Systematic review and meta-analysis to assess the racial disparities in the outcomes of carotid endarterectomy in the United States.

OBJECTIVE: Race-based disparities in health care have been related to a myriad of prevailing factors among minorities in the United States. This study aims to study the race-based differences in the outcomes of carotid endarterectomy (CEA). METHODS: The PROSPERO database registered the review protocol (CRD42023428253). A systematic English literature review was performed using literature databases PubMed and Scopus from inception till June 2023. The review was designed on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and included studies reporting mortality, stroke, or composite outcome of mortality and stroke after CEA for carotid artery disease, regardless of any degree of stenosis including both symptomatic and asymptomatic patients. The risk of bias was evaluated utilizing the Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) tool. A pooled odds ratio (OR) for the overall mortality was computed, and a P value of < .05 was designated as statistically significant. Interstudy heterogeneity was evaluated by Q-metric and quantified using Higgins I2 statistics. RESULTS: Twelve studies were identified which included a total of 574,055 patients who underwent CEA from 1998 to 2022. Eleven of 12 studies reported 30-day mortality as an outcome for patients undergoing CEA in which 524,708 patients (92.5%) were White and 42,797 (7.5%) were non-White. The overall pooled OR indicated a statistical significance in 30-day mortality between White and non-White patients undergoing CEA (OR, 1.73; 95% confidence interval [CI], 1.37-2.18; P = .011) with substantial heterogeneity (I2 = 56.3%). Eleven of 12 studies reported stroke as an outcome for patients undergoing CEA in which 524,708 patients (92.5%) were White and 42,801 (7.5%) were non-White. The overall pooled OR indicated no statistical significance in stroke between White and non-White patients undergoing CEA (OR, 1.46; 95% CI, 1.28-1.65; P = .111) with moderate heterogeneity (I2 = 35.9%). Five of 12 studies reported composite mortality or stroke as an outcome for patients undergoing CEA. The overall pooled OR indicated no statistical significance in composite mortality or stroke between White and non-White patients undergoing CEA (OR, 1.40; 95% CI, 1.24-1.59; P = .467) with no heterogeneity (I2 = 0.0%). CONCLUSIONS: Non-White patients have a relatively higher risk of mortality; however, no significant difference was observed between the racial groups in terms of stroke or a composite outcome of mortality or stroke. The odds of mortality in non-White patients have been persistent throughout recent studies.

Patients living farther from a tertiary care center are more likely to undergo peripheral arterial bypass for acute and chronic limb-threatening ischemia.

OBJECTIVE: The aim of this study was to assess the association between the proximity to the tertiary care hospital and the severity of peripheral arterial disease (PAD) at the time of lower extremity bypass (LEB) in a rural-urban mix region. METHODS: Patients undergoing LEB from 2010 to 2020 at Penn State Milton S. Hershey Medical Center were reviewed and stratified into two study groups based on a median distance from hospital (ie, Group I: ≥34 miles and Group II: <34 miles). Patients' demographic features, preoperative data including comorbidities, and medications were analyzed. A univariate analysis for the patient characteristics between the two study groups, along with evaluation of postoperative outcomes, and a multivariate predictive modeling to study the PAD stage as the indication of LEB was performed. A P-value of < .05 was set as a significant difference between the groups for all the analyses. RESULTS: There were 175 patients (49.9%) in Group I and 176 patients (50.1%) in Group II with a mean age of 65 ± 11.92 years (median, 64.61 years). No significant difference was observed in gender (P = .530), age (P = .906), and functional status (P = .830) between study groups. It was observed that patients in Group I were more likely to be overweight or obese (71.3% vs 57%; P = .007) and had a prior history of myocardial infarction (24.3% vs 15.3%; P = .036) in comparison to Group II. No postoperative outcomes were found to be statistically different between the study groups. The multivariate analyses based on various confounders displayed that patients in Group I had 56% higher likelihood of LEB for chronic limb-threatening ischemia (adjusted odds ratio, 1.56; 95% confidence interval, 0.92-2.62; P = .042). Group I patients also had five times higher odds of LEB for acute limb ischemia (adjusted odds ratio, 5.07; 95% confidence interval, 1.42-18.13; P = .012) as compared with those in the Group II. CONCLUSIONS: Patients' proximity to a major tertiary hospital may have implications on the disease progression for patients with PAD and could also be related to inadequate vascular services in primary and secondary hospitals. Lack of preventive care and disease management in regions afar from a tertiary hospital could be other implicating factors and highlights the need for outreach programs, along with distribution of vascular specialists, to reduce geographical disparities and ensure equity in access to care.

Octogenarians fare better under local anesthesia for elective endovascular aortic aneurysm repair.

OBJECTIVE: With an aging patient population, an increasing number of octogenarians are undergoing elective endovascular abdominal aortic aneurysm repair (EVAR) in the United States. Multiple studies have shown that, for the general population, use of local anesthetic (LA) for EVAR is associated with improved short-term and long-term outcomes as compared with performing these operations under general anesthesia (GA). Therefore, this study aimed to study the association of LA for elective EVARs with perioperative outcomes, among octogenarians. METHODS: The Vascular Quality Initiative database (2003-2021) was used to conduct this study. Octogenarians (Aged ≥80 years) were selected and sorted into two study groups: LA (Group I) and GA (Group II). Our primary outcomes were length of stay and mortality. Secondary outcomes included operative time, estimated blood loss, return to operating room, cardiopulmonary complications, and discharge location. RESULTS: Of the 16,398 selected patients, 1197 patients (7.3%) were included in Group I, and 15,201 patients (92.7%) were in Group II. Procedural time was significantly shorter for the LA group (114.6 vs 134.6; P < .001), as was estimated blood loss (152 vs 222 cc; P < .001). Length of stay was significantly shorter (1.8 vs 2.6 days; P < .001), and patients were more likely to be discharged home (LA 88.8% vs GA 86.9%; P = .036) in the LA group. Group I also experienced fewer pulmonary complications; only 0.17% experienced pneumonia and 0.42% required ventilator support compared with 0.64% and 1.02% in Group II, respectively. This finding corresponded to fewer days in the intensive care unit for Group I (0.41 vs 0.69 days; P < .001). No significant difference was seen in 30-day mortality cardiac, renal, or access site-related complications. Return to operating room was also equivocal between the two groups. Multivariate regression analysis confirmed GA was associated with a significantly longer length of stay and significantly higher rates of non-home discharge (adjusted odds ratio [AOR], 1.59; P < .001 and AOR, 1.40; P = .025, respectively). When stratified by the New York Heart Association classification system, classes I, II, III, and IV (1.55; P < .001; 1.26; P = .029; 2.03; P < .001; 4.07; P < .001, respectively) were associated with significantly longer hospital stays. CONCLUSIONS: The use of LA for EVARs in octogenarians is associated with shorter lengths of stay, fewer respiratory complications, and home discharge. These patients also experienced shorter procedure times and less blood loss. There was no statistically significant difference in 30-day mortality, return to operating room, or access-related complications. LA for octogenarians undergoing EVAR should be considered more frequently to shorten hospital stays and decrease complication rates.

Longer Operative Time for Lower Extremity Bypass Surgery is Associated With Inferior Outcomes.

INTRODUCTION: This study aims to assess the association of operative time with the postoperative length of stay and unplanned return to the operating room in patients undergoing femoral to below knee popliteal bypasses, stratified by autologous vein graft or polytetrafluoroethylene (PTFE). MATERIALS AND METHODS: A retrospective analysis of vascular quality initiative database (2003-2021). The selected patients were grouped into the following: vein bypass (group I) and PTFE (group II) patients. Each group was further stratified by a median split of operative time (i.e., 210 min for autologous vein and 155 min for PTFE) to study the outcomes. The outcomes were assessed by univariate and multivariate approach. RESULTS: Of the 10,902 patients studied, 3570 (32.7%) were in the autologous vein group, while 7332 (67.3%) were in the PTFE group. Univariate analysis revealed autologous vein and PTFE graft recipients that had increased operative times were associated with a longer mean postoperative length of stay and a higher incidence of all-cause return to the operating room. In PTFE group, patients with prolonged operative times were also found to be associated with higher incidence of major amputation, surgical site infection, and cardiovascular events, along with loss of primary patency within a year. CONCLUSIONS: For patients undergoing femoral to below knee popliteal bypasses using an autologous vein or PTFE, longer operative times were associated with inferior outcomes. Mortality was not found to be associated with prolonged operative time.

Favorable Trends in Mortality Among Patients with Concomitant Peripheral Arterial Disease and Diabetes Mellitus Over Past Two Decades.

BACKGROUND: This study examines the temporal trends in diabetes and peripheral artery disease (PAD)-related mortality in the United States, considering sociodemographic and regional factors, using data from death certificates in a national public database. METHODS: Data were extracted from the CDC WONDER (Centers for Disease Control and Prevention Wide Ranging Online Data for Epidemiologic Research) database from 1999 to 2020. Age-adjusted mortality rates (AAMR) per 100,000 individuals and annual percent changes (APC) with 95% confidence intervals (CI) were calculated. RESULTS: Between 1999 and 2020, there were 2,252,252 PAD-related and 5,413,811 diabetes-related deaths, with 469,699 deaths involving both conditions. The overall AAMR for PAD and diabetes-related mortality (aged ≥ 25 years) decreased from 7.97 in 1999 to 6.37 in 2020, with a notable decline from 2001 to 2010 (APC: -6.16, 95% CI: -7.07, -5.23). The AAMR for PAD-related mortality fell from 40.25 to 30.56, while the AAMR for diabetes-related deaths rose from 76.71 to 93.63. Males and non-Hispanic (NH) Black individuals had higher AAMRs than females and other racial groups. The highest crude mortality rate (CMR) was in the 80-84 age group. Non-metropolitan areas consistently reported higher AAMRs than metropolitan areas, and states like Ohio, Vermont, District of Columbia, and West Virginia had significantly higher rates. CONCLUSION: Over two decades, PAD and diabetes-related mortality trends show a positive overall reduction in AAMR. However, disparities persist, with higher rates among males, NH Black individuals, and residents of non-metropolitan areas. Significant state-level variations highlight the need for targeted interventions and tailored healthcare strategies.

Beta Blockers are Associated with Increased Mortality Without a Decrease in Reinterventions After Endovascular Abdominal Aortic Repair (EVAR).

INTRODUCTION: Predictors of sac behavior after endovascular aortic aneurysm repair (EVAR) and the impact of sac behavior on long-term survival are not well known. There are limited multicenter trials studying the impact of beta blockers (BBs) on sac behavior. BBs have consistently failed to show a benefit on abdominal aortic aneurysm sac regression in patients with connective tissue disorders and the general population. This study aims to assess the association between BBs and sac behavior after EVAR. METHODS: Patients undergoing EVAR registered in Vascular Quality Initiative (2003-2021) stratified by BB and no BB on discharged after an index procedure were assessed at follow-up of 30 days and 1 year. The primary outcomes included mortality and reintervention at 30 days and 1 year. The causes of reintervention were also studied at the defined time endpoints. Categorical and continuous variables were analyzed separately for association between the 2 groups. A P value of <0.05 was considered statistically significant. RESULTS: A total of 50,411 patients, stratified by BB (28,866; 57.3%), and no BB (21,545; 42.7%) were studied. Patients with hypertension, diabetes, chronic obstructive pulmonary disease, coronary artery disease, prior history of coronary artery bypass graft or percutaneous coronary intervention, prior angioplasty or stent, lower extremity bypass, carotid surgery, major amputation, and smokers were more likely to be on a BB at the time of discharge (P < 0.05). There was no significant difference in reinterventions when comparing patients with and without BB (P = 0.061). At 30-day follow-up, there was no significant difference between the 2 groups for any cause of reintervention. At 1-year follow-up, patients on BB were less likely to need reintervention for graft occlusion (no BB 18.70%, BB 11.77%, P = 0.002). There was no significant difference in reintervention for all other causes at 1-year follow-up. There was an increase in 30-day (no BB 0.20%, BB 0.33%, P = 0.007) and 1-year mortality (no BB 2.35%, BB 3.19%, P < 0.001) in patients on BBs. A time to event adjusted analysis based on Cox proportional hazard model revealed a 26% higher risk of 1-year mortality for patients on BB (hazard ratio: 1.26 [1.10-1.41] P < 0.001). CONCLUSIONS: Despite theoretical benefits of BBs on aneurysm behavior, review of the largest national vascular surgery database shows that patients on BBs do not have lower incidence of endovascular reinterventions after EVAR while additionally showing a higher mortality in this patient population.

Race-Based Variation in the Utilization of Epidural Analgesia in Addition to General Anesthesia for Open Abdominal Aortic Aneurysm Repair in the United States.

BACKGROUND: Epidural analgesia (EA) is recommended along with general anesthesia (GA) for patients undergoing open abdominal aortic aneurysm repair (AAA) and is known to be associated with improved postoperative outcomes. This study evaluates inequities in using this superior analgesic approach and further assesses the disparities at patient and hospital levels. METHODS: A retrospective analysis was performed using the Vascular Quality Initiative database of adult patients undergoing elective open AAA repair between 2003 and 2022. Patients were grouped and analyzed based on anesthesia utilization, that is, EA + GA (Group I) and GA only (Group II). Study groups were further stratified by race, and outcomes were studied. Univariate and multivariate analyses were performed to study the impact of race on the utilization of EA with GA. A subgroup analysis was also carried out to learn the EA analgesia utilization in hospitals performing open AAA with the least to most non-White patients. RESULTS: A total of 8,940 patients were included in the study, of which EA + GA (Group I) comprised n = 4,247 (47.5%) patients, and GA (Group II) had n = 4,693 (52.5%) patients. Based on multivariate regression analysis, the odds ratio of non-White patients receiving both EA and GA for open AAA repair compared to White patients was 0.76 (95% confidence interval: 0.53-0.72, P < 0.001). Of the patients who received both EA + GA, non-White race was associated with increased length of intensive care unit stay and a longer total length of hospital stay compared to White patients. Hospitals with the lowest quintile of minorities had the highest utilization of EA + GA for all patients compared to the highest quintile. CONCLUSIONS: Non-White patients are less likely to receive the EA + GA than White patients while undergoing elective open AAA repair, demonstrating a potential disparity. Also, this disparity persists at the hospital level, with hospitals with most non-White patients having the least EA utilization, pointing toward system-wide disparities.

Preoperative Chronic Steroid Use is Associated with Increased Incidence of Postoperative Mortality and Limb Loss following Peripheral Arterial Bypass Surgery for Chronic Limb Threatening Ischemia.

BACKGROUND: Steroids are a commonly prescribed medication in the United States and have been associated with poor surgical and treatment outcomes. The objective of this study is to assess the relationship between chronic steroid use and surgical outcomes of femoropopliteal and femoral-distal bypasses in patients suffering from chronic limb threatening ischemia (CLTI). METHODS: All adult patients undergoing femoropopliteal and femoral-distal bypasses with single segment autologous vein with an indication of CLTI in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) between 2012 and 2021 were stratified between chronic preoperative steroid use (Group I) and no preoperative use (Group II). Primary outcomes of the study included 30-day mortality, amputation, and combined outcome of mortality and/or limb loss. Secondary outcomes included specific bypass related, cardiovascular, respiratory and renal outcomes. RESULTS: A total of 8,324 patients (66.8% Male, 33.2% Females) underwent peripheral arterial bypass operations for the indication of chronic limb threatening ischemia. The median age was 68 years. Group I included 408 patients (4.9%) and Group II included 7,916 patients (95.1%). As compared to patients in Group II, those in Group I were more likely to be females (Group I: 42.2% vs. Group II: 32.8%), more likely to have co-existing chronic obstructive pulmonary disease (Group I: 20.6% vs. Group II: 11.8%), less likely to be diabetic (Group I: 45.9% vs. Group II: 48%), less likely to be smokers (Group I: 30.6% vs. Group II: 45.4%) and more likely to be in American Society of Anesthesiologists III or IV Classes (Group I: 98% vs. Group II: 96.5%) (all P < 0.05). Primary outcomes were as follows: 30-day mortality (Group I: 3.3% vs. Group II: 1.7%), amputation (Group I: 5.9% vs. Group II: 2.8%), 30-day mortality and/or amputation (Group I: 9.1% vs. Group II: 4.5%) (all P < 0.05). Among secondary outcomes, the following were found to be statistically significant: untreated loss of patency (Group I: 4.2% vs. Group II: 1.7%), significant bleeding (Group I: 26.2% vs. Group II: 16.5%), wound infection/complication (Group I: 18.6% vs. Group II: 15%), and return to operating room (Group I: 21.8% vs. Group II: 16.7%) (all P < 0.05). As compared to patients with an indication of tissue loss (Rutherford's class V and VI), patients in Group I with an indication of rest pain (Rutherford's class IV) were more likely to experience 30-day mortality, major amputation and a composite of mortality and amputation. Risk adjusted analysis showed that chronic steroid use has a statistically significant effect on 30-day mortality (adjusted odds ratio [AOR] 1.7, P = 0.05), amputation (AOR 2.05, P < 0.001), composite outcomes of mortality and amputation (AOR 1.959, P < 0.001), untreated loss of patency (AOR 2.31, P = 0.002), bleeding (AOR 1.33, P < 0.011) and unplanned return to the operating room (AOR 1.36, P = 0.014). CONCLUSIONS: Chronic steroid use in patients undergoing femoropopliteal or femoral-distal bypass is associated with a higher risk of 30-day mortality, major amputation, readmission, bleeding, return to operating room, and untreated loss of patency. No significant difference in outcomes were appreciated in patients with chronic steroid use and with Rutherford class V or VI disease (tissue loss), suggesting that the effects of steroids may be less prominent in those with the most advanced peripheral arterial disease. These findings may aid physicians with risk stratification and preoperative discussions regarding open revascularization in patients receiving chronic steroid therapy. More studies including randomized trials are needed to guide perioperative management of steroids in this cohort.

The implications of surgeon case volume and hospital volume on outcomes of aortobifemoral bypasses in obese patients.

BACKGROUND: Aortobifemoral (ABF) bypass is the gold standard for treating symptomatic aortoiliac occlusive disease. In the era of heightened interest in the length of stay (LOS) for surgical patients, this study aims to investigate the association of obesity with postoperative outcomes at the patient, hospital, and at surgeon levels. METHODS: This study used the Society of Vascular Surgery Vascular Quality Initiative suprainguinal bypass database from 2003 to 2021. The selected study cohort was divided into obese patients (body mass index ≥30) (group I) and nonobese patients (body mass index <30) (group II). Primary outcomes of the study included mortality, operative time, and postoperative LOS. Univariate and multivariate logistic regression analyses were performed to study the outcomes of ABF bypass in group I. Operative time and postoperative LOS were transformed into binary values by median split for regression analysis. A P value of .05 or less was deemed statistically significant in all the analyses of this study. RESULTS: The study cohort consisted of 5392 patients. In this population, 1093 were obese (group I) and 4299 were nonobese (group II). Group I was found to have more females with higher rates of comorbid conditions, including hypertension, diabetes mellitus, and congestive heart failure. Patients in group I had increased odds of prolonged operative time (≥250 minutes) and an increased LOS (≥6 days). Patients in this group also had a higher chance of intraoperative blood loss, prolonged intubation, and required vasopressors postoperatively. There was also an increased odds of postoperative decline in renal function in the obese population. Patients with prior history of coronary artery disease, hypertension, diabetes mellitus, and urgent or emergent procedures were found to be risk factors for a LOS of more than 6 days in obese patients. An increase in the surgeons' case volume was associated with lesser odds of an operative time of 250 minutes or more; however, no significant impact was found on postoperative LOS. Hospitals where 25% or more of ABF bypasses were performed on obese patients were also more likely to have LOS of less than 6 days after ABF operations, compared with hospitals where less than 25% of ABF bypasses were performed on obese patients. Patients undergoing ABF for chronic limb-threatening ischemia or acute limb ischemia had a longer LOS and increased operative times. CONCLUSIONS: ABF bypass in obese patients is associated with prolonged operative times and a longer LOS than in nonobese patients. Obese patients operated by surgeons with more cases of ABF bypasses have shorter operative times. A hospital's increasing proportion of obese patients was related to a decreased LOS. These findings support the known volume-outcome relationship that, with a higher surgeon case volume and increased proportion of obese patients in a hospital, there is an improvement in outcomes of obese patients undergoing ABF bypass.

Patients from distressed communities are more likely to be symptomatic at endovascular aneurysm repair and have an increased risk of being lost to long-term follow-up.

BACKGROUND: Endovascular aortic aneurysm repair (EVAR) has become the preferred modality to repair abdominal aortic aneurysms (AAAs). However, the effect of the distressed communities index (DCI) on the outcomes of EVAR is still unknown. In the present study, we investigated the effect of DCI on the postoperative outcomes after EVAR. METHODS: The Society for Vascular Surgery Vascular Quality Initiative database was used for the present study. Patients who had undergone EVAR from 2003 to 2021 were selected for analysis. The study cohort was divided into two groups according to their DCI score. Patients with DCI scores ranging from 61 to 100 were assigned to group I (DCI >60), and those with DCI scores ranging from 0 to 60 were assigned to group II (DCI ≤60). The primary outcomes included the 30-day and 1-year mortality and major adverse cardiovascular events at 30 days. Regression analyses were performed to study the postoperative outcomes. P values ≤ .05 were deemed statistically significant for all analyses in the present study. RESULTS: A total of 60,972 patients (19.5% female; 80.5% male) had undergone EVAR from 2003 to 2021. Of these patients, 18,549 were in group I (30.4%) and 42,423 in group II (69.6%). The mean age of the study cohort was 73 ± 8.9 years. Group I tended to be younger (mean age, 72.6 vs 73.7 years), underweight (3.5% vs 2.5%), and African American (10.8% vs 3.5%) and were more likely to have Medicaid insurance (3.6% vs 1.9%; P < .05 for all). Group I had had more smokers (87.3% vs 85.3%), a higher rate of comorbidities, including hypertension (84.5% vs 82.9%), diabetes (21.7% vs 19.7%), coronary artery disease (30.3% vs 28.6%), chronic obstructive pulmonary disease (36.9% vs 31.8%), and moderate to severe congestive heart failure (2.6% vs 2%; P < .05 for all). The group I patients were more likely to undergo EVAR for symptomatic AAAs (11.1% vs 7.9%; P < .001; adjusted odds ratio [aOR], 1.25; 95% confidence interval [CI], 1.15-1.37; P < .001) with a higher risk of mortality at 30 days (aOR, 3.98; 95% CI, 2.23-5.44; P < .001) and 1 year (aOR, 1.74; 95% CI, 1.43-2.13; P < .001). A higher risk of being lost to follow-up (28.9% vs 26.3%; P < .001) was also observed in group I. CONCLUSIONS: Patients from distressed communities who require EVAR tended to have multiple comorbidities. These patients were also more likely to be treated for symptomatic AAAs, with a higher risk of mortality. An increased incidence of lost to long-term follow-up was also observed for this population. Surgeons and healthcare systems should consider these outcomes and institute patient-centered approaches to ensure equitable healthcare.

Depression Is Associated With Non-Home Discharge After Coronary Artery Bypass Graft.

INTRODUCTION: Depression is disproportionately high in patients with coronary artery disease and has been associated with adverse outcomes following coronary artery bypass graft (CABG). One quality metric, non-home discharge (NHD), can have substantial implications for patients and health care resource utilization. Depression increases the risk of NHD after many operations, but it has not been studied after CABG. We hypothesized that a history of depression would be associated with an increased risk of NHD following CABG. METHODS: CABG cases were identified from the 2018 National Inpatient Sample using ICD-10 codes. Depression, demographic data, comorbidities, length of stay (LOS), rate of NHD were analyzed using appropriate statistical tests where a P-value < 0.05 was defined as statistically significant. Adjusted multivariable logistic regression models were used to assess independent association between depression and NHD as well as LOS while controlling for confounders. RESULTS: There were 31,309 patients, of which 2743 (8.8%) had depression. Depressed patients were younger, females, in a lower income quartile, and more medically complex. They also demonstrated more frequent NHD and prolonged LOS. After adjusted multivariable analysis, depressed patients had a 70% increased odds of NHD (adjusted odds ratio: 1.70 [1.52-1.89] P < 0.001) and a 24% increased odds of prolonged LOS (AOR: 1.24 [1.12-1.38] P < 0.001). CONCLUSIONS: From a national sample, depressed patients were associated with more frequent NHD following CABG. To our knowledge, this is the first study to demonstrate this, and it highlights the need for improved preoperative identification in order to improve risk stratification and timely allocation of discharge services.

Association of Preoperative Frailty with Inferior Outcomes for Patients Undergoing Lower Extremity Bypass for Chronic Limb Threatening Ischemia: A Systematic Review.

BACKGROUND: Frailty is a risk factor associated with adverse postoperative outcomes following lower extremity bypass (LEB) surgery in patients with peripheral arterial disease (PAD). Chronic limb threatening ischemia (CLTI) represents the worst form of PAD, and frailty is common among patients presenting with CLTI. Multiple frailty assessment scores have been developed for the past 2 decades; however, a universal clinical assessment tool for measuring frailty has not yet been established due to the complexity of the concept. This systematic review aimed to evaluate the use of a frailty index as a predictor of postoperative outcomes in patients undergoing LEB. METHODS: The review protocol was registered in the international prospective register of systematic reviews (PROSPERO) database (CRD42022358888). A systematic literature search was conducted using the PubMed and Scopus databases. The review followed the preferred reporting items for systematic reviews and metaanalyses (PRISMA) guidelines. The risk of bias was evaluated using the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool. A total of 3,929 studies were initially selected originally and were eventually left with 6 studies that met the inclusion criteria of this systematic review. RESULTS: Six studies were examined that assessed the relationship between frailty index and long-term mortality following LEB for CLTI were screened. All analyses were published between 2017 and 2020 and included a broad spectrum of patients who underwent LEB. The results of these studies showed inconsistencies in the reporting of postoperative outcomes and the time endpoint of these events. However, all correlated with higher frailty index and increased mortality rate. CONCLUSIONS: Higher frailty index preoperatively is associated with an increased likelihood of postoperative comorbidities after undergoing LEB. Identifying and addressing the preoperative frailty index of these patients may be a practical approach to reducing postoperative adverse outcomes. A thorough review of the frailty spectrum and standardized reporting of outcomes in the context of frailty could be helpful to have a more comprehensive understanding of this subject.

A Systematic Review and Meta-Analysis to Assess the Impact of Pre-existing Comorbidities on the 30-Day Readmission after Lower Extremity Bypass Surgery for Peripheral Artery Occlusive Disease.

BACKGROUND: Unplanned hospital readmissions after surgical operations are considered a marker for suboptimal care during index hospitalizations and are associated with poor patient outcomes and increased healthcare resource utilization. Patients undergoing lower extremity bypass (LEB) operations for severe peripheral arterial disease (PAD) have one of the highest readmission rates, among all the vascular and nonvascular surgical operations. This review is meant to evaluate the impact of pre-existing comorbidities (diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hypertension (HTN), and coronary artery disease (CAD))-on the 30-day readmission rates among patients who underwent LEB for severe PAD. METHODS: The review protocol was registered to the PROSPERO database (CRD42021261067). A systematic review of the English literature was performed using PubMed, Scopus, and the Cochrane Library databases from inception till April 2022. The review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and included only studies reporting on 30-day readmission following LEB for occlusive PAD. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach and was reported as high, moderate, or low. The risk of bias was evaluated utilizing the Risk of Bias in Nonrandomized Studies - of Interventions (ROBINS-I) tool. A pooled odds ratio (OR) for each study was computed, and a P-value of <0.05 was designated as statistically significant. Interstudy heterogeneity was evaluated by Q-metric and quantified using Higgins I2 statistics. RESULTS: Five studies reported data on 30-day readmission after LEB for occlusive PAD. A total of 19,739 patients were included. Readmission occurred among 3,559 (18%) patients. DM and COPD were reported by all 5 selected studies, and CHF and HTN were reported by 4 studies. CAD was least reported among the selected 5 pre-existing conditions, with only 2 studies mentioning it. HTN (OR, 1.35; 95% confidence interval (CI), 1.10-1.64; P ≤ 0.001; I2 = 52.20%), DM (OR, 1.52; 95% CI, 1.30-1.79; P ≤ 0.001; I2 = 74.51%), and CHF (OR, 1.85; 95% CI, 1.51-2.25; P ≤ 0.001; I2 = 50.48%) were all found to be associated with an increased risk of 30-day readmission, while the presence of COPD (OR, 1.16; 95% CI, 0.98-1.36; P = 0.09; I2 = 61.93%) and CAD (OR, 1.30; 95% CI, 0.94-1.78; P = 0.11; I2 = 51.01%) was not associated with early readmission on meta-analysis of the available studies. CONCLUSIONS: The pre-existing comorbidities HTN, DM, and CHF increase the risk of 30-day readmission after LEB for occlusive PAD. The identification of these risk factors can help stratify the patients and further guide in understanding the variety of factors that contribute in hospital readmissions.

A triangulation model for assessment of change in classroom behavior of medical teachers participating in faculty development program on lecturing skills.

BACKGROUND & AIMS: We utilized a triangulation method of a faculty development program's (FDP) evaluation comprising short-course workshops on classroom behaviors and lecturing skills of basic sciences faculty in a medical school. METHODS & RESULTS: This study utilized data from the pre and post evaluation of classroom lectures by an expert observer. Course participants were observed before the inception of a 4-month FDP and after 6-months of program completion. Findings at 6-month post-FDP interval were supplemented with students' and participant's self-evaluation. Expert evaluation of 15 participants showed that more participants were summarizing lectures at the end of their class (p = 0.021), utilizing more than one teaching tool (p = 0.008) and showing a well-structured flow of information (p = 0.013). Among the students, majority (95.5%, n = 728) agreed on "teachers were well-prepared for the lecture", however, a low number (66.1%, n = 504) agreed on "teachers were able to make the lecture interesting". On self-evaluation (n = 12), majority of the participants (91.7%, n = 11) thought these FDP workshops had a positive impact on their role as a teacher. CONCLUSIONS: Gathering feedback from multiple sources can provide a more holistic insight into the impact of an FDP and can provide a robust framework for setting up future FDP targets.

Postoperative decline in ambulatory function after lower extremity bypass is associated with higher short- and long-term mortality.

OBJECTIVE: Although the importance of preexisting functional and ambulatory status among patients undergoing lower extremity bypass (LEB) has been increasingly recognized, a paucity of reported data is available on the significance of a postoperative decline in ambulatory status after LEB surgery. The purpose of the present analysis was to determine the effects of a new decline in ambulatory status after LEB surgery on the postoperative short- and long-term outcomes. METHODS: The Vascular Quality Initiative infrainguinal bypass dataset was queried from 2003 to 2021 for patients with peripheral arterial disease (PAD) who had undergone LEB. Information on ambulatory status at admission and discharge from the hospital was recorded. Patients with a decline in ambulatory status at discharge from the hospital were included in group I, and those who had maintained their ambulatory status at discharge were included in group II. The primary outcomes were mortality, amputation, and a composite outcome of mortality or amputation at 30 days and 1 year postoperatively. The secondary outcomes were major adverse cardiovascular events, myocardial infarction, congestive heart failure, stroke, dysrhythmia, pneumonia, and the need for prolonged ventilation. RESULTS: A total of 40,478 patients were included in the present study, of whom 16,032 (39.6%) were included in group I and 24,446 (60.4%) were included in group II. The patients in group I were more often aged >70 years, women, African American, transferred from another hospital or rehabilitation facility, prior or current smokers, or had an American Society of Anesthesiologists classification of III or IV compared with those with unchanged ambulatory status (P < .05 for all). Patients with a decline in ambulatory status had had a greater incidence of mortality at 30 days (2.4% vs 0.6%; P < .001) and 1 year (9.7% vs 7%; P < .001) postoperatively. Patients with a decline in ambulatory status had had a greater occurrence of major adverse cardiovascular events, myocardial infarction, stroke, dysrhythmia, and the need for prolonged ventilation. The following factors were associated with a decline in postoperative ambulatory status: older age (70-79 years: adjusted odds ratio [aOR], 1.20; 95% confidence interval [CI], 1.07-1.34; P = .001; and ≥80 years: aOR, 1.18; 95% CI, 1.05-1.35; P = .007), female sex (aOR, 1.06; 95% CI, 1.00-1.11; P = .019), African-American race (aOR, 1.15; 95% CI, 1.07-1.21; P < .001), transfer from another hospital or rehabilitation unit (aOR, 1.30; 95% CI, 1.18-1.41; P < .001), and a history of diabetes mellitus (aOR, 1.12; 95% CI, 1.06-1.17; P = .004). The magnitude of decline in ambulatory function was associated with worse primary outcomes. Patients whose ambulatory function had declined from ambulatory to bedridden after LEB surgery had had the highest mortality (aOR, 21 at 30 days and 15 at 1 year). CONCLUSIONS: A new decline in ambulatory function at discharge from the hospital after LEB surgery was associated with increased short- and long-term mortality and the composite outcome of mortality or amputation. It was also associated with reduced amputation-free survival at 30 days and 1 year postoperatively.

Fenestrated endovascular abdominal aortic aneurysm repair in octogenarians is associated with higher mortality and an increased incidence of nonhome discharge.

OBJECTIVE: Fenestrated endovascular abdominal aortic aneurysm repair (FEVAR) has been increasingly becoming the endovascular treatment of choice for patients with juxtarenal abdominal aortic aneurysms with an infrarenal neck, not suitable for traditional endovascular abdominal aortic aneurysm repair. Older patients are at a high risk of developing complications after elective procedures. A review of the literature showed mixed results for FEVAR in the elderly patient population. In the present study, we investigated the occurrence of mortality (both short and long term), discharge destination, and other postoperative outcomes in the octogenarian population who had undergone FEVAR for the management of abdominal aortic aneurysms in a large, national surgical database. METHODS: A retrospective analysis of patients who had undergone FEVAR in the Society for Vascular Surgery Vascular Quality Initiative database was performed from July 2010 to June 2019. The study cohort excluded patients aged <18 years and concomitant procedures for snorkeling of visceral branches of the aorta. The final selected cohort was divided into two patient groups: group I, patients aged <80 years (nonoctogenarians); and group II, patients aged ≥80 years (octogenarians). The primary outcomes were mortality at 30 days (short term), 6 months, and 1 year (long term) and the discharge destination. The secondary outcomes included postoperative length of stay, intensive care unit stay, postoperative major cardiac events, and the need for intervention. Computation of models to measure the outcomes and identify the risk factors contributing to mortality at 30 days and discharge to a nonhome destination was performed using multiple logistic regression analyses. Cox proportional hazards regression analysis was performed to study the long-term mortality in the patient groups. RESULTS: A total of 5507 patients had undergone FEVAR in the 9-year period in the Society for Vascular Surgery Vascular Quality Initiative database (group I, nonoctogenarians, n = 4424 [80.3%]; group II, octogenarians, n = 1156 [19.7%]). Octogenarians were more likely to be women, white, Medicare insured, and hypertensive. This group also had lower rates of former or current smokers, a lower glomerular filtration rate, a lower incidence of late-stage chronic kidney disease, and an aneurysm diameter >5.5 cm. Greater estimated blood loss and longer procedures were also noted in the octogenarian group compared with the nonoctogenarian group. Multiple logistic regression analysis showed that octogenarians had had greater mortality at 30 days (7.3%; adjusted odds ratio [aOR], 1.21; 95% confidence interval [CI], 1.0-1.45; P = .044), 6 months (13.7%; aOR, 1.52; 95% CI, 1.24-1.81; P < .001), and 1 year (17.5%; aOR, 1.67; 95% CI, 1.34-2.07; P < .001). The present analysis to measure the discharge destination showed that octogenarians had a greater risk of discharge to nonhome destinations (26.7%; aOR, 1.50; 95% CI, 1.24-1.81; P < .001). Octogenarians had a lower risk of ≥2 days of an intensive care unit stay (aOR, 0.76; 95% CI, 0.67-0.91; P < .001) but a greater risk of experiencing dysrhythmia (10.1%; aOR, 1.32; 95% CI, 1.01-7.1; P = .036) following the procedure compared with the nonoctogenarians. CONCLUSIONS: In our retrospective analysis of a large, national surgical database, we found that of the patients undergoing FEVAR to manage juxtarenal abdominal aortic aneurysms, octogenarians had greater mortality and a greater risk of being discharged to nonhome locations compared with nonoctogenarians.

Imaging Approaches to the Diagnosis of Vascular Diseases.

PURPOSE OF REVIEW: Vascular imaging is a complex field including numerous modalities and imaging markers. This review is focused on important and recent findings in atherosclerotic carotid artery plaque imaging with an emphasis on developments in magnetic resonance imaging (MRI) and computed tomography (CT). RECENT FINDINGS: Recent evidence shows that carotid plaque characteristics and not only established measures of carotid plaque burden and stenosis are associated independently with cardiovascular outcomes. On carotid MRI, the presence of a lipid-rich necrotic core (LRNC) has been associated with incident cardiovascular disease (CVD) events independent of wall thickness, a traditional measure of plaque burden. On carotid MRI, intraplaque hemorrhage (IPH) presence has been identified as an independent predictor of stroke. The presence of a fissured carotid fibrous cap has been associated with contrast enhancement on CT angiography imaging. Carotid artery plaque characteristics have been associated with incident CVD events, and advanced plaque imaging techniques may gain additional prominence in the clinical treatment decision process.

Asymptomatic Preoperative Leukocytosis Before Carotid Endarterectomy is Associated With Increased Risk of Stroke: A Study From NSQIP Database.

BACKGROUND: Carotid endarterectomy (CEA) is the gold standard operation for treating carotid artery stenosis in patients with symptomatic carotid stenosis of more than 50% and asymptomatic carotid stenosis of more than 80%. Asymptomatic leukocytosis before CEA represents a clinical dilemma for surgeons about the management options. The objectives of this study are to identify the relationship between asymptomatic preoperative leukocytosis and postoperative complications in patients undergoing CEA and to assess the relationship between asymptomatic preoperative leukocytosis and postoperative complications in the cohort of patients with symptomatic carotid stenosis. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database for the years 2011-2019 was utilized for this analysis. Patients with preoperative sepsis, septic shock, pneumonia, wound infections, disseminated cancer, renal failure, and history of chronic steroid use were excluded. The remaining patients were sub-grouped based on white blood cell (WBC) count: Normal WBC (<11k/µL) and High WBC (≥11k/µL). Bivariate analysis between the patient characteristics and preoperative WBC levels was performed following simple and multiple regression analysis. A P-value of <0.05 was set as significant. RESULTS: Of the 26,332 patients in the study cohort, 7.4% (n =1,946) had preoperative leukocytosis. Patients with preoperative leukocytosis were relatively younger (mean age: 41.5 +/- 9.7 vs 44.3 +/- 9.1; P< 0.001) and more likely to be females (43% vs. 38.5; P< 0.001) than patients with normal WBC count. Patients with preoperative leukocytosis were also more likely to have DM, COPD, a bleeding disorder, be smokers, and be functionally dependent. The analysis revealed that patients with preoperative leukocytosis had a significantly higher rate of stroke, length of stay (LOS)>1- week, acute occlusion or revision, acute renal failure, and return to OR when compared to patients with normal WBC count. Furthermore, patients with high WBC count also experienced higher occurrences of infectious complications, such as wound dehiscence, wound infections, pneumonia, and sepsis. However, there was no difference in the overall 30-day mortality. Multivariate regression analysis showed patients with preoperative leukocytosis had anincreased risk of stroke (AOR 1.5, CI: 1.1-1.9, P = 0.009), LOS>1 week (AOR 1.3, CI: 1.1-1.5, P = 0.003), and return to OR (AOR 1.3, CI: 1.0-1.8, P = 0.030). The increased LOS was especially more pronounced in symptomatic carotid stenosis patients with preoperative leukocytosis. The occurrence of LOS>1 week was 4.91% in asymptomatic stenosis patients with high WBC count compared to 21.5% in symptomatic stenosis patients with high WBC count (P< 0.001). CONCLUSIONS: Patients with asymptomatic preoperative leukocytosis undergoing CEA have a significantly higher risk of stroke and infectious complications in the postoperative period. Furthermore, patients with symptomatic carotid disease are especially at an increased risk of prolonged LOS. A routine preoperative hematological evaluation may be recommended as a risk assessment tool for patients undergoing CEA, and postponing the elective operation in patients with asymptomatic CEA may be advised unless a thorough preoperative infectious workup is completed.

Implementation of Transitional Care Planning is Associated with Reduced Readmission Rates in Patients Undergoing Lower Extremity Bypass Surgery for Peripheral Arterial Disease.

BACKGROUND: Patients undergoing lower extremity bypasses (LEB) are at a high risk of developing post-discharge complications requiring readmission. Health systems have developed several strategies to mitigate this risk. One such measure is developing comprehensive Transitional Care Program (TCP), which includes phone calls to patients after being discharged from the hospital. Our study aimed to assess short-term readmission, mortality, and amputation rates of patients who participated in TCP by completing at least one post-discharge follow-up phone call after undergoing LEB for revascularization of peripheral arterial disease (PAD). METHODS: A retrospective review was completed for patients who underwent LEB surgery between January 2010 and January 2020 to treat PAD at Penn State Hershey Medical Center. Immediate discharge follow-up was done via telephone calls using a standardized script. Patients were then divided into two groups, those who did not have a successful follow-up call (Group I) and those who had at least one successful follow-up call within seven days after discharge (Group II). Univariate analysis was used to compare preoperative demographics, intraoperative variables, and postoperative outcomes. The probability of readmission and risk factors contributing to it were computed using multiple stepwise forward regression analyses. Epidemiological analysis was done to evaluate the risk of readmission in the group receiving post-discharge follow-up calls. RESULTS: A total of 457 patients underwent LEB from 2010 to 2020 and qualified for inclusion in the study. Among these patients, 126 (27.6%) did not have a successful post-discharge follow-up call (Group I), whereas, 331 (72.4%) patients did complete a successful call (Group II). The mean age of patients was 66.7 years. There were no significant differences in preoperative baseline patient characteristics or intraoperative factors. Patients who completed a successful call had lower readmission rates within thirty days of the operation (8.8 vs. 17.5%, P = 0.008), and this was sustained in multivariate analysis (adjusted odds ratio AOR: 0.18, [confidence interval CI: 0.05-0.66], P = 0.009). However, no differences were observed for thirty-day mortality (Group-I: 3.2% versus Group-II: 1.2%, P = 0.152) or amputation (Group-I: 9.6% versus Group II 5.9%, P = 0.162). Among those who had a successful call, patients with a history of smoking (AOR: 4.05 [CI: 1.21, 17.12] P = 0.025), diabetes mellitus (AOR: 3.42 [CI: 1.35, 8.7] P = 0.01) and myocardial infarction (AOR: 7.15 [CI: 1.76, 20.1] P = 0.006) had a much higher chances of readmission. Risk analysis using epidemiological methods showed that by receiving a call, the risk of readmission could be dropped to half (RR: 0.50 [CI: 0.30, 0.84]), with an attributable risk reduction of -8.7% (CI: -15.9%, -1.4%). CONCLUSIONS: This single-institution retrospective study demonstrates the importance of immediate discharge follow-up phone calls in patients who undergo open lower extremity revascularization to reduce thirty-day readmissions. Our analysis showed patients who received immediate follow-up phone calls were less likely to be readmitted to the hospital. The development of reliable and efficient systems to enhance immediate discharge follow-up in vascular surgery patients is pivotal to improving quality of care, preventing readmissions, and reducing healthcare costs.

Unraveling the Jeopardy: Child health in Afghanistan.

A humanitarian crisis started in Afghanistan after the United States and international Allies withdrew in August 2021, causing numerous challenges and have especially impacted children. Children in Afghanistan have been affected by a long history of suffering from violence, war, and poverty. The US withdraw and COVID-19 pandemic have caused an economic crisis causing high rates of child malnutrition and prevented them from receiving healthcare and education. In the long run, the impacts of the current situation will significantly affect the child growth, education, and psychological health. There is a need for international organizations to intervene now to ensure children do not further suffer and have the option for a bright future. In turn, ensuring a brighter future for Afghanistan.