Symptomatic carotid webs require aggressive intervention.

OBJECTIVE: Carotid web (CaWeb) is a rare form of fibromuscular dysplasia that can produce embolic stroke. Misdiagnosis of symptomatic CaWeb as "cryptogenic stroke" or "embolic stroke of unknown source" is common and can lead to recurrent, catastrophic neurologic events. Reports of CaWeb in the literature are scarce, and their natural history is poorly understood. Appropriate management remains controversial. METHODS: CaWeb was defined as a single, shelf-like, linear projection in the posterolateral carotid bulb causing a filling defect on computed tomography angiography (CTA) or cerebral angiography. Cases of symptomatic CaWeb at a single institution with a high-volume stroke center were identified through collaborative evaluation by vascular neurologists and vascular surgeons. RESULTS: Fifty-two patients with symptomatic CaWeb were identified during a 6-year period (2016-2022). Average age was 49 years (range, 29-73 years), 35 of 52 (67%) were African American, and 18 of 52 (35%) were African American women under age 50. Patients initially presented with stroke (47/52; 90%) or transient ischemic attack (5/52; 10%). Stenosis was <50% in 49 of 52 patients (94%) based on NASCET criteria, and 0 of 52 (0%) CaWebs were identified with carotid duplex. Definitive diagnosis was made by CTA examined in multiple planes or cerebral angiography examined in a lateral projection to adequately assess the posterolateral carotid bulb, where 52 of 52 (100%) of CaWebs were seen. Early in our institutional experience, 10 of 52 patients (19%) with symptomatic CaWeb were managed initially with dual antiplatelet and statin therapy or systemic anticoagulation; all suffered ipsilateral recurrent stroke at an average interval of 43 months (range, 1-89 months), and five were left with permanent deficits. Definitive treatment included carotid endarterectomy in 27 of 50 (56%) or carotid stenting in 23 of 50 (46%). Two strokes were irrecoverable, and intervention was deferred. Web-associated thrombus was observed in 20 of 50 (40%) on angiography or grossly upon carotid exploration. Average interval from initial stroke to intervention was 39 days. After an average follow-up of 38 months, there was no reported postintervention stroke or mortality. CONCLUSIONS: To our knowledge, this is the largest single-institution analysis of symptomatic CaWeb yet reported. Our series demonstrates that carotid duplex is inadequate for diagnosis, and that medical management is unacceptable for symptomatic CaWeb. Recurrent stroke occurred in all patients managed early in our experience with medical therapy alone. We have since adopted an aggressive interventional approach in cases of symptomatic CaWeb, with no postoperative stroke reported over an average follow-up of 38 months. In younger patients presenting with cryptogenic stroke, especially African American women, detailed review of lateral cerebral angiography or multi-planar, fine-cut CTA images is required to accurately rule out or diagnose CaWeb and avoid recurrent neurologic events.

Current Medicare reimbursement for complex endovascular aortic repair is inadequate based on results from a multi-institutional cost analysis.

OBJECTIVE: Complex endovascular juxta-, para- and suprarenal abdominal aortic aneurysm repair (comEVAR) is frequently accomplished with commercially available fenestrated (FEVAR) devices or off-label use of aortoiliac devices with parallel branch stents (chEVAR). We sought to evaluate the implantable vascular device costs incurred with these procedures as compared with standard Medicare reimbursement to determine the financial viability of comEVAR in the modern era. METHODS: Five geographically distinct institutions with high-volume, complex aortic centers were included. Implantable aortoiliac and branch stent device cost data from 25 consecutive, recent, comEVAR in the treatment of juxta-, para-, and suprarenal aortic aneurysms at each center were analyzed. Cases of rupture, thoracic aneurysms, reinterventions, and physician-modified EVAR were excluded, as were ancillary costs from nonimplantable equipment. Data from all institutions were combined and stratified into an overall cost group and two, individual cost groups: FEVAR or chEVAR. These groups were compared, and each respective group was then compared with weighted Medicare reimbursement for Diagnosis-Related Group codes 268/269. Median device costs were obtained from an independent purchasing consortium of >3000 medical centers, yielding true median cost-to-institution data rather than speculative, administrative projections or estimates. RESULTS: A total of 125 cases were analyzed: 70 FEVAR and 53 chEVAR. Two cases of combined FEVAR/chEVAR were included in total cost analysis, but excluded from direct FEVAR vs chEVAR comparison. Median Medicare reimbursement was calculated as $35,755 per case. Combined average implantable device cost for all analyzed cases was $28,470 per case, or 80% of the median reimbursement ($28,470/$35,755). Average FEVAR device cost per case ($26,499) was significantly lower than average chEVAR cost per case ($32,122; P < .002). Device cost was 74% ($26,499/$35,755) of total reimbursement for FEVAR and 90% ($32,122/$35,755) for chEVAR. CONCLUSIONS: Results from this multi-institutional analysis show that implantable device cost alone represents the vast majority of weighted total Medicare reimbursement per case with comEVAR, and that chEVAR is significantly more costly than FEVAR. Inadequate Medicare reimbursement for these cases puts high-volume, high-complexity aortic centers at a distinct financial disadvantage. In the interest of optimizing patient care, these data suggest a reconsideration of previously established, outdated, Diagnosis-Related Group coding and Medicare reimbursement for comEVAR.

Impact of presenting stroke severity and thrombolysis on outcomes following urgent carotid interventions.

BACKGROUND: Carotid interventions are increasingly performed in select patients following acute stroke. We aimed to determine the effects of presenting stroke severity (National Institutes of Health Stroke Scale [NIHSS]) and use of systemic thrombolysis (tissue plasminogen activator [tPA]) on discharge neurological outcomes (modified Rankin scale [mRS]) after urgent carotid endarterectomy (uCEA) and urgent carotid artery stenting (uCAS). METHODS: Patients undergoing uCEA/uCAS at a tertiary Comprehensive Stroke Center (January 2015 to May 2022) were divided into two cohorts: (1) no thrombolysis (uCEA/uCAS only) and (2) use of thrombolysis before the carotid intervention (tPA + uCEA/uCAS). Outcomes were discharge mRS and 30-day complications. Regression models were used to determine an association between tPA use and presenting stroke severity (NIHSS) and discharge neurological outcomes (mRS). RESULTS: Two hundred thirty-eight patients underwent uCEA/uCAS (uCEA/uCAS only, n = 186; tPA + uCEA/uCAS, n = 52) over 7 years. In the thrombolysis cohort compared with the uCEA/uCAS only cohort, the mean presenting stroke severity was higher (NIHSS = 7.6 vs 3.8; P = .001), and more patients presented with moderate to severe strokes (57.7% vs 30.2% with NIHSS >4). The 30-day stroke, death, and myocardial infarction rates in the uCEA/uCAS only vs tPA + uCEA/uCAS were 8.1% vs 11.5% (P = .416), 0% vs 9.6% (P < .001), and 0.5% vs 1.9% (P = .39), respectively. The 30-day stroke/hemorrhagic conversion and myocardial infarction rates did not differ with tPA use; however, the difference in deaths was significantly higher in the tPA + uCEA/uCAS cohort (P < .001). There was no difference in neurological functional outcome with or without thrombolysis use (mean mRS, 2.1 vs 1.7; P = .061). For both minor strokes (NIHSS ≤4 vs NIHSS >4: relative risk, 1.58 vs 1.58, tPA vs no tPA, respectively, P = .997) and moderate strokes (NIHSS ≤10 vs NIHSS >10: relative risk, 1.94 vs 2.08, tPA vs no tPA, respectively; P = .891), the likelihood of discharge functional independence (mRS score of ≤2) was not influenced by tPA. CONCLUSIONS: Patients with a higher presenting stroke severity (NIHSS) had worse neurological functional outcomes (mRS). Patients presenting with minor and moderate strokes were more likely to have discharge neurological functional independence (mRS of ≤2), regardless of whether they received tPA or not. Overall, presenting NIHSS is predictive of discharge neurological functional autonomy and is not influenced by the use of thrombolysis.

Neurologic outcomes of carotid and other emergent interventions for ischemic stroke over 6 years with dataset enhanced by machine learning.

BACKGROUND: The current mainstays of ischemic stroke treatment include the use of thrombolysis (tissue plasminogen activator [tPA]), urgent carotid endarterectomy (uCEA) or urgent carotid artery stenting (uCAS), and mechanical endovascular reperfusion/thrombectomy (MER). Scarce data describe the presenting stroke severity and neurologic outcomes for these acute ischemic stroke interventions, alone or in combination. The authors hypothesize that patients undergoing carotid interventions experience better functional neurologic outcomes than other stroke interventions. METHODS: A comprehensive stroke center dataset was combined with data for stroke-related procedures, comorbidities, complications, and physician documentation collected from electronic medical record data. A total of 10,975 patient encounter records from January 1, 2015, through July 31, 2021, were retrieved. The presenting stroke severity was determined by vascular/stroke neurologists using the National Institutes of Health Stroke Scale (NIHSS). Functional neurologic outcomes were reported using the modified Rankin scale (mRS) score, which quantifies the degree of neurologic disability. Because mRS values were only available for 3627 encounters in the original dataset, the authors developed a machine learning algorithm to analyze physician documentation and assign an mRS value. After the exclusion and machine learning analysis, a total of 5170 patient encounters were included for statistical analysis. Statistical analyses included the χ2 test, one-way analysis of variance and logistic regression on 30-day complications, stroke severity, and neurologic outcomes. RESULTS: Patients were divided into five cohorts: (1) uCEA or uCAS (n = 189), (2) tPA alone (n = 1053), (3) MER alone (n = 418), (4) tPA + MER (n = 199), and (5) no intervention (n = 3311). Patients undergoing uCEA/uCAS were significantly more likely to be male, smokers, and have a history of peripheral arterial disease compared with other stroke cohorts. The length of stay was shortest for patients who only received tPA or no intervention (6 days), followed by uCEA/uCAS (7.2 days), MER (10.2 days), and tPA + MER (8.8 days) cohorts (P < .001). The 30-day mortality was highest in the MER cohort (12.2%) and lowest in the uCEA/uCAS cohort (2.6%). The uCEA/uCAS cohort compared with other cohorts had the lowest presenting stroke severity (NIHSS 4.9 vs NIHSS 6.9-16.0), and best neurologic outcomes (mRS 1.7 vs mRS 1.8-2.6). CONCLUSIONS: After an ischemic stroke, patients undergoing urgent carotid interventions had the lowest presenting stroke severity (NIHSS) and highest rate of independent neurologic outcomes (mRS) compared with other stroke interventions. Incoming stroke severity correlates with functional neurologic outcomes, and patients who present with an NIHSS of 10 or less who undergo uCEA/uCAS have a high likelihood of independent neurologic functional outcome (mRS of ≤2).

Nationally Representative Readmission Factors Associated with Endovascular versus Open Repair of Abdominal Aortic Aneurysm.

BACKGROUND: Hospital readmissions are tied to financial penalties and thus significantly influence health-care policy. Many current studies on readmissions lack national representation by not tracking readmissions across hospitals. The recently released Nationwide Readmission Database is one of the most comprehensive national sources of readmission data available, making it an invaluable resource to understand this critically important health policy issue. METHODS: The Nationwide Readmission Database for 2013 and 2014 was queried for adult patients with abdominal aortic aneurysm (441.4) undergoing endovascular (39.71) or open (38.44) repair. Outcomes examined were overall/initial admission mortality and overall/30-day readmissions. Multivariate logistic regression for these outcomes was also performed on multiple readmission factors. RESULTS: Fifty-three thousand four hundred seventeen patients underwent abdominal aortic aneurysm repair (47,431 endovascular aortic repair [EVAR] versus 5,986 open surgical repair [OSR]). Significant differences were found for EVAR versus OSR on overall readmissions, initial admission cost, readmission costs, length of stay, days to readmission, and overall/initial admission mortality. Multivariate logistic regression analysis found that length of stay > 30, Charlson Comorbidity Index > 1, discharge disposition, and female sex were all significant predictors of 30-day readmission. Repair type was significantly associated with 30-day readmissions; however, it was not a significant factor for overall readmissions. CONCLUSION: There are significant differences in costs, prognosis, and readmission rates for EVAR versus OSR. Given that these differences are being used to create "acceptable" readmission rates, disbursement quotas among hospitals, and subsequent penalties for providers outside the expected rates, it is only prudent to obtain the most accurate information to guide those policies. LEVEL OF EVIDENCE: Care management/epidemiological, level IV.

Severe Increase in Nursing Labor Cost and Effect on Surgical Department Financial Margins at an Academic, Tertiary Medical Center.

BACKGROUND: A pre-existing nationwide nursing shortage drastically worsened during the pandemic, causing a significant increase in nursing labor costs. We examined the financial impact of these changes on department of surgery financial margins. STUDY DESIGN: Operating room, inpatient, and outpatient financial metrics were analyzed. Monthly averages from a 14-month control cohort, January 2019 to February 2020 (pre-COVID-19), were compared with a 21-month cohort, March 2020 to November 2021 (COVID-19). True revenue and cost data from hospital accounting records, not estimates or administrative projections, were analyzed. Statistics were performed with standard Student's t -test and the Anderson-Darling normality test. RESULTS: Monthly surgical nursing costs increased significantly, with concomitant significant decreases in departmental contribution to margin. No significant change was observed in case volume per month, length of stay per case, or surgical acuity, as standardized by the US Centers for Medicare & Medicaid Services Case Mix Index. To obviate insurance payor mix as a variable and standardize cost data, surgical nursing expense per relative value unit was analyzed, demonstrating a significant increase. Hospital-wide agency nursing costs increased from $5.1 to $13.5 million per month (+165%) in 2021. CONCLUSIONS: Our results demonstrate a significant increase in surgical nursing labor costs with a resultant erosion of department of surgery financial margins. Use of real-time accounting data instead of commonly touted administrative approximations or Medicare projections increases both the accuracy and generalizability of the data. The long-term impact of both direct costs from supply chain interruption and indirect costs, such as limited operating room and ICU access, will require further study. Clearly this ominous trend is not viable, and fiscal recovery will require sustained, strategic workforce allocation.

Exercise Therapy in the Management of Peripheral Arterial Disease.

The incidence and prevalence of peripheral artery disease (PAD) are increasing globally and have a marked economic burden in the United States. The American Heart Association/American College of Cardiology guidelines recommend exercise therapy as a Class 1A, but its utilization remains suboptimal. This state-of-the-art review aims to provide a comprehensive review of the most updated information available on PAD, along with its risk factors, management options, outcomes, economic burden, and the role of exercise therapy in managing PAD.

Successful treatment of a persistent type IA endoleak with endoanchors following chimney endovascular aortic repair.

The chimney endovascular aortic repair technique has become an increasingly used option for the treatment of juxtarenal aortic aneurysms; however, type IA and gutter endoleaks complicate this approach in up to 5.9% of cases. Successful treatment of these leaks is challenging. We report a case of a patient who underwent two-vessel chimney endovascular aortic repair in the treatment of a 5.9-cm juxtarenal aortic aneurysm and developed a type IA endoleak. The endoleak was successfully treated with Heli-FX EndoAnchor placement. Resolution of the endoleak was noted at continued follow-up through 54 months.

A single molecular beacon probe is sufficient for the analysis of multiple nucleic acid sequences.

Molecular beacon (MB) probes are dual-labeled hairpin-shaped oligodeoxyribonucleotides that are extensively used for real-time detection of specific RNA/DNA analytes. In the MB probe, the loop fragment is complementary to the analyte: therefore, a unique probe is required for the analysis of each new analyte sequence. The conjugation of an oligonucleotide with two dyes and subsequent purification procedures add to the cost of MB probes, thus reducing their application in multiplex formats. Here we demonstrate how one MB probe can be used for the analysis of an arbitrary nucleic acid. The approach takes advantage of two oligonucleotide adaptor strands, each of which contains a fragment complementary to the analyte and a fragment complementary to an MB probe. The presence of the analyte leads to association of MB probe and the two DNA strands in quadripartite complex. The MB probe fluorescently reports the formation of this complex. In this design, the MB does not bind the analyte directly; therefore, the MB sequence is independent of the analyte. In this study one universal MB probe was used to genotype three human polymorphic sites. This approach promises to reduce the cost of multiplex real-time assays and improve the accuracy of single-nucleotide polymorphism genotyping.

The Nitric Oxide System in Peripheral Artery Disease: Connection with Oxidative Stress and Biopterins.

Peripheral artery disease (PAD) pathophysiology extends beyond hemodynamics to include other operating mechanisms, including endothelial dysfunction. Oxidative stress may be linked to endothelial dysfunction by reducing nitric oxide (NO) bioavailability. We aimed to investigate whether the NO system and its regulators are altered in the setting of PAD and to assess the relationship between NO bioavailability and oxidative stress. Sera from 35 patients with intermittent claudication (IC), 26 patients with critical limb ischemia (CLI), and 35 non-PAD controls were analyzed to determine levels of tetrahydrobiopterin (BH4), dihydrobiopterin (BH2), nitrate/nitrite (nitric oxides, or NOx), arginine, citrulline, asymmetric dimethylarginine (ADMA), symmetric dimethylarginine (SDMA), and the oxidative stress markers 8-Oxo-2'-deoxyguanosine (8-OHdG), 4-hydroxynonenal (4-HNE), advanced glycation end products (AGEs), and protein carbonyls. NOx was significantly lower in IC and CLI patients compared to controls in association with elevated oxidative stress, with the greatest NOx reductions observed in CLI. Compared with controls, IC and CLI patients had reduced BH4, elevated BH2, and a reduced BH4/BH2 ratio. SDMA, the arginine/SDMA ratio, and the arginine/ADMA ratio were significantly higher in CLI patients. The NO system and its regulators are significantly compromised in PAD. This dysregulation appears to be driven by increased oxidative stress and worsens as the disease progresses from claudication to CLI.