Comparative Analysis of Outcomes of Unibody Endoprosthesis and Aortobifemoral Bypass for Aortoiliac Occlusive Disease.

BACKGROUND: Aortoiliac occlusive disease (AIOD) has traditionally been treated with aortobifemoral bypass (ABF). Unibody endograft (UBE) for AIOD, however, has been increasingly utilized in selected patients. We report outcomes of patients undergoing ABF or UBE for AIOD. METHODS: Patients (2016-2021) undergoing elective ABF or UBE with a unibody device for AIOD were identified at an academic institution. Chi-square and Kaplan-Meier analysis were used to evaluate outcomes by group. RESULTS: One hundred thirty-one patients undergoing UBE or ABF were screened, with 82 included. Twenty-one patients underwent UBE (25.6%) and 61 (74.4%) underwent ABF. UBE patients were older (63.8 vs. 58.2 years; P = 0.01), with a higher prevalence of diabetes (52.4 vs. 19.7%; P = 0.004). Significant differences were seen between UBE and ABF including a shorter surgery length (214 vs. 360 min; P = 0.0001), less blood loss (300 vs. 620 mls; P = 0.001), larger minimum aortic diameter (14.6 vs. 12.6; P = 0.0006), larger common iliac artery (9.5 vs. 7.9; P = 0.005) and lower postoperative ankle-brachial index (0.8 vs. 0.9; P = 0.04). There were no differences in TASC C/D iliac lesions in the UBE than ABF group (66.6% vs. 63.9%; P < 0.82) or Trans-Atlantic Inter-Society Consensus classification femoropopliteal lesions. Unadjusted analysis revealed no significant differences between UBE and ABF for 30-day mortality (0 vs. 1.6%; P = 1), stroke (0 vs. 3.3%; P = 1), or major adverse cardiac events (4.8 vs. 4.9%; P = 1). There were no significant differences in mid-term surgical outcomes over a mean follow-up period of 23.7 months between UBE and ABF groups; specifically endovascular (0 vs. 8.2%; P = 0.3) or open/hybrid reintervention (9.5 vs. 14.8%; P = 0.7) with similar limb occlusion (4.8 vs. 27.8; P = 0.12). Kaplan-Meier estimated primary, primary-assisted, and secondary patency at 36 months were similar with 94%, 100%, and 94% for UBE and 86%, 95%, and 86% for ABF, respectively. Estimated survival at 36 months was 95% for UBE and 97% for ABF (P = 0.8). CONCLUSIONS: Equivalent outcomes were seen between AIOD treated with UBE or ABF in similar patient populations. Mid-term outcomes such as reintervention and patency are similar for UBE and ABF. We still recommend ABF over UBE as a primary modality of treatment in surgically fit patients with greater complexity aortoiliac lesions and with smaller arterial diameters, especially women.

Intraluminal crossing of infrainguinal SFA chronic total occlusions may offer patency superiority compared to subintimal crossing.

OBJECTIVES: Patency for chronic total occlusions (CTO) of the superficial femoral artery (SFA) after endovascular interventions traditionally demonstrate a low 1-year patency ranging from 40%-60%. The optical coherence tomography (OCT) catheter (Avinger Inc., Redwood City, CA) uses light-based technology imaging to cross Trans-Atlantic Inter-Society Consensus D (TASC D) lesions intraluminally with direct intra-arterial visualization. Insufficient data exist evaluating intraluminal crossing with OCT imaging compared with traditional subintimal techniques. We evaluated outcomes for TASC D lesions crossed intraluminally. METHODS: A retrospective analysis of patients with SFA TASC D lesions crossed intra-arterially with the OCT catheter imaging. Descriptive statistics evaluated patient characteristics which included patient demographics, Rutherford scores, ABIs, CTA information, lesion categorization, as well as runoff score. Patency at baseline, 30-day, 6-month, and 1-year outcomes were compared using t-tests. Cumulative patency rates were evaluated using Kaplan-Meier analysis. RESULTS: 101 patients underwent elective intervention for SFA TASC D lesions with the OCT catheter. The crossing rate was 78.2%, mean lesion length was 16.2 cm, and runoff at the tibial level was 2.2 patent vessels. Mean age and BMI were 64 years and 29 kg/m2, respectively. Patient characteristics are male (57%); Caucasian (90%); ever smoking (85%); hypertension (82%), hyperlipidemia (70%), and diabetes (46%). Pre-operative computed tomography demonstrated SFA lesions were predominantly eccentric (91%) with mild to moderate calcification (90%). All underwent PTA, 87% were stented (mean stent length: 186.1 mm), mean crossing time was 13.4 min. Pre-operative, 30-day, 6-month, and 1-year post-operative mean Rutherford-Becker scores were 4, 1, 1, and 1, respectively (p < 0.0001). Mean pre-operative ABI was 0.49, compared to 0.84 at 30 days, 0.64 at 6 months, and 0.67 at 1 year (p < .0001). Duplex demonstrated 6- and 12-month primary patency of 89% and 75%; primary-assisted patency was 94% and 84%. CONCLUSIONS: The OCT imaging catheter successfully crossed long chronic total occlusions of the SFA using direct intra-arterial imaging. Compared to subintimal techniques, patients had high 1-year primary patency and prolonged symptom improvement with intraluminal crossing. These data suggest that intraluminal crossing of TASC D lesions may be superior to traditional subintimal crossing techniques.

Discharge process challenges of an academic vascular surgery service: A qualitative study.

Vascular surgery patients have a high incidence of unplanned hospital readmissions and complications. Previous research has not fully examined specific elements of the hospital discharge process for vascular surgery patients to identify issues that may contribute to readmissions. The objective of this qualitative descriptive study was to explore challenges identified by healthcare providers and patients regarding the discharge process from an academic vascular surgery service. Data were collected from eight focus group interviews and analyzed for relevant themes. Patients and healthcare providers identified several challenges within the standard discharge process, including ineffective communication, insufficient time for discharge education, and limitations accessing providers with post-discharge concerns. These obstacles may be ameliorated in part by specialized coordinators, caregiver support, and use of adaptive strategies outside of the current discharge process. The discharge challenges described by study participants likely contribute to adverse post-hospitalization outcomes, including unplanned hospital readmissions. A multifaceted approach that incorporates standardized discharge processes, as well as informal problem-solving strategies, is recommended to improve hospital discharge and outcomes for vascular surgery patients.

A qualitative study evaluating the discharge process for vascular surgery patients to identify significant themes for organizational improvement.

OBJECTIVE: Transition from the hospital to an outpatient setting is a multifaceted process requiring coordination among a variety of services and providers to ensure a high-quality discharge. Vascular surgery patients comprise a complex population that experiences high unplanned readmission rates. We performed a qualitative study to identify themes for process improvement for vascular surgery patients. A validated discharge process, RED (Re-Engineered Discharge), was used to identify additional actionable themes to create a more efficient discharge process tailored specifically to the vascular surgery population. METHODS: A prospective, qualitative analysis at a tertiary center using a semi-structured focus group interview guide was performed to evaluate the current discharge process and identify opportunities for improvement. Focus groups were Zoom recorded, transcribed into electronic text files, and were loaded into Dedoose qualitative software for analysis using a directed content analysis approach. Two researchers independently thematically coded each transcript, starting with accepted discharge components to identify new thematic categories. Prior to analysis, all redundancy of codes was resolved, and all team members agreed on text categorization and coding. RESULTS: Eight focus groups with a total of 38 participants were conducted. Participants included physicians (n = 13), nursing/ancillary staff (n = 14), advanced nurse practitioners (n = 2), social worker/dietitian/pharmacist (n = 3), and patients (n = 6). Transcript analyses revealed facilitators and barriers to the discharge process. In addition to traditional RED components, unique concepts pertinent to vascular surgery patients included patient complexity, social determinants of health, technology literacy, complexity of ancillary services, discharge appropriateness, and use of advanced nurse practitioners for continuity. CONCLUSIONS: Specific themes were identified to target and enhance the future vRED (vascular Re-Engineered Discharge) bundle. Thematic targets for improvement include increased planning, organization, and communication prior to discharge to address vascular surgery patients' multiple comorbidities, extensive medication lists, and need for complex ancillary services at the time of discharge. Other thematic barriers discovered to improve include provider awareness of patient health literacy, patient understanding of complex discharge instructions, patient technology barriers, and intrinsic social determinants of health in this population. To address these discovered barriers, organizational targets to improve include enhanced social support, the use of advanced nurse practitioners for education reinforcement, and increased coordination. These results provide a framework for future quality improvement targeting the vascular surgery discharge process.

Modified frailty index as an indicator for outcomes after lower extremity endovascular revascularization.

BACKGROUND: The 5-factor frailty index is associated with adverse outcomes after various procedures. This study aimed to evaluate the performance of the 5-factor frailty index after lower extremity endovascular revascularization. METHODS: The American College of Surgeons' National Surgical Quality Improvement Program Database as retrospectively analyzed for patients undergoing lower extremity endovascular revascularization between 2015 and 2019. Outcomes were assessed using bivariate analyses and multivariate logistic regression analyses. RESULTS: In the study, 11,947 lower extremity endovascular revascularization performed between 2015 and 2019 were identified from National Surgical Quality Improvement Program Database. Median age was 69 (standard deviation 11.44) years, 4,727 (39.6%) were female, and 7,570 (63.4%) were White. In addition, 7,541 (62.9%) were performed for chronic limb threatening ischemia. Thirty-day mortality was 1.7%. Bivariate analysis demonstrated that a 5-factor frailty index score greater than 0.6 was associated with higher rates of discharge to SNF (28.6% vs 8.2%, P < .001, reference 5-factor frailty index = 0), cardiopulmonary arrest (2.0% vs 0.1%, P < .001), readmission (21.1% vs 10.8%, P < .001), reintubation (2.8% vs 0.3%, P < .001), and 30-day mortality (5.1% vs 0.7%, P < .001). Beta blocker use, higher age, chronic limb threatening ischemia indication, and 5-factor frailty index were all associated with increased 30-day mortality. Multivariate logistic regression showed that 5-factor frailty index >0.6 predicted 3 times higher odds for 30-day mortality (odds ratio, 2.988; P = .013), with physiologic high risk (odds ratio, 2.118; P < .001), chronic limb threatening ischemia indication (odds ratio, 2.157; P < .001), and inpatient procedures (odds ratio, 3.409; P < .001) also showing increased risk for mortality. CONCLUSION: For patients undergoing lower extremity endovascular revascularization, higher 5-factor frailty index was associated with increased hospital resource utilization and 30-day mortality. The 5-factor frailty index may be useful for preoperative risk stratification and predicting adverse outcomes in patients undergoing lower extremity endovascular revascularization.

No Link Between Inadvertent Surgical Glove Contamination and Surgical Site Infection in Patients Undergoing Elective Neurosurgical Operations.

INTRODUCTION: Controllable factors associated with surgical site infections (SSIs) have focused on reducing contamination of the surgical field with potential pathogens. The aim of this prospective study is to determine the incidence of glove contamination in a series of elective neurosurgical operations and determine the relationship of such glove contamination to subsequent SSI. We hypothesize that contamination of surgical gloves is associated with subsequent SSI. METHODS: In this prospective quality improvement study, gloves of the surgical team were swabbed for standard culture just prior to wound closure of elective neurosurgical operations. Patient characteristics, surgical details, and occurrence of subsequent SSIs were collected retrospectively from the electronic medical records. Data were analyzed with χ2 with Fisher's exact test and Student's t test. RESULTS: Surgical glove contamination occurred in 10 of 96 elective neurosurgical cases (10.4%). SSIs occurred in 6 cases (6.2%), but no SSI occurred in a case in which surgical glove contamination occurred (P = 1). SSI was associated with younger patient age (P = 0.0448), and surgical glove contamination was associated with less resident experience (P = 0.0354). CONCLUSIONS: Surgical glove contamination identified at the time of wound closure does not correlate with the development of subsequent SSI in elective neurosurgical operations.

New perspectives on robotic pancreaticoduodenectomy: An analysis of the National Cancer Database.

BACKGROUND: Pancreatic ductal adenocarcinoma is a common malignancy. Despite all advancements, the prognosis remains, poor with an overall 5-year survival of only 10.8%. Recently, a robotic platform has become an attractive tool for treating pancreatic cancer (PC). While recent studies indicated improved lymph node (LN) harvest during robotic pancreaticoduodenectomy (PD), data on long-term outcomes are insufficient. AIM: To evaluate absolute LN harvest during PD. Secondary outcomes included evaluating the association between LN harvest and short- and long-term oncological outcomes for three different surgical approaches. METHODS: We conducted an analysis of the National Cancer Database, including patients diagnosed with PC who underwent open, laparoscopic, or robotic PD in 2010-2018. One-way analysis of variance was used to compare continuous variables, chi-square test - for categorical. Overall survival was defined as the time between surgery and death. Median survival time was estimated with the Kaplan-Meier method, and groups were compared with the Wilcoxon test. A Cox proportional hazards model was used to assess the association of covariates with survival after controlling for patient characteristics and procedure type. RESULTS: 17169 patients were included, 8859 (52%) males; mean age 65; 14509 (85%) white. 13816 (80.5%) patients had an open PD, 2677 (15.6%) and 676 (3.9%) - laparoscopic and robotic PD respectively. Mean comorbidity index (Charlson-Deyo Score) 0.50. On average, 18.84 LNs were harvested. Mean LN harvest during open, laparoscopic and robotic PD was 18.59, 19.65 and 20.70 respectively (P < 0.001). On average 2.49 LNs were positive for cancer and did not differ by the procedure type (P = 0.26). Vascular invasion was noted in 42.6% of LNs and did differ by the approach: 42.1% for open, 44.0% for laparoscopic and 47.2% for robotic PD (P = 0.015). Median survival for open PD was 26.1 mo, laparoscopic - 27.2 mo, robotic - 29.1 mo (P = 0.064). Survival was associated with higher LN harvest, while higher number of positive LNs was associated with higher mortality. CONCLUSION: Our study suggests that robotic PD is associated with increased intraoperative LN harvest and has comparable short-term oncological outcomes and survival compared to open and laparoscopic approaches.