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1.
Semin Vasc Surg ; 34(3): 125-131, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34642032

RESUMO

Since the onset of the COVID-19 pandemic, a concentrated research effort has been undertaken to elucidate risk factors underlying viral infection, severe illness, and death. Recent studies have investigated the association between blood type and COVID-19 infection. This article aims to comprehensively review current literature and better understand the impact of blood type on viral susceptibility and outcomes.

2.
Am J Surg ; 2021 Aug 09.
Artigo em Inglês | MEDLINE | ID: mdl-34465448

RESUMO

OBJECTIVES: Perioperative inefficiency can increase cost. We describe a process improvement initiative that addressed preoperative delays on an academic vascular surgery service. METHODS: First case vascular surgeries from July 2019-January 2020 were retrospectively reviewed for delays, defined as late arrival to the operating room (OR). A stakeholder group spearheaded by a surgeon-informaticist analyzed this process and implemented a novel electronic medical records (EMR) preoperative tool with improved preoperative workflow and role delegation; results were reviewed for 3 months after implementation. RESULTS: 57% of cases had first case on-time starts with average delay of 19 min. Inappropriate preoperative orders were identified as a dominant delay source (average delay = 38 min). Three months post-implementation, 53% of first cases had on-time starts with average delay of 11 min (P < 0.05). No delays were due to missing orders. CONCLUSIONS: Inconsistent preoperative workflows led to inappropriate orders and delays, increasing cost and decreasing quality. A novel EMR tool subsequently reduced delays with projected savings of $1,200/case. Workflow standardization utilizing informatics can increase efficiency, raising the value of surgical care.

3.
J Comput Assist Tomogr ; 45(5): 704-710, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34469902

RESUMO

OBJECTIVE: The aim of this study was to assess self-reported breast cancer prevalence potentially associated with occupational radiation exposure from fluoroscopy-guided procedures in female physicians using current standard protection measures. METHODS: An institutional review board-approved survey was shared as a link to self-identified female physicians. We compared self-reported prevalence of breast cancer among women physicians with longer than 10 years of postfellowship practice in specialties with heavy fluoroscopy exposure versus specialties with low fluoroscopy exposure. We compared the distribution of breast cancer risk factors and personal radiation safety measures. RESULTS: A total of 303 women physicians participated in the survey. There were 8 (16%) of 49 from the first study group and 8 (18%) of 44 from the second study group who self-reported a diagnosis of breast cancer. There were no differences in the distribution of breast cancer risk factors between the 2 groups or prevalence of breast cancer (P = 0.81). CONCLUSIONS: Self-reported breast cancer prevalence is similar between women physicians who are practicing fluoroscopically heavy and light medical specialties.


Assuntos
Neoplasias da Mama/epidemiologia , Exposição Ocupacional/estatística & dados numéricos , Médicas/estatística & dados numéricos , Exposição à Radiação/estatística & dados numéricos , Radiografia Intervencionista/estatística & dados numéricos , Feminino , Fluoroscopia/estatística & dados numéricos , Humanos , Pessoa de Meia-Idade , Prevalência , Radiografia Intervencionista/métodos
4.
J Vasc Surg ; 2021 Sep 22.
Artigo em Inglês | MEDLINE | ID: mdl-34560216

RESUMO

BACKGROUND: The Society for Vascular Surgery (SVS) recently published clinical practice guidelines on the management of visceral aneurysms. However, studies investigating the perioperative outcomes of open repair of visceral aneurysms have been limited to single-center experiences with variable results that span multiple decades. In the present study, we sought to detail the morbidity and mortality associated with open repair of visceral aneurysms using a national database in the contemporary era. METHODS: National Surgical Quality Improvement Program data from 2013 to 2019 were queried for patients who had undergone open repair of visceral aneurysms, which had been classified as mesenteric, renal, or splenic using Current Procedural Terminology and International Classification of Diseases codes. The primary endpoint was the composite of major complications (cardiovascular, pulmonary, progressive renal failure, deep wound infection, return to operating room, sepsis) and 30-day mortality. Logistic regression was used to identify the predictors of the primary endpoint for nonruptured aneurysm cases. RESULTS: Of the 304 aneurysms, 263 were nonruptured (137 mesenteric, 66 renal, 60 splenic) and 41 were ruptured (24 mesenteric, 1 renal, 16 splenic) and had undergone open repair. For those with nonruptured aneurysms, their mean age was 59.4 ± 14.7 years and 48.3% were women. For those with nonruptured aneurysms, the 30-day mortality was 1.9% and the major complication rate was 12.9%. A return to the operating room (5.3%) and prolonged ventilator support (3.8%) were especially common. As expected, rupture was associated with significantly greater mortality (22.0%; P < .001) and major complications (34.1%; P = .001). The use of postoperative transfusion was common in the elective group but was significantly greater in the ruptured group (24.3% vs 80.5%; P < .001). The predictors of the primary outcome for nonruptured aneurysms included male sex (odds ratio [OR], 2.93; 95% confidence interval [CI], 1.28-6.7; P = .011), anticoagulation (not discontinued before surgery) or bleeding disorder (OR, 4.52; 95% CI, 1.37-14.7; P = .012), and albumin <3.0 g/dL (OR, 4.66; 95% CI, 1.17-18.6; P = .029). Neither age nor aneurysm location were significant risk factors. CONCLUSIONS: Open repair of visceral aneurysms was associated with acceptable morbidity and mortality, although these risks are significantly greater once ruptured. Male sex, bleeding risk, and low albumin were all risk factors for adverse events and should be considered for operative planning and postoperative care.

5.
J Vasc Surg ; 2021 Aug 25.
Artigo em Inglês | MEDLINE | ID: mdl-34450243

RESUMO

OBJECTIVE: Prior research in vascular surgery has identified significant gender disparities in leadership positions, but few data exist regarding gender disparities in vascular publications. This study aims to evaluate authorship trends by gender in the three highest impact factor vascular surgery journals. METHODS: In this bibliometric analysis, PubMed was searched for articles published in the European Journal of Vascular and Endovascular Surgery, the Journal of Vascular Surgery, and Annals of Vascular Surgery from 2015 to 2019. The web-based application Genderize used predictive algorithms to classify names of first and last authors as male or female. Statistical analyses regarding trends in authorship were performed using Stata16. RESULTS: A total of 6457 articles were analyzed, with first author gender predicted with >90% confidence in 83% (4889/5796) and last author gender in 88% (5078/5796). Overall, 25% (1223/4889) of articles had women first authors, and 10% (501/5078) had women last authors. From 2015 to 2019, there was a slight increase in the proportion of articles written by women first authors (P = .001), but no increase in the proportion of articles written by women last authors (P = .204). The proportion of articles written by women last authors was lower than the proportion of active women vascular surgeons in 2015 (8% of articles vs 11% of surgeons; P = .015), 2017 (9% of articles vs 13% of surgeons; P < .001), and 2019 (11% of articles vs 15% of practicing surgeons; P < .001). The average number of last-author publications was higher for men (2.35 ± 3.76) than for women (1.62 ± 1.88, P = .001). The proportion of unique authors who were women was less than the proportion of active women vascular surgeons in 2017 (10% unique authors vs 13% surgeons; P = .047), but not in 2015 (9% unique authors vs 11% surgeons; P = .192) or 2019 (13% unique authors vs 15% surgeons; P = .345). Notably, a woman last author was associated with 1.45 higher odds of having a woman first author (95% confidence interval, 1.17-1.79; P = .001). CONCLUSIONS: Over the past 5 years, there has been no significant increase in women last authors among top-tier journals in vascular surgery. Women remain under-represented as last authors in terms of proportion of published articles, but not in terms of proportion of unique authors. Nevertheless, women last authors are more likely to publish with women first authors, indicating the importance of women-led mentorship in achieving publication gender equity. Support for women surgeons through grants and promotions is essential not only for advancing last authorship gender equity, but for advancing junior faculty and trainee academic careers.

6.
Circulation ; 144(14): 1091-1101, 2021 Oct 05.
Artigo em Inglês | MEDLINE | ID: mdl-34376058

RESUMO

BACKGROUND: Literature detailing the natural history of asymptomatic penetrating aortic ulcers (PAUs) is sparse and lacks long-term follow-up. This study sought to determine the rate of asymptomatic PAU growth over time and adverse events from asymptomatic PAU. METHODS: A cohort of patients with asymptomatic PAU from 2005 to 2020 was followed. One ulcer was followed per patient. Primary end points were change in size over time and the composite of symptoms, radiographic progression, rupture, and intervention; cumulative incidence function estimated the incidence of the composite outcome. Ulcer size and rate of change were modeled using a linear mixed-effects model. Patient and anatomic factors were evaluated as potential predictors of the outcomes. RESULTS: There were 273 patients identified. The mean age was 75.5±9.6 years; 66.4% were male. The majority of ulcers were in the descending thoracic aorta (53.9%), followed by abdominal aorta (41.4%) and aortic arch (4.8%). Fusiform aneurysmal disease was present in 21.6% of patients at a separate location; 2.6% had an associated intramural hematoma; 23.6% had at least 1 other PAU. Symptoms developed in 1 patient who ruptured; 8 patients (2.9%) underwent an intervention for PAU (1 for rupture, 2 for radiographic progression, 5 for size/growth) at a median of 3.1 years (interquartile range, 1.0-6.5) after diagnosis. Five- and 10-year cumulative incidence of the primary outcome, adjusted for competing risk of death, was 3.6% (95% CI, 1.6%-6.9%) and 6.5% (95% CI, 3.1%-11.4%), respectively. For 191 patients with multiple computed tomography scans (760 total computed tomographies) with a median radiographic follow-up of 3.50 years (interquartile range, 1.20-6.63 years), mean initial ulcer width, ulcer depth, and total diameter were 13.6 mm, 8.5 mm, and 31.4 mm, respectively. A small but statistically significant change over time was observed for ulcer width (0.23 mm/y) and total diameter (0.24 mm/y); ulcer depth did not significantly change over time. Hypertension, hyperlipidemia, diabetes, initial ulcer width >20 mm, thrombosed PAU, and associated saccular aneurysm were associated with larger changes in ulcer size over time; however, the magnitude of difference was small, ranging from 0.4 to 1.9 mm/y. CONCLUSIONS: Asymptomatic PAU displayed minimal growth and infrequent complications including rupture. Asymptomatic PAU may be conservatively managed with serial imaging and risk factor modification.

7.
J Vasc Surg ; 2021 Jun 29.
Artigo em Inglês | MEDLINE | ID: mdl-34197946

RESUMO

OBJECTIVE: Penetrating atherosclerotic ulcers (PAUs) in aortic branch vessels are rare. There is a paucity of data regarding their long-term natural history and associated management. This study aimed to determine the prevalence and natural history of aortic branch PAUs. METHODS: Institutional data on all patients with an aortic branch PAU from 2005 to 2020 were retrospectively reviewed. Branch PAUs were defined as any PAU in the iliac, mesenteric, or arch vessels. End points included symptoms, end-organ events, and interventions. All computed tomography angiographies (CTAs) for each patient were reviewed, and total diameter, ulcer width, and ulcer depth were recorded on each computed tomography scan for the branch PAUs. Rate of change was compared between groups (iliac vs arch and visceral vessels) using a linear mixed-effects model. RESULTS: Among 58,800 patients who underwent a CTA, 367 patients had an aortic PAU (prevalence: 0.6%) and 58 patients had a branch PAU (prevalence: 0.1%). Among those 58 patients, there were 66 ulcerated branches. There were 50 iliac (42 common iliac, 7 internal, and 1 external), 11 arch (8 left subclavian, 3 innominate), and 5 visceral ulcers (3 superior mesenteric artery, 1 celiac, and 1 renal). Mean age was 74.0 ± 8.8 years, and 86% of patients were male; 74% had hypertension, 79% had hyperlipidemia, and 59% had a concomitant aortic aneurysm. There were 45 PAU vessels with >1 CTA (total of 167 CTAs) with a median follow-up of 4.0 years (interquartile range: 2.0-6.2 years). Total vessel diameter increased in size by 0.27 mm/y but did not differ between groups (iliac vs visceral/arch vessels). PAU width and depth also did not significantly change over time, nor did it differ between groups. No branch PAUs caused symptoms, end-organ events, or rupture, nor required intervention due to symptoms and/or progression. Four PAUs spontaneously resolved (2 iliac, 2 other), and 1 iliac PAU progressed to a saccular aneurysm. CONCLUSIONS: This is one of the largest studies evaluating the natural history of branched PAUs objectively via CTA. Branch PAUs are rare-the prevalence was one-sixth that of aortic PAUs. There was minimal growth noted in a median follow-up of 4 years, and no PAUs required intervention for symptoms or progression. Asymptomatic branch PAUs may be safely observed.

8.
J Surg Educ ; 2021 Jun 04.
Artigo em Inglês | MEDLINE | ID: mdl-34099428

RESUMO

OBJECTIVE: Recent initiatives have targeted the issue of gender and ethnic/racial disparities in general surgery and vascular surgery. However, the prevalence of these disparities in general and vascular surgical training programs is unknown. DESIGN: A retrospective analysis was conducted using data from three separate sources, including the US Graduate Medical Education annual report, Electronic Residency Application Service database, and National Resident Matching Program annual report. Demographic information regarding gender distribution and ethnic/racial identity was collected from 328 general surgery residency programs, 59 vascular surgery residency programs, and 100 vascular surgery fellowship programs across the US. The primary outcomes of this study were to evaluate national trends in gender and ethnic diversity in general surgery and vascular surgery training programs, including both traditional fellowship and integrated residency paradigms. RESULTS: From 2011-2020, general surgery residency programs showed a positive trend towards both female applicants (from 31.9%-41.5%) and trainees (from 36.2%-43.1%) (p < 0.0001 each). The proportion of minority trainees decreased, primarily among Black (from 7.2%-5.4%) and Asian trainees (from 21.5%-19.2%) (p < 0.0001 each). Concurrently, the number of vascular integrated residency programs grew from 27 to 59, resulting in a fivefold increase in trainees (from 64-335). Despite this growth, there was no change in the proportion of women applicants or trainees for both vascular integrated residency (24.9% applicants; 36.2% trainees) and fellowship programs (27.4% applicants; 25.9% trainees) over the study period (p = 0.11, 0.89, 0.43, and 0.13 respectively). Moreover, there was no significant change in proportion of minority trainees in both vascular integrated residency and fellowship programs. CONCLUSION: While general surgery programs have expanded in proportion of both female applicants and trainees, racial diversity has decreased. Gender and racial diversity in vascular training has not changed. Future initiatives in general and vascular surgery should focus on recruitment and promotion of proficient women and minority trainees.

10.
J Vasc Surg ; 74(4): 1109-1116, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33887425

RESUMO

OBJECTIVE: Splenectomy is often performed during open thoracoabdominal aortic aneurysm (TAAA) repair, because capsular tears are common and can be associated with significant bleeding. It is unknown whether splenectomy affects the short- or long-term outcomes after TAAA repair. METHODS: All open type I to IV TAAA repairs performed from 1987 to June 2015 were evaluated using a single institutional database. The primary endpoints were in-hospital death, major adverse events (MAE) and long-term survival. The secondary endpoint was hospital length of stay (LOS). All repairs performed for aneurysm rupture were excluded. Univariate analysis was conducted using the Fisher's exact test for categorical variables and the Wilcoxon rank sum test for continuous variables. Logistic and linear multivariable regression were used for the in-hospital endpoints, and survival analyses were performed using Cox proportional hazards modeling and Kaplan-Meier techniques. RESULTS: A total of 649 patients met the study inclusion criteria. Of the 649 patients, 150 (23%) underwent concurrent splenectomy (CS) and six required emergency splenectomy secondary to bleeding postoperatively, leading to 156 cases of total in-hospital splenectomy. The perioperative mortality rate was 5.2% in the CS group and 5.2% in the non-CS group (P = 1.0). MAE were experienced by 48% of the CS patients compared with 34% of the non-CS patients (P = .003). Multivariable analysis revealed splenectomy was not independently predictive of perioperative death (adjusted odds ratio, 0.95; 95% confidence interval [CI], 0.41-2.23; P = .9). However, splenectomy was independently associated with any MAE (adjusted odds ratio, 1.78; 95% CI, 1.19-2.65; P = .005). Splenectomy was also associated with a longer length of stay (+5.39 days; 95% CI, 1.86-8.92; P = .003). No survival difference was found between the cohorts in the total splenectomy cohort in the unadjusted (log-rank P = 1.0) or adjusted (splenectomy adjusted hazard ratio, 1.02; 95% confidence interval, 0.78-1.35; P = .9). CONCLUSIONS: CS during open TAAA repair did not lead to increased perioperative mortality but did lead to significantly increased perioperative morbidity and longer hospital lengths of stay. We found no difference in long-term survival outcomes when CS was performed. Splenectomy during TAAA repair did not affect long-term survival.

11.
Semin Vasc Surg ; 34(1): 59-64, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33757637

RESUMO

Chronic venous insufficiency (CVI) affects more than 25 million adults in the United States alone, and more 6 million with advanced stages of venous disease. The high incidence of CVI and the increasing costs of care, place a heavy financial burden on the US health care system. Recent studies estimate the total cost of care at more than $3 billion per year. These staggering numbers highlight the importance of timely diagnosis, treatment, and prevention of CVI. In this article, we review the epidemiology and prevalence of CVI, and its financial impact on national health care budget. Racial disparities in CVI and the impact of socioeconomic status on access to care are also discussed. Finally, we discuss CVI-related screening programs and the importance of preventative measures in venous disease.


Assuntos
Custos de Cuidados de Saúde , Insuficiência Venosa , Fatores Etários , Orçamentos , Doença Crônica , Efeitos Psicossociais da Doença , Feminino , Disparidades em Assistência à Saúde/economia , Humanos , Incidência , Masculino , Prevalência , Prognóstico , Fatores Raciais , Medição de Risco , Fatores de Risco , Fatores Sexuais , Determinantes Sociais da Saúde , Fatores Socioeconômicos , Estados Unidos/epidemiologia , Insuficiência Venosa/diagnóstico , Insuficiência Venosa/economia , Insuficiência Venosa/epidemiologia , Insuficiência Venosa/terapia
12.
J Vasc Surg Venous Lymphat Disord ; 9(5): 1297-1301, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-33529718

RESUMO

OBJECTIVE: Duplex ultrasonography is the reference standard for diagnosing chronic venous insufficiency. Bilateral venous reflux ultrasound studies are among the most time-consuming and physically demanding tests for vascular ultrasound technologists to perform. Furthermore, if a venous procedure is required, many insurance policies require that a diagnostic venous ultrasound scan for reflux must be performed within 1 year of the procedure. If the intervention is scheduled for >1 year after the ultrasound scan, the insurance company might require a repeat venous ultrasound scan before granting insurance authorization. Hence, ordering bilateral venous duplex ultrasound scans to evaluate for reflux when an intervention might only be performed on one limb within the year could be a waste of time and resources. The aim of the present study was to determine the utility of ordering bilateral vs unilateral studies to evaluate for reflux in patients with suspected chronic venous insufficiency and to determine whether a resource-saving potential exists for vascular laboratories through optimization of the process of ordering venous duplex ultrasound studies. METHODS: A retrospective review of all patients who had undergone bilateral lower extremity ultrasound scanning to evaluate for reflux from January 1, 2016 to December 31, 2016 at the Massachusetts General Hospital vascular laboratory was performed. The demographics, indications for ultrasound scanning, comorbidities, time required to perform the ultrasound study, and interval to intervention were documented. The data were analyzed using SPSS statistical software (IBM Corp, Armonk, NY). RESULTS: During the study period, 13,854 ultrasound studies had been performed in our vascular laboratory, of which 606 (4.4%) had been bilateral ultrasound scans for venous insufficiency. The time allotted for a bilateral study was 2 hours. Of the 606 studies evaluated, 152 (25.1%) showed no evidence of reflux, 284 (46.9%) showed bilateral lower extremity reflux, and 170 (28.1%) showed only venous insufficiency in one leg. Venous ablation, phlebectomy, and/or sclerotherapy were performed for 28.7% of the patients. However only 6.2% of patients had undergone venous procedures on both legs within 1 year after the ultrasound studies. Ablation was the most common procedure performed (54.6%), followed by phlebectomy (27.%) and sclerotherapy (17.9%). Overall, 94.7% of patients had not undergone a venous procedure on both legs within 1 year after the ultrasound studies and, hence, would have required a repeat duplex ultrasound scan to ensure insurance coverage for future procedures. CONCLUSIONS: Most bilateral ultrasound scans for venous insufficiency will not result in an intervention. Thus, most patients (95%) could have undergone a unilateral scan before the initial intervention instead of bilateral duplex ultrasound scanning.

13.
J Vasc Surg ; 74(1): 161-169.e1, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33548436

RESUMO

OBJECTIVE: Covered stents (CS) to treat superficial femoral artery (SFA) occlusive disease have become more common. However, concerns about patients presenting with acute limb ischemia (ALI) after failure due to coverage of important collaterals have been raised. Herein, we determine if CS are associated with ALI after failure. METHODS: Vascular Quality Initiative peripheral vascular intervention and infrainguinal bypass datasets were queried from 2010 to 2020 for patients who underwent SFA stenting with a bare metal stent (BMS) or CS and who also had a subsequent ipsilateral SFA endovascular reintervention or bypass recorded in the Vascular Quality Initiative. The initial SFA stenting procedure will be referred to as the index procedure and the subsequent procedure will be referred to as the reintervention. Patients with aneurysmal pathology, prior infrainguinal bypass, and ALI at the index procedure were excluded. Patients with pre-index inflow/outflow procedures were not excluded. The primary outcome was ALI at reintervention. Other outcomes included higher degree of ischemia (claudication vs rest pain vs tissue loss vs ALI) and reoperative factors. Predictors of the primary outcome were determined with multivariable logistic regression. The index treatment length and pre-index ankle-brachial index were forced into the model. RESULTS: There were 3721 patients: 3338 with index BMS, 383 with index CS. The mean patients age was 66.3 ± 11.0 years and 59.2% were male. Baseline covariates were similar between the groups; during the index procedure, more patients with BMS underwent plain balloon angioplasty (68.7% vs 62.1%; P = .001) and had shorter total index treatment length (median, 15.0 cm [interquartile range, 10.0-25.0 cm] vs 20.0 cm [interquartile range, 12.0-30.0 cm]; P < .001). At reintervention, ALI was the presenting symptom for 12.0% of the CS cohort vs 6.3% of the BMS cohort (P < .001). More patients with an index CS underwent major amputation at the time of reintervention (2.6% vs 1.0%; P = .006). Reinterventions for the patients with a CS more often used bypass, pharmacologic thrombolysis, and mechanical thrombolysis. CS at the index procedure was a predictor of ALI at reintervention (odds ratio, 1.87; 95% confidence interval, 1.31-2.65; P = .001) while controlling for age, time difference between procedures, body mass index, chronic obstructive pulmonary disorder, preoperative anticoagulation and antiplatelet, prior carotid intervention and major amputation, index procedure fluoroscopy time and treatment length, and pre-index ankle-brachial index. CONCLUSIONS: In patients undergoing reintervention for failed SFA stents, CS are more likely to present with ALI than those with failed SFA BMS.


Assuntos
Materiais Revestidos Biocompatíveis , Procedimentos Endovasculares , Artéria Femoral , Isquemia/etiologia , Metais , Doença Arterial Periférica/terapia , Artéria Poplítea , Stents , Doença Aguda , Idoso , Amputação , Circulação Colateral , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Feminino , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/fisiopatologia , Humanos , Isquemia/diagnóstico por imagem , Isquemia/fisiopatologia , Isquemia/cirurgia , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/fisiopatologia , Artéria Poplítea/diagnóstico por imagem , Artéria Poplítea/fisiopatologia , Intervalo Livre de Progressão , Desenho de Prótese , Fluxo Sanguíneo Regional , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo
14.
J Vasc Surg ; 74(2): 514-520.e2, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33600933

RESUMO

OBJECTIVE: The presence of cancer increases arterial thromboembolic events, specifically myocardial infarction and stroke, before a formal diagnosis of cancer. To the best of our knowledge, this increase in thrombotic risk has not been studied in patients with lower extremity bypass grafts. In the present study, we aimed to determine the effect of occult cancer on femoropopliteal bypass patency. METHODS: A retrospective review of femoropopliteal bypass procedures completed from 2001 to 2018 was performed. International Classification of Diseases, 9th and 10th revision, codes corresponding to breast, lung, prostate, colorectal, skin, brain, and hematologic cancer were used to identify patients who had had occult cancer. Occult cancer was defined as cancer diagnosed within ≤1 year after the bypass procedure. The demographics, comorbidities, bypass configuration and conduit, 1-month, 3-month, 6-month, and 1-year occlusion rates, major adverse limb events, and mortality rates were analyzed. Statistical analysis included t tests, χ2 tests, and Cox regression analysis. RESULTS: A total of 621 procedures in 517 patients met the inclusion criteria. Of the 621 procedures, 36 (5.8%) were classified as procedures in patients with occult cancer. The patients with occult cancer had had higher occlusion rates at 3 months (27.8% vs 8.0%; P < .001), 6 months (30.5% vs 15.1%; P < .01), and 1 year (44.4% vs 19.8%; P < .001). In Cox regression analysis for bypass thrombosis at 1 year, the only significant predictors were occult cancer (hazard ratio [HR], 2.03; P = .01), below-the-knee distal target (HR, 1.88; P < .01), and a compromised conduit (HR, 2.14; P < .001). CONCLUSIONS: We found an increase in bypass graft thrombosis rates in patients who had undergone femoropopliteal bypass who had had occult cancer. Thrombosis of the graft within 1 year postoperatively might be a sign of occult cancer.


Assuntos
Implante de Prótese Vascular/efeitos adversos , Oclusão de Enxerto Vascular/etiologia , Neoplasias/complicações , Doença Arterial Periférica/cirurgia , Trombose/etiologia , Idoso , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Feminino , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/mortalidade , Humanos , Masculino , Neoplasias/diagnóstico , Neoplasias/mortalidade , Doença Arterial Periférica/complicações , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/mortalidade , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Trombose/diagnóstico por imagem , Trombose/mortalidade , Fatores de Tempo , Resultado do Tratamento
15.
Vasc Endovascular Surg ; 55(5): 441-447, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-33602047

RESUMO

OBJECTIVES: Data from 2011-2014 showed lower extremity bypass(LEB) outperforming infrainguinal endovascular intervention(IEI) regarding major adverse limb events(MALE) but noted no significant difference in major adverse cardiac events(MACE) in propensity matched cohorts. This study aimed to determine if more recent(2015-2018) endovascular outcomes data have improved relative to surgical bypass. METHODS: Patients who underwent intervention for chronic limb threatening ischemia (CLTI) from 2015-2018 were identified using the American College of Surgeons National Quality Improvement Program(NSQIP) Vascular Surgery module. The cohort was categorized as undergoing lower extremity bypass(LEB) or infrainguinal endovascular intervention(IEI). Primary 30-day outcomes included major adverse cardiac events(MACE), major adverse limb events(MALE), and major amputation. Inverse probability weighting was used for multivariable analysis. RESULTS: A total of 10,783 patients underwent an infrainguinal intervention for CLTI from 2015-2018. Of these, 6,003(55.7%) underwent LEB and 4,780(44.3%) underwent IEI. Forty percent of the cohort was considered "high anatomic risk" by Objective Performance Goals(OPG) standards, and 13.6% were considered "high clinical risk." The IEI cohort vs. the LEB cohort experienced a Myocardial infarction(MI)/Stroke rate of 1.8% vs. 3.6%(p < .001), and had a mortality rate of 2.0% vs. 1.7%(p = .22), which yielded a composite MACE of 3.4% vs. 4.8%(p = .001). The rate of reintervention for IEI vs LEB was 4.4% vs. 5.3%(p = .04), the loss of patency (without re-intervention) rate was 1.8% vs. 1.8%(p = 1.0), and the major amputation rate was 4.1% vs. 3.5%(p = .15), which resulted in a MALE rate of 9.1% vs. 8.8%(p = .50). Following inverse probability weighting, comparing the IEI to the referent LEB, MALE AOR = 1.17, 95% CI[1.01 -1.36], p = .036, MACE AOR = 0.61, 95% CI[0.49-0.74], p < .001, and major amputation AOR = 1.31, 95% CI[1.05 -1.62], p = .016. CONCLUSION: Endovascular outcomes continue to demonstrate inferiority in major amputation and overall MALE. However, endovascular intervention has a significantly reduced incidence of MACE. Overall, these results demonstrate an improvement in endovascular MACE rates in recent years relative to surgical bypass.


Assuntos
Procedimentos Endovasculares , Isquemia/terapia , Doença Arterial Periférica/terapia , Enxerto Vascular , Idoso , Idoso de 80 Anos ou mais , Amputação , Estado Terminal , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Isquemia/diagnóstico , Isquemia/mortalidade , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Melhoria de Qualidade , Indicadores de Qualidade em Assistência à Saúde , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Enxerto Vascular/efeitos adversos , Enxerto Vascular/mortalidade
16.
J Trauma Acute Care Surg ; 90(1): 1-10, 2021 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-33017355

RESUMO

BACKGROUND: Despite advances in management of extremity vascular injuries, "hard signs" remain the primary criterion to determine need for imaging and urgency of exploration. We propose that hard signs are outdated and that hemorrhagic and ischemic signs of vascular injury may be of greater clinical utility. METHODS: Extremity arterial injuries from the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment registry were analyzed to examine the relationships between hard signs, ischemic signs, and hemorrhagic signs of extremity vascular injury with workup, diagnosis, and management. RESULTS: Of 1,910 cases, 1,108 (58%) had hard signs of vascular injury. Computed tomography angiography (CTA) was more commonly used as the diagnostic modality in patients without hard signs, while operative exploration was primarily used for diagnosis in hard signs. Patients undergoing CTA were more likely to undergo endovascular or hybrid repair (EHR) (10.7%) compared with patients who underwent exploration for diagnosis (1.5%). Of 915 patients presenting with hemorrhagic signs, CTA was performed 14.5% of the time and was associated with a higher rate of EHR and observation. Of the 490 patients presenting with ischemic signs, CTA was performed 31.6% of the time and was associated with higher rates of EHR and observation. Hemorrhagic signs were associated with arterial transection, while ischemic signs were associated with arterial occlusion. Patients with ischemic signs undergoing exploration for diagnosis received more units of packed red blood cells during the first 24 hours. There was no difference in amputation rate, reintervention rate, hospital length of stay, or mortality in comparing groups who underwent CTA versus exploration. CONCLUSION: Hard signs have limitations in identification and characterization of extremity arterial injuries. A strategy of using hemorrhagic and ischemic signs of vascular injury is of greater clinical utility. Further prospective study is needed to validate this proposed redefinition of categorization of presentations of extremity arterial injury. LEVEL OF EVIDENCE: Diagnostic, level III.


Assuntos
Traumatismos do Braço/patologia , Lesões do Sistema Vascular/patologia , Adulto , Braço/irrigação sanguínea , Braço/patologia , Traumatismos do Braço/diagnóstico , Traumatismos do Braço/cirurgia , Procedimentos Endovasculares , Feminino , Humanos , Isquemia/diagnóstico , Isquemia/patologia , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estados Unidos , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/cirurgia , Adulto Jovem
17.
J Vasc Surg Venous Lymphat Disord ; 9(2): 299-306, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-32795617

RESUMO

OBJECTIVE: There are no societal ultrasound (US) guidelines detailing appropriate patient selection for deep vein thrombosis (DVT) imaging in patients with COVID-19, nor are there protocol recommendations aimed at decreasing exposure time for US technologists. We aimed to provide COVID-19-specific protocol optimization recommendations limiting US technologist exposure while optimizing patient selection. METHODS: A novel two-pronged algorithm was implemented to limit the DVT US studies on patients with COVID-19 prospectively, which included direct physician communication with the care team and a COVID-19-specific imaging protocol was instated to reduce US technologist exposure. To assess the pretest risk of DVT, the sensitivity and specificity of serum d-dimer in 500-unit increments from 500 to 8000 ng/mL and a receiver operating characteristic curve to assess performance of serum d-dimer in predicting DVT was generated. Rates of DVT, pulmonary embolism, and scan times were compared using t-test and Fisher's exact test (before and after implementation of the protocol). RESULTS: Direct physician communication resulted in cancellation or deferral of 72% of requested examinations in COVID-19-positive patients. A serum d-dimer of >4000 ng/mL yielded a sensitivity of 80% and a specificity of 70% (95% confidence interval, 0.54-0.86) for venous thromboembolism. Using the COVID-19-specific protocol, there was a significant (50%) decrease in the scan time (P < .0001) in comparison with the conventional protocol. CONCLUSIONS: A direct physician communication policy between imaging physician and referring physician resulted in deferral or cancellation of a majority of requested DVT US examinations. An abbreviated COVID-19-specific imaging protocol significantly decreased exposure time to the US technologist.


Assuntos
Algoritmos , COVID-19/transmissão , Pessoal de Saúde , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Exposição Ocupacional/prevenção & controle , Ultrassonografia Doppler , Trombose Venosa/diagnóstico por imagem , Adulto , Idoso , COVID-19/complicações , Protocolos Clínicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Trombose Venosa/etiologia
18.
Ann Vasc Surg ; 72: 227-236, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32927041

RESUMO

INTRODUCTION: The gold-standard for management of combined common femoral artery (CFA) and superficial femoral artery (SFA) atherosclerotic occlusive disease has traditionally been open femoral endarterectomy and femoral-popliteal bypass. Hybrid approaches involving an open and endovascular component are increasingly common. The aim of this study was to compare perioperative outcomes in patients who underwent an open versus hybrid revascularization. METHODS: NSQIP data, years 2012-2017, were queried for patients who underwent nonemergent CFA endarterectomy with either SFA transluminal intervention or bypass. The primary outcome of interest was a composite of cardiovascular, pulmonary, and renal complications (systemic) and mortality. Two propensity-weight adjusted analyses were performed: 1) comparing hybrid and prosthetic bypass 2) comparing hybrid and vein bypass. RESULTS: There were 4,478 patients included (1,537 hybrid, 1,408 prosthetic, 1,533 vein); 64.8% were men, and the mean age was 67.8 ± 9.7 years; 29.9% had claudication, 38.8% had tissue loss, and 31.3 were unspecified. In the propensity-weighted analysis comparing hybrid to prosthetic bypass, there was no difference in systemic complications (OR = 1.29 for prosthetic vs. hybrid; 95% CI: 0.95-1.76; P = 0.107) or mortality (OR = 1.54; 95% CI: 0.71-3.33; P = 0.275). Prosthetic bypass was associated with more deep surgical-site infections (OR = 2.02; 95% CI: 1.19-3.45; P = 0.010), postoperative sepsis (OR = 2.07; 95% CI: 1.13-3.76; P = 0.018), unplanned 30-day readmission (OR = 1.28; 95% CI: 1.04-1.58; P = 0.021), and the composite of any complication (OR = 1.38; 95% CI: 1.18-1.61; P < 0.001). In the propensity-weighted analysis comparing hybrid to vein bypass, there was no difference in systemic complications (OR = 1.10 for vein vs. hybrid; 95% CI: 0.81-1.49; P = 0.552) or mortality (OR = 0.91; 95% CI: 0.42-2.00; P = 0.819). Vein bypass was associated with more superficial surgical-site infections (OR = 1.45; 95% CI: 1.04-2.02; P = 0.028), and the composite of any complication (OR = 1.32; 95% CI: 1.13-1.54; P = 0.001). Overall mortality was significantly higher patients with systemic complications (13.9% vs 0.1%; P < 0.001). Systemic complications were less common in patients with claudication undergoing hybrid revascularization than vein or prosthetic bypass. CONCLUSIONS: Claudicants undergoing bypass experienced more systemic complications than those undergoing hybrid procedures, but there appears to be no increased risk of systemic complications or mortality with open reconstruction when compared to hybrid procedures for other indications. Other complications, such as infection, postoperative transfusion, and readmission, were more common in the bypass groups.

19.
J Vasc Surg ; 73(3): 942-949.e1, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32861862

RESUMO

OBJECTIVE: After surgery or other interventions, unplanned readmissions are associated with poor outcomes and drain health care resources. Patients with critical limb ischemia (CLI) are at particularly high risk of readmission, and readmissions result in increased health care costs. The primary aims of the study were to discover and compare the 30-day readmission rates of patients who underwent lower extremity surgical bypass (LEB) and endovascular infrainguinal endovascular intervention (IEI) for CLI and to evaluate the relationship between unplanned readmissions likely related to the primary procedure for IEI compared with LEB. METHODS: The Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program was queried to identify all infrainguinal LEB or IEI for CLI from 2015 to 2018. Those who were not eligible for the primary outcome of interest were excluded. The primary 30-day outcome was unplanned readmission. Univariate analyses for primary and secondary outcomes were performed using Fisher's exact and Wilcoxon rank-sum testing. Multivariate analysis was performed using inverse probability weighting and independent risk factors for readmission were identified with logistic regression. RESULTS: There were 12,873 patients who met inclusion criteria. In the LEB cohort, there were 7270 (56.5%) patients, and in the IEI cohort, there were 5603 (43.5%) patients. Thirty percent (n = 1696) of the IEI cohort underwent a tibial intervention, and 49% (n = 3547) underwent a distal bypass. The IEI cohort was more likely to be high physiologic risk (P < .001) and to present with tissue loss (P < .001), whereas the LEB cohort was more likely to have high anatomic risk features (P < .001) and be performed under emergent conditions (P < .001). After multivariable analysis, LEB was found to be independently predictive for both unplanned readmissions due to any cause (adjusted odds ratio, 1.35; 95% confidence interval, 1.22-1.51; P < .001) and procedure-related unplanned interventions (adjusted odds ratio, 1.85; 95% confidence interval, 1.63-2.11; P < .001). Independent predictors of readmission were LEB, preoperative sepsis, severe chronic kidney disease, dependent functional status, insulin-dependent diabetes mellitus, high-risk physiologic features, African American race, preoperative steroid use, history of severe chronic obstructive pulmonary disease, and preoperative tissue loss. CONCLUSIONS: LEB is independently associated with unplanned readmission from all causes and from procedure-related causes after adjusting for the measured confounders. More research is required to determine the economic burden of these readmissions.

20.
J Vasc Surg ; 73(2): 372-380, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-32454233

RESUMO

OBJECTIVE: The COVID-19 pandemic has had major implications for the United States health care system. This survey study sought to identify practice changes, to understand current personal protective equipment (PPE) use, and to determine how caring for patients with COVID-19 differs for vascular surgeons practicing in states with high COVID-19 case numbers vs in states with low case numbers. METHODS: A 14-question online survey regarding the effect of the COVID-19 pandemic on vascular surgeons' current practice was sent to 365 vascular surgeons across the country through REDCap from April 14 to April 21, 2020, with responses closed on April 23, 2020. The survey response was analyzed with descriptive statistics. Further analyses were performed to evaluate whether responses from states with the highest number of COVID-19 cases (New York, New Jersey, Massachusetts, Pennsylvania, and California) differed from those with lower case numbers (all other states). RESULTS: A total of 121 vascular surgeons responded (30.6%) to the survey. All high-volume states were represented. The majority of vascular surgeons are reusing PPE. The majority of respondents worked in an academic setting (81.5%) and were performing only urgent and emergent cases (80.5%) during preparation for the surge. This did not differ between states with high and low COVID-19 case volumes (P = .285). States with high case volume were less likely to perform a lower extremity intervention for critical limb ischemia (60.8% vs 77.5%; P = .046), but otherwise case types did not differ. Most attending vascular surgeons worked with residents (90.8%) and limited their exposure to procedures on suspected or confirmed COVID-19 cases (56.0%). Thirty-eight percent of attending vascular surgeons have been redeployed within the hospital to a vascular access service or other service outside of vascular surgery. This was more frequent in states with high case volume compared with low case volume (P = .039). The majority of vascular surgeons are reusing PPE (71.4%) and N95 masks (86.4%), and 21% of vascular surgeons think that they do not have adequate PPE to perform their clinical duties. CONCLUSIONS: The initial response to the COVID-19 pandemic has resulted in reduced elective cases, with primarily only urgent and emergent cases being performed. A minority of vascular surgeons have been redeployed outside of their specialty; however, this is more common among states with high case numbers. Adequate PPE remains an issue for almost a quarter of vascular surgeons who responded to this survey.


Assuntos
COVID-19/epidemiologia , Pandemias/estatística & dados numéricos , Assistência ao Paciente/estatística & dados numéricos , Equipamento de Proteção Individual/estatística & dados numéricos , Prática Profissional/estatística & dados numéricos , Procedimentos Cirúrgicos Vasculares/estatística & dados numéricos , COVID-19/diagnóstico , Procedimentos Cirúrgicos Eletivos/normas , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Pesquisas sobre Serviços de Saúde , Humanos , Internet , Assistência ao Paciente/normas , Padrões de Prática Médica/normas , Padrões de Prática Médica/estatística & dados numéricos , Prática Profissional/normas , SARS-CoV-2 , Cirurgia Torácica/normas , Cirurgia Torácica/estatística & dados numéricos , Estados Unidos/epidemiologia , Procedimentos Cirúrgicos Vasculares/normas
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