Trends and perioperative outcomes of patients with human immunodeficiency virus (HIV) undergoing lower extremity revascularization.

The development of highly active antiretroviral therapy (HAART) has significantly improved the life expectancy of patients with human immunodeficiency virus (HIV), but has led to the rise of chronic conditions including peripheral artery disease (PAD). However, trends and outcomes among patients with HIV undergoing lower extremity revascularization are poorly characterized. The aim of this study was to investigate the trends and perioperative outcomes of lower extremity revascularization among patients with HIV and PAD in a national database. The National Inpatient Sample (NIS) was reviewed between 2003 and 2014. All hospital admissions with a diagnosis of PAD undergoing lower extremity revascularization were stratified based on HIV status. Outcomes were assessed using propensity score matching and multivariable regression. Among all patients undergoing lower extremity revascularization for PAD, there was a significant increase in the proportion of patients with HIV from 0.21% in 2003 to 0.52% in 2014 (p < 0.01). Patients with HIV were more likely to be younger, male, and have fewer comorbidities, including coronary artery disease and diabetes, at the time of intervention compared to patients without HIV. With propensity score matching and multivariable regression, HIV status was associated with increased total hospital costs, but not length of stay, major amputation, or mortality. Patients with HIV with PAD who undergo revascularization are younger with fewer comorbidities, but have increased hospital costs compared to those without HIV. Lower extremity revascularization for PAD is safe for patients with HIV without increased risk of in-hospital major amputation or mortality, and continues to increase each year.

Costs and complications of endovascular inferior vena cava filter retrieval.

OBJECTIVE: Advanced endovascular techniques are frequently used for challenging inferior vena cava (IVC) filter retrieval. However, the costs of IVC filter retrieval have not been studied. This study compares IVC filter retrieval techniques and estimates procedural costs. METHODS: Consecutive IVC filter retrievals performed at a tertiary center between 2009 and 2014 were retrospectively reviewed. Procedures were classified as standard retrieval (SR) if they required only a vascular sheath and a snare device and as advanced endovascular retrieval (AER) if additional endovascular techniques were used for retrieval. Cost data were based on hospital bills for the procedures. Patients' characteristics, filter dwell time, retrieval procedure details, complications, and costs were compared between the groups. All statistical comparisons were performed using SAS 9.3 software. RESULTS: There were 191 IVC filter retrievals (SR, 157; AER, 34) in 183 patients (mean age, 55 years; 51% male). Fifteen filters (7.9%) were placed at an outside hospital. The indications for placement were mostly therapeutic (76% vs 24% for prophylaxis). All IVC filters were retrievable, with Bard Eclipse (Bard Peripheral Vascular, Tempe, Ariz; 34%) and Cook Günther Tulip (Cook Medical, Bloomington, Ind; 24%) the most common. Venous ultrasound examination of the lower extremities of 133 patients (70%) was performed before retrieval, whereas only 5 patients (2.6%) received a computed tomography scan of the abdomen. There was no difference in the mean filter dwell time in the two groups (SR, 147.9 ± 146.1 days; AER, 161.4 ± 91.3 days; P = .49). AERs were more likely to have had prior attempts at retrieval (23.5%) compared with SRs (1.9%; P < .001). The most common AER techniques used were the wire loop and snare sling (47.1%) and the stiff wire displacement (44.1%). Bronchoscopy forceps was used in four cases (11.8%); this was the only off-label device used. AERs were more likely to require more than one venous access site for the retrieval procedure (23.5% vs 0%; P < .001). AERs were significantly more likely to have longer fluoroscopy time (34.4 ± 18.3 vs 8.1 ± 7.9 minutes; P < .001) and longer total procedural time (102.8 ± 59.9 vs 41.1 ± 25.0 minutes; P < .001) compared with SRs. The complication rate was higher with AER (20.6%) than with SR (5.2%; P = .006). Most complications were abnormal radiologic findings that did not require additional intervention. The procedural cost of AER was significantly higher (AER, $14,565 ± $6354; SR, $7644 ± $2810; P < .001) than that of SR. This translated to an average increase in cost of $6921 ± $3544 per retrieval procedure for AER. CONCLUSIONS: Advanced endovascular techniques provide a feasible alternative when standard IVC filter retrieval techniques do not succeed. However, these procedures come with a higher cost and higher rate of complications.

National trends in hospitalizations for venous thromboembolism.

OBJECTIVE: The management of venous thromboembolism (VTE) has evolved during the last decade. This study sheds light on the national trends in hospital admissions, outcomes, and economic burden for VTE. METHODS: The National Inpatient Sample (NIS) was reviewed between 2003 and 2013 for hospitalizations for VTE, defined as admissions with a principal diagnosis of deep venous thrombosis (DVT) or pulmonary embolism (PE). Outcomes measured were incidence, inpatient mortality, rates of interventions, hospital length of stay (LOS), and charges. A multivariate analysis was used to identify independent predictors of mortality in patients with VTE. RESULTS: There were 3,368,409 admissions for VTE (54% female; mean age, 62.9 years), at an average of 818 per 100,000 admissions per year. Hospitalizations for PE and VTE significantly increased (P < .01), with no change for DVT (P = .13). Use of catheter-directed thrombolysis increased (0.8% to 2.7%; P < .01), with no significant change in use during the study period (P = .10). The mortality associated with hospitalizations for VTE, PE, and DVT decreased (P < .01). Mean LOS decreased from 5.79 to 4.77 days (P < .01), whereas mean hospital charges increased from $29,755 to $39,171 (P < .01). At the national level, the economic burden of VTE hospitalizations increased from $7.8 billion in 2003 to $12.1 billion in 2013 (P < .01). Older age (odds ratio [OR], 1.03), female gender (OR, 1.05), race (OR, 1.43 for Asian, 1.18 for African American, and 1.18 for Hispanic compared with white), PE (OR, 4.12), and Charlson Comorbidity Index (CCI) ≥3 (OR, 2.75) were all predictors of inpatient mortality (P < .01 for all ORs). CONCLUSIONS: Hospitalizations for VTE increased during the past decade, whereas mortality decreased. Despite a decrease in LOS, there is a rise in economic burden of VTE on the health care system.