Outcomes of early transcarotid artery revascularization versus carotid endarterectomy after acute neurologic events.

OBJECTIVE: Carotid revascularization within 14 days of a neurologic event has been recommended by society guidelines. Transcarotid artery revascularization (TCAR) carries the lowest overall stroke rate for any carotid artery stenting technique. However, the outcomes of TCAR within 14 days of a neurologic event have not been directly compared with those after carotid endarterectomy (CEA). METHODS: We compared the 30-day outcomes of symptomatic patients who had undergone TCAR and CEA within 14 days of a stroke or transient ischemic attack (TIA) from January 2016 to February 2020 using the Society for Vascular Surgery Vascular Quality Initiative carotid artery stenting and CEA databases. Propensity score matching was used to adjust for patient risk factors. The primary outcome was a composite of postoperative ipsilateral stroke, death, and myocardial infarction (MI). RESULTS: A total of 1281 symptomatic patients had undergone TCAR and 13,429 patients had undergone CEA within 14 days of a neurologic event. After 1:1 propensity matching, 728 matched pairs were included for analysis. The primary composite outcome of stroke, death, or MI was more frequent in the TCAR group (4.7% vs 2.6%; P = .04). This was driven by a higher rate of postoperative ipsilateral stroke in the TCAR group (3.8% vs 1.8%; P = .005). No differences were found between TCAR and CEA in terms of death (0.7% vs 0.8%; P = .8) or MI (0.8% vs 1%; P = .7). Although TCAR procedures were shorter (median, 69 minutes [interquartile range, 53-85 minutes]; vs median, 120 minutes [interquartile range, 93-150 minutes]; P < .001) and the postoperative length of stay was similar (2 days; P = .3) compared with CEA, the TCAR patients were more likely to be discharged to a facility other than home (26% vs 19%; P < .01). Performing TCAR within 48 hours of a stroke was an independent predictor of postoperative stoke or TIA (odds ratio, 5.4; 95% confidence interval, 1.8-16). This increased risk of postoperative stroke or TIA was not found when performing TCAR within 48 hours of a TIA. CONCLUSIONS: TCAR within 14 days of a neurologic event resulted in higher ipsilateral postoperative stroke rates compared with CEA, especially when performed within 48 hours after a stroke.

The Association Between Preoperative Independent Ambulatory Status and Outcomes After Open Abdominal Aortic Aneurysm Repairs.

BACKGROUND: Preoperative functional status is appreciated as a key determinant of decision-making when evaluating patients for complex elective surgeries. We used the Vascular Quality Initiative to analyze the effect of being able to independently ambulate on outcomes after open abdominal aortic aneurysm (AAA) repairs. METHODS: We identified all patients who underwent elective or urgent open AAA repairs from January 2013 to August 2019 in the Vascular Quality Initiative registry. We recorded demographic variables, comorbidities, and operative factors such as approach, operative ischemia time, proximal clamp site, and presence of iliac aneurysms. Short-term and long-term outcomes included 30-day mortality, any perioperative complications, failure to rescue (defined as death after a complication), and 1-year all-cause mortality. We dichotomized patients based on their ability to independently ambulate (Ambulatory) or inability to ambulate independently (Non-Ambulatory) and used both multivariable logistic regressions and cox-proportional hazards models to evaluate outcomes. RESULTS: Of 5,371 patients, 328 (6.1%) could not ambulate independently and were more likely to be older (median age 69 vs. 72), female (25% vs. 38%), and have greater comorbidities. Overall outcomes were: 4.3% for 30-day mortality, 38.7% for complications, 10.2% for failure-to-rescue, and 6.9% for 1-year mortality. Univariate analysis showed higher rates of all adverse outcomes in non-ambulatory patients. On adjusted analysis, non-ambulatory patients had increased odds of complications by 46% (OR 1.46 [95%-CI 1.11-1.91]) and 1-year mortality by 46% (HR 1.46 [95%-CI 1.06-1.99]), but not failure to rescue (OR 1.05 [95%-CI 0.67-1.62]) or 30-day mortality (OR 1.22 [95%-CI 0.82-1.81]). Increased hospital volume, age, and increased operative renal ischemia time were independently associated with adverse outcomes. CONCLUSIONS: Non-ambulatory status was observed in a small percentage of patients undergoing open AAA repair but was associated with higher rates of post-operative complications and 1-year mortality. Ambulatory capacity is one of the key determinants of outcomes following open AAA repair. In patients with poor ambulatory function, a conservative approach is highly recommended over invasive open surgical intervention.

Association of insurance status with timing of hemodialysis access placement.

OBJECTIVE: Patients without adequate outpatient follow-up often present requiring emergency hemodialysis and then undergo permanent dialysis access placement at a later time. We sought to examine the relationship between type of insurance and whether a patient was already on dialysis at time of surgery. METHODS: The Vascular Quality Initiative Hemodialysis Access registry was queried for all adult patients undergoing first time permanent hemodialysis access between January 2015 and September 2019. Patient and procedural characteristics were examined in patients split by private insurance-Medicare more than 65 years of age, Medicare less than 65 years of age, and Medicaid. The primary outcome was whether patients were on dialysis at the time of surgery. RESULTS: There were 19,307 adult patients that underwent first time placement of an arteriovenous fistula or graft. Of these patients, 9729 (50%) had Medicare, 7179 (37%) had private insurance, and 2399 (12%) had Medicaid. The patients with Medicare were subgrouped by age with 2968 (31%) being less than 65 years of age and 6761 (69%) being more than 65 years of age. Patients with Medicare and less than 65 were the most likely to be on dialysis at the time of surgical access placement at 67%, whereas 59% of Medicaid patients were on dialysis, and 53% each group of patients with Medicare and more than 65 years of age and private insurance were on dialysis. After adjustment for patient characteristics, patients with Medicare who were less than 65 and more than 65 years of age were both significantly more likely to be on dialysis at time of surgery compared with private insurance with odds ratio (OR) of 1.64 (95% confidence interval [CI], 1.49-1.80; P < .001) and an OR of 1.11 (95% CI, 1.03-1.20; P = .007), respectively. After adjustment, patients with Medicaid were no longer significantly more likely to be on dialysis. Secondary outcomes demonstrated, after adjustment, no difference in the association between a surgical fistula vs graft in any insurance groups; however, patients with Medicare and who were less than 65 years of age were more likely to have a nonradial artery used for anastomosis with an OR of 1.18 (95% CI, 1.04-1.34; P = .011). CONCLUSIONS: Certain types of insurance are correlated with being on dialysis at the time of access placement. Although associations were seen between insurance type and surgical access characteristics, these were associations predominantly insignificant when patient demographics and status of dialysis were controlled for. These potential gaps in care represent an area for improvement that deserves further exploration.

Adoption and Usage of Video Telehealth in a Large, Academic Department of Surgery.

Objectives: To understand the impact that video telehealth has on outpatient visit volume and reimbursement as a method of maintaining care. Background: As the coronavirus disease 2019 (COVID-19) spread across the United States starting in 2020, it caused numerous areas of medicine and healthcare to reexamine how we provide care to patients across all disciplines. One method clinicians used to rapidly adapt to these transformed settings was video telehealth, which was previously rarely used. Methods: This retrospective review examined outpatient volume and reimbursement data of a large, academic department of surgery. The study reviewed data during 2 time periods: pre-COVID-19 (February 1, 2020, to March 15, 2020) and COVID-19 (March 16, 2020, to April 30, 2020). Results: During the period of February 1 to April 30, 13,193 outpatient visits were analyzed. The pre-COVID-19 group contained 9041 (68.5%) visits, whereas the COVID-19 group contained 4152 (31.4%) visits. All divisions noted a drop in visit volume from pre-COVID-19 compared with COVID-19. There was rapid adoption of video telehealth during COVID-19, which made up most patient visits during that time (61.3%). We also found that video telehealth led to significant reimbursements while also allowing patients in numerous states to receive care. Conclusions: Previously, video telehealth was used by clinicians in a small portion of outpatient visits. However, safety concerns surrounding COVID-19 forced multiple changes to the way care is provided. Although outpatient volume at our center was less than that before the pandemic, video telehealth was rapidly adopted by providers and allowed for safe and effective outpatient care to patients in a high number of states while still being reimbursed at a high rate.

Bladder Networking: A Unique Case of Cholecystovesicular Fistula.

We present a case of a 60-year-old woman with chronic lower abdominal pain and green urine. Further workup revealed a cholecystovesicular fistula (CVF), a newly coined term to indicate a fistula between the gallbladder and the urinary bladder. The CVF was treated surgically. The pathophysiology of CVF is thought to result from gallbladder perforation into the liver. Over time, a tract forms inferiorly until it meets another organ, in this case, the urinary bladder. This later complication of the gallbladder disease joins the broader spectrum of cholecystic fistulas. To our knowledge, a CVF has never been reported in the literature.

Biodegradable arginine-based poly(ester-amide)s as non-viral gene delivery reagents.

A novel family of synthetic biodegradable poly(ester-amide)s (Arg-PEAs) was evaluated for their biosafety and capability to transfect rat vascular smooth muscle cells, a major cell type participating in vascular diseases. Arg-PEAs showed high binding capacity toward plasmid DNA, and the binding activity was inversely correlated to the number of methylene groups in the diol segment of Arg-PEAs. All Arg-PEAs transfected smooth muscle cells with an efficiency that was comparable to the commercial transfection reagent Superfect. However, unlike Superfect, Arg-PEAs, over a wide range of dosages, had minimal adverse effects on cell morphology, viability or apoptosis. Using rhodamine-labeled plasmid DNA, we demonstrated that Arg-PEAs were able to deliver DNA into nearly 100% of cells under optimal polymer-to-DNA weight ratios, and that such a high level of delivery was achieved through an active endocytosis mechanism. A large portion of DNA delivered, however, was trapped in acidic endocytotic compartments, and subsequently was not expressed. These results suggest that with further modification to enhance their endosome escape, Arg-PEAs can be attractive candidates for non-viral gene carriers owning to their high cellular uptake nature and reliable cellular biocompatibility.