Contemporary trends and outcomes of thrombolytic therapy for acute lower extremity ischemia.

OBJECTIVE: Acute limb ischemia is a common vascular emergency requiring immediate intervention. Thrombolysis has been widely utilized for acute limb ischemia; the purpose of this study is to analyze contemporary trends, outcomes and complications of thrombolysis for acute limb ischemia. METHODS: Patients were identified from the Nationwide Inpatient Sample (2003-2013) using ICD-9. Patients undergoing emergency thrombolysis for acute limb ischemia were evaluated. Three groups were analyzed: thrombolysis alone, thrombolysis and endovascular procedure (T+ENDO), and failed thrombolysis requiring open surgery (T+OPEN). RESULTS: A total of 162,240 patients with acute limb ischemia were estimated: 33,615 patients (20.7%) underwent thrombolysis as the initial treatment. Mean age was 66.2 ± 34.9 years with 54% male. The utilization of thrombolysis increased significantly during the study period (16.8-24.2%, p < 0.0001). The most common group was thrombolysis and endovascular procedure (40.7%), followed by thrombolysis alone (34.1%), and T+OPEN (25.2%). Thrombolysis and endovascular procedure increased significantly over time (31.6-47.8%, p < 0.0001) whereas thrombolysis alone and T+OPEN significantly decreased (39.6-28.6% and 28.7-23.6%, respectively, p < 0.0001). Overall mortality was 4.9%; thrombolysis and endovascular procedure compared to thrombolysis alone and T-OPEN had a lower mortality rate (3.2% vs. 6.1% and 5.9%, p < 0001). The overall stroke rate was 1.9%; thrombolysis alone had the highest stroke rate (3.0%, p < 0.0001) with thrombolysis and endovascular procedure the lowest (1.2%) and T+OPEN 1.7%. The highest amputation rate was T+OPEN (11.6%, p < 0.001) compared to thrombolysis and endovascular procedure (5.1%) and thrombolysis alone (5.3%). T+OPEN had the highest incidence of cardiac (5.5%), respiratory (7.3%) and renal complications (12.5%), pneumonia (4.0%), and fasciotomy (16.8%) (all p < 0.0001). CONCLUSION: Thrombolysis remains an effective treatment for acute limb ischemia with increased utilization over time. There was a significant increase in thrombolysis and endovascular procedure leading to improved outcomes. Thrombolysis alone carried the highest mortality and stroke rate, with T+OPEN associated with the highest amputation and complications. Although thrombolysis is effective, 25% of patients required an open procedure suggesting that patient selection for thrombolysis first instead of open surgery continues to be a clinical challenge.

Racial and Socioeconomic Disparities After Carotid Procedures.

BACKGROUND: Race has been associated with inferior outcomes after multiple procedures, but the association of socioeconomic status with procedures for cerebrovascular disease is not well established. MATERIALS AND METHODS: Elective carotid artery stenting (CAS) and carotid endarterectomy (CEA) procedures were identified in the National Inpatient Sample, 2012 to 2014. Median household income was estimated from patient ZIP codes. Chi-square and multivariable logistic regression analysis evaluated outcomes, accounting for age, race, gender, comorbidities, procedure, income, insurance, and hospital characteristics. RESULTS: We identified 234 825 carotid procedures (205 835 CEA and 28 990 CAS). Blacks and Hispanics were more likely to be among the lowest quartile income patients (LQIPs) compared to whites (53.5% and 38.7% vs 27.0%, respectively; P < .0002). Compared to highest income quartile patients, LQIP had lower rates of private insurance (16.3% vs 22.0%) and higher Medicaid use (4.7% vs 2.0%; all P < .0002). Lowest quartile income patients were more likely to receive CAS (odds ratio [OR] = 1.32, 95% confidence interval [CI]: 1.27-1.37), as were blacks and Hispanics (OR = 1.09, 95% CI: 1.02-1.26; OR = 1.31, 95% CI: 1.24-1.40, respectively). In multivariable regression, postoperative stroke was associated with LQIP, black race, and Hispanic ethnicity (OR = 1.16, 95% CI: 1.06-1.28; OR = 1.52, 95% CI: 1.33-1.73; OR = 1.43, 95% CI: 1.24-1.64, respectively). Subgroup analysis demonstrated that whites also had higher odds of stroke in the lower income quartile (OR = 1.2, 95% CI: 1.1-1.4). Mortality was associated with LQIP (OR = 1.6, 95% CI: 1.2-2.1), black race (OR = 1.8, 95% CI: 1.4-2.5), and CAS (OR = 1.3, 95% CI: 1.1-1.6). Length of stay in the lowest income quartile was longer than in patients with the highest income ( P < .0001). CONCLUSIONS: Race was associated with increased hospital mortality, postoperative stroke, and overall complications after carotid procedures. Lower income was significantly associated with increased stroke and mortality irrespective of race. Disparate utilization and outcomes for carotid procedures are multifactorial. Efforts to reduce disparities will need to focus on race and other socioeconomic factors.

Preoperative assessment of computerized tomography angiography to predict success for crossing long Trans-Atlantic Inter-Society Consensus D lesions using the optical coherence tomography catheter.

Objectives Optical coherence tomography chronic total occlusion catheter, the Ocelot (Avinger Inc., Redwood City, CA), has been utilized to cross Trans-Atlantic Inter-Society Consensus D lesions. This study evaluated the preoperative computerized tomography angiography of chronic total occlusions in the superficial femoral artery to predict clinical success. Methods We reviewed all patients who underwent lower extremity procedures with the Ocelot catheter from June 2014 to August 2016. Patients who had a preoperative computerized tomography angiography were evaluated. Final outcomes, plaque morphology, lesion length, calcium surface area, lesion location, and patient characteristics were analyzed. Results A total of 107 patients underwent lower extremity interventions with the Ocelot catheter. Seventy patients had a preoperative computerized tomography angiography scan prior to lower extremity intervention and 77% (54) had Trans-Atlantic Inter-Society Consensus D lesions that were crossed. Mean age was 62.8 years and 68.6% were male. Mean chronic total occlusion length was 182.7 mm (170.8 mm crossed vs. 222.6 mm uncrossed, p = 0.03). Calcium distribution differed significantly ( p<.01): circumferential (14.8 vs. 12.5%); eccentric (85 vs. 62.5%); and complete calcium occlusion (0 vs. 25%) for lesions that were crossed and uncrossed, respectively. Significant differences ( p<.0001) were found when calcium occlusion was less than 50% (87 vs. 31%), 51-75% (9.3 vs. 31.2%), and 76-100% (3.7 vs. 37.5%). Total calcium length in crossed lesion was 51.6 mm, and 92.8 mm in uncrossed lesions ( p = 0.10). No significant differences were noted for patient gender, occlusion location (proximal, middle, and distal superficial femoral artery), and kidney function. Conclusion The Ocelot catheter is an effective method to cross long Trans-Atlantic Inter-Society Consensus D lesions. Superficial femoral artery lesions longer than 17 cm and focal plaque morphology, specifically a total cross-sectional area of calcium and a calcium surface area greater than 50% were most predictive of failure to cross Trans-Atlantic Inter-Society Consensus D superficial femoral artery lesions. Computerized tomography angiography is an effective tool to predict success for crossing chronic total occlusions using optical coherence tomography technology and a critical consideration for patient selection.

Management of High-Throughput DNA Sequencing Projects: Alpheus.

High-throughput DNA sequencing has enabled systems biology to begin to address areas in health, agricultural and basic biological research. Concomitant with the opportunities is an absolute necessity to manage significant volumes of high-dimensional and inter-related data and analysis. Alpheus is an analysis pipeline, database and visualization software for use with massively parallel DNA sequencing technologies that feature multi-gigabase throughput characterized by relatively short reads, such as Illumina-Solexa (sequencing-by-synthesis), Roche-454 (pyrosequencing) and Applied Biosystem's SOLiD (sequencing-by-ligation). Alpheus enables alignment to reference sequence(s), detection of variants and enumeration of sequence abundance, including expression levels in transcriptome sequence. Alpheus is able to detect several types of variants, including non-synonymous and synonymous single nucleotide polymorphisms (SNPs), insertions/deletions (indels), premature stop codons, and splice isoforms. Variant detection is aided by the ability to filter variant calls based on consistency, expected allele frequency, sequence quality, coverage, and variant type in order to minimize false positives while maximizing the identification of true positives. Alpheus also enables comparisons of genes with variants between cases and controls or bulk segregant pools. Sequence-based differential expression comparisons can be developed, with data export to SAS JMP Genomics for statistical analysis.