RESUMO
OBJECTIVE: Surgeons' prescription practices and the opioid epidemic have received significant attention in the media. Limited data exist, however, on the impact of prior or coexistent opioid use on vascular surgery outcomes. This study aimed to quantify the incidence, economic burden, and clinical impact of pre-existing opioid dependency in patients undergoing lower extremity bypass (LEB) surgery. METHODS: Data were collected from 1,132,645 weighted (230,858 unweighted) patient admissions for LEB in the National Inpatient Sample for the years 2002 to 2015. Patients with a concomitant diagnosis of opioid abuse or dependency were identified using International Classification of Diseases, Ninth Revision codes. Matched cohorts of patients with (n = 606 unweighted) and without (n = 32,343 unweighted) opioid dependence were created using coarsened exact matching to control for patient demographics. Linear regression was used to control for hospital-level factors and to identify differential outcomes for patients with opioid dependency. Our primary end points were hospital cost and length of stay. Our secondary end points were surgical complications and in-hospital mortality. RESULTS: There were 1,132,645 (230,858 unweighted) patient admissions for LEB in the National Inpatient Sample during 2002 to 2015. There were 3190 (0.3%) patients (643 unweighted) who had a diagnosis of pre-existing opioid dependency. The incidence of opioid dependency rose over time (2002, 0.13%; 2015, 0.63%; R2 = 0.90; P < .001). Before matching, opioid-dependent patients were younger (53.9 ± 12.3 years vs 66.7 ± 12.1 years; P < .001) and more likely to be male (65.2% vs 61.9%; P < .001), to be nonwhite (37.9% vs 24.1%; P < .001), to pay with Medicaid (29.6% vs 7.4%; P < .001), and to fall in the lowest income quartile based on ZIP code (39.6% vs 27.5%; P < .001). After matching, opioid-dependent patients (n = 606 unweighted vs n = 32,343 unweighted nonopioid-dependent patients) were at increased risk of surgical site infections (odds ratio [OR], 1.61; P = .006), major bleeding (OR, 1.56; P = .04), acute kidney injury (OR, 1.46; P = .02), and deep venous thrombosis (OR, 2.53; P = .005). Linear regression of matched cohorts revealed that opioid-dependent patients had an increased length of hospital stay (11.76 days vs 9.80 days; P < .001) and an increased mean inflation-adjusted in-hospital cost of U.S. $7032 ($37,522 vs $30,490; P < .001). CONCLUSIONS: The incidence of pre-existing opioid dependency in patients undergoing LEB continues to rise. Patients with opioid use disorder undergoing LEB surgery have substantial increases in length of hospital stay and costs. These findings highlight the importance of early preoperative recognition of this disorder in vascular surgery patients and open the opportunity for early intervention in that cohort.
Assuntos
Custos Hospitalares , Transtornos Relacionados ao Uso de Opioides/economia , Doença Arterial Periférica/economia , Doença Arterial Periférica/cirurgia , Enxerto Vascular/economia , Adulto , Idoso , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Pacientes Internados , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Transtornos Relacionados ao Uso de Opioides/mortalidade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Complicações Pós-Operatórias/economia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Enxerto Vascular/efeitos adversos , Enxerto Vascular/mortalidadeRESUMO
OBJECTIVE: Despite the established guidelines, there is not a clear consensus about how to manage antiplatelet therapy after carotid surgery. It is a common practice in vascular surgery to use the combination of aspirin and clopidogrel in the treatment of such patients. In this work, we analyzed the impact on long-term survival of antiplatelet therapy in patients treated for carotid stenosis at a single institution over a 10-year period. METHODS: Outcomes of 471 patients who underwent carotid intervention (1999-2008) were analyzed. Discharge prescription summaries were retrieved, and patients were divided into two groups according to their antiplatelet regimen: aspirin-only group and aspirin plus clopidogrel group. Only patients with a minimum of 30 days of confirmed antiplatelet therapy were included. All-cause mortality during follow-up represented the primary outcome, whereas stroke and bleeding at 30 days and during follow-up represented secondary end points. When local records were sparse, the Social Security Death Index was queried to confirm mortality. The International Classification of Diseases, 9th Revision (ICD-9 codes), was reviewed for treatment related to a bleeding condition. RESULTS: When divided by indication, there was an increased mortality rate in patients with asymptomatic carotid disease receiving dual antiplatelet therapy as compared with aspirin alone (47% vs 40%; P = .05). Patients with symptomatic carotid disease had a nonsignificant decrease in all-cause mortality if they received dual antiplatelet therapy (38% vs 39%; P = .53). In a subgroup analysis, there was a significant increase in the rate of all-cause mortality among patients older than 75 years receiving dual antiplatelet therapy for asymptomatic carotid disease (82% vs 56%; P = .001), whereas there was a nonsignificant decrease in mortality in patients older than 75 years receiving dual antiplatelet therapy for symptomatic carotid disease (47% vs 63%; P = .50). There was no difference in secondary outcomes (stroke and bleeding) regardless of the indication or the antiplatelet therapy. CONCLUSIONS: In this retrospective, single-institution study, the use of dual antiplatelet therapy (aspirin plus clopidogrel) in patients intervened for asymptomatic carotid disease was related to increased all-cause mortality, whereas it did not significantly influence the outcome in patients with symptomatic carotid disease.
Assuntos
Angioplastia/mortalidade , Aspirina/uso terapêutico , Estenose das Carótidas/terapia , Endarterectomia das Carótidas/mortalidade , Inibidores da Agregação Plaquetária/uso terapêutico , Ticlopidina/análogos & derivados , Idoso , Alabama/epidemiologia , Angioplastia/efeitos adversos , Angioplastia/instrumentação , Aspirina/efeitos adversos , Doenças Assintomáticas , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico , Estenose das Carótidas/mortalidade , Clopidogrel , Quimioterapia Combinada , Endarterectomia das Carótidas/efeitos adversos , Feminino , Hemorragia/etiologia , Hemorragia/mortalidade , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Inibidores da Agregação Plaquetária/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Stents , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Ticlopidina/efeitos adversos , Ticlopidina/uso terapêutico , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: To identify risk factors and stratify their effect of compromising 3-year survival in patients treated for asymptomatic carotid disease based upon recently updated guidelines from the Society for Vascular Surgery. METHODS: Outcomes of 506 patients who underwent carotid intervention for asymptomatic carotid disease (1999-2008) were analyzed. Hospital computerized medical records were reviewed. When local records were sparse, Social Security Death Index was queried to confirm mortality. Following multivariable Cox regression analysis, a score was assigned based on the calculated hazard ratio (HR) in the following fashion: HR 1.5-1.9 = 1 point; HR 2.0-3.0 = 2 points; and HR >3 = 3 points. The sum of those points comprised the final score for each patient. Kaplan-Meier analyses were then performed to delineate survival differences. RESULTS: Seventy patients (13.83%) did not survive beyond 3 years after the procedure. Age >80 years (HR, 1.79; P = .05; score 1), diabetes mellitus (HR, 1.99; P < .05; score 1), coronary artery intervention (HR, 2.03; P < .01; score 2), severe chronic kidney disease defined as glomerular filtration rate <30 and not on dialysis (HR, 2.46; P = .03; score 2), dialysis patients (HR, 5.67; P = .001; score 3), and chronic obstructive pulmonary disease (HR, 3.53; P < .001; score 3) negatively influenced 3-year survival. Patients with score ≤2 experienced 3-year mortality of 6.0%, whereas score >2 was associated with 31.6% 3-year mortality (HR, 6.10; P < .001). The score value was not associated with the stroke rate at any time point. The resultant score was validated in a separate population of patients with symptomatic carotid disease. CONCLUSIONS: This easy predictive score underscores the association of medical risk factors with decreased 3-year survival. This finding may impact future clinical decisions for management of asymptomatic carotid disease.
Assuntos
Doenças Assintomáticas/mortalidade , Doenças Assintomáticas/terapia , Estenose das Carótidas/mortalidade , Estenose das Carótidas/cirurgia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Prognóstico , Medição de Risco , Taxa de Sobrevida , Fatores de TempoRESUMO
Aortic stent graft repair has recently been applied as an alternative therapy for infrarenal ruptured abdominal aortic aneurysms (rAAAs). We retrospectively assessed outcome in a continuous series at a single institution (an academic tertiary referral center) of patients with infrarenal rAAAs treated by either open or endovascular repair. Between October 1999 and July 2004, 24 patients were treated at the University of Alabama Hospital for infrarenal rAAA. They were treated by either open procedure (n = 15) or endovascular stent graft repair (n = 9). Outcome parameters included mortality, morbidity, procedure time, blood loss, and length of stay. Endovascular aneurysm repair (EVAR) was performed whenever the anatomy was deemed suitable and experienced personnel were available. Age (mean 70.8 years for EVAR vs. 72.2 years for open), gender (men 71% vs. women 75%), AAA size (mean 6.7 vs. 6.4 cm), early mortality (22% vs. 26%), and major morbidity (56% vs. 53%) were similar in both groups. Blood loss difference between the two groups was statistically significant (p = 0.0001). Our series supports the feasibility and short-term viability of EVAR for infrarenal rAAA when anatomy is suitable and patient and facility conditions are favorable.