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1.
Vascular ; : 1708538120923420, 2020 May 07.
Artigo em Inglês | MEDLINE | ID: mdl-32379584

RESUMO

OBJECTIVE: Diabetic foot ulcer, which often leads to lower limb amputation, is a devastating complication of diabetes that is a major burden on patients and the healthcare system. The main objective of this study is to determine the economic burden of diabetic foot ulcer-related care. METHODS: We conducted a multicenter study of all diabetic foot ulcer patients admitted to general internal medicine wards at seven hospitals in the Greater Toronto Area, Canada from 2010 to 2015, using the GEMINI database. We compared the mean costs of care per patient for diabetic foot ulcer-related admissions, admissions for other diabetes-related complications, and admissions for the top five most costly general internal medicine conditions, using the Ontario Case Costing Initiative. Regression models were used to determine adjusted estimates of cost per patient. Propensity-score matched analyses were performed as sensitivity analyses. RESULTS: Our study cohort comprised of 557 diabetic foot ulcer patients; 2939 non-diabetic foot ulcer diabetes patients; and 23,656 patients with the top 5 most costly general internal medicine conditions. Diabetic foot ulcer admissions incurred the highest mean cost per patient ($22,754) when compared to admissions with non-diabetic foot ulcer diabetes ($8,350) and the top five most costly conditions ($10,169). Using adjusted linear regression, diabetic foot ulcer admissions demonstrated a 49.6% greater mean cost of care than non-diabetic foot ulcer-related diabetes admissions (95% CI 1.14-1.58), and a 25.6% greater mean cost than the top five most costly conditions (95% CI 1.17-1.34). Propensity-scored matched analyses confirmed these results. CONCLUSION: Diabetic foot ulcer patients incur significantly higher costs of care when compared to admissions with non-diabetic foot ulcer-related diabetes patients, and the top five most costly general internal medicine conditions.

4.
Br J Anaesth ; 124(5): 544-552, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32216957

RESUMO

BACKGROUND: Use of neuraxial anaesthesia for open abdominal aortic aneurysm repair is postulated to reduce mortality and morbidity. This study aimed to determine the 90-day outcomes after elective open abdominal aortic aneurysm repair in patients receiving combined general and neuraxial anaesthesia vs general anaesthesia alone. METHODS: A retrospective population-based cohort study was conducted from 2003 to 2016. All patients ≥40 yr old undergoing open abdominal aortic aneurysm repair were included. The propensity score was used to construct inverse probability of treatment weighted regression models to assess differences in 90-day outcomes. RESULTS: A total of 10 447 elective open abdominal aortic aneurysm repairs were identified; 9003 (86%) patients received combined general and neuraxial anaesthesia and 1444 (14%) received general anaesthesia alone. Combined anaesthesia was associated with significantly lower hazards for all-cause mortality (hazard ratio [HR]=0.47; 95% confidence interval [CI], 0.37-0.61) and major adverse cardiovascular events (HR=0.72; 95% CI, 0.60-0.86). Combined patients were at lower odds for acute kidney injury (odds ratio [OR]=0.66; 95% CI, 0.49-0.89), respiratory failure (OR=0.41; 95% CI, 0.36-0.47), and limb complications (OR=0.30; 95% CI, 0.25-0.37), with higher odds of being discharged home (OR=1.32; 95% CI, 1.15-1.51). Combined anaesthesia was also associated with significant mechanical ventilation and ICU and hospital length of stay benefits. CONCLUSIONS: Combined general and neuraxial anaesthesia in elective open abdominal aortic aneurysm repair is associated with reduced 90-day mortality and morbidity. Neuraxial anaesthesia should be considered as a routine adjunct to general anaesthesia for elective open abdominal aortic aneurysm repair.


Assuntos
Anestesia Epidural/métodos , Anestesia Geral/métodos , Raquianestesia/métodos , Aneurisma da Aorta Abdominal/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Anestesia Epidural/mortalidade , Anestesia Geral/mortalidade , Raquianestesia/mortalidade , Anestésicos Combinados , Aneurisma da Aorta Abdominal/mortalidade , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Ontário/epidemiologia , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Resultado do Tratamento
5.
Diabetes Obes Metab ; 2020 Feb 06.
Artigo em Inglês | MEDLINE | ID: mdl-32030863

RESUMO

In the EMPA-REG OUTCOME trial, we explored the association between pre-randomization uric acid level tertile (<309.30 µmol/L; 309.30 to <387.21 µmol/L; ≥387.21 µmol/L) and cardiovascular (CV) death, hospitalization for heart failure (HHF), HHF or CV death, all-cause mortality, three-point major adverse CV events (MACE), and incident or worsening nephropathy. Patients with type 2 diabetes and CV disease received empagliflozin or placebo. The median baseline plasma uric acid level was 344.98 µmol/L, and patients' baseline characteristics were mainly balanced across tertiles. Baseline uric acid levels were associated with cardio-renal outcomes: in the placebo group, for the highest versus lowest tertile, the multivariable hazard ratios for three-point MACE, HHF or CV death, and incident or worsening nephropathy were 1.22 (95% confidence interval [CI] 0.89-1.67; P = 0.2088), 1.51 (95% CI 1.02-2.23; P = 0.0396) and 1.77 (95% CI 1.33-2.34; P < 0.0001), respectively. When tested as a continuous variable, baseline uric acid was associated with all outcomes in the placebo group. Empagliflozin improved all cardio-renal outcomes across tertiles, with all interaction P values >0.05. Further investigation of these relationships is required.

6.
J Vasc Surg ; 2020 Feb 18.
Artigo em Inglês | MEDLINE | ID: mdl-32085959

RESUMO

OBJECTIVE: Existing data regarding endovascular aortic repair (EVAR) of ruptured abdominal aortic aneurysm (rAAA) are conflicting in their findings. The purpose of this paper was to determine the long-term outcomes of EVAR vs open surgical repair (OSR) for treatment of rAAA. METHODS: A population-based retrospective cohort study of all patients 40 years or more that underwent OSR or EVAR of rAAA in Ontario, Canada, from 2003 to 2016 was conducted. Administrative data from the province of Ontario was used as the data source. The propensity for repair approach was calculated using a logistic regression model including all covariates and used for inverse probability of treatment weighting. Cox proportional hazards regression was conducted using the weighted cohort to determine the survival and major adverse cardiovascular event (MACE)-free survival of EVAR relative to OSR for rAAA up to 10 years after repair. RESULTS: A total of 2692 rAAA (261 EVAR [10%] and 2431 OSR [90%]) repairs were recorded from April 1, 2003, to March 31, 2016. Mean follow-up for the entire cohort was 3.4 years (standard deviation [SD], 3.9 years), with a maximum follow-up of 14.0 years. OSR patients were followed for a mean of 3.5 years (SD, 4.0 years) and maximum of 14.0 years, and EVAR patients were followed for a mean of 2.7 years (SD, 2.7 years) and a maximum of 11.4 years. Median survival was 2.7 years overall, and 2.5 and 3.7 years for OSR and EVAR patients, respectively. There were no significant baseline differences between EVAR and OSR patients after inverse probability of treatment weighting. EVAR patients were at lower hazard for all-cause mortality (hazard ratio, 0.49; 95% confidence interval, 0.37-0.65; P < .01), and MACE (hazard ratio, 0.51, 95% confidence interval, 0.40-0.66; P < .01) within 30 days of repair. There were no statistically significant differences between EVAR and OSR in the hazard for all-cause mortality or MACE from 30 days to 5 years, and 5 to 10 years. Despite this, the upfront mortality and MACE benefits of EVAR persisted for more than 4.5 years after repair. CONCLUSIONS: This population-based cohort study using administrative data from Ontario, Canada, demonstrated lower hazards for all-cause mortality and MACE within 30 days of operation in favor of EVAR, but no differences in the mid- or longer-term results. More work is needed to understand and improve the long-term outcomes of ruptured endovascular aortic aneurysm repair and ruptured open surgical repair.

7.
J Vasc Surg ; 71(3): 1046-1054.e1, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32089200

RESUMO

OBJECTIVE: Owing to the lack of comparative evidence between the endovascular technologies for arteriovenous fistula (AVF) stenosis treatments, we sought to summarize the reported data comparing the effectiveness of different endovascular approaches for the treatment of AVF stenoses at the juxta-anastomotic site. METHODS: We performed a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched from inception to June 12, 2018 for observational and randomized studies that had examined the effectiveness of AVF stenosis treatment using plain percutaneous balloon angioplasty (PTA), cutting balloon angioplasty, drug-eluting balloon (DEB) angioplasty, high-pressure balloon angioplasty, and stenting. Bias was assessed using the Newcastle-Ottawa scale for observational studies and the Cochrane Collaboration tool for randomized studies. Article screening, full-text review, assessment of bias, and data collection were conducted in duplicate, with a third reviewer to reconcile any discrepancies. We conducted a qualitative synthesis of the available evidence and a quantitative meta-analysis for the primary assisted patency outcome. The meta-analysis was conducted using Review Manager, version 5.3, using random effects models, with the I2 statistic used to assess heterogeneity. Statistical significance was set at P < .05. RESULTS: Our search yielded 3683 reports. Of these, three randomized trials and three observational studies were included. Three studies with 342 patients had described the effectiveness of high-pressure balloon angioplasty, conventional PTA, and stenting and had analyzed the data qualitatively. Three studies with 141 patients had investigated native AVF patency after DEB angioplasty and conventional PTA and were included in the meta-analysis. DEB angioplasty showed significantly greater primary assisted patency rates at 12 months after treatment compared with PTA (odds ratio, 3.66; 95% confidence interval, 1.32-10.14; I2 = 49%). No statistically significant differences were found in 6-month primary assisted patency among the treatment groups (odds ratio, 2.03; 95% confidence interval, 0.64-6.45; I2 = 50%). A total of 58 of 72 AVFs remained patent 6 months after DEB angioplasty compared with 45 of 69 at 6 months after PTA. At 12 months after treatment, 48 of 72 AVFs remained patent after DEB angioplasty compared with 23 of 69 AVFs after PTA. CONCLUSIONS: Our findings suggest DEB angioplasty is a more effective treatment option for AVF stenosis at the juxta-anastomotic site compared with PTA. Although DEB angioplasty might provide longer term patency than other endovascular treatments, further high-quality data are needed to confirm this finding.

8.
Biochem Biophys Res Commun ; 524(1): 50-56, 2020 Mar 26.
Artigo em Inglês | MEDLINE | ID: mdl-31980166

RESUMO

Pulmonary arterial hypertension (PAH) is a rare, but progressive and devastating vascular disease with few treatment options to prevent the advancement to right ventricular dysfunction hypertrophy and failure. Empagliflozin, a sodium-glucose cotransporter 2 (SGLT2) inhibitor, enhances urinary glucose excretion as well as reduces cardiovascular events and mortality in individuals with type 2 diabetes. While empagliflozin has been reported to lower systemic hypertension due to increased diuresis, the effect of empagliflozin on PAH is unknown. We used monocrotaline (MCT)-treated Sprague-Dawley rats to determine if empagliflozin alters PAH-associated outcomes. Compared to vehicle control, daily empagliflozin administration significantly improved survival in rats with severe MCT-induced PAH. Hemodynamic assessments showed that empagliflozin treatment significantly reduced mean pulmonary artery pressure, right ventricular systolic pressure, and increased pulmonary acceleration time. Empagliflozin treatment resulted in reduced right ventricular hypertrophy and fibrosis. Histological and molecular assessments of lung vasculature revealed significantly reduced medial wall thickening and decreased muscularization of pulmonary arterioles after empagliflozin treatment compared to vehicle-treated rats. In summary, SGLT2 inhibition with empagliflozin lowered mortality, reduced right ventricle systolic pressure, and attenuated maladaptive pulmonary remodeling in MCT-induced PAH. Clinical studies evaluating the efficacy of SGLT-2 inhibition should be considered for patients with PAH.

9.
Artigo em Inglês | MEDLINE | ID: mdl-31780062

RESUMO

OBJECTIVE: We sought to determine the early and late outcomes of endovascular versus open thoracoabdominal aortic aneurysm repair. METHODS: We performed a multicenter population-based study across the province of Ontario, Canada, from 2006 to 2017. The primary end point was mortality. Secondary end points were time to first event of a composite of mortality, permanent spinal cord injury, permanent dialysis, and stroke, the individual end points of the composite, patient disposition at discharge, hospital length of stay, myocardial infarction, and secondary procedures at follow-up. RESULTS: A total of 664 adults undergoing surgical repair of a thoracoabdominal aortic aneurysm (endovascular: n = 303 [45.5%] vs open: n = 361 [54.5%]) were identified using an algorithm of administrative codes validated against the operative records. Propensity score matching resulted in 241 patient pairs. Endovascular repairs increased during the study and currently comprise more than 50% of total repairs. In the matched sample, open repair was associated with a higher incidence of in-hospital death (17.4% vs 10.8%, P = .04), complications (26.1% vs 17.4%, P = .02), discharge to rehabilitation facilities (18.7% vs 10.0%, P = .02), and longer length of stay (12 [7-21] vs 6 [3-13] days, P < .01). Long-term mortality was not significantly different (hazard ratio, 1.09; 95% confidence interval, 0.78-1.50), nor were the other secondary end points, with the exception of secondary procedures, which were higher in the endovascular group (hazard ratio, 2.64; 95% confidence interval, 1.54-4.55). At 8 years, overall survival was 41.3% versus 44.6% after endovascular and open repair (P = .62). CONCLUSIONS: Endovascular repair was associated with improved early outcomes but higher rates of secondary procedures after discharge. Long-term survival after thoracoabdominal aortic aneurysm repair is poor and independent of repair technique.

10.
J Vasc Surg ; 2019 Nov 02.
Artigo em Inglês | MEDLINE | ID: mdl-31690525

RESUMO

OBJECTIVE: The purpose of the study was to provide a systematic review of the literature reporting the contemporary early outcomes after endovascular and open repair of thoracoabdominal aortic aneurysms (TAAAs). METHODS: MEDLINE and Embase were searched for studies from January 2006 to March 2018 that reported either endovascular (using branched or fenestrated endografts) or open repair of TAAA in at least 10 patients. Outcomes of interest included perioperative mortality, spinal cord injury (SCI), renal failure requiring dialysis, and stroke. Pooled proportions were determined using a random-effects model. RESULTS: The analysis included 71 studies, of which 24 and 47 reported outcomes after endovascular and open TAAA repair, respectively. Endovascular cohort patients were older and had higher rates of coronary artery disease, chronic obstructive pulmonary disease, and diabetes. Endovascular repair was associated with higher rates of SCI (13.5%; 95% confidence interval [CI], 10.5%-16.7%) compared with open repair (7.4%; 95% CI, 6.2%-8.7%; P < .01) but similar rates of permanent paralysis (5.2% [95% CI, 3.8%-6.7%] vs 4.4% [95% CI, 3.3%-5.6%]; P = .39), lower rates of postoperative dialysis (6.4% [95% CI, 3.2%-9.5%] vs 12.0% [95% CI, 8.2%-16.3%]; P = .03) but similar rates of being discharged on permanent dialysis (3.7% [95% CI, 2.0%-5.9%] vs 3.8% [95% CI, 2.9%-5.3%]; P = .93), a trend to lower stroke (2.7% [95% CI, 1.9%-3.6%] vs 3.9% [95% CI, 3.0%-4.9%]; P = .06), and similar perioperative mortality (7.4% [95% CI, 5.9%-9.1%] vs 8.9% [95% CI, 7.2%-10.9%]; P = .21). CONCLUSIONS: This systematic review summarizes the contemporary literature results of endovascular and open TAAA repair. Endovascular repair studies included patients with more comorbidities and were associated with higher rates of SCI but similar rates of permanent paraplegia, whereas open repair studies had higher rates of postoperative dialysis but similar rates of being discharged on permanent dialysis. Perioperative mortality rates were similar. Universally adopted reporting standards for patient characteristics, outcomes, and the conduct of contemporary comparative studies will allow better assessment and comparisons of the risks associated with the two surgical treatment options for TAAA.

11.
Cell Metab ; 30(4): 609-613, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31477497

RESUMO

Hess et al. quantified circulating aldehyde dehydrogenase-expressing (ALDHhi) cell subsets in people with T2DM given either empagliflozin (EMPA) or placebo. EMPA treatment increased circulating pro-angiogenic CD133+ progenitor cells, decreased pro-inflammatory ALDHhi granulocyte precursors, and increased ALDHhi monocytes with M2 polarization. EMPA treatment improved T2DM-associated "regenerative cell depletion" contributing to enhanced vascular health.

12.
CMAJ ; 191(35): E955-E961, 2019 Sep 03.
Artigo em Inglês | MEDLINE | ID: mdl-31481423

RESUMO

BACKGROUND: The evolving clinical burden of limb loss secondary to diabetes and peripheral artery disease remains poorly characterized. We sought to examine secular trends in the rate of lower-extremity amputations related to diabetes, peripheral artery disease or both. METHODS: We included all individuals aged 40 years and older who underwent lower-extremity amputations related to diabetes or peripheral artery disease in Ontario, Canada (2005-2016). We identified patients and amputations through deterministic linkage of administrative health databases. Quarterly rates (per 100 000 individuals aged ≥ 40 yr) of any (major or minor) amputation and of major amputations alone were calculated. We used time-series analyses with exponential smoothing models to characterize secular trends and forecast 2 years forward in time. RESULTS: A total of 20 062 patients underwent any lower-extremity amputation, of which 12 786 (63.7%) underwent a major (above ankle) amputation. Diabetes was present in 81.8%, peripheral artery disease in 93.8%, and both diabetes and peripheral artery disease in 75.6%. The rate of any amputation initially declined from 9.88 to 8.62 per 100 000 between Q2 of 2005 and Q4 of 2010, but increased again by Q1 of 2016 to 10.0 per 100 000 (p = 0.003). We observed a significant increase in the rate of any amputation among patients with diabetes, peripheral artery disease, and both diabetes and peripheral artery disease. Major amputations did not significantly change among patients with diabetes, peripheral artery disease or both. INTERPRETATION: Lower-extremity amputations related to diabetes, peripheral artery disease or both have increased over the last decade. These data support renewed efforts to prevent and decrease the burden of limb loss.

13.
Circulation ; 140(21): 1693-1702, 2019 Nov 19.
Artigo em Inglês | MEDLINE | ID: mdl-31434508

RESUMO

BACKGROUND: SGLT2 (sodium-glucose cotransporter 2) inhibitors lower cardiovascular events in type 2 diabetes mellitus but whether they promote direct cardiac effects remains unknown. We sought to determine if empagliflozin causes a decrease in left ventricular (LV) mass in people with type 2 diabetes mellitus and coronary artery disease. METHODS: Between November 2016 and April 2018, we recruited 97 individuals ≥40 and ≤80 years old with glycated hemoglobin 6.5% to 10.0%, known coronary artery disease, and estimated glomerular filtration rate ≥60mL/min/1.73m2. The participants were randomized to empagliflozin (10 mg/day, n=49) or placebo (n=48) for 6 months, in addition to standard of care. The primary outcome was the 6-month change in LV mass indexed to body surface area from baseline as measured by cardiac magnetic resonance imaging. Other measures included 6-month changes in LV end-diastolic and -systolic volumes indexed to body surface area, ejection fraction, 24-hour ambulatory blood pressure, hematocrit, and NT-proBNP (N-terminal pro b-type natriuretic peptide). RESULTS: Among the 97 participants (90 men [93%], mean [standard deviation] age 62.8 [9.0] years, type 2 diabetes mellitus duration 11.0 [8.2] years, estimated glomerular filtration rate 88.4 [16.9] mL/min/1.73m2, LV mass indexed to body surface area 60.7 [11.9] g/m2), 90 had evaluable imaging at follow-up. Mean LV mass indexed to body surface area regression over 6 months was 2.6 g/m2 and 0.01 g/m2 for those assigned empagliflozin and placebo, respectively (adjusted difference -3.35 g/m2; 95% CI, -5.9 to -0.81g/m2, P=0.01). In the empagliflozin-allocated group, there was significant lowering of overall ambulatory systolic blood pressure (adjusted difference -6.8mmHg, 95% CI -11.2 to -2.3mmHg, P=0.003), diastolic blood pressure (adjusted difference -3.2mmHg; 95% CI, -5.8 to -0.6mmHg, P=0.02) and elevation of hematocrit (P=0.0003). CONCLUSIONS: Among people with type 2 diabetes mellitus and coronary artery disease, SGLT2 inhibition with empagliflozin was associated with significant reduction in LV mass indexed to body surface area after 6 months, which may account in part for the beneficial cardiovascular outcomes observed in the EMPA-REG OUTCOME (BI 10773 [Empagliflozin] Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients) trial. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02998970.

14.
JAMA Netw Open ; 2(7): e196578, 2019 Jul 03.
Artigo em Inglês | MEDLINE | ID: mdl-31290986

RESUMO

Importance: Knowledge regarding the long-term outcomes of elective treatment of abdominal aortic aneurysm (AAA) using endovascular aortic repair (EVAR) is increasing. However, data with greater than 10 years' follow-up remain sparse and are lacking from population-based studies. Objective: To determine the long-term outcomes of EVAR compared with open surgical repair (OSR) for elective treatment of AAA. Design, Setting, and Participants: This retrospective, population-based cohort study used linked administrative health data from Ontario, Canada, to identify all patients 40 years and older who underwent elective EVAR or OSR for AAA repair from April 1, 2003, to March 31, 2016, with follow-up terminating on March 31, 2017. A total of 17 683 patients were identified using validated procedure and billing codes and were propensity score matched. Analysis was conducted from June 26, 2018, to January 16, 2019. Exposures: Elective EVAR or OSR for AAA. Main Outcomes and Measures: The primary outcome was overall survival. Secondary outcomes were major adverse cardiovascular event-free survival, defined as being free of death, myocardial infarction, or stroke; reintervention; and secondary rupture. Results: Among 17 683 patients who received elective AAA repairs (mean [SD] age, 72.6 [7.8] years; 14 286 [80.8%] men), 6100 (34.5%) underwent EVAR and 11 583 (65.5%) underwent OSR. From these patients, 4010 well-balanced propensity score-matched pairs of patients were defined, with a mean (SD) age of 73.0 (7.6) years and 6583 (82.1%) men. In the matched cohort, the mean (SD) follow-up was 4.4 (2.7) years, and maximum follow-up was 13.8 years. The overall median survival was 8.9 years. Compared with OSR, EVAR was associated with a higher survival rate up to 1 year after repair (91.0% [95% CI, 90.1%-91.9%] vs 94.0% [95% CI, 93.3%-94.7%]) and a higher major adverse cardiovascular event-free survival rate up to 4 years after repair (69.9% [95% CI, 68.3%-71.3%] vs 72.9% [95% CI, 71.4%-74.4%]). Cumulative incidence of reintervention was higher among patients who underwent EVAR compared with those who underwent OSR at the 7-year follow-up (45.9% [95% CI, 44.1%-47.8%] vs 42.2% [95% CI, 40.4%-44.0%]). Survival analyses demonstrated no statistically significant differences in long-term survival, reintervention, and secondary rupture for patients who underwent EVAR compared with those who underwent OSR. Kaplan-Meier analysis suggested superior long-term major adverse cardiovascular event-free survival among patients who underwent EVAR compared with those who underwent OSR (32.6% [95% CI, 26.9%-38.4%] vs 14.1% [95% CI, 4.0%-30.4%]; stratified log-rank P < .001) during a maximum follow-up of 13.8 years. Conclusions and Relevance: Endovascular aortic repair was not associated with a difference in long-term survival during more than 13 years' maximum follow-up. The reasons for these findings will require studies to consider specific graft makes and models, adherence to instructions for use, and types and reasons for reintervention.

15.
Clin Invest Med ; 42(2): E19-25, 2019 06 23.
Artigo em Inglês | MEDLINE | ID: mdl-31228962

RESUMO

PURPOSE: The positive predictive value (PPV) of endovascular and open thoracoabdominal aortic aneurysm (TAAA) repair coding was assessed in Ontario health administrative databases. METHODS: Between 1 January 2006 and 31 March 2016, a random sample of 192 patients was identified using Canadian Classification of Health Intervention (CCI) procedure codes and Ontario Health Insurance Plan (OHIP) billing codes from administrative data. Blinded chart reviews were conducted at two cardiovascular centers to assess the level of agreement between the administrative records and the corresponding patients' hospital charts. The PPV was calculated with 95% confidence intervals using hospital charts as the gold standard. RESULTS: The PPV for the single endovascular TAAA repair code, 1ID80GQNRN, was 0.90 (0.78, 0.97). A combination of all nine CCI open TAAA repair codes was performed, with a PPV of 0.62 (0.47, 0.76). The combination of any one of the nine CCI codes AND the single OHIP code for open TAAA repair (R803) rendered a PPV of 0.98 (0.90, 1.00). CONCLUSIONS: Endovascular TAAA repair may be identified using a single CCI code (1ID80GQNRN). Open TAAA repair may be identified using a combination of CCI and OHIP codes. Researchers may therefore use administrative data to conduct population-based studies of endovascular and open repair of TAAA.

16.
J Vasc Surg ; 70(3): 954-969.e30, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31147117

RESUMO

OBJECTIVE: This study synthesized the literature comparing the long-term (5-9 years) and very long-term (≥10 years) all-cause mortality, reintervention, and secondary rupture rates between endovascular aneurysm repair (EVAR) and open surgical repair (OSR) of abdominal aortic aneurysm (AAA). METHODS: MEDLINE, Embase, and CENTRAL databases were searched from inception to May 2018 for studies comparing EVAR to OSR with a minimum follow-up period of 5 years. Study selection, data abstraction, and quality assessment were conducted by two independent reviewers, with a third author resolving discrepancies. Study quality was assessed using the Cochrane and Newcastle-Ottawa scales. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects models. Heterogeneity was quantified using the I2 statistic, and publication bias was assessed using funnel plots. RESULTS: Our search yielded 3431 unique articles. Three randomized controlled trials and 68 observational studies comparing 151,092 EVAR to 148,692 OSR patients were included. Inter-rater agreement was excellent at the screening (κ = 0.78) and full-text review (κ = 0.89) stages. Overall, the risk of bias was low to moderate. For long-term outcomes, 54 studies reported all-cause mortality (n = 203,246), 23 reported reintervention (n = 157,151), and 4 reported secondary rupture (n = 150,135). EVAR was associated with higher long-term all-cause mortality (OR, 1.19; 95% CI, 1.06-1.33; P = .003, I2 = 91%), reintervention (OR, 2.12; 95% CI, 1.67-2.69; P < .00001, I2 = 96%), and secondary rupture rates (OR, 4.84; 95% CI, 2.63-8.89; P < .00001, I2 = 92%). For very long-term outcomes, 15 studies reported all-cause mortality (n = 48,721), 9 reported reintervention (n = 7511), and 1 reported secondary rupture (n = 1116). There was no mortality difference between groups, but EVAR was associated with higher reintervention (OR, 2.47; 95% CI, 1.71-3.57; P < .00001, I2 = 84%) and secondary rupture rates (OR, 8.10; 95% CI, 1.01-64.99; P = .05). Subanalysis of more recent studies, with last year of patient recruitment 2010 or after, demonstrated no long-term mortality differences between EVAR and OSR. CONCLUSIONS: EVAR is associated with higher long-term all-cause mortality, reintervention, and secondary rupture rates compared with OSR. In the very long-term, EVAR is also associated with higher reintervention and secondary rupture rates. Notably, EVAR mortality has improved over time. Vigilant long-term surveillance of EVAR patients is recommended.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Retratamento , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
17.
CMAJ Open ; 7(2): E379-E384, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31147379

RESUMO

BACKGROUND: Recent years have seen centralization of vascular surgery services in Ontario. We sought to examine the trends in overall and approach-specific elective and ruptured abdominal aortic aneurysm repair by hospital type (teaching v. community). METHODS: We conducted a population-based time-series analysis of elective and ruptured abdominal aortic aneurysm repairs in Ontario, Canada, from 2003 to 2016. Quarterly cumulative incidences of repairs per 100 000 Ontarians aged 40 years and older were calculated. We fit exponential smoothing models to the data stratified by approach and hospital type to examine repair trends. RESULTS: We identified 19 219 elective and 2722 ruptured repairs between 2003 and 2016. The cumulative incidences of overall elective repair and elective open surgical repair decreased by 1.15% (p = 0.008) and 67% (p < 0.001), respectively, in teaching hospitals and by 23% (p < 0.001) and 60% (p < 0.001), respectively, in community hospitals. The cumulative incidence of elective endovascular repair increased 667% in teaching hospitals (p < 0.001). Elective endovascular repair began in community centres after 2010 and increased to 0.98/100 000 (p < 0.001), resulting in a rebound in overall elective repair in the community. Overall ruptured repairs and ruptured open repairs decreased by 84% (p < 0.001) and 88% (p = 0.002), respectively, at community hospitals. Ruptured endovascular repairs at community hospitals increased from no procedures before 2006 to 0.03/100 000 in 2016 (p = 0.005). INTERPRETATION: There has been substantial uptake of endovascular aortic repair in teaching and community hospitals in Ontario, and community hospital uptake of endovascular repair has begun decentralization of abdominal aortic aneurysm repair. Increased experience and training in endovascular repair and reduced specialized care requirements will probably lead to continued decentralization.

18.
BMJ Qual Saf ; 28(11): 901-907, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31127067

RESUMO

BACKGROUND: Events occurring outside the hospital setting are underevaluated in surgical quality improvement initiatives and research. OBJECTIVE: To quantify regional variation in home care nursing following vascular surgery and explore its impact on emergency department (ED) visits and hospital readmission. METHODS: Patients who underwent elective vascular surgery and were discharged directly home were identified from population-based administrative databases for the province of Ontario, Canada, 2006-2015. The index surgeries included carotid endarterectomy, open and endovascular aortic aneurysm repair and bypass for lower extremity peripheral arterial disease. Home care nursing within 30 days of discharge was captured and compared across regions. Using multilevel logistic regression, we characterised the association between home care nursing and the risk of an ED visit or hospital readmission within 30 days of discharge. RESULTS: The cohort included 23 617 patients, of whom 9002 (38%) received home care nursing within 30 days of discharge home. Receipt of nursing care after discharge home varied widely across Ontario's 14 administrative health regions (range 16%-84%), even after accounting for differences in patient case mix. A lower likelihood of an ED visit or hospital readmission within 30 days of discharge was observed among patients who received home care nursing following three of four index surgeries: carotid endarterectomy OR 0.74, 95% CI 0.61 to 0.91; endovascular aortic aneurysm repair OR 0.85, 95% CI 0.72 to 0.99; open aortic aneurysm repair OR 1.06, 95% CI 0.91 to 1.23; bypass for lower extremity peripheral arterial disease OR 0.81, 95% CI 0.72 to 0.92. CONCLUSION: Home care nursing may contribute to reducing ED visits and hospital readmission and is variably prescribed after vascular surgery.

19.
Surg Innov ; 26(5): 588-598, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31074330

RESUMO

Background. Lithoplasty is a method of alleviating vessel stenosis by using localized high-speed pressure waves to disrupt calcium deposits. A systematic review of the literature was performed to summarize the early outcomes of lithoplasty in peripheral and coronary artery disease. Methods. We searched EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials from database inception to July 2018 for original studies describing the use of lithoplasty. Study selection and data extraction were performed in duplicate, with a third author resolving discrepancies. Results. A total of 9 records were included from the 201 studies eligible for screening. In total, 211 patients with vascular calcification lesions underwent lithoplasty. The patients on average had an age of 73.2 years and had a maximum follow-up period of 5.5 months. Most lesions (72%, 152/212) were in peripheral artery beds, with the remainder occurring in coronary vessels. Lesioned vessels typically had severe calcium burden 62.6% (131/210), with an average initial stenosis of 76.6% (range, 68.1%-77.8%). After treatment, the average residual stenosis was 21.0% (range, 13.3%-26.2%), with a mean acute gain of vessel diameter of 2.5 mm. A limited number of type D dissections occurred, with a total of 2.4% (5/211) of patients requiring stent implantation. Conclusions. Recent studies suggest that lithoplasty is a promising intervention to decrease vessel stenosis in both peripheral artery disease and coronary artery disease, with minimal occurrence of major adverse events. Further research studies, with more rigorous study designs, are needed to determine the effectiveness of lithoplasty in vascular calcifications.


Assuntos
Estenose Coronária/terapia , Litotripsia/métodos , Doenças Vasculares Periféricas/terapia , Calcificação Vascular/terapia , Humanos
20.
J Vasc Surg ; 70(5): 1675-1681.e6, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31126762

RESUMO

OBJECTIVE: The objective was to characterize the growing body of literature regarding nonoperative management of blunt thoracic aortic injury (BTAI). METHODS: A systematic search of MedLine, Embase, and Cochrane Central was completed to identify original articles reporting injury characteristics and outcomes in patients with BTAI managed nonoperatively during their index hospitalization. Article title and abstract screening, full-text review, and data abstraction were performed in duplicate, with discrepancies resolved by a third reviewer. The quality of each study was evaluated using the Oxford Centre for Evidence-Based Levels of Evidence. RESULTS: Of 2162 identified studies, 74 were included and reported on 8606 patients with BTAI who were managed nonoperatively between 1970 and 2016. Only one study was prospective. The median nonoperative sample size per study was 11 patients. The characterization of aortic injury grade differed across studies. Follow-up varied widely from 1 day to 118 months. Injury healing or improvement on follow-up imaging occurred in 34% (226 of 673 patients; reported in 37 studies), most often in the context of grade I intimal injury. Injury progression or requirement for a thoracic endovascular aneurysm repair for injury progression was 7.6% (66 of 873 patients; reported in 46 studies). A total of 37 studies reported aortic-related death, with an overall rate of 4.5% (37 of 827 patients) and a rate of 1% in grade I and II injuries (1 of 153 patients) and 18% in grade III and IV (9 of 50 patients). CONCLUSIONS: An increasing number of reports support nonoperative management of grade I intimal injury, consistent with Society for Vascular Surgery guidelines. However, a retrospective interpretation of the determinants of management, heterogeneous injury characterization, and variable follow-up remain major limitations to the informed use of nonoperative management across all BTAI grades.

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