old, P = 0.005), with higher Charlson Comorbidity Indices (4.4 vs. 4.1, P < 0.001), and required more hospital resources on index admission ($113,699 vs. $91,854, P < 0.001). These patients were prevalent for higher 30-, and 90-day readmission rates (34.7% vs. 24.5%, P < 0.001 and 54.7% vs. 42.0%, P < 0.001, respectively). On their first postamputation readmission, LOS (16.3 days vs. 14.7 days, P = 0.004) and hospital charge ($48,964 vs. $44,388, P = 0.002) were significantly higher. Multivariate regression analysis demonstrated that the CF was an independent predictor for 30-day (hazard ratio (HR) 1.65, 95% confidence interval (CI) 1.39-1.96, P < 0.001) and 90-day (HR 1.66, 95% CI 1.42-1.95, P < 0.001) readmission after the major lower extremity amputation, but not for mortality (HR 0.83, 95% CI 0.56-1.23, P = 0.36). CONCLUSIONS: CF after major lower extremity amputation is associated with higher readmission rate, LOS, and hospital charge. Collaboration of care providers to maintain continuity of care for peripheral vascular disease patients may enhance quality of care and reduce health care cost.

Analysis of a Novel Inpatient Acute Limb Ischemia Alert System.

OBJECTIVES: Acute limb ischemia (ALI) is a surgical emergency that generally develops in the outpatient setting. Hospitalized patients are also at risk for acute limb ischemia, but their presentation may be atypical or altered by medical therapy. Our institution developed an alert system to facilitate the prompt recognition and treatment of ALI that occurs in the inpatient population. We aimed to evaluate the usage of the system after the first 2 years of operation. METHODS: All ALI alerts from October 2017 to December 2019 were collected from paging records and analyzed for location, timing, and the need for intervention. Alerts undergoing vascular intervention were classified as urgent (within 8 hours) or delayed (after 8 hr). Time and location data were evaluated to determine patterns of usage and true-positive rate of the system. RESULTS: From October 2017 to December 2019, there were 237 ALI alerts obtained from paging records containing time and location information for the alert. More alerts originated from ICUs relative to non-ICU floors (68% vs. 33%, P< 0.001), however a greater proportion of non-ICU floor alerts required intervention compared to ICU alerts (32.0% vs. 5.1%, P < .0001). The highest number of ALI alerts were from the Medical ICU (MRICU) (45.9%) and medical/surgical floors (33.3%), followed by Surgical ICU (20.2%). Alerts were more common within 3 hr of morning and evening nursing shift changes (47.3%, P < 0.001). From the 237 total alerts, the patient was able to be identified retrospectively in 186 cases, and of these 27 resulted in operative interventions (14.5%, positive predictive value), with 11 patients (40.7%) requiring urgent intervention with a median time to intervention of 3.5 hr (range 2.2-4.8), and 16 (59%) alerts undergoing a delayed intervention at a mean of 3 days (range 2-4). A total of 73 (39.2%) alert patients died during their admission, of which 65 (89.0%) were in an ICU, and no deaths were directly related to ALI. The median time to death was 2 days (range 0-95 days), and in 22 cases death occurred <24 hr from time of alert. CONCLUSION: Our novel hospital-wide ALI alert system demonstrates a 14.5% positive predictive value for ischemia that resulted in an intervention. Alerts were more likely to originate from the ICU setting and during nursing shift changes. Alerts originating from non-ICU floors were 5 times more likely to undergo surgical intervention for ALI. Further analysis is required to assess the effect of this system on patient safety, outcome, and allocation of institutional resources.

Outcomes of laparoscopic-assisted ERCP in gastric bypass patients at a community hospital center.

BACKGROUND: Obesity is a prevalent issue in today's society, increasing the number of gastric weight loss surgeries (Bowman et al. in Surg Endosc. https://doi.org/10.1007/s00464-016-4746-8 , 2016; Choi et al. in Surg Endosc. https://doi.org/10.1007/s00464-013-2850-6 , 2013; Paranandi et al. in Frontline Gastroenterol. https://doi.org/10.1136/flgastro-2015-100556 , 2015; Richardson et al. in http://www.ingentaconnect.com/content/sesc/tas , 2012). This presents an anatomical challenge to biliary disease requiring endoscopic retrograde cholangiopancreatography (ERCP) as the traditional is technically difficult, requiring a longer endoscope with a reported success rate of less than 70% (Roberts et al. in https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016032/ , 2008). A solution is laparoscopic-assisted ERCP (LA-ERCP) via gastrostomy. We present our experience with LA-ERCP at our teaching community hospital in a large cohort of patients. METHODS: An IRB-approved retrospective chart review was performed on patients with prior gastric bypass surgery who underwent LA-ERCP from April 2008 to April 2016. The procedure involved two bariatric surgeons and one gastroenterologist. The gastric remnant was secured to the abdominal wall with a purse-string suture and transfascial stay sutures. After gastrostomy creation of a duodenoscope was inserted to perform ERCP. Biliary sphincterotomy, dilation, and stone removal were performed as indicated. We observed the incidence of postoperative outcomes, including acute pancreatitis, reoperation, post-procedure infection, pain control, hospital readmission, and bile leak. RESULTS: Thirty-two patients met inclusion criteria. The majority of indications for LA-ERCP was choledocholithiasis (16/32). The remainder of cases included indications such as abnormal LFTs with biliary dilation (11/32), acute pancreatitis (2/32), cholangitis (2/32), and bile leak (1/32). LA-ERCP was successfully performed in all patients. Biliary sphincterotomy and stone extraction were performed on 31/32 patients. One patient underwent sphincterotomy and stent placement for bile leak after recent laparoscopic cholecystectomy. One patient developed acute pancreatitis with elevated pancreatic enzymes which resolved on POD2. The median length of stay was 2 days. CONCLUSION: LA-ERCP is a safe and feasible alternative to open surgery and can be safely implemented at community hospitals with adequately trained providers. Our large study proves that in this minimally invasive era, LA-ERCP provides gastric bypass patients a safe alternative with less pain and increased satisfaction.

Active Tobacco Use in Patients with Claudication Does Not Affect Outcomes after Endovascular Interventions.

BACKGROUND: With the advent of endovascular procedures, the indications for intervention in claudicants have become less strict. Many interventionalists, however, will not intervene in patients with lifestyle-limiting claudication unless they have discontinued tobacco use. Many patients are unable to comply with this goal, and there is little published evidence to suggest that continued tobacco use results in poorer outcomes. We sought to determine if it is justified to deny this group of patients endovascular, potentially lifestyle-improving, procedures based on their outcomes. METHODS: A retrospective chart review was performed between 2007 and 2011 at a midsize community teaching hospital. Patients included had documented lifestyle-limiting claudication, underwent endovascular therapy, and had no previous vascular intervention. Patients were divided into 2 groups: active smokers (AS) and nonsmokers (NS) including former and never smokers. The primary outcome was the need for reintervention and the secondary outcomes were the need for surgical revascularization, limb loss, myocardial infarction (MI), stroke, and death. RESULTS: One hundred thirty-eight patients met inclusion criteria with 89 being male (64.5%). Forty-seven (34%) were active smokers versus 91 (66%) who were nonsmokers. Mean age at initial intervention for all 138 subjects was 66.34 years (standard deviation 10.7) and was not statistically different between the AS and NS groups. Mean follow-up was 3.6 years and was not significantly different between the two groups. Between the two groups (AS vs NS), there was no statistically significant difference between the rate of reintervention, surgical bypass, and limb loss. We also did not observe any significant difference in the rate of MI, stroke, or death during our follow-up period. CONCLUSIONS: Although tobacco use has been shown to negatively impact bypass patency, our data show that it does not appear to increase the need for reintervention, conversion to open surgical revascularization, limb loss, or other morbidities in patients undergoing endovascular interventions for claudication. We continue to strongly recommend all our patients who smoke to discontinue tobacco use. Our results, however, do not support the notion that those patients who are unable to quit should be denied the potential benefit of an endovascular intervention. The most important limitation of our study is the small numbers of patients available for review. Larger studies will be necessary to confirm our findings.

Successful Use of Orbital Atherectomy as an Adjunct in Treating Extensively Calcified Mesenteric Artery Lesions.

BACKGROUND: To describe the use of orbital technique of atherectomy as an adjunct to successful angioplasty and stent placement of the superior mesenteric artery (SMA). CASE REPORT: The technique is demonstrated in a 68-year-old man with critical SMA stenosis. The SMA was cannulated with 0.014-in wire, but the lesion was highly stenotic and densely calcified and prevented the passage of even the smallest 1.5-mm balloon. Orbital atherectomy was thus performed with a 1.25-mm CSI crown. Balloon angioplasty was then possible with a 4 mm × 2 cm balloon followed by placement of a 7 mm × 22 mm balloon-mounted stent. CONCLUSIONS: The use of atherectomy as an adjunct to angioplasty and stenting in extensive, calcified SMA lesions supports the value of this technique to avoid a much larger and morbid open procedure.

Repeated Endovascular Interventions Are Worthwhile, Even After Thrombosis, to Maintain Long-Term Use of Autogenous Dialysis Fistulas.

OBJECTIVES: Patients often require multiple access re-interventions to improve fistula patency and the overall usable lifespan of autogenous arteriovenous fistula (aAVF). There is no consensus on the appropriate number of re-interventions after which an access should be abandoned and new access placed. We evaluated whether repeated endovascular interventions for failing/failed aAVF are worthwhile or futile. METHODS: A retrospective review was performed on aAVFs created between 2009-2014. Fistula function was evaluated until January 2017. Functional fistula patency (FFP) was defined as the total time of functional fistula use for hemodialysis, from time of cannulation to time of measurement or fistula abandonment, including all interventions performed to maintain/reestablish patency. Primary outcomes were FFP duration and number of post-dialysis interventions. RESULTS: The study included 163 patients. Mean age was 67 (SD = 15.03). The only variable statistically different between functional fistulas and abandoned fistulas was obesity (p = 0.03). At the end of the study period, 145 (89.0%) patients continued to have functional fistulas, and 73 (44.8%) patients died, but had functional fistulas at time of death. Median FFP for the functional group was 3.18 years (range 0.01-7.01 years) and median number of interventions was 1 (range 0-13). In 18 patients (11%), the fistula was abandoned, most commonly due to thrombosis (47.1%), followed by infection (23.5%). No fistula was abandoned because of an unacceptable rate of reintervention. Median FFP in the abandoned group was 0.91 years (range 0.03-5.30 years), and median number of interventions was 0 (range of 0-5). CONCLUSIONS: Through repeated interventions on aAVFs, none of the patients in our study exhausted all hemodialysis access options prior to transplantation, death or loss to follow-up. These results may indicate repeated and/or more frequent revisions do not negatively affect the FFP nor do they increase the overall risk for abandonment of aAVFs.

Rare Case of Acute Type B Dissection Causing Complete Collapse of EVAR Stent.

We describe a unique case of an acute type B aortic dissection in a patient with a history of a previously placed infrarenal aortic stent for an abdominal aortic aneurysm. The patient presented with a hypertensive emergency and left lower extremity ischemia, and imaging revealed complete collapse of the previously placed stent graft with extension into the iliac limbs. He underwent emergent endovascular intervention. When the false lumen was entered by puncturing the dissection plane with a sheath, immediate reexpansion of the stent graft was observed. The entry point of the dissection was covered with 2 overlapping stents, restoring flow within the true lumen. Although aortic stent collapse from acute type B aortic dissections is extremely rare, we demonstrate that endovascular release of the outflow obstruction and depressurizing the false lumen can resolve this dreaded complication.