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1.
Br J Anaesth ; 2020 Mar 23.
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.

2.
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.

3.
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.

4.
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.

5.
Artigo em Inglês | MEDLINE | ID: mdl-31409492

RESUMO

OBJECTIVES: Off-pump coronary artery bypass (OPCAB) may benefit select high-risk patients. We sought to analyze the long-term outcomes of OPCAB versus on-pump coronary artery bypass (ONCAB) in patients with moderate renal failure. METHODS: A retrospective cohort analysis of primary isolated CAB surgery performed in Ontario, Canada, from October 2008 to March 2016 in the CorHealth Ontario Cardiac Registry identified 50,115 cases. Of these, 7782 (15.5%) had estimated glomerular filtration rate (eGFR) of 30 to 59 mL/min/1.73 m2. OPCAB was compared to ONCAB after propensity score matching. RESULTS: Following propensity score matching, 1578 patient pairs were formed. Total number of bypass grafts was higher in ONCAB (3.31 ± 1.01 vs 3.12 ± 1.14; P < .01) and more arterial grafts were used in OPCAB (1.55 ± 0.71 vs 1.14 ± 0.58; P < .01). OPCAB was associated with lower rate of in-hospital stroke (0.7% vs 2.2%; P < .01), renal failure requiring dialysis (1.2% vs 2.9%; P < .01), and blood transfusion (52.4% vs 69.3%; P < .01). There was no difference in perioperative mortality (2.4% vs 3.0%; P = .36) between OPCAB and ONCAB, respectively. At 8-year follow-up, survival probability was not different when comparing OPCAB versus ONCAB: 62% versus 65%, respectively (hazard ratio, 0.98; 95% confidence interval, 0.84-1.13; P = .38). Cumulative incidence of permanent dialysis did not differ at 8-year follow-up: 7% versus 7%, respectively (hazard ratio, 1.01; 95% confidence interval, 0.72-1.43; P = .74. CONCLUSIONS: OPCAB is associated with improved in-hospital renal outcomes, but is not associated with changes in short- or long-term mortality, or with the long-term cumulative incidence of end-stage renal failure requiring permanent dialysis in patients with moderate renal failure.

6.
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.

7.
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.

8.
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
9.
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.

10.
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
11.
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.

13.
J Vasc Surg ; 70(1): 241-245.e2, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30852036

RESUMO

OBJECTIVE: Previous data suggest that physicians have suboptimal knowledge about peripheral artery disease (PAD). Our aim was to evaluate Canadian medical students' knowledge of PAD to determine if this knowledge gap exists early in medical training. METHODS: We conducted a descriptive, cross-sectional, interview-based study of graduating medical students at the University of Toronto. We used a standardized questionnaire to evaluate students' knowledge of PAD and coronary artery disease (CAD) in the following domains: clinical presentation, risk factors, preventative measures, treatment, and complications. We calculated mean (standard deviation [SD]) scores for each CAD and PAD knowledge domain and examined for differences in PAD vs CAD scores. RESULTS: Seventy-two graduating medical students participated in this study, of which females accounted for 58%. Nearly all participants reported being exposed to PAD (89%) and CAD (92%) through their medical school curriculum. Overall, medical students scored better in identifying CAD characteristics (mean [SD] score, 16.4 [2.7]) compared with PAD (mean [SD] score, 14.6 [3.2]) (P < .0001). This difference was driven by the inferior performance of students in identifying risk factors (P < .0001), preventative measures (P = .049), and complications (P < .0001) of PAD compared with CAD. Out-of-class exposure (eg, clinical rotation, research experience) had a positive impact on students knowledge of both PAD and CAD. CONCLUSIONS: Our results demonstrate suboptimal knowledge of medical graduates of both CAD and PAD. Although they share common atherosclerotic risk factors and cardiovascular complications, medical students were less likely to associate these with PAD than CAD. We recommend a comprehensive module that incorporates all presentations of atherosclerotic disorders to enhance students' understanding of these pathologies in medical schools.


Assuntos
Doença da Artéria Coronariana , Educação de Graduação em Medicina , Conhecimentos, Atitudes e Prática em Saúde , Doença Arterial Periférica , Estudantes de Medicina/psicologia , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/fisiopatologia , Doença da Artéria Coronariana/terapia , Estudos Transversais , Currículo , Avaliação Educacional , Escolaridade , Feminino , Humanos , Entrevistas como Assunto , Masculino , Ontário , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/fisiopatologia , Doença Arterial Periférica/terapia , Universidades
14.
Ann Vasc Surg ; 58: 166-173.e4, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30771465

RESUMO

BACKGROUND: Vascular surgeons have a central role in managing peripheral artery disease (PAD). This study assessed their knowledge, attitudes, and behaviors regarding pharmacologic risk reduction in PAD and results were compared to a similar 2004 survey conducted by our group. METHODS: An online questionnaire was administered to 161 active members of the Canadian Society for Vascular Surgery. RESULTS: Forty-eight participants (30%) completed the survey. Recommended targets for low-density lipoprotein cholesterol, blood pressure, and glucose were known by 52%, 38%, and 50% of vascular surgeons, respectively. Almost all participants recognized antiplatelet dosages and statin indications, but less than half could identify indications (29%) and precautions (44%) for angiotensin converting enzyme (ACE) inhibitor therapy. A majority (58%) routinely evaluate risk factors in <50% of their patients. Most vascular surgeons regularly provide risk reduction counseling, but less than 10% initiate or modify antihypertensive or ACE inhibitor therapy. Compared to 2004, knowledge of targets and indications/precautions for common cardiovascular medications and frequency of risk factor assessment have not changed. Rates of counseling for diabetes control and statin prescription have improved, but remain suboptimal. Regarding newer medications with cardiovascular benefit, less than 10% would prescribe proprotein convertase subtilisin/kexin type 9 and sodium-glucose cotransporter 2 inhibitors if they were available. The majority of vascular surgeons rate their PAD risk reduction knowledge as average and support an up-to-date Canadian PAD guideline. Most participants believe that risk reduction therapy is best provided by family physicians and internists, but also acknowledge that vascular surgeons should be well-versed in assessing and managing risk factors in PAD. CONCLUSIONS: Significant knowledge and action gaps exist among Canadian vascular surgeons with regards to pharmacologic cardiovascular risk reduction in PAD. Although there is recognition that vascular surgeons are central to the medical management of patients with PAD, few routinely evaluate risk factors and prescribe medications. There is little evidence of sufficient improvement since 2004. New educational and clinical strategies are needed to improve PAD risk reduction pharmacotherapy among Canadian vascular surgeons.


Assuntos
Anti-Hipertensivos/uso terapêutico , Atitude do Pessoal de Saúde , Diabetes Mellitus/tratamento farmacológico , Dislipidemias/tratamento farmacológico , Conhecimentos, Atitudes e Prática em Saúde , Hipertensão/tratamento farmacológico , Hipoglicemiantes/uso terapêutico , Hipolipemiantes/uso terapêutico , Doença Arterial Periférica/tratamento farmacológico , Cirurgiões/psicologia , Anti-Hipertensivos/efeitos adversos , Canadá , Diabetes Mellitus/sangue , Diabetes Mellitus/diagnóstico , Dislipidemias/sangue , Dislipidemias/diagnóstico , Pesquisas sobre Serviços de Saúde , Humanos , Hipertensão/diagnóstico por imagem , Hipertensão/fisiopatologia , Hipoglicemiantes/efeitos adversos , Hipolipemiantes/efeitos adversos , Doença Arterial Periférica/sangue , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/fisiopatologia , Guias de Prática Clínica como Assunto , Padrões de Prática Médica , Lacunas da Prática Profissional , Prognóstico , Medição de Risco , Fatores de Risco , Sociedades Médicas
16.
Ann Surg ; 270(2): 378-383, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-29672398

RESUMO

BACKGROUND: Early readmission to hospital after surgery is an omnipresent quality metric across surgical fields. We sought to understand the relative importance of hospital readmission among all health services received after hospital discharge. OBJECTIVE: The aim of this study was to characterize 30-day postdischarge cost and risk of an emergency department (ED) visit, readmission, or death after hospitalization for elective major vascular surgery. METHODS: This is a population-based retrospective cohort study of patients who underwent elective major vascular surgery - carotid endarterectomy, EVAR, open AAA repair, bypass for lower extremity peripheral arterial disease - in Ontario, Canada, between 2004 and 2015. The outcomes of interest included quality metrics - ED visit, readmission, death - and cost to the Ministry of Health, within 30 days of discharge. Costs after discharge included those attributable to hospital readmission, ED visits, rehab, physician billing, outpatient nursing and allied health care, medications, interventions, and tests. Multivariable regression models characterized the association of pre-discharge characteristics with the above-mentioned postdischarge quality metrics and cost. RESULTS: A total of 30,752 patients were identified. Within 30 days of discharge, 2588 (8.4%) patients were readmitted to hospital and 13 patients died (0.04%). Another 4145 (13.5%) patients visited an ED without requiring admission. Across all patients, over half of 30-day postdischarge costs were attributable to outpatient care. Patients at an increased risk of an ED visit, readmission, or death within 30 days of discharge differed from those patients with relatively higher 30-day costs. CONCLUSION: Events occurring outside the hospital setting should be integral to the evaluation of quality of care and cost after hospitalization for major vascular surgery.


Assuntos
Benchmarking , Procedimentos Cirúrgicos Eletivos/normas , Custos de Cuidados de Saúde , Alta do Paciente/economia , Doença Arterial Periférica/cirurgia , Vigilância da População/métodos , Procedimentos Cirúrgicos Vasculares/normas , Idoso , Custos e Análise de Custo , Procedimentos Cirúrgicos Eletivos/economia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Ontário , Fatores de Tempo , Procedimentos Cirúrgicos Vasculares/economia
17.
Curr Opin Cardiol ; 34(2): 178-184, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30543542

RESUMO

PURPOSE OF REVIEW: To suggest a practical approach for the application of data from the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial in patients with peripheral artery disease (PAD). RECENT FINDINGS: The COMPASS trial showed that low-dose rivaroxaban 2.5 mg twice daily plus daily aspirin was superior to aspirin alone in reducing major adverse cardiovascular and cerebrovascular events, and major adverse limb events among patients with stable atherosclerotic vascular disease, including those with PAD. The risk for major bleeding, however, was higher with rivaroxaban plus aspirin. Critical limb ischemia at baseline (rest pain, ulcer, or gangrene), previous limb or foot amputation, or a history of peripheral revascularization surgery or stenting were independently associated with increased major adverse limb events within the trial. SUMMARY: Intensification of antithrombotic therapy with low-dose rivaroxaban plus aspirin should be considered in low bleeding risk PAD patients who are at increased risk for ischemic and/or limb events. A practical approach for clinicians is presented to help incorporate COMPASS data into practice.


Assuntos
Doença Arterial Periférica , Inibidores da Agregação de Plaquetas , Rivaroxabana , Quimioterapia Combinada , Inibidores do Fator Xa , Humanos , Doença Arterial Periférica/tratamento farmacológico , Inibidores da Agregação de Plaquetas/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto , Rivaroxabana/uso terapêutico , Cirurgiões
18.
J Am Heart Assoc ; 7(16): e009745, 2018 08 21.
Artigo em Inglês | MEDLINE | ID: mdl-30369318

RESUMO

Background Statins are commonly used for the prevention of cardiovascular events; however, statins are underutilized in patients with noncoronary atherosclerosis. We sought to establish the rates of statin use in patients with carotid artery disease and to examine the association between statin therapy and outcomes after carotid revascularization. Methods and Results In this population-level retrospective cohort study, we identified all individuals aged ≥66 years who underwent carotid endarterectomy or stenting in Ontario, Canada (2002-2014). The primary outcome was a composite of 1-year stroke, myocardial infarction, or death (major adverse cardiac and cerebrovascular events). Five-year risks were also examined. Adjusted hazard ratios were computed using inverse probability of treatment weighting based on propensity scores. A total of 7893 of 10 723 patients (73.6%) who underwent carotid revascularization were on preprocedural statin therapy; moderate- or high-dose therapy was utilized by 7384 patients (68.9%). The composite rate of 1-year major adverse cardiac and cerebrovascular events was lower among statin users (adjusted hazard ratio: 0.76; 95% confidence interval, 0.70-0.83). Patients who were on persistent long-term statin therapy after the carotid procedure continued to experience significantly lower risk of major adverse cardiac and cerebrovascular events at 5 years (adjusted hazard ratio: 0.75, 95% confidence interval, 0.71-0.80). The beneficial associations with statin use were observed regardless of type of carotid revascularization procedure, carotid artery symptom status, or statin dose. Conclusions Continuous statin therapy was associated with a 25% lower risk of long-term adverse cardiovascular events in patients with significant carotid disease. Along with other supportive evidence, statins should be considered in patients undergoing carotid revascularization, and efforts are required to increase statin use in this undertreated population.


Assuntos
Estenose das Carótidas/terapia , Endarterectomia das Carótidas , Procedimentos Endovasculares , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Stents , Idoso , Doenças das Artérias Carótidas/terapia , Feminino , Humanos , Masculino , Mortalidade , Infarto do Miocárdio/epidemiologia , Modelos de Riscos Proporcionais , Fatores de Proteção , Estudos Retrospectivos , Acidente Vascular Cerebral/epidemiologia , Resultado do Tratamento
19.
Clin Invest Med ; 41(3): E148-E155, 2018 09 30.
Artigo em Inglês | MEDLINE | ID: mdl-30315751

RESUMO

PURPOSE: To determine the positive predictive values (PPV) of Ontario administrative data codes for the identification of open (OSR) and endovascular (EVAR) repairs of elective (eAAA) and ruptured (rAAA) abdominal aortic aneurysms. METHODS: We randomly identified 319 eAAA and rAAA repairs at two Toronto hospitals between April 2003 and March 2015, using administrative health data in Ontario, Canada. International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) codes I71.3 and I71.4, were used to identify rAAA and eAAA patients, respectively. A blinded retrospective chart review was conducted and served as the gold standard comparator. Re-abstracted records were compared to Canadian Classification of Health Interventions (CCI) and Ontario Health Insurance Plan (OHIP) codes in the Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD) and OHIP databases. We calculated the PPV and 95% confidence intervals (95% CI) of individual and combined procedure and billing codes for elective and ruptured OSR and EVAR (eOSR, eEVAR, rOSR, and rEVAR). RESULTS: Permutation of codes allowed identification of eOSR with 95% PPV (95% CI 88, 98), eEVAR with 96% PPV (95% CI 90, 99), rOSR with 87% PPV (95% CI 79, 93) and rEVAR with 91% PPV (95% CI 59, 100). CONCLUSIONS: Diagnostic, procedure and billing code combinations allow identification of eOSR, eEVAR, rOSR and rEVAR patients in Ontario administrative data with a high degree of certainty.


Assuntos
Aneurisma da Aorta Abdominal , Bases de Dados Factuais , Feminino , Humanos , Masculino , Ontário
20.
J Am Heart Assoc ; 7(19): e008657, 2018 10 02.
Artigo em Inglês | MEDLINE | ID: mdl-30371297

RESUMO

Background There are no recognized pharmacological treatments for abdominal aortic aneurysms ( AAA ), although statins are suggested to be beneficial. We sought to summarize the literature regarding the effects of statins on human AAA growth, rupture, and 30-day mortality. Methods and Results We conducted a systematic review and meta-analysis of randomized and observational studies using the Cochrane CENTRAL database, MEDLINE , and EMBASE up to June 15, 2018. Review, abstraction, and quality assessment were conducted by 2 independent reviewers, and a third author resolved discrepancies. Pooled mean differences and odds ratios with 95% confidence intervals were calculated using random effects models. Heterogeneity was quantified using the I2 statistic, and publication bias was assessed using funnel plots. Our search yielded 911 articles. One case-control and 21 cohort studies involving 80 428 patients were included. The risk of bias was low to moderate. Statin use was associated with a mean AAA growth rate reduction of 0.82 mm/y (95% confidence interval 0.33, 1.32, P=0.001, I2=86%). Statins were also associated with a lower rupture risk (odds ratio 0.63, 95% confidence interval 0.51, 0.78, P<0.0001, I2=27%), and preoperative statin use was associated with a lower 30-day mortality following elective AAA repair (odds ratio 0.55, 95% confidence interval 0.36, 0.83, P=0.005, I2=57%). Conclusions Statin therapy may be associated with reduction in AAA progression, rupture, and lower rates of perioperative mortality following elective AAA repair. These data argue for widespread statin use in AAA patients. Clinical Trial Registration URL : www.crd.york.ac.uk . Unique identifier: CRD 42017056480.


Assuntos
Aneurisma Roto/prevenção & controle , Aneurisma da Aorta Abdominal/tratamento farmacológico , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Assistência Perioperatória/métodos , Procedimentos Cirúrgicos Vasculares/métodos , Aneurisma Roto/mortalidade , Aneurisma Roto/cirurgia , Aneurisma da Aorta Abdominal/mortalidade , Aneurisma da Aorta Abdominal/cirurgia , Progressão da Doença , Saúde Global , Humanos , Taxa de Sobrevida/tendências
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