Large-Diameter Fenestrated Endograft Repair of Abdominal Aortic Aneurysms Is Not Associated With Medium-Term Outcomes.

INTRODUCTION: Recent data suggests that infrarenal abdominal aortic aneurysm (AAA) endovascular repair (EVAR) with large diameter grafts (LGs) may have a higher risk of endoleak and reintervention. However, this has not been studied extensively for fenestrated endovascular aneurysm repair (fEVAR). We, therefore, sought to evaluate the outcomes of patients undergoing fEVAR with large-diameter endografts. METHODS: Patients from the national Vascular Quality Initiative registry who underwent fEVAR for intact juxtarenal AAA were identified. Patients with genetic causes for aneurysms, those with prior aortic surgery, and those undergoing repair for symptomatic or ruptured aneurysms were excluded. Rates of endoleaks and reintervention at periprocedural and long-term follow-up timepoints (9-22 mo) were analyzed in grafts 32 mm or larger (LG) and were compared to those smaller than 32 mm (small diameter graft). RESULTS: A total of 693 patients (22.8% LG) were identified. Overall, demographic variables were comparable except LG exhibited a more frequent history of coronary artery disease (32.9% versus 25.4%, P = 0.037). There were no significant differences in the rates of endoleak at procedural completion. Overall survival at 5 y was no different. The rate of reintervention at 1 y was also no different (log-rank P = 0.86). CONCLUSIONS: While graft size appears to have an association with outcomes in infrarenal aneurysm repair, the same does not appear to be true for fEVAR. Further studies should evaluate the long-term outcomes associated with LG which could alter the approach to repair of AAA with large neck diameters traditionally treated with standard infrarenal EVAR.

Improving glaucoma staging in clinical practice by combining the ICD-10 glaucoma severity classification system and optical coherence tomography.

OBJECTIVE: The International Classification of Disease, 10th revision (ICD-10) codes used for glaucoma severity classification are based on the 24-2 visual-field (VF) test. This study aim was to assess the added value of providing clinicians with optical coherence tomography (OCT) data, in addition to functional data, for glaucoma staging in clinical practice. EXPOSURE: Disease classification was determined for 54 glaucoma eyes, according to the principles of the ICD-10 guidelines. Eyes were independently graded in a masked fashion using the 24-2 VF test and 10-2 VF test, with and without OCT information. The reference standard (RS) for severity was determined using a previously published automated structure-function topographic agreement for glaucomatous damage using all available information. RESULTS: The RS classified eyes as mild, moderate and advanced in 3, 16 and 35 cases, respectively. Individual and combined 24-2 and 10-2 based gradings were significantly different from the RS (all P < 0.005), with Kappa agreements of 0.26, 0.45 and 0.42 respectively (P < 0.001). Classifications using OCT combined with either of the VF were not-significantly different from the RS (P > 0.3) with Kappa agreements of 0.56 and 0.57 respectively (P < 0.001). Combining 24-2 with OCT had less severity overestimations while 10-2 with OCT had fewer underestimations. CONCLUSION: Combining OCT and VF data provides better staging of glaucoma severity than VF data alone. The 24-2 and OCT combination seems most appropriate given the high concordance with the RS and less overestimation of severity. Incorporating structural information into disease stages allows clinicians to set more appropriate severity-based treatment targets for individual patients.

Progression of Early Glaucomatous Damage: Performance of Summary Statistics From Optical Coherence Tomography and Perimetry.

Purpose: Performance comparison of optical coherence tomography (OCT) and visual field (VF) summary metrics for detecting glaucomatous progression. Methods: Thirty healthy control eyes (mean deviation [MD], -1.25 ± 2.03; pattern standard deviation [PSD] , 1.78 ± 0.77) and 91 patient eyes comprised of 54 glaucoma patients and 37 glaucoma suspects (MD, -1.58 ± 1.96; PSD, 2.82 ± 1.92) with a follow-up of at least 1 year formed a group to evaluate progression with event analyses (P-Event). A subset of eyes with an additional criterion of a minimum of four tests was used for trend analyses (P-Trend) (30 healthy controls and 73 patients). For P-Event analysis, test-retest variability thresholds (lower 5th percentile) were estimated with repeat tests within a 4-month period. A P-Event eye was considered a "progressor" if the difference between follow-up and baseline tests exceeded the variability thresholds. For the P-Trend analysis, rates of change were calculated based on least-squares regression. Negative rates with significant (P < 0.05) values were considered progressing. For a reference standard, 17 patient eyes were classified as definitely progressing based on clear evidence of structural and corresponding functional progression. Results: Isolated OCT and VF summary metrics were either inadequately sensitive or not too specific. Combinations of OCT-OCT and OCT-VF metrics markedly improved specificity to nearly 100%. A novel combination of OCT metrics (circumpapillary retinal nerve fiber layer and ganglion cell layer) showed high precision, with 13 of the 15 statistical progressors confirmed as true positives. Conclusions: Although relying solely on metrics is not recommended for clinical purposes, in situations requiring very high specificity and precision, combinations of OCT-OCT metrics can be used. Translational Relevance: All available OCT and VF metrics can miss eyes with progressive glaucomatous damage and/or can falsely identify progression in stable eyes.

Routine Ophthalmological Examination Rates in Adults with Sickle Cell Disease Are Low and Must Be Improved.

The American Academy of Ophthalmology and the National Heart, Lung and Blood Institute recommend patients with sickle cell disease (SCD) undergo dilated funduscopic exams (DFE) every 1-2 years to screen for sickle retinopathy. There is a paucity of data on the adherence rate to these guidelines; a retrospective study was performed to evaluate our institution's adherence. A chart review of 842 adults with SCD, seen 3/2017-3/2021 in the Montefiore healthcare system (All Patients), was done. Only about half of All Patients (n = 842) had >1 DFE during the study period (Total Examined Patients, n = 415). The Total Examined Patients were categorized as screening, those without retinopathy (Retinopathy-, n = 199), or follow-up, including individuals previously diagnosed with retinopathy (Retinopathy+, n = 216). Only 40.3% of screening patients (n = 87) had DFE at least biennially. As expected, there was a significant decrease in the average DFE rate of the Total Examined Patients after the COVID-19 pandemic started (13.6%) compared to pre-COVID (29.8%, p < 0.001). Similarly, there was a significant decrease in the screening rate of Retinopathy- patients from 18.6% on average pre-COVID to 6.7% during COVID (p < 0.001). This data shows the sickle retinopathy screening rate is low and innovative approaches may need to be employed to remedy this issue.

The ICD-10 Glaucoma Severity Score Underestimates the Extent of Glaucomatous Optic Nerve Damage.

PURPOSE: To evaluate the International Classification of Disease, Tenth Revision (ICD-10) codes used for glaucoma severity classification, which are based on the location of visual field (VF) defects; given the known poor sensitivity of the 24-2 visual field test to early disease and macular damage, we hypothesized that the ICD-10 codes would not accurately reflect the extent of glaucomatous damage. DESIGN: Retrospective validity and reliability analysis. METHODS: We evaluated 80 eyes with glaucomatous optic neuropathy (GON). Masked reviewers assigned an ICD-10 severity grade based on 24-2 VF. Two additional masked examiners determined the presence of optical coherence tomography (OCT) structural damage in each hemifield and/or central 5 degrees to define an OCT-based equivalent ICD-10 classification. RESULTS: A total of 80 eyes with GON were classified as mild, moderate and advanced in 15, 23, and 42 cases, respectively, based on the 24-2 VF, and in 6, 7, and 67 cases, respectively, based on OCT. The OCT classifications were more severe in 29 of 80 cases (36%). In 33 cases (41.3%), macular damage detected by OCT was missed by the 24-2. In 4 of 80 cases (5%), the VF overestimated the severity, likely due to variability of the 24-2 test. CONCLUSIONS: The ICD-10 system relies solely on damage seen on the 24-2 and as provides a 24-2 functional score rather than a "glaucoma" severity score. OCT revealed wide variation of damage across grades, with a significant proportion of the eyes showing macular structural damage missed with the 24-2 VF. Adding OCT information to the ICD-10 system would help it to more accurately reflect the extent of glaucomatous damage.

The OCT RNFL Probability Map and Artifacts Resembling Glaucomatous Damage.

Purpose: The purpose of this study was to improve the diagnostic ability of the optical coherence tomography (OCT) retinal nerve fiber layer (RNFL) probability (p-) map by understanding the frequency and pattern of artifacts seen on the p-maps of healthy control (HC) eyes resembling glaucomatous damage. Methods: RNFL p-maps were generated from wide-field OCT cube scans of 2 groups of HC eyes, 200 from a commercial normative group (HC-norm) and 54 from a prospective study group, as well as from 62 patient eyes, which included 32 with early glaucoma (EG). These 32 EG eyes had 24-2 mean deviation (MD) better than -6 dB and perimetric glaucoma as defined by 24-2 and 10-2 criteria. For the HC groups, "glaucoma-like" arcuates were defined as any red region near the temporal half of the disc. Results: Seven percent of the 200 HC-norm and 11% of the 54 HC RNFL p-maps satisfied the definition of "glaucoma-like," as did all the patients' p-maps. The HC p-maps showed two general patterns of abnormal regions, "arcuate" and "temporal quadrant," and these patterns resembled those seen on some of the RNFL p-maps of the EG eyes. A "vertical midline" rule, which required the abnormal region to cross the vertical midline through the fovea, had a specificity of >99%, and a sensitivity of 75% for EG and 93% for moderate to advanced eyes. Conclusions: Glaucoma-like artifacts on RNFL p-maps are relatively common and can masquerade as arcuate and/or widespread/temporal damage. Translational Relevance: A vertical midline rule had excellent specificity. However, other OCT information is necessary to obtain high sensitivity, especially in eyes with early glaucoma.

Detecting glaucoma with only OCT: Implications for the clinic, research, screening, and AI development.

A method for detecting glaucoma based only on optical coherence tomography (OCT) is of potential value for routine clinical decisions, for inclusion criteria for research studies and trials, for large-scale clinical screening, as well as for the development of artificial intelligence (AI) decision models. Recent work suggests that the OCT probability (p-) maps, also known as deviation maps, can play a key role in an OCT-based method. However, artifacts seen on the p-maps of healthy control eyes can resemble patterns of damage due to glaucoma. We document in section 2 that these glaucoma-like artifacts are relatively common and are probably due to normal anatomical variations in healthy eyes. We also introduce a simple anatomical artifact model based upon known anatomical variations to help distinguish these artifacts from actual glaucomatous damage. In section 3, we apply this model to an OCT-based method for detecting glaucoma that starts with an examination of the retinal nerve fiber layer (RNFL) p-map. While this method requires a judgment by the clinician, sections 4 and 5 describe automated methods that do not. In section 4, the simple model helps explain the relatively poor performance of commonly employed summary statistics, including circumpapillary RNFL thickness. In section 5, the model helps account for the success of an AI deep learning model, which in turn validates our focus on the RNFL p-map. Finally, in section 6 we consider the implications of OCT-based methods for the clinic, research, screening, and the development of AI models.

The current state of vascular surgery presence and educational content in Google and YouTube internet search results.

BACKGROUND: Information on the internet regarding vascular disease has not been extensively assessed. Our goal was to compile and appraise the information available via Google and YouTube searches regarding various topics of interest for vascular surgeons (VS) and related procedures with a focus on the role of the VS. METHODS: The Google and YouTube platforms were independently queried for 25 keywords/phrases relating to common vascular diagnoses and procedures by two separate researchers from March to July 2019. Paid advertisements or a Society for Vascular Surgery (SVS) webpage or affiliated video in the first 25 results was documented. Results were reviewed for information regarding the responsible medical specialty and the target audience, and disease-related information (screening, risk factors, risk reduction, diagnostic testing, operative treatment, alternative treatment, follow-up, complications, and recovery). RESULTS: From the Google search, 357 unique domains of 1241 total webpages were identified with 75% directed toward the public. An SVS page was present in 56% of the first-page results and least likely to be present in searches for claudication, gangrene, carotid stent, rib resection, and thrombolysis. VS were mentioned as referral physicians in 56% of the 68% of websites that mentioned a specialty, endovascular specialists/interventional radiology in 20%, and cardiothoracic surgeons in 19%. Only 4% of the websites contained information from all categories, with the greatest number for aortic dissection. Advertisements were present in 18% of all searches (most commonly for "varicose vein," "varicose vein surgery," and "inferior vena cava filter"). From YouTube, 1247 search results (613 unique videos) were evaluated with 64% directed toward the public. An SVS affiliated video was present in 36% of searches. In the 47% of videos where a specialty was mentioned, 56% mentioned VS, interventional radiology in 10%, and cardiothoracic surgeons in 7%. Only 0.24% of the videos contained information from all categories. The greatest number of content categories was in videos related to peripheral arterial disease. Across both platforms, dialysis access searches yielded results with the least number of content categories. CONCLUSIONS: Patient-related information regarding vascular surgical topics is readily available on the internet, but the content is highly variable and not comprehensive. Only half of the searches mention VS as the referral physician of choice or authority for these medical conditions. Further efforts should focus on developing the online presence of vascular surgery, improving the quality of education of vascular disease on the internet, and directing patients to the vascular specialists to treat these conditions.

Effect of Chronic Hematologic Malignancies on In-Hospital Outcomes of Patients With ST-Segment Elevation Myocardial Infarction.

In view of hemorrhagic and prothrombotic tendencies, ST-segment elevation myocardial infarction (STEMI) patients with chronic hematologic malignancies (CHM) are felt to be at a higher risk and hence denied standard reperfusion strategies. In-hospital outcomes of CHM patients presenting with STEMI are unclear. The Nationwide Inpatient Sample data files from 2003 to 2014 were used to extract adult patients who presented with a primary diagnosis of STEMI. Patients who had a diagnosis of CHM defined as chronic myelogenous leukemia, chronic lymphocytic leukemia, essential thrombocythemia, polycythemia vera, chronic monocytic leukemia, and multiple myeloma were identified. The primary study outcome measure was in-hospital mortality. Inverse probability weighting-adjusted binary logistic regression was performed to identify independent predictors of in-hospital mortality. Of 2,715,807 STEMI patients included in the final analyses, 11,974 (0.4%) patients had a diagnosis of CHM. Patients with CHM were significantly older, had a higher prevalence of co-morbidities, and had a significantly higher unadjusted in-hospital mortality (14.9% vs 9.0%; p <0.001). After adjusting for co-morbidities, CHM did not independently predict a higher in-hospital mortality (odds ratio = 1.02, 95% confidence interval = 0.96 to 1.09; p = 0.461). In patients with CHM who presented with STEMI, percutaneous coronary intervention was found to be associated with a significant reduction in in-hospital mortality (odds ratio = 0.22, 95% confidence interval = 0.18 to 0.27; p <0.001) (c-statistic = 0.81). In conclusion, CHM patients presenting with STEMI should be treated with similar treatment strategies as those without CHM, including revascularization if indicated, as there appears to be a sizable outcome advantage with this approach.

Variability of forearm collateral circulation: An observational study of serial hand plethysmography testing.

OBJECTIVES: Evaluation of plethysmography as a reliable triage tool to access collateral circulation in the hand prior to transradial access. BACKGROUND: Hand plethysmographic testing has been used for access site triage prior to cardiac catheterization despite a lack of data supporting its result's stability. METHODS: Cohort of consecutive outpatients presenting for evaluation prior to cardiac catheterization underwent hand plethysmographic testing at the beginning of the office visit and before discharge. Demographics and clinical data was recorded. RESULTS: Hands (N = 887) in 445 patients were evaluated using the Barbeau plethysmography technique. Barbeau Test (BT) patterns A, B, C, and D were observed in 58%, 30%, 8% and 4% on initial evaluation. On preliminary evaluation, 780 (88%) hands had a "low-risk" pattern (A or B) and 107 (12%) hands had a "high-risk" pattern (C or D). Repeat evaluation performed 50 ±â€¯26 min later revealed a 'low-risk' pattern in 809 (91%) hands with 78 (9%) of hands showing a persistent "high risk" pattern. In 29 (27%) high-risk hands, spontaneous conversion to pattern B within <1 h occurred. Reverse Barbeau Test (RBT) at baseline showed pattern A, B, C and D in 95.9%, 2.8%, 1% and .4% respectively. There was no significant change in RBT upon follow-up evaluation. Strength of the radial artery pulsation was significantly associated with the pattern of RBT and the strength of ulnar pulsation was associated with the results of the BT. CONCLUSIONS: Plethysmographic testing of forearm circulation demonstrates variability over short intervals suggesting poor reliability for access site triage.