The study of transcarotid artery revascularization under local versus general anesthesia with results from the Society for Vascular Surgery Vascular Quality Initiative.

OBJECTIVE: The primary purpose of this study was to examine any potential difference in clinical outcomes between transcarotid artery revascularization performed under local anesthesia compared with general anesthesia by utilizing a large national database. METHODS: The primary outcome of the study was a composite endpoint of postoperative in-hospital stroke, myocardial infarction and mortality following transcarotid artery revascularization for the index procedure. Secondary outcomes included a composite outcome of postoperative in-hospital stroke, transient ischemic attack, myocardial infarction and mortality along with several subsets of its components and each individual component, flow reversal time (min), radiation dose (GY/cm2), contrast volume utilized (mL), total procedure time (min), extended total length of stay (>1 day) and extended postoperative length of stay (>1 day). Statistical analyses employed both descriptive measures to characterize the study population and analytic measures such as multivariable mixed-effect linear and logistic regressions using both unmatched and propensity-score matched cohorts. RESULTS: A total of 2609 patients undergoing transcarotid artery revascularization between the years 2016 and 2018 in the US were identified, with 82.3% performed under general anesthesia and 17.7% under local anesthesia. The primary composite outcome was observed in 2.3% of general anesthesia patients versus 2.6% of local anesthesia patients (p = 0.808). The rate of postoperative transient ischemic attack and/or myocardial infarction was 1.6% with general anesthesia versus 1.1% with local anesthesia (p = 0.511). For adjusted regression analysis, general anesthesia and local anesthesia were comparable in terms of primary outcome (OR: 0.72; 95% CI: 0.27-1.93, p = 0.515). As for the secondary outcomes, no significant differences were found except for contrast, where the results demonstrated significantly less need for contrast with procedures performed under general anesthesia (coefficient: 4.94; 95% CI: 1.34-8.54, p = 0.007). A trend towards significance was observed for lower rate of postoperative transient ischemic attack and/or myocardial infarction (OR: 0.33; 95% CI: 0.09-1.18, p = 0.088) and lower flow reversal time under local anesthesia (coefficient: -0.94: 95% CI: -2.1-0.22, p = 0.111). CONCLUSIONS: Excellent outcomes from transcarotid artery revascularization for carotid stenosis were observed in the VQI database between the years 2016 and 2018, under both local anesthesia and general anesthesia. The data demonstrate the choice of anesthesia for transcarotid artery revascularization does not appear to have any effect on clinical outcomes. Surgical teams should perform transcarotid artery revascularization under the anesthesia type they are most comfortable with.

Quality of Life and Traditional Outcome Results at 1 Year in Elderly Patients Having Critical Limb Ischemia and the Role of Conservative Treatment.

INTRODUCTION: Revascularization is the cornerstone of the treatment of critical limb ischemia (CLI), but the number of elderly frail patients increase. Revascularization is not always possible in these patients and conservative therapy seems to be an option. The goals of this study are to analyze the 1-year quality of life (QoL) results and mortality rates of elderly patients with CLI and to investigate if conservative treatment could be an acceptable treatment option. METHODS: Patients with CLI ≥70 years old were included in a prospective observational cohort study in 2 hospitals in the Netherlands between 2012 and 2016 and were divided over 3 treatment modalities: endovascular therapy, surgical revascularization, and conservative treatment. The World Health Organization Quality of Life (WHOQoL-Bref) instrument, a generic QoL assessment tool that includes components of physical, psychological, social relationships and environment, was used to evaluate QoL at baseline, 6 months, and 1 year. RESULTS: In total, 195 patients (56% male, 33% Rutherford 4, mean age of 80) were included. Physical QoL significantly increased after surgical (10.4 vs 14.9, P < .001), endovascular (10.9 vs 13.7, P < .001), and conservative therapy (11.6 vs 13.2, P = .01) at 1 year. One-year mortality was relatively low after surgery (10%) compared to endovascular (40%) and conservative therapy (37%). CONCLUSION: The results of this study could not be used to designate the superior treatment used in elderly patients with CLI. Conservative treatment could be an acceptable treatment option in selected patients with CLI unfit for revascularization. Treatment of choice in elderly patients with CLI is based on multiple factors and should be individualized in a shared decision-making process.

Type A Aortic Dissection in the United Kingdom: The Untold Facts.

There is a lack of evidence on multiple levels for appropriate recognition, management, and outcome results in Type A aortic dissection management in the United Kingdom. A huge amount of retrospective data exists in the literature which provides nonmeaningful prospect to a service that meets the current era. Electronic searches were performed on PubMed and Cochrane databases with no limits placed on dates. Search terms were charted to MeSH terms and combined using Boolean operations, and also used as key words. Papers were selected on the basis of title and abstract. The reference lists of selected papers were reviewed to identify any relevant papers that might be suitable for inclusion in the study. Papers were selected based on providing primary end points of death, rupture, or dissection and/or information regarding aortic aneurysm growth. Papers were not excluded based on patient population age. We demonstrated the lack of evidence for quality outcomes in type A aortic dissection in the United Kingdom. This highlighted the unwarranted variation seen in this entity and the caveats needed to improve structuring of type A aortic dissection from early identification in emergency departments to arrival at destination site for optimum intervention. Emergency services should be restructured to meet the immediate affirmation of diagnosis with gold standard imaging modality available. Management of this dire disease should be instituted at local hospitals prior to transportation and results should be audited regularly to improve quality outcomes. Attempts should be made to create local area networks to improve the efficiencies and outcomes of the service and transfer to centers with concentration of expertise. Recognition of regional networks by the UK Government Care Quality Commission should in part based on cumulative evidence sought after from virtual multidisciplinary teams. Unwarranted variation is an avenue that requires to be addressed to rise with service provision that meets our patients aspiration and be of current evidence in the 21st era.

Lipiodol deposition in portal vein tumour thrombus predicts treatment outcome in HCC patients after transarterial chemoembolisation.

OBJECTIVE: To study lipiodol deposition in portal vein tumour thrombus (PVTT) in predicting the treatment outcome of hepatocellular carcinoma (HCC) patients after transarterial chemoembolisation (TACE). METHODS: We retrospectively reviewed data from 379 HCC patients with PVTT who underwent TACE as the initial treatment at Sun Yat-Sen University Cancer Center from January 2008 to December 2015. Patients were grouped by positive and negative lipiodol deposition based on the extent of lipiodol deposition in PVTT. The overall survival (OS) and progression-free survival (PFS) were compared between negative and positive lipiodol deposition groups; furthermore, the value of the combinatorial evaluation of tumour responses and lipiodol deposition in PVTT in predicting prognosis was analysed in subgroup patients with stable disease (SD) after TACE. RESULTS: Of the 379 patients, 264 (69.7%) had negative and 115 (30.3%) had positive lipiodol deposition in PVTT after TACE. Multivariate analysis identified positive lipiodol deposition in PVTT as an independent prognostic factor for favourable OS (p = 0.001). The median OS and PFS of negative and positive lipiodol deposition groups were 4.70 vs. 8.97 months (p = 0.001) and 3.1 months vs. 5.8 months (p < 0.001). In subgroup patients, the median OS and PFS of negative and positive lipiodol deposition groups were 4.7 months vs. 10.5 months (p < 0.001) and 3.5 months vs. 7.0 months (p < 0.001), respectively. CONCLUSIONS: The patients with positive lipiodol deposition in PVTT had a longer OS than those with negative lipiodol deposition. Furthermore, the positive lipiodol deposition in PVTT can further differentiate HCC patients with favourable prognosis from SD patients. KEY POINTS: • Lipiodol deposition in PVTT is a prognostic indicator for HCC patients after TACE treatment. • Positive lipiodol deposition in PVTT is associated with a better prognosis.

Vascular surgery: An essential hospital resource in modern health care.

OBJECTIVE: In modern health care, vascular surgeons frequently serve as a unique resource to other surgical specialties for vascular exposure, repair, reconstruction, or control. These services occur both in planned and unplanned clinical settings. We analyzed the frequency, outcomes, and value of vascular services in this setting to other surgical specialties and the hospital. METHODS: Intraoperative planned and unplanned vascular surgery operative consultations were reviewed over a 3-year period (2013-2016). Patient demographics, requesting surgical specialty, indication and type of vascular intervention, and work relative value units generated were recorded. Univariate and multivariate analysis of factors affecting a composite outcome of in-hospital and 30-day mortality or morbidity, or both, was performed. RESULTS: Seventy-six vascular surgery intraoperative consultations were performed, of which 56% of the consultations were unplanned. The most common unplanned consultation was for bleeding (33%). The aorta and lower extremity were the most common vascular beds requiring vascular services. The mean work relative value units generated per vascular surgery intervention was 23.8. In-hospital and 30-day mortality was 9.2%. No difference in mortality and morbidity was found between planned and unplanned consultations. Factors associated with the composite mortality/morbidity outcome were coronary artery disease (P = .002), heart failure (P = .02), total operative blood loss (P = .009), consultation for limb ischemia (P = .013), and vascular consultation for the lower extremity (P = .01). On multivariate analysis, high operative blood loss (>5000 mL) remained significant (P = .04), and coronary artery disease approached significance (P = .06). CONCLUSIONS: The need for vascular surgery services is frequent, involves diverse vascular beds, and occurs commonly in an unplanned setting. When requested, vascular surgery services effectively facilitate the completion of the nonvascular procedure, even those associated with significant intraoperative blood loss. Vascular surgery services are essential to other surgical specialties and the hospital in today's modern health care environment.

Management of Vascular Trauma during the Paris Terrorist Attack of November 13, 2015.

BACKGROUND: On November 13, 2015, Paris and Saint-Denis were the targets of terrorist attacks. The Public Hospitals of Paris Organization and the Percy Armed Forces Instruction Hospitals were mobilized to face the mass casualty situation. The objective of this study is to analyze the management of the victims presenting with a nonthoracic vascular trauma (NTVT). METHODS: All the data relating to the victims of NTVT who required a specific vascular open or endovascular treatment were analyzed retrospectively. A 6-month follow-up was obtained for all the patients. RESULTS: Among the 351 wounded, 20 (5.7%) patients had an NTVT and were dispatched in 8 hospitals (11 men of average age 32). NTVTs were gunshots in 17 cases (85%) or due to a handmade bomb in 3 cases (15%). Twelve patients (60%) received cardiopulmonary resuscitation during prehospital care. NTVT affected the limbs (14 cases, 70%) and the abdomen or the small pelvis (6 cases, 30%). All the patients were operated in emergency. Arterial lesions were treated with greater saphenous vein bypasses, by ligation, and/or embolization. Eleven venous lesions were treated by direct repair or ligation. Associated lesions requiring a specific treatment were present in 19 patients (95%) and were primarily osseous, nervous, and abdomino-pelvic. Severe postoperative complications were observed in 9 patients (45%). Fourteen patients (70%) required blood transfusion (6.4 U of packed red blood cells on average, range 0-48). There were no deaths or amputation and all vascular reconstructions were patent at 6 months. CONCLUSIONS: The effectiveness of the prehospital emergency services and a multisite and multidisciplinary management made it possible to obtain satisfactory results for NTVT casualties. All the departments of vascular surgery must be prepared to receive many wounded victims in the event of terrorist attacks.

Vascular surgeon-hospitalist comanagement improves in-hospital mortality at the expense of increased in-hospital cost.

OBJECTIVE: We have shown that vascular surgeon- hospitalist co management resulted in improved in-hospital mortality rates. We now aim to assess the impact of the hospitalist co management service (HCS) on healthcare cost. METHODS: A total of 1558 patients were divided into three cohorts and compared: 516 in 2012, 525 in 2013, and 517 in 2014. The HCS began in January 2013. Data were standardized for six vascular surgeons that were present 2012-2014. New attendings were excluded. Ten hospitalists participated. Case mix index (CMI), contribution margin, total hospital charges (THCs), length of stay (LOS), actual direct costs (ADCs), and actual variable indirect costs (AVICs) were compared. Analysis of variance with post-hoc tests, t-tests, and linear regressions were performed. RESULTS: THC rose by a mean difference of $14,578.31 between 2012 and 2014 (P < .001) with a significant difference found between all groups during the study period (P = .0004). ADC increased more than AVIC; however, both significantly increased over time (P = .0002 and P = .014, respectively). A mean $3326.63 increase in ADC was observed from 2012 to 2014 (P < .0001). AVIC only increased by an average $392.86 during the study period (P = .01). This increased cost was observed in the context of a higher CMI and longer LOS. CMI increased from 2.25 in 2012 to 2.53 in 2014 (P = .006). LOS increased by a mean 1.02 days between 2012 and 2014 (P = .016), and significantly during the study period overall (P = .018). After adjusting for CMI, LOS increases by only 0.61 days between 2012 and 2014 (P = .07). In a final regression model, THC is independently predicted by comanagement, CMI, and LOS. After adjusting for CMI and LOS, the increase in THC because of comanagement (2012 vs 2014) accounts for only $4073.08 of the total increase (P < .001). During this time, 30-day readmission rates decreased by ∼7% (P = .005), while related 30-day readmission rates decreased by ∼2% (P = .32). Physician contribution margin remained unchanged over the 3-year period (P = .76). The most prevalent diagnosis-related group was consistent across all years. Variation in the principal diagnosis code was observed with the prevalence of circulatory disorders because of type II diabetes replacing atherosclerosis with gangrene as the most prevalent diagnosis in 2013 and 2014 compared with 2012. CONCLUSIONS: In-hospital cost is significantly higher since the start of the HCS. This surge may relate to increased CMI, LOS, and improved coding. This increase in cost may be justified as we have observed sustained reduction in in-hospital mortality and slightly improved readmission rates.

Management of Acute Mesenteric Ischemia: A Critical Review and Treatment Algorithm.

BACKGROUND: Acute mesenteric ischemia (AMI) due to a sudden loss or decrease in blood perfusion to the mesentery represents a highly lethal condition. However, the optimal surgical management remains debatable and merits a more clear recommendation based on a higher level of evidence. METHODS: A systematic review of articles published between 2000 and 2013 was performed. Patients were divided into endovascular treatment (ET), open surgery (OS), and hybrid technique (HT) groups. Data of patients' demographics, procedural information, clinical outcomes including mortality, morbidity, primary patency rate, technique success, primary intestinal resection rate, and second-look laparotomy rate, and follow-up were all retrieved. Comparison between the ET and the OS groups was made using 2-sided Student t test and 2-sided χ(2) test or Fisher exact test where appropriate. RESULTS: Twenty-eight articles with a total of 1110 patients were included for the review. The ET group had lower in-hospital mortality and morbidity but similar survival rate during follow-up compared to the OS group. The primary patency rate was higher in the ET group. The overall bowel resection rate was lower in the ET group, and nearly every patient in the cohort who required second-look laparotomy required bowel resection. The HT group seemed to have the lowest mortality and acceptable second-look laparotomy rate and morbidity. Comparison between the HT group and other groups was not possible due to the limited number of cases available for review. CONCLUSION: Endovascular treatment may serve as a first-line therapy for select patients when there is a low suspicion for intestinal necrosis. Open surgery should be reserved for emergency conditions requiring exploratory laparotomy. Hybrid technique may be an especially effective approach for treating AMI, with low morbidity and mortality, although further studies are required comparing it to OS and ET.

The effect of a hospitalist comanagement service on vascular surgery inpatients.

OBJECTIVE: Vascular surgery patients have increased medical comorbidities that amplify the complexity of their care. We assessed the effect of a hospitalist comanagement service on inpatient vascular surgery outcomes. METHODS: We divided 1059 patients into two cohorts for comparison: 515 between January 2012 and December 2012, before the implementation of a hospitalist comanagement service, and 544 between January 2013 and October 2013, after the initiation of a hospitalist comanagement service. Nine vascular surgeons and 10 hospitalists participated in the hospitalist comanagement service. End points measured were in-hospital mortality, length of stay (LOS), 30-day readmission rates, visual analog scale pain scores (0-10), inpatient adult safety assessments using the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators, and resident perceptions assessed by survey. RESULTS: The in-hospital mortality rate decreased from 1.75% to 0.37% after the implementation of the hospitalist comanagement service (P = .016), with a decrease in the observed-to-expected ratio from 0.89 to 0.22. The risk-adjusted in-hospital mortality decreased from 1.56% to 0.0008% (P = .003). Mean LOS was lower in the base period, at 5.1 days vs 5.5 days (P < .001), with an observed-to-expected ratio of 0.83 and 0.78, respectively. The risk-adjusted LOS increased from 4.2 days to 4.3 days (P < .001). The overall 30-day readmission rate was unchanged, at 23.1% compared with 22.8% (P = .6). The related 30-day readmission rate was also similar, at 11.5% compared with 11.4% (P = .5). Patients reporting no pain during hospitalization increased from 72.8% before the hospitalist comanagement service to 77.8% after (P = .04). Reports of moderate pain decreased from 14% to 9.6% (P = .016). Mild and severe pain scores were similar between the two groups. Adult safety measured by AHRQ demonstrated a decrease from three to zero patients in the number of deaths among surgical patients with treatable complications (P = .04). Most house staff reported that the comanagement program had a positive effect on patient care and education. CONCLUSIONS: The hospitalist comanagement service has resulted in a significant decrease in in-hospital mortality rates, patient safety, as measured by AHRQ, and improved pain scores. Resident surveys demonstrated perceived improvement in patient care and education. Continued observation will be necessary to assess the long-term effect of the hospitalist comanagement service on quality metrics.

Autologous platelet-rich plasma reduces transfusions during ascending aortic arch repair: a prospective, randomized, controlled trial.

BACKGROUND: Blood conservation using autologous platelet-rich plasma (aPRP), a technique of whole blood harvest that separates red blood cells from plasma and platelets before cardiopulmonary bypass with retransfusion of the preserved platelets after completion of cardiopulmonary bypass, has not been studied extensively. We sought to prospectively determine whether aPRP reduces blood transfusions during ascending and transverse aortic arch repair. METHODS: We randomly assigned 80 patients undergoing elective ascending and transverse aortic arch repair using deep hypothermic circulatory arrest to receive either aPRP (n = 38) or no aPRP (n = 42). Volume of aPRP retransfused was 726 ± 124 mL. The primary end point was transfusion amount. Secondary end points were death, stroke, renal failure, pulmonary failure, and transfusion costs. Perioperative transfusion rate was defined as blood transfusions given during surgery and up to 72 hours afterward. The surgeon and intensivist were blinded to the treatment arm. Because an anesthesiologist initiated the protocol, the surgeon was not aware of aPRP collection, as this occurred only after the sterile drape was in place. In addition, because cell salvage was performed on all cases, differentiation in perfusionist activities (during spinning of aPRP) was not evident. Platelet, fresh frozen plasma, and cryoprecipitate intraoperative transfusions were performed only after heparin was reversed and the patient was judged as coagulopathic on the basis of associated criteria: cryoprecipitate transfusion for fibrinogen level less than 150 µg/dL, platelet transfusion for platelet count less than 80,000, and fresh frozen plasma when thromboelastogram test was suggestive or a partial thromboplastin time was greater than 55 seconds, and prothrombin time was greater than 1.6 seconds. RESULTS: Early mortality, stroke, and respiratory complications were similar between groups. Only acute renal failure was reduced in the aPRP group, 7% versus 0% (p < 0.014). Mean transfusion rate of packed red blood cells was reduced by 34%, fresh frozen plasma by 52.8%, cryoprecipitate by 70%, and platelets by 56.7% in the aPRP group (p < 0.02). Hospital length of stay (9.4 ± 5.3 days versus 12.7 ± 6.3 days; p < 0.014) and transfusion costs ($1,396 ± $1,755 versus $2,762 ± $2,267; p < 0.004) were reduced in the aPRP group. CONCLUSIONS: The use of aPRP reduced allogeneic transfusions during ascending and transverse aortic arch repair with deep hypothermic circulatory arrest. This translated to less acute renal failure, decreased length of stay, and lower transfusion costs. Further studies examining the coagulation factors of aPRP are required.

Provision of vascular surgery in England in 2012.

INTRODUCTION: In 2009 the Vascular Society of Great Britain and Ireland reported its recommendations for The Provision of Vascular Services for Patients with Vascular Disease. The objective is to halve the UK elective surgery mortality rate for Abdominal Aortic Aneurysm to 3.5% by 2013. From 16th March 2012, statutory approval has been given by Parliament to recognise Vascular Surgery as a Specialty in the UK. This study assesses the provision of vascular surgery in acute trusts across England. METHOD: From the Department of Health, 169 acute trusts were identified in England and each acute trust was emailed under the Freedom of Information Act. RESULTS: There was a 98.8% response rate. There are currently 80 trusts in England providing acute and elective arterial and aortic surgery, with 48 vascular hubs and 32 trusts which either provide a local on call network or are currently under review. Within the 48 vascular hubs there are a mean of 4.8 consultants and 3.75 middle grades. The on call rota was on average a 1 in 6. CONCLUSION: This study has shown that currently 80 trusts in England provide acute and elective arterial and aortic surgery with 48 centralised complex and arterial vascular services. An integrated vascular service will provide the best quality of care, develop the latest techniques and improve clinical standards.

Remodelling of vascular (surgical) services in the UK.

The last few years have seen major changes in the delivery of vascular services in the UK. An increasingly elderly population with greater expectations from their medical services has challenged established methods. It also became apparent that outcomes for low volume, high risk index vascular interventions such as abdominal aortic aneurysm repair were poor in the UK compared to the rest of Europe. Other ongoing challenges were the introduction of a national aortic aneurysm screening programme and the development of vascular surgery as a separate speciality. This article details the approach taken to modernise vascular services in the UK, using a quality framework agreed by vascular specialists, which drove the structural change to move vascular interventions into fewer, higher volume centres. The introduction of modern networks is designed to maintain services in surrounding hospitals without on site vascular inpatient services. The initial effects of this service remodelling are positive, with elective aortic aneurysm mortality rates falling nationally from 7.5 to 2.4 per cent.

Intraoperative blood product resuscitation and mortality in ruptured abdominal aortic aneurysm.

OBJECTIVES: The resuscitation of patients with ruptured abdominal aortic aneurysms (RAAAs) has not been well studied, and the potential benefit of autotransfusion (AT) is unknown. The increased use of fresh-frozen plasma (FFP) has been associated with decreased mortality rates in trauma patients and may also improve RAAA survival. We explored the influence of intraoperative AT and FFP resuscitation on mortality rates in massively transfused RAAA patients. METHODS: A single-center review of RAAA patient records from April 1989 to October 2009 was undertaken. Clinical data and outcomes were studied. Operative and anesthesia records were queried for intraoperative transfusion totals. Massive transfusion was defined as ≥10 units of red blood cells (RBCs) inclusive of AT units. RESULTS: We identified 151 RAAA patients, of which 89 (60%) received a massive transfusion and comprised the study population. These 89 patients had an in-hospital mortality rate of 44%. Univariate predictors of mortality included increased age, preoperative hypotension, operative blood loss, and crystalloid, RBCs, and FFP volume. AT was used in 85 patients, with an increased ratio of AT:RBC units associated with survival. Mortality was 34% with AT:packed RBCs (PRBC) ≥1 (high AT) and 55% with AT:PRBC of <1 (low AT; P = .04). On multivariate analysis, age > 74 years (P = .03), lowest preoperative systolic blood pressure (SBP) <90 mm Hg (P = .06), blood loss >6 liters (P = .06), and low AT (P = .02) independently predicted mortality. The mean RBC:FFP ratio was similar in those that died (2.7) and in those that lived (2.9; P = .66). RBC:FFP ≤2 (high FFP) was present in 38 (43%) patients, with mortality of 49%. RBC:FFP >2 (low FFP) had 40% mortality (P = .39). RBC:FFP ratios decreased over time from 3.6 (years 1989 to 1999) to 2.2 (years 2000 to 2009; P < .001), but more liberal use of FFP was not associated with decreased mortality (47% vs 41%; P = .56). AT:PRBC ratios were stable over time (range, 1.4-1.2; P = .18). CONCLUSIONS: Greater use of AT but not of FFP was associated with survival in massively transfused RAAA patients. No mortality benefit was seen with increased FFP, but few patients had high FFP transfusion ratios. Further study to identify RAAA patients at risk for massive transfusion should be undertaken and a potentially greater role for AT in RAAA resuscitation investigated.

NSQIP reveals significant incidence of death following discharge.

BACKGROUND: The rates of post-discharge deaths after surgical procedures are unknown and may represent areas of quality improvement. The NSQIP database captures 30-d outcomes not included within normal administrative databases, and can thus differentiate between in-hospital and post-discharge deaths. METHODS: Retrospective analysis of NSQIP from 2005 through 2007. Inclusion criteria were procedures whose median length of stay was greater than 1 d (to exclude outpatient procedures), and whose overall death rate was greater than 2% (to include only procedures where mortality was a significant issue). Procedures where less than 25 deaths occurred were excluded (for sample size concerns). RESULTS: There were 363,897 patients with 2236 different CPT codes captured in NSQIP. There were 6395 deaths; among them, 1486 (23.2%) occurred after discharge. Thirty-eight CPT codes met the analysis threshold. In two of the CPT codes, there were no post-discharge deaths (repair of ruptured abdominal aortic aneurysm [AAA], repair of ruptured AAA involving iliacs). In the other 36 CPT codes, the proportion of deaths occurring after discharge ranged from 6.3% (repair of thoracoabdominal aneurysm) to 50.0% (femoral-distal bypass with vein). The highest percentage of post-discharge mortality occurs on d 1 after discharge. Fifty percent of post-discharge mortality occurs by d 7; 95% occurs by d 21. CONCLUSION: Approximately one-fourth of postoperative deaths occur after hospital discharge. There is significant variation across surgical procedures in the likelihood of postoperative deaths occurring after discharge. These data indicate a need for closer and more frequent monitoring of post-surgical patients. These data also call into question conclusions drawn from hospital-based outcomes analyses for at least some key diseases/procedures. This analysis demonstrates the power of the risk-adjusted 30-d follow-up NSQIP data, but perhaps more importantly, the responsibility of surgeons to monitor and optimize the discharge process.

Critical limb ischemia-need to look beyond limb salvage.

BACKGROUND: Revascularization is the optimal treatment for critical limb ischemia (CLI). Traditional measures of outcome of intervention are as follows: graft patency, limb salvage rates, and patient survival rates; however, these have little meaning for a patient if he/she cannot ambulate independently or go back to work. This study was undertaken to assess the functional outcome of intervention in these patients. METHODS: Fifty patients with CLI treated over a 3-year period were included in this prospective clinical study. After evaluation, treatment was given to each patient on the basis of the Transatlantic Inter-society Consensus II guidelines. The outcome of treatment and the functional restoration to pre-illness lifestyle were assessed at the end of 1 month, and then at 6 months. RESULTS: Fifty patients with CLI were included in the study; male to female ratio was 9:1, and the mean age at presentation was 45 years. After evaluation, only 38 patients (76%) were found suitable for revascularization. Traditional measures of success showed a graft patency rate of 75%, limb salvage rate of 89.5%, and patient survival rate of 96% at 6 months after treatment. All eight parameters of quality-of-life analysis showed significant improvement as assessed by the Research and Development (RAND) 36-Item Health Survey 1.0 form. However, among the 38 patients who were revascularized, 20 (52.6%) went back to their initial occupation after 6 months, 12 (31.6%) remained at home even though they were ambulant, and five (13.2%) were able to manage only limited activities; one patient succumbed to death. CONCLUSION: With only 53% of revascularized patients returning to work, a salvaged leg does not equate with return to premorbid ambulatory/occupational status, although there might be improvement in quality of life because of other reasons. As surgeons, we need to look beyond leg salvage and graft patency and take on a more holistic approach.

A comparison of endovascular revascularization with traditional therapy for the treatment of acute mesenteric ischemia.

OBJECTIVES: Few centers have adopted endovascular therapy for the treatment of acute mesenteric ischemia (AMI). We sought to evaluate the effect of endovascular therapy on outcomes for the treatment of AMI. METHODS: A single-center, retrospective cohort review was performed on all consecutive patients with thrombotic or embolic AMI presenting between 1999 and 2008. Patients with mesenteric venous thrombosis, nonocclusive mesenteric ischemia, and ischemia associated with aortic dissection were excluded. Demographic factors, preoperative metabolic status, and etiology were compared. Primary clinical outcomes included endovascular technical success, operative complications, and in-hospital mortality. RESULTS: Seventy consecutive patients were identified with AMI (mean age, 64 ± 13 years). Etiology of mesenteric ischemia was 65% thrombotic and 35% embolic occlusions. Endovascular revascularization was the preferred treatment (81%) vs operative therapy (19%). Successful endovascular treatment was achieved in 87%. Endovascular therapy required laparotomy in 69% vs traditional therapy in 100% (P < .05), with a median 52-cm necrotic bowel resected (interquartile range [IQR], 11-140 cm) vs 160 cm (IQR, 90-250 cm; P < .05), respectively. Acute renal failure and pulmonary failure occurred less frequently with endovascular therapy (27% vs 50%; P < .05 and 27% vs 64%; P < .05). Successful endovascular treatment resulted in a mortality rate of 36% compared with 50% (P < .05) with traditional therapy, whereas the mortality rate for endovascular failures was 50%. Endovascular therapy was associated with improved mortality in thrombotic AMI (odds ratio, 0.10; 95% confidence interval, 0.10-0.76; P < .05). CONCLUSIONS: Endovascular therapy has altered the management of AMI, and there are measurable advantages to this approach. Using endovascular therapy as the primary modality for AMI reduces complications and improves outcomes.

Elevated preoperative phosphorus levels are an independent risk factor for cardiovascular mortality.

BACKGROUND/AIMS: Serum phosphorus levels have been associated with adverse long-term outcome in several populations, however, no prior studies evaluated short-term postoperative outcome. The present study evaluated the predictive value of phosphorus levels on 30-day outcome after vascular surgery. METHODS: The study included patients scheduled for major vascular surgery (aortic aneurysm repair, lower extremity revascularization or carotid surgery), divided into four quartiles based on the preoperative fasting phosphorus level. The endpoints of the analyses were all-cause and cardiovascular mortality during the first 30 postoperative days and during long-term follow-up (median 3.6 years, interquartile range 1.8-8.0). RESULTS: Prior to surgery, 1,798 patients were categorized into the following quartiles: <2.9 mg/dl (n = 459), 2.9-3.4 mg/dl (n = 456), 3.4-3.8 mg/dl (n = 444) and >3.8 mg/dl (n = 439), respectively. During the first 30 postoperative days, 81 (4.5%) patients died of which 66 (81%) secondary to a cardiovascular cause. In multivariate analyses, an independent association was observed between phosphorus level >3.8 mg/dl and all-cause (OR 2.53, 95% CI 1.2-5.4) or cardiovascular mortality (OR 2.37, 95% CI 1.1-5.7). Baseline serum phosphorus >3.8 mg/dl was also significantly associated with long-term all-cause mortality (HR 1.38, 95% CI 1.1-1.7). CONCLUSIONS: Preoperative elevated serum phosphorus demonstrated an independent relationship with the occurrence of all-cause and cardiovascular mortality during the first 30 days after major vascular surgery. In addition, an elevated serum phosphorus was independently associated with long-term mortality.

Changes in red blood cell transfusion practice during the turn of the millennium: a retrospective analysis of adult patients undergoing elective open abdominal aortic aneurysm repair using the Mayo database.

BACKGROUND: Significant changes in perioperative red blood cell (RBC) transfusion practice during the past two decades have been reported but similar data are not available for patients undergoing abdominal aortic aneurysm (AAA) surgery. METHODS: Adult patients who had undergone primary, elective, open AAA repair were stratified into one of two transfusion-related groups: early practice (1980-1982) or late practice (2003-2006). RBC transfusion and hemoglobin concentration (Hb) were analyzed as a continuous variable and compared between groups with use of the rank sum test. Perioperative complications were compared between groups with Fisher's exact test. Data were age adjusted, and analyses were corrected for multiple comparisons. RESULTS: Compared with the early practice group, patients in the late practice group had significantly lower intraoperative (mean 10 +/- 1.4 vs. 11.5 +/- 1.5 g/dL), postoperative (11.9 +/- 1.4 vs. 13.4 +/- 1.5 g/dL), and discharge Hbs (mean 10.8 +/- 1.2 vs. 12.5 +/- 1.5 g/dL) (p < 0.0001 for each variable). Patients in the late practice group were significantly less likely to receive intraoperative allogenic transfusions (46% vs. 99%, p < 0.0001). Additionally, significantly fewer total allogenic units of RBCs per patient were transfused in the late practice group (mean 1.7 vs. 4.3, p < 0.0001). Intraoperative autotransfusions were used in 97% of the late practice patients but in none of the early practice patients (p < 0.0001). In the late practice group, 119 patients (40%) experienced a major perioperative morbidity or mortality event compared with 106 patients (35%) in the early practice group (p = 0.27). CONCLUSION: In this retrospective analysis, we observed significantly lower perioperative Hb, fewer allogenic RBC transfusions, and more autotransfusions in open AAA repairs done in 2003-2006 versus those done in 1980-1982. Additionally, late transfusion practice patients were older and had more comorbid diseases. Despite these observations, no significant differences in perioperative morbidity or mortality were observed between groups.

Intraoperative blood salvage in vascular surgery - worth the effort?

Intraoperative autologous transfusions have been used for many years to avoid transmission of infections, especially in vascular surgery, where blood usage is considerable. Several autotransfusion devices exist, but these devices are often associated with negative outcomes such as cost, contamination, and removal of essential blood components (e.g. platelets). Preoperative autologous blood donation is another blood preservation method to avoid possible transfusion-related infections. Several vascular surgery groups have compared the use of these techniques, and their results are discussed in this review. Cell saver techniques often do not prevent the need for transfusions, nor are they very cost-effective; therefore, their use should be considered on a case-by-case basis.