RESUMEN
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.
Asunto(s)
Enfermedad Arterial Periférica , Enfermedades Vasculares Periféricas , Humanos , Anciano , Resultado del Tratamiento , Estudios Retrospectivos , Extremidad Inferior/irrigación sanguínea , Amputación Quirúrgica/efectos adversos , Readmisión del Paciente , Factores de Riesgo , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/cirugíaRESUMEN
BACKGROUND: We evaluate the relationship between the hospital case volume (HCV) and mortality outcomes after open aortic repair (OAR) and endovascular aortic repair (EVAR) of intact (iEVAR) and ruptured (rEVAR) abdominal aortic aneurysm (AAA) using a contemporary administrative database. METHODS: The Healthcare Cost and Utilization Project Database for New York (2016) and New Jersey/Maryland/Florida (2016-2017) were queried using International Classification of Disease-10th edition to identify patients who had undergone OAR and EVAR. The hospitals were categorized into quartiles (Q) per overall (EVAR + OAR) volume, OAR-alone volume and EVAR-alone volume. Cox regression adjusted for confounding factors was used to estimate hazard ratios (HRs) for mortality. RESULTS: A total of 8,825 patients (mean age, 73.5 ± 9.5 years; 6,861 male [77.7%]) had undergone 1,355 OARs and 7,470 EVARs. Overall HCV had no impact on in-hospital mortality across quartiles after (iEVAR) (range, 0.7%-1.4%, P = 0.15), (rEVAR) (range, 20.5%-29.6%, P = 0.63) and open repair of intact AAA (iOAR) (range, 4.9%-8.8%, P = 0.63). However, the mortality rates after open repair of ruptured AAA (rOAR) in highest-volume (Q4) hospitals were significantly lower than those in the 3 lower quartile hospitals (23.1% vs. 44.7%, P < 0.001). When analyzed per OAR-alone volume, the same findings were observed (22.0% for Q4 vs. 41.6% for Q1-3, P < 0.001). Furthermore, in Q4 hospitals per the OAR-alone volume analysis, the mortality hazard was greater for rEVAR (39.0%) than for rOAR (22.0%) (HR = 2.3, 95% confidence interval, 1.02-5.34, P < 0.05). CONCLUSIONS: The mortality rates for iEVAR, rEVAR and iOAR were independent of HCV. However, after rOAR, mortality rates in high OAR volume hospitals were lower than those in the lower quartile hospitals, and, at least comparable to those of rEVAR. EVAR-first strategy for ruptured AAA might not be applicable to all cases. Patent-specific, individualized treatment should be the gold standard. For patients requiring rOAR, transfer to a regional center of excellence, when clinical safe, should be encouraged.
Asunto(s)
Aneurisma de la Aorta Abdominal , Rotura de la Aorta , Reparación Endovascular de Aneurismas , Mortalidad Hospitalaria , Hospitales de Alto Volumen , Hospitales de Bajo Volumen , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/mortalidad , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Rotura de la Aorta/cirugía , Rotura de la Aorta/mortalidad , Rotura de la Aorta/diagnóstico por imagen , Bases de Datos Factuales , Reparación Endovascular de Aneurismas/efectos adversos , Reparación Endovascular de Aneurismas/mortalidad , Complicaciones Posoperatorias/mortalidad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Estados UnidosRESUMEN
OBJECTIVE: The interfacility transfer (IT) of patients with a ruptured abdominal aortic aneurysm (rAAA) occurs not infrequently to allow for a higher level of care. In the present study, we evaluated, using a contemporary administrative database, the effects of IT on mortality after rAAA repair. METHODS: The Healthcare Cost and Utilization Project Database for New York (2016) and New Jersey, Maryland, and Florida (2016-2017) was queried using the International Classification of Diseases, 10th edition, to identify patients who had undergone open or endovascular repair of AAAs. The hospitals were categorized into quartiles (Qs) per overall volume. The mortality rates for IT vs nontransferred (NT) rAAA patients stratified by treatment modality (open aneurysm repair of an rAAA [rOAR] vs endovascular aneurysm repair of an rAAA [rEVAR]) were compared. A Cox proportional hazard model was used to estimate the hazard ratios (HRs) for mortality. RESULTS: A total of 1476 patients had presented with a rAAA, of whom 673 (45.7%) were not treated. Of the remaining 803 patients, 226 (28.1%) were transferred, of whom 50 (22.1%) had died without repair after IT. The remaining 753 patients (IT, n = 176; NT, n = 576) had undergone rEVAR (n = 492) or rOAR (n = 261). The baseline characteristics were similar between the IT and NT patients, except for a greater proportion of black patients (P = .03), lower income families (P = .049), and rOAR (45.5% vs 31.4%; P = .001) for the IT patients. The overall mortality rates were similar between the NT (30.2%) and IT (27.3%) groups (P = .46). The subgroup analysis revealed that the operative mortality rates after rEVAR were similar between the NT and IT patients, without significant differences among the hospital quartiles. After rOAR, however, the operative mortality rates were lower for the IT patients, largely owing to improved outcomes in the Q4 hospitals (Q4 vs Q1-Q3, P = .001). Cox regression analysis demonstrated that age (HR, 1.03; 95% confidence interval, 1.00-1.06; P = .02) and treatment at a low-volume hospital (Q1-Q3; HR, 1.89; 95% confidence interval, 1.02-3.51; P = .04) were predictors of mortality. The total charges were similar (IT, $286,727; vs NT, $265,717; P = .38). CONCLUSIONS: The results from the present study have shown that <30% of rAAA patients deemed a candidate for repair will be transferred. We found that IT did not affect the mortality rates after rEVAR, irrespective of the hospital volume. For rOAR candidates, however, regionalization of care with prompt transfer to a high-volume center could improve the survival benefits without increased healthcare costs.
Asunto(s)
Aneurisma de la Aorta Abdominal , Rotura de la Aorta , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Humanos , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/efectos adversos , Resultado del Tratamiento , Factores de Tiempo , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/cirugía , Hospitales de Bajo Volumen , Estudios Retrospectivos , Factores de Riesgo , Complicaciones Posoperatorias/etiologíaRESUMEN
OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) is the preferred operative treatment of blunt thoracic aortic injuries (BTAIs). Its use is associated with improved outcomes compared with open surgical repair and nonoperative management. However, the optimal time from injury to repair is unknown and remains a subject of debate across different societal practice guidelines. The purpose of this study was to evaluate national trends in the management of BTAI, with a specific focus on the impact of timing of repair on outcomes. METHODS: Using the National Trauma Data Bank, we identified adult patients with BTAI between 2012 and 2017. Patients with prehospital or emergency department cardiac arrest or incomplete data sets were excluded from analysis. Patients were classified according to timing of repair: group 1, <24 hours; and group 2, ≥24 hours. The primary outcome evaluated was in-hospital mortality; secondary outcomes included overall hospital and intensive care unit length of stay. Multivariable logistic regression was performed to identify independent predictors of mortality. RESULTS: The analysis was completed for 2821 patients who underwent TEVAR for BTAI with known operative times. The overall mortality in the patient cohort was 8.4% (238/2821); 75% of patients undergoing TEVAR were repaired within 24 hours. Mortality was more than twofold greater in group 1 compared with group 2 (9.8% [207/2118] vs 4.4% [31/703]; P = .001). This mortality benefit persisted across injury severity groups and was independent of the presence of serious extrathoracic injuries. Logistic regression analysis, adjusting for age ≥65 years, Glasgow Coma Scale score ≤8, systolic blood pressure ≤90 mm Hg at admission, and serious extrathoracic injuries, showed a higher adjusted mortality in group 1 (odds ratio, 2.54; 95% confidence interval, 1.66-3.91; P = .001). CONCLUSIONS: The majority of patients with BTAI undergo endovascular repair within 24 hours of injury. Patients undergoing delayed repair have improved survival compared with those repaired within the first 24 hours of injury in spite of similar injury patterns and severity. In patients with BTAIs without signs of imminent rupture, delaying endovascular repair beyond 24 hours after injury should be considered.
Asunto(s)
Aorta Torácica/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Traumatismos Torácicos/cirugía , Tiempo de Tratamiento , Lesiones del Sistema Vascular/cirugía , Heridas no Penetrantes/cirugía , Adulto , Anciano , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/lesiones , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Implantación de Prótesis Vascular/tendencias , Toma de Decisiones Clínicas , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Procedimientos Endovasculares/tendencias , Femenino , Mortalidad Hospitalaria , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Tempo Operativo , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Traumatismos Torácicos/diagnóstico por imagen , Traumatismos Torácicos/mortalidad , Factores de Tiempo , Tiempo de Tratamiento/tendencias , Resultado del Tratamiento , Lesiones del Sistema Vascular/diagnóstico por imagen , Lesiones del Sistema Vascular/mortalidad , Heridas no Penetrantes/diagnóstico por imagen , Heridas no Penetrantes/mortalidad , Adulto JovenRESUMEN
OBJECTIVE: Posthospital syndrome (PHS) is an acquired, transient period of health vulnerability after a hospital admission for acute illness. It is characterized by physiologic deconditioning secondary to stressors from disruption in circadian rhythm, depletion of nutritional and physiologic reserve as well as the pain and discomfort associated with hospitalization. PHS is reported as an independent risk factor for readmission and adverse postoperative outcomes. The aim of this study is to investigate whether preoperative hospitalization affects outcomes of elective endovascular repair of abdominal aortic aneurysm (EVAR). METHODS: The Healthcare Cost and Utilization Project State Inpatient Database for California (2009-2011) were queried using International Classification of Disease Codes, Ninth Edition, codes of 441.4 (abdominal aneurysm without mention of rupture), 397.1 (EVAR with graft), and 397.8 (EVAR with branching or fenestrated graft). PHS exposure is defined as any inpatient admission 30 or fewer days before elective EVAR. Primary outcomes are all-cause mortality and overall complications. Secondary outcomes include length of stay (LOS), 30-day readmission, and hospital charge. RESULTS: A total of 6155 patients were identified. of which 327 patients (5.6%) had more than one episode of hospital admission 30 days or less before elective EVAR. In-hospital mortality was comparable after PHS exposure (P = .09). However, PHS exposure was associated with increased 30-day readmission (9.5% vs 18.4%; P < .001), LOS (3.0 vs 4.5 days; P < .001), and overall complications (14.8% vs 24.5%; P < .001). Risk adjustment was made based on age, sex, race, baseline comorbidities, and reason for preoperative admission. Multivariate logistic regression analysis demonstrated that PHS exposure was a predictor for longer LOS (odds ratio [OR], 2.5; 95% confidence interval [CI], 2.0-3.2; P < .001), higher incidence of 30-day readmission (OR, 2.0; 95% CI, 1.4-2.6; P < .001), and overall complications (OR, 1.7; 95% CI, 1.3-2.2; P < .001). Additional cost associated with increased 30-day readmission attributable to PHS exposure was estimated at $448,302 per 100 cases. CONCLUSIONS: PHS is an independent risk-adjusted predictor for increased LOS, 30-day readmission, and overall complications after elective EVAR. Recent hospital admission should be assessed carefully before elective EVAR. Medical optimization with an attempt to delay elective surgery by up to 30 days may help to improve surgical outcomes and decrease unnecessary health care expenditures.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Procedimientos Quirúrgicos Electivos/efectos adversos , Procedimientos Endovasculares/efectos adversos , Pacientes Internos/psicología , Complicaciones Posoperatorias/epidemiología , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/mortalidad , Femenino , Mortalidad Hospitalaria , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Admisión del Paciente/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/psicología , Medición de Riesgo/estadística & datos numéricos , Factores de Riesgo , Síndrome , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: The objective of this study was to review our institute's open aortic surgery volume experience and its impact on Accreditation Council for Graduate Medical Education trainees. METHODS: A review was conducted of the vascular surgery department's operative database for all cases that underwent aortic aneurysm repair, whether open aortic repair (OAR), endovascular aneurysm repair (EVAR), or fenestrated EVAR (FEVAR). We also reviewed our graduating trainees' case logs. In the setting of our regionalized referral center, all patients who underwent open or endovascular aortic intervention between 2010 and 2014 at our main campus were included. The total number of aortic procedures performed by our graduation trainees was determined. All aortic aneurysm interventions, both open and endovascular (both EVAR and FEVAR), were included. The main outcome measures were the total number of aortic interventions, any change in trends of intervention, and the total number of open aortic cases that our graduation trainees had. RESULTS: During the 5-year period analyzed, a total of 1389 abdominal aortic aneurysm repair procedures were performed by OAR, EVAR, and FEVAR. Of those, 462 were OARs, representing 33.2% of the total; 440 were EVARs, representing 31.6%; and 487 were FEVARs, representing 35.2%. For all OAR procedures, there was a significant increase in the proportion of these cases over time (P = .014). The total number of EVAR and FEVAR cases performed annually during this time did not change, whereas the number of OAR cases has increased. Of the OARs, 59.3% were performed for juxtarenal aneurysms, whereas 22.9% involved type IV thoracoabdominal aortic aneurysms. On average, graduating vascular surgery trainees performed 23.1 OARs before graduation (range, 19-26). CONCLUSIONS: In contrast to the documented national trend of decreased OAR, our institute continues to see increased OAR relative to EVAR and FEVAR. Moreover, we theorized that the preservation of OAR volume in our program and other similar institutions might offer a practical solution to the challenge of addressing vascular surgery training in aortic surgery by OAR, EVAR, and FEVAR. Inclusive discussions at the national and international levels are needed to reach consensus regarding the future of vascular surgery training and key issues, such as additional, mandatory, subspecialized training in OAR and FEVAR for both residents and fellows who wish to receive certification in OAR; creation of centers of excellence for open aortic surgery that would centralize OAR and direct trainees to those centers for their needed training; and possibly development of new training strategies whereby single cases can be shared among trainees with alternating roles as exposure and closure vs repair.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Torácica/cirugía , Servicios Centralizados de Hospital , Educación de Postgrado en Medicina , Procedimientos Endovasculares/educación , Hospitales de Alto Volumen , Regionalización , Cirujanos/educación , Procedimientos Quirúrgicos Vasculares/educación , Carga de Trabajo , Servicios Centralizados de Hospital/tendencias , Competencia Clínica , Curriculum , Bases de Datos Factuales , Educación de Postgrado en Medicina/tendencias , Procedimientos Endovasculares/tendencias , Hospitales de Alto Volumen/tendencias , Humanos , Ohio , Derivación y Consulta/tendencias , Regionalización/tendencias , Cirujanos/tendencias , Factores de Tiempo , Procedimientos Quirúrgicos Vasculares/tendenciasRESUMEN
OBJECTIVE: Through-knee amputation (TKA) is a rare amputation performed in <2% of all major lower extremity amputations in the United States. Despite biomechanical benefits and improved rehabilitation compared with above-knee amputation (AKA), TKA has largely been abandoned by vascular surgeons because of concerns for poor wound healing. The purpose of this study was to evaluate surgical outcomes of TKA. METHODS: The American College of Surgeons National Surgical Quality Improvement Program between 2005 and 2012 was queried using Current Procedural Terminology codes indicating AKA and TKA. Baseline characteristics were reviewed, and logistic regression analysis was performed to identify predictors of 30-day mortality. Propensity score matching was used to balance comorbidities between AKA and TKA. Operative variables and postoperative complications were compared between the groups. RESULTS: A total of 7469 AKA and 251 TKA patients were identified among 15,932 major lower extremity amputations. Baseline characteristics were examined. White race, chronic obstructive pulmonary disease, dyspnea, emergent operation, steroid use, myocardial infarction, congestive heart failure, high American Society of Anesthesiologists score, old age, preoperative sepsis or septic shock, and dialysis dependency were associated with increased 30-day mortality. Independent lifestyle and smoking (within 1 year) were protective against early death. Baseline comorbidities were not statistically significant after 1:1 propensity score matching. Operative outcomes were similar in both groups (AKA vs TKA). Wound infection (7.2% vs 11.2%; P = .16), dehiscence rate (1.2% vs 0.8%; P = 1.0), and 30-day mortality (9.6% vs 11.2%; P = .66) were comparable. Other outcome parameters, including cardiopulmonary and genitourinary complications, were similar except for a higher likelihood of return to the operating room in the TKA group (27.9% vs 12.4%; P < .01). Postoperative mortality was not associated with TKA (P = .77) or reoperation (P = .42), but it was associated with the patients' physiologic conditions (dyspnea, sepsis, emergent operation, high American Society of Anesthesiologists score, and dependent lifestyle). Predictors of reoperation were contaminated wound (hazard ratio [HR], 2.19; confidence interval [CI], 1.17-3.23; P = .015), sepsis or septic shock (HR, 2.63; CI, 1.37-5.05; P = .004), chronic obstructive pulmonary disease (HR, 2.81; CI, 1.23-6.42; P = .014), and wound infection (HR, 4.91; CI, 2.06-11.70; P < .001). Presence of peripheral vascular disease was not associated with post-TKA reoperation (P = .073). CONCLUSIONS: TKA demonstrated similar postoperative morbidity and mortality compared with AKA. Wound infection and risk of dehiscence were equivalent. TKA did demonstrate a higher rate of reoperation; however, neither TKA nor reoperation predicted postoperative mortality. Patients in stable physiologic condition without active infection can safely undergo elective TKA to maximize rehabilitation potential.
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Amputación Quirúrgica/métodos , Rodilla/cirugía , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica/efectos adversos , Amputación Quirúrgica/mortalidad , Distribución de Chi-Cuadrado , Bases de Datos Factuales , Estudios de Factibilidad , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/terapia , Puntaje de Propensión , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos , Cicatrización de HeridasRESUMEN
OBJECTIVE: Acute limb ischemia (ALI) in a pediatric patient is a rare condition but may result in lifelong disability. A paucity of evidence exists to derive treatment guidelines; some surgeons advocate conservative management over invasive measures. The purpose of this study was to evaluate the role of surgical revascularization in the pediatric population and outcomes of conservative vs surgical management. METHODS: The Healthcare Cost and Utilization Project State Inpatient Database (California, Iowa, and New York) between 2007 and 2013 was queried using International Classification of Diseases, Ninth Revision codes. Patients were stratified into two cohorts: conservative management and surgical management. Each group was further subdivided into three age groups: infant (<24 months), child (<12 years), and adolescent (<18 years). Outcome variables included mortality, amputation status, length of hospital stay, and hospital charge. RESULTS: A total of 1576 pediatric patients with ALI were identified among 6,122,535 pediatric admissions (26 per 100,000 admissions). Average age was 9.9 ± 7.1 years. There were 263 patients who underwent surgical revascularization. The conservative management group was younger (5.8 ± 6.2 vs 9.2 ± 6.1 years; P < .01). Otherwise, baseline characteristics were similar between the two groups. Overall, the amputation rate was low (<2%; n = 28), especially in the upper extremities (<0.2%). Outcomes of conservative management and surgical revascularization were similar for mortality (5.0% vs 3.4%; P = .34), amputation (1.9% vs 1.1%; P = .46), length of hospital stay (15.4 vs 12.9 days; P = .07), and hospital charge ($281,794 vs $288,507; P = .28). In subgroup analysis, infants had less concomitant orthopedic injury than other age groups. Children demonstrated a higher likelihood of associated upper extremity injury and operative revascularization (P < .01) than infants or adolescents. In infants, mortality was higher and surgical intervention was associated with longer hospital stay (29.5 ± 34.4 days vs 45.6 ± 31.6 days; P = .02) and larger health care expenditure ($467,885 ± $638,653 vs $1,099,343 ± $695,872; P < .01). CONCLUSIONS: Pediatric ALI is a rare entity and is associated with low amputation and mortality rates. Among the pediatric age cohorts, infants with ALI are at higher risk of in-hospital mortality than older age groups are. Surgical intervention is not associated with improved limb salvage or mortality. Nonoperative management may be considered an initial treatment modality, but further research is needed to elucidate which important subset of pediatric patients benefit from open or endovascular operative intervention.
Asunto(s)
Tratamiento Conservador , Procedimientos Endovasculares , Isquemia/epidemiología , Isquemia/terapia , Enfermedad Arterial Periférica/epidemiología , Enfermedad Arterial Periférica/terapia , Procedimientos Quirúrgicos Vasculares , Enfermedad Aguda , Adolescente , Factores de Edad , Amputación Quirúrgica , Niño , Preescolar , Toma de Decisiones Clínicas , Tratamiento Conservador/efectos adversos , Tratamiento Conservador/economía , Tratamiento Conservador/mortalidad , Análisis Costo-Beneficio , Bases de Datos Factuales , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/economía , Procedimientos Endovasculares/mortalidad , Femenino , Precios de Hospital , Costos de Hospital , Mortalidad Hospitalaria , Humanos , Lactante , Isquemia/economía , Isquemia/mortalidad , Tiempo de Internación , Recuperación del Miembro , Masculino , Enfermedad Arterial Periférica/economía , Enfermedad Arterial Periférica/mortalidad , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiología , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/economía , Procedimientos Quirúrgicos Vasculares/mortalidadRESUMEN
Iliac arterial disease, unfavorable anatomy, and prior stenting all pose challenges to access in endovascular abdominal aortic repair (EVAR) and thoracic aortic repair (TEVAR). Iliac access injury during T/EVAR may lead to rupture, dissection, thrombosis, or distal ischemia. Some have advocated iliac stent prior to T/EVAR in patients with suboptimal iliac access. The rate of complication and iliac stent migration during subsequent T/EVAR is undocumented. This case report describes a unique instance of self-expanding iliac stent migration during TEVAR which pinched the thoracic aortic endograft causing functional aortic coarctation.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Procedimientos Endovasculares/instrumentación , Migración de Cuerpo Extraño/etiología , Oclusión de Injerto Vascular/etiología , Arteria Ilíaca/cirugía , Stents , Angioplastia de Balón , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aortografía/métodos , Implantación de Prótesis Vascular/efectos adversos , Angiografía por Tomografía Computarizada , Procedimientos Endovasculares/efectos adversos , Migración de Cuerpo Extraño/diagnóstico por imagen , Migración de Cuerpo Extraño/terapia , Oclusión de Injerto Vascular/diagnóstico por imagen , Oclusión de Injerto Vascular/terapia , Humanos , Arteria Ilíaca/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
Venous aneurysm, a rare venous anomaly, poses increased risk of distal thromboembolic event. Superficial venous aneurysm, such as greater saphenous vein aneurysm, is an uncommon subset with nonspecific symptoms and often a delay in diagnosis. Symptomatic patients or patients with a thromboembolic event may benefit from surgical intervention with low morbidity. This case report describes an isolated spontaneous greater saphenous vein aneurysm which was successfully ligated and resected for symptomatic relief and prevention of distal thromboembolism.
Asunto(s)
Aneurisma , Vena Safena , Aneurisma/diagnóstico por imagen , Aneurisma/cirugía , Angiografía por Tomografía Computarizada , Humanos , Ligadura , Masculino , Persona de Mediana Edad , Flebografía/métodos , Vena Safena/diagnóstico por imagen , Vena Safena/cirugía , Resultado del Tratamiento , Ultrasonografía Doppler en ColorRESUMEN
OBJECTIVE: Supraceliac aortic cross-clamping (SCXC) is routinely used during open aortic reconstruction (OAR) of pararenal aortic disease when suprarenal control is not feasible. On occasion, however, aortic control may be obtained at the supramesenteric level by supramesenteric cross-clamping (SMXC) between the superior mesenteric artery and the celiac axis. The purpose of this study was to compare outcomes between patients who had SMXC vs SCXC during OAR for both aneurysmal and occlusive diseases. METHODS: A retrospective chart review identified 69 patients who underwent elective OAR requiring SMXC (n = 18) or SCXC (n = 51). All patients with thoracoabdominal aneurysms and those who had inframesenteric (suprarenal and infrarenal) aortic control were excluded. Propensity score-based matching was performed to adjust for confounding factors in a 1:1 ratio to compare outcomes. Late survival was estimated by Kaplan-Meier methods. RESULTS: Propensity score-based matching was performed at a 1:1 ratio; 18 SMXC cases were matched with 18 SCXC cases. The average age was 66.7 years, and men constituted 72%. Baseline characteristics were matched, except for the incidence of peripheral vascular occlusive disease (72.2% in the SMXC group vs 33.3% in the SCXC group; P = .04). A majority (80.6%) of patients underwent OAR for aneurysmal disease (72.2% in the SMXC group, 88.9% in the SCXC group). Intraoperatively, there were no differences in operative times (325 minutes for SMXC vs 298 minutes for SCXC; P = .48), but the SMXC group had a longer renal ischemia time (40 minutes vs 28 minutes; P = .03). There were no significant differences in intraoperative blood loss (2.4 L vs 1.6 L; P = .2) or blood product transfusion requirements (packed red blood cells, 2.2 units vs 1.6 units [P = .5]; Cell Saver, 1.3 L vs 0.7 L [P = .09]). Overall complication rates did not differ significantly (27.8% for SMXC vs 44.4% for SCXC; P = .24). Thirty-day mortality rates did not differ between the two groups (0% for SMXC vs 5.6% for SCXC; P = 1). CONCLUSIONS: In this study, there were no differences in early morbidity or mortality between SMXC and SCXC during aortic reconstruction. SMXC, however, can be performed safely and effectively in properly selected patients. A larger, multicenter prospective study would help elucidate the potential benefits.
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Aorta/cirugía , Aneurisma de la Aorta/cirugía , Arteriopatías Oclusivas/cirugía , Implantación de Prótesis Vascular/métodos , Procedimientos de Cirugía Plástica/métodos , Anciano , Aorta/diagnóstico por imagen , Aneurisma de la Aorta/diagnóstico por imagen , Aneurisma de la Aorta/mortalidad , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/mortalidad , Pérdida de Sangre Quirúrgica , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Distribución de Chi-Cuadrado , Constricción , Procedimientos Quirúrgicos Electivos , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Tempo Operativo , Selección de Paciente , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Puntaje de Propensión , Procedimientos de Cirugía Plástica/efectos adversos , Procedimientos de Cirugía Plástica/mortalidad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
Electroencephalograms (EEGs) measure a brain signal that contains abundant information about the human brain function and health. For this reason, recent clinical brain research and brain computer interface (BCI) studies use EEG signals in many applications. Due to the significant noise in EEG traces, signal processing to enhance the signal to noise power ratio (SNR) is necessary for EEG analysis, especially for non-invasive EEG. A typical method to improve the SNR is averaging many trials of event related potential (ERP) signal that represents a brain's response to a particular stimulus or a task. The averaging, however, is very sensitive to variable delays. In this study, we propose two time delay estimation (TDE) schemes based on a joint maximum likelihood (ML) criterion to compensate the uncertain delays which may be different in each trial. We evaluate the performance for different types of signals such as random, deterministic, and real EEG signals. The results show that the proposed schemes provide better performance than other conventional schemes employing averaged signal as a reference, e.g., up to 4 dB gain at the expected delay error of 10°.
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Electroencefalografía/métodos , Funciones de Verosimilitud , Encéfalo/fisiología , Interfaces Cerebro-Computador , Potenciales Evocados/fisiología , Humanos , Modelos Teóricos , Procesamiento de Señales Asistido por ComputadorRESUMEN
OBJECTIVE: Although the endovascular aneurysm repair trial 2 (EVAR-2) demonstrated no benefit of EVAR in high-risk (HR) patients, EVAR is still performed widely in this patient cohort. This study compares the midterm outcomes after EVAR in HR patients with those in normal-risk (NR) patients. In turn, these data are compared with the EVAR-2 data. METHODS: A retrospective review from January 2006 to December 2013 identified 247 patients (75 HR [30.4%], 172 NR [69.6%]) who underwent elective EVAR for infrarenal aortic aneurysm in an academic tertiary institution and its affiliated Veterans Administration hospital. The same HR criteria used in the EVAR-2 trial were employed. Overall survival, graft-related complications, and reintervention rates were estimated by the Kaplan-Meier method. HR group outcomes were compared with the EVAR-2 data. RESULTS: HR patients had a larger abdominal aortic aneurysm size and had a higher prevalence of cardiac disease (P < .01), chronic obstructive pulmonary disease (P = .02), renal insufficiency (P < .01), and cancer (P < .01). Use of aspirin (63% HR vs 66% NR; P = .6), statin (83% HR vs 72% NR; P = .2), and beta-blockers (71% HR vs 60% NR; P = .2) was similar; in the EVAR-2 trial, the corresponding use of these medications was 58%, 42%, and not available, respectively. Perioperative mortality (0% HR vs 1.2% NR; P = 1.0) and early complication rates (4% HR vs 6% NR; P = .8) were similar. In contrast, perioperative mortality in the EVAR-2 trial was 9%. At a mean follow-up of 3 years, the incidence rates of delayed secondary interventions for aneurysm- or graft-related complications were 7% for HR patients and 10% for NR patients (P = .5). The 1-, 2-, and 4-year survival rates in HR patients (85%, 77%, 65%) were lower than those in NR patients (97%, 97%, 93%; P < .001), but this was more favorable compared with a 36% 4-year survival in the EVAR-2 trial. No difference was seen in long-term reintervention-free survival in HR and NR patients (P = .8). Backward stepwise logistic regression analysis identified five prognostic indicators for post-EVAR death: age, chronic kidney disease stages 4 and 5, congestive heart failure, home oxygen use, and current cancer therapy. CONCLUSIONS: EVAR can be performed in patients unfit for open surgical repair with excellent early survival and long-term durability. These outcomes in the HR group compare more favorably to the EVAR-2 trial data. However, not all HR patients for open surgical repair derive the benefit from EVAR. The decision to proceed with EVAR in HR patients should be individualized, depending on the number and severity of risk factors.
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Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Centros Médicos Académicos , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico , Aneurisma de la Aorta Abdominal/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Distribución de Chi-Cuadrado , Comorbilidad , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Illinois , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Selección de Paciente , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/terapia , Modelos de Riesgos Proporcionales , Retratamiento , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Centros de Atención Terciaria , Factores de Tiempo , Resultado del TratamientoRESUMEN
Objective. In vivocalcium imaging is a standard neuroimaging technique that allows selective observation of target neuronal activities. In calcium imaging, neuron activation signals provide key information for the investigation of neural circuits. For efficient extraction of the calcium signals of neurons, selective detection of the region of interest (ROI) pixels corresponding to the active subcellular region of the target neuron is essential. However, current ROI detection methods for calcium imaging data exhibit a relatively low signal extraction performance from neurons with a low signal-to-noise power ratio (SNR). This is problematic because a low SNR is unavoidable in many biological experiments.Approach.Therefore, we propose an iterative correlation-based ROI detection (ICoRD) method that robustly extracts the calcium signal of the target neuron from a calcium imaging series with severe noise.Main results.ICoRD extracts calcium signals closer to the ground-truth calcium signal than the conventional method from simulated calcium imaging data in all low SNR ranges. Additionally, this study confirmed that ICoRD robustly extracts activation signals against noise, even withinin vivoenvironments.Significance.ICoRD showed reliable detection from neurons with a low SNR and sparse activation, which were not detected by conventional methods. ICoRD will facilitate our understanding of neural circuit activity by providing significantly improved ROI detection in noisy images.
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Calcio , Neuroimagen , Neuronas , Relación Señal-RuidoRESUMEN
Developing countries are primarily associated with poor roadway and lighting infrastructure challenges, which has a considerable effect on their traffic accident fatality rates. These rates are further increased as bus/minibus drivers indulge in risky driving, mainly during weekends when traffic and police surveillance is low to maximise profits. Although these factors have been mentioned in the literature as key indicators influencing accident severity of buses/minibuses, there is currently no study that explored the complex mechanisms underpinning the simultaneous effect of pavement and light conditions on the generation of accident severity outcomes while considering weekly temporal stability of the accident-risk factors. This study seeks to investigate the variations in the effect of contributing factors on the severity of bus/minibus accidents in Ghana across various combinations of pavement and light conditions and to identify the exact effects of weekdays and weekends on severity outcomes using a random parameter ordered logit model with heterogeneity in the means to account for unobserved heterogeneity in the police-reported data. Preliminary analysis demonstrated that accident-risk factors used in the models were temporally unstable, warranting the division of the data into both weekend and weekday time-periods. A wide variety of factors such as sideswipes, median presence, merging, and overtaking had significantly varying effects on bus/minibus accident severities under different combinations of pavement and light conditions for both weekdays and weekends. Insights drawn from this study, together with the policy recommendations provided, can be employed by engineers and policymakers to improve traffic safety in developing nations.
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Conducción de Automóvil , Países en Desarrollo , Accidentes de Tránsito , Humanos , Modelos Logísticos , Vehículos a MotorRESUMEN
As a surrogate for human tactile cognition, an artificial tactile perception and cognition system are proposed to produce smooth/soft and rough tactile sensations by its user's tactile feeling; and named this system as "tactile avatar". A piezoelectric tactile sensor is developed to record dynamically various physical information such as pressure, temperature, hardness, sliding velocity, and surface topography. For artificial tactile cognition, the tactile feeling of humans to various tactile materials ranging from smooth/soft to rough are assessed and found variation among participants. Because tactile responses vary among humans, a deep learning structure is designed to allow personalization through training based on individualized histograms of human tactile cognition and recording physical tactile information. The decision error in each avatar system is less than 2% when 42 materials are used to measure the tactile data with 100 trials for each material under 1.2N of contact force with 4cm s-1 of sliding velocity. As a tactile avatar, the machine categorizes newly experienced materials based on the tactile knowledge obtained from training data. The tactile sensation showed a high correlation with the specific user's tendency. This approach can be applied to electronic devices with tactile emotional exchange capabilities, as well as advanced digital experiences.
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Biomimética/métodos , Cognición , Aprendizaje Profundo , Tacto , Interfaz Usuario-Computador , Adulto , Femenino , Humanos , Masculino , Adulto JovenRESUMEN
OBJECTIVE: Central venous stenosis is one of the most challenging complications in patients requiring hemodialysis. Venous thoracic outlet syndrome is an underappreciated cause of central venous stenosis in patients requiring dialysis that can result in failed percutaneous intervention and loss of a functioning dialysis access. Limited data exist about the safety and outcomes of first rib resection in patients requiring hemodialysis, and the results have been confounded by the various surgical approaches used. The purpose of the present study was to evaluate the safety, operative outcomes, and patency of the existing dialysis access after transaxillary thoracic outlet decompression. METHODS: A retrospective medical record review was performed from January 2008 to December 2019 of patients who had undergone thoracic outlet decompression for subclavian vein stenosis with ipsilateral upper extremity hemodialysis access. The baseline characteristics and comorbidities were reviewed. The operative and postoperative course were evaluated. The survival and patency rates were analyzed using the life-table method and Kaplan-Meier curve. RESULTS: A total of 18 extremities in 18 patients were identified. Their mean age was 59 ± 11 years, and 89% were men. A total of 13 fistulas and 5 grafts were included. All patients had undergone repair via a transaxillary approach. First rib resection, anterior scalenectomy, and circumferential venolysis were performed in all 18 patients. The mean operative time was 99 ± 19 minutes, with an estimated blood loss of 78 ± 66 mL. The median length of stay was 2 days. No patient had died at 30 days. The survival rate at 1 year was 83%. The primary, primary-assisted, and secondary patency at 1 year were 42%, 69%, and 93%, respectively. CONCLUSIONS: Thoracic outlet decompression via the transaxillary approach is a technically feasible and safe operation in patients with ipsilateral upper extremity hemodialysis access. Patients with threatened dialysis access due to subclavian vein stenosis should be carefully evaluated for possible extrinsic compression at the costoclavicular junction. These patients might benefit from transaxillary first rib resection, scalenectomy, and venolysis.
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Diálisis Renal , Vena Subclavia , Enfermedades Vasculares/cirugía , Anciano , Constricción Patológica/cirugía , Descompresión Quirúrgica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Procedimientos Quirúrgicos Vasculares/métodosRESUMEN
As a promising future treatment for stroke rehabilitation, researchers have developed direct brain stimulation to manipulate the neural excitability. However, there has been less interest in energy consumption and unexpected side effect caused by electrical stimulation to bring functional recovery for stroke rehabilitation. In this study, we propose an engineering approach with subthreshold electrical stimulation (STES) to bring functional recovery. Here, we show a low level of electrical stimulation boosted causal excitation in connected neurons and strengthened the synaptic weight in a simulation study. We found that STES with motor training enhanced functional recovery after stroke in vivo. STES was shown to induce neural reconstruction, indicated by higher neurite expression in the stimulated regions and correlated changes in behavioral performance and neural spike firing pattern during the rehabilitation process. This will reduce the energy consumption of implantable devices and the side effects caused by stimulating unwanted brain regions.
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Estimulación Eléctrica/métodos , Rehabilitación de Accidente Cerebrovascular/métodos , Accidente Cerebrovascular/terapia , Algoritmos , Encéfalo/metabolismo , Encéfalo/fisiopatología , Manejo de la Enfermedad , Humanos , Modelos Biológicos , Actividad Motora , Neuronas/metabolismo , Recuperación de la Función , Accidente Cerebrovascular/fisiopatología , Sinapsis/metabolismo , Potenciales SinápticosRESUMEN
Detecting Alzheimer's disease (AD) is an important step in preventing pathological brain damage. Working memory (WM)-related network modulation can be a pathological feature of AD, but is usually modulated by untargeted cognitive processes and individual variance, resulting in the concealment of this key information. Therefore, in this study, we comprehensively investigated a new neuromarker, named "refined network," in a prefrontal cortex (PFC) that revealed the pathological features of AD. A refined network was acquired by removing unnecessary variance from the WM-related network. By using a functional near-infrared spectroscopy (fNIRS) device, we evaluated the reliability of the refined network, which was identified from the three groups classified by AD progression: healthy people (N=31), mild cognitive impairment (N=11), and patients with AD (N=18). As a result, we identified edges with significant correlations between cognitive functions and groups in the dorsolateral PFC. Moreover, the refined network achieved a significantly correlating metric with neuropsychological test scores, and a remarkable three-class classification accuracy (95.0%). These results implicate the refined PFC WM-related network as a powerful neuromarker for AD screening.
RESUMEN
Common iliac artery (CIA) aneurysms present across a spectrum of anatomic variants that can pose unique operative challenges. A wide variety of procedural approaches have been described in the literature with current therapeutic options including both open and endovascular repair. These techniques may involve either ligation or embolization of the internal iliac artery (IIA) with reliance on collateralized blood flow to the pelvis to mitigate postoperative complications. However, preservation of the IIA is often preferred. This case report describes a hybrid surgical approach for treating CIA aneurysms while preserving IIA perfusion. Our technique mitigates the risks of hypogastric artery dissection (including hypogastric vein injury) in the presence of a large CIA aneurysm.