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BACKGROUND: Length of stay (LOS) is a major driver of cost and resource utilization following lower extremity bypass (LEB). However, the variable comorbidity burden and mobility status of LEB patients makes implementing enhanced recovery after surgery pathways challenging. The aim of this study was to use a large national database to identify patient factors associated with ultrashort LOS among patients undergoing LEB for peripheral artery disease. METHODS: All patients undergoing LEB for peripheral artery disease in the National Surgical Quality Improvement Project database from 2011 to 2018 were included. Patients were divided into two groups based on the postoperative length of stay : ultrashort (≤2 days) and standard (>2 days). Thirty-day outcomes were compared using descriptive statistics, and multivariable logistic regression was used to identify patient factors associated with ultrashort LOS. RESULTS: Overall, 17,510 patients were identified who underwent LEB, of which 2678 patients (15.3%) had an ultrashort postoperative LOS (mean, 1.8 days) and 14,832 (84.7%) patients had a standard LOS (mean, 7.1 days). When compared to patients with a standard LOS, patients with an ultrashort LOS were more likely to be admitted from home (95.9% vs 88.0%; P < .001), undergo elective surgery (86.1% vs 59.1%; P < .001), and be active smokers (52.1% vs 40.4%; P < .001). Patients with an ultrashort LOS were also more likely to have claudication as the indication for LEB (53.1% vs 22.5%; P < .001), have a popliteal revascularization target rather than a tibial/pedal target (76.7% vs 55.3%; P < .001), and have a prosthetic conduit (40.0% vs 29.9%; P < .001). There was no significant difference in mortality between the two groups (1.4% vs 1.8%; P = .21); however, patients with an ultrashort LOS had a lower frequency of unplanned readmission (10.7% vs 18.8%; P < .001) and need for major reintervention (1.9% vs 5.6%; P < .001). On multivariable analysis, elective status (odds ratio , 2.66; 95% confidence interval [CI], 2.33-3.04), active smoking (OR, 1.18; 95% CI, 1.07-1.30), and lack of vein harvest (OR, 1.55; 95% CI, 1.41-1.70) were associated with ultrashort LOS. Presence of rest pain (OR, 0.57; 95% CI, 0.51-0.63), tissue loss (OR, 0.30; 95% CI, 0.27-0.34), and totally dependent functional status (OR, 0.54; 95% CI, 0.35-0.84) were associated negatively with an ultrashort LOS. When examining the subgroup of patients who underwent vein harvest, totally dependent (OR, 0.38; 95% CI, 0.19-0.75) and partially dependent (OR, 0.53; 95% CI, 0.32-0.88) functional status were persistently negatively associated with ultrashort LOS. CONCLUSIONS: Ultrashort LOS (≤2 days) after LEB is uncommon but feasible in select patients. Preoperative functional status and mobility are important factors to consider when identifying LEB patients who may be candidates for early discharge.
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OBJECTIVE: Women and minorities remain under-represented in academic vascular surgery. This under-representation persists in the editorial peer review process which may contribute to publication bias. In 2020, the Journal of Vascular Surgery (JVS) addressed this by diversifying the editorial board and creating a new Editor of Diversity, Equity, and Inclusion (DEI). The impact of a DEI editor on modifying the output of JVS has not yet been examined. We sought to determine the measurable impact of a DEI editor on diversifying perspectives represented in the journal, and on contributing to changes in the presence of DEI subject matter across published journal content. METHODS: The authorship and content of published primary research articles, editorials, and special articles in JVS were examined from November 2019 through July 2022. Publications were examined for the year prior to initiation of the DEI Editor (pre), the year following (post), and from September 2021 to July 2022, accounting for the average 47-week time period from submission to publication in JVS (lag). Presence of DEI topics and women authorship were compared using χ2 tests. RESULTS: During the period examined, the number of editorials, guidelines, and other special articles dedicated to DEI topics in the vascular surgery workforce or patient population increased from 0 in the year prior to 4 (16.7%) in the 11-month lag period. The number of editorials, guidelines, and other special articles with women as first or senior authors nearly doubled (24% pre, 44.4% lag; P = .31). Invited commentaries and discussions were increasingly written by women as the study period progressed (18.7% pre, 25.9% post, 42.6% lag; P = .007). The number of primary research articles dedicated to DEI topics increased (5.6% pre, 3.3% post, 8.1% lag; P = .007). Primary research articles written on DEI topics were more likely to have women first or senior authors than non-DEI specific primary research articles (68.0% of all DEI vs 37.5% of a random sampling of non-DEI primary research articles; P < .001). The proportion of distinguished peer reviewers increased (from 2.8% in 2020 to 21.9% in 2021; P < .001). CONCLUSIONS: The addition of a DEI editor to JVS significantly impacted the diversification of topics, authorship of editorials, special articles, and invited commentaries, as well as peer review participation. Ongoing efforts are needed to diversify subject matter and perspective in the vascular surgery literature and decrease publication bias.
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Autoria , Especialidades Cirúrgicas , Feminino , Humanos , Revisão por Pares , Viés de Publicação , Procedimentos Cirúrgicos Vasculares , Diversidade, Equidade, InclusãoRESUMO
OBJECTIVE: The Society for Vascular Surgery (SVS) clinical practice guidelines recommend best medical therapy (BMT) as first-line therapy before offering revascularization to patients with intermittent claudication (IC). Notably, atherectomy and tibial-level interventions are generally discouraged for management of IC; however, high regional market competition may incentivize physicians to treat patients outside the scope of guideline-directed therapy. Therefore, we sought to determine the association between regional market competition and endovascular treatment of patients with IC. METHODS: We examined patients with IC undergoing index endovascular peripheral vascular interventions (PVI) in the SVS Vascular Quality Initiative from 2010 to 2022. We assigned the Herfindahl-Hirschman Index as a measure of regional market competition and stratified centers into very high competition (VHC), high competition, moderate competition, and low competition cohorts. We defined BMT as preoperative documentation of being on antiplatelet medication, statin, nonsmoking status, and a recorded ankle-brachial index. We used logistic regression to evaluate the association of market competition with patient and procedural characteristics. A sensitivity analysis was performed in patients with isolated femoropopliteal disease matched by the TransAtlantic InterSociety classification of disease severity. RESULTS: There were 24,669 PVIs that met the inclusion criteria. Patients with IC undergoing PVI were more likely to be on BMT when treated in higher market competition centers (odds ratio [OR], 1.07 per increase in competition quartile; 95% confidence interval [CI], 1.04-1.11; P < .0001). The probability of undergoing aortoiliac interventions decreased with increasing competition (OR, 0.84; 95% CI, 0.81-0.87; P < .0001), but there were higher odds of receiving tibial (OR, 1.40; 95% CI, 1.30-1.50; P < .0001) and multilevel interventions in VHC vs low competition centers (femoral + tibial OR, 1.10; 95% CI, 1.03-1.14; P = .001). Stenting decreased as competition increased (OR, 0.89; 95% CI, 0.87-0.92; P < .0001), whereas exposure to atherectomy increased with higher market competition (OR, 1.15; 95% CI, 1.11-1.19; P < .0001). When assessing patients undergoing single-artery femoropopliteal intervention for TransAtlantic InterSociety A or B lesions to account for disease severity, the odds of undergoing either balloon angioplasty (OR, 0.72; 95% CI, 0.625-0.840; P < .0001) or stenting only (OR, 0.84; 95% CI, 0.727-0.966; P < .0001) were lower in VHC centers. Similarly, the likelihood of receiving atherectomy remained significantly higher in VHC centers (OR, 1.6; 95% CI, 1.36-1.84; P < .0001). CONCLUSIONS: High market competition was associated with more procedures among patients with claudication that are not consistent with guideline-directed therapy per the SVS clinical practice guidelines, including atherectomy and tibial-level interventions. This analysis demonstrates the susceptibility of care delivery to regional market competition and signifies a novel and undefined driver of PVI variation among patients with claudication.
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Claudicação Intermitente , Doença Arterial Periférica , Humanos , Claudicação Intermitente/terapia , Claudicação Intermitente/cirurgia , Doença Arterial Periférica/terapia , Doença Arterial Periférica/cirurgia , Fatores de Risco , Procedimentos Cirúrgicos Vasculares , Aterectomia/efeitos adversos , Resultado do Tratamento , Estudos RetrospectivosRESUMO
BACKGROUND: There are no published standards for the expected findings on noninvasive testing following distal revascularization and interval ligation (DRIL). This study evaluated the hemodynamic results and duplex ultrasound characteristics of DRIL. METHODS: A retrospective chart review of patients who underwent DRIL using autogenous vein between 2008 and 2019 was performed. Patients with both preoperative and follow-up noninvasive testing were included. RESULTS: Thirty-eight patients were included in the study. Median time to first follow-up was 30 days (range 1-226 days), where 12 had complete resolution of their symptoms and 26 had partial resolution. Of the 27 patients that had preoperative and postoperative testing, the wrist brachial index improved from 0.56 to 0.90 with the median finger pressure improving from 56 to 73 (P < 0.001). Seventeen patients had a second follow-up (sFU) at a median time from DRIL of 196 days (range 106-843 days). There was no significant difference in wrist brachial index or finger pressures between first follow-up and sFU. Duplex ultrasound of the DRIL conduits (n = 32) showed a very consistent pattern with elevated median velocities proximally (inflow 235 cm/sec, proximal anastomosis 217.7 cm/sec) and distinctly slower median velocities distally (midconduit 46.4 cm/sec, distal anastomosis 78.3 cm/sec, outflow 59.3 cm/sec). The same pattern of velocities was held constant at the sFU (n = 16). CONCLUSIONS: In this study, velocities at the proximal anastomosis were significantly higher than velocities more distal in the DRIL bypass without evidence of stenosis. This may be due to hemodynamic changes in the brachial artery associated with presence of a fistula. Elevated velocities at the proximal anastomosis do not necessarily warrant further evaluation or intervention without other evidence of conduit compromise.
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Derivação Arteriovenosa Cirúrgica , Mãos , Humanos , Mãos/irrigação sanguínea , Estudos Retrospectivos , Resultado do Tratamento , Extremidade Superior/cirurgia , Ligadura , Isquemia/cirurgia , Grau de Desobstrução VascularRESUMO
OBJECTIVE: Age ≥80 years is known to be an independent risk factor for periprocedural stroke after transfemoral carotid artery stenting (TF-CAS) but not after carotid endarterectomy (CEA). The objective of the present study was to compare the perioperative outcomes for CEA, TF-CAS, and transcarotid artery revascularization (TCAR) among octogenarian patients (aged ≥80 years) overall and stratified by symptom status and degree of stenosis. METHODS: All patients aged ≥80 years with 50% to 99% carotid artery stenosis who had undergone CEA, TF-CAS, or TCAR in the Vascular Quality Initiative (2005-2020) were included. We compared the perioperative (30-day) incidence of ipsilateral stroke or death for CEA vs TF-CAS vs TCAR using analysis of variance and multivariable logistic regression models. The results were confirmed in a sensitivity analysis stratified by symptom status and degree of stenosis. RESULTS: Overall, 28,571 carotid revascularization procedures were performed in patients aged ≥80 years: CEA, n = 20,912 (73.2%), TF-CAS, n = 3628 (12.7%), and TCAR, n = 4031 (14.1%). The median age was 83 years (interquartile range, 81.0-86.0 years); 49.8% of the patients were symptomatic (51.9% CEA, 46.2% TF-CAS, 42.4% TCAR); and 60.7% had high-grade stenosis (59.0% CEA, 65.2% TF-CAS, 65.4% TCAR). Perioperative stroke/death occurred most frequently following TF-CAS (6.6%), followed by TCAR (3.1%) and CEA (2.5%; P < .001). After adjusting for baseline differences between groups, the odds ratio (OR) for stroke/death was greater for TF-CAS vs CEA (adjusted OR [aOR], 3.35; 95% confidence interval [CI], 2.65-4.23), followed by TCAR vs CEA (aOR 1.49, 95% CI 1.18-1.87). The risk of perioperative stroke/death remained significantly greater for TF-CAS compared with CEA regardless of symptom status and degree of stenosis (P < .05 for all). In contrast, the risk of stroke/death was higher for TCAR vs CEA for asymptomatic patients (aOR, 2.04; 95% CI, 1.41-2.94) and those with high-grade stenosis (aOR, 1.49; 95% CI, 1.11-2.05) but similar for patients with symptomatic and moderate-grade disease (P > .05 for both). The risk of myocardial infarction was lower with TCAR (aOR, 0.59; 95% CI, 0.40-0.87) and TF-CAS (aOR, 0.56; 95% CI, 0.40-0.87) compared with CEA overall. CONCLUSIONS: Overall, TCAR and CEA can be safely offered to older adults, in particular, symptomatic patients and those with moderate-grade stenosis. TF-CAS should be avoided in older patients when possible.
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Estenose das Carótidas , Endarterectomia das Carótidas , Acidente Vascular Cerebral , Idoso , Idoso de 80 Anos ou mais , Artérias Carótidas , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/cirurgia , Constrição Patológica/complicações , Endarterectomia das Carótidas/efeitos adversos , Humanos , Octogenários , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Stents/efeitos adversos , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: In randomized controlled trials and retrospective series, women have higher rates of periprocedural stroke and death following carotid endarterectomy and transfemoral carotid artery stenting compared with men. We sought to compare outcomes by sex following transcarotid artery revascularization (TCAR) among patients in the Vascular Quality Initiative (VQI). METHODS: We reviewed all patients in the VQI who underwent TCAR from 2017 to 2020. We stratified the analysis by symptom status. The primary outcome was in-hospital stroke/death, and secondary outcomes were in-hospital stroke and death and 1-year stroke/death, stroke, and death. We used multivariable logistic and Cox regression models to assess the association of sex with in-hospital and 1-year outcomes after adjusting for preoperative and intraoperative characteristics. RESULTS: We identified 15,851 patients who underwent TCAR, of whom 7391 (47%) were symptomatic (2708 or 37% female) and 8460 (53%) were asymptomatic (3097 or 37% female). Women were less frequently considered anatomic high risk than men in both groups (symptomatic: 43% vs 46%; P = .004; asymptomatic: 44% vs 48%; P = .004). Among symptomatic patients, women more often had severe ≥70% stenosis (89% vs 87%; P = .02). There were no differences in in-hospital death, stroke, or stroke/death for women vs men following TCAR among symptomatic or asymptomatic patients (all P > .05). After adjusting for baseline differences between groups, female sex was not associated with in-hospital stroke/death in either symptomatic (odds ratio, 1.05; 95% confidence interval, 0.72-1.56) or asymptomatic (odds ratio, 0.93; 95% confidence interval, 0.53-1.63) patients undergoing TCAR. There were also no differences in 1-year stroke, death, or stroke/death risk for women compared with men with and without symptoms on unadjusted or adjusted analyses (P > .05). CONCLUSIONS: We found no sex differences in in-hospital or 1-year stroke/death following TCAR, regardless of symptom status. TCAR appears to be as safe of a surgical procedure for women as for men in patients with both symptomatic and asymptomatic carotid artery disease.
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Estenose das Carótidas/cirurgia , Procedimentos Endovasculares/métodos , Indicadores de Qualidade em Assistência à Saúde , Sistema de Registros , Stents , Acidente Vascular Cerebral/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Canadá/epidemiologia , Estenose das Carótidas/complicações , Endarterectomia das Carótidas , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Incidência , Masculino , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Taxa de Sobrevida/tendências , Fatores de Tempo , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Revascularization practices with respect to asymptomatic carotid stenosis (ACAS) are known to vary widely among proceduralists. In addition, regional market competition has been previously shown to drive more aggressive practices in a number of surgical procedures. The aim of our study was to examine the association of regional market competition with revascularization thresholds for ACAS. METHODS: All patients undergoing carotid revascularization in the Vascular Quality Initiative carotid endarterectomy and stenting databases (2016-2020) were included. High-grade carotid stenosis was defined as ≥80%. We calculated the Herfindahl-Hirschman Index (HHI; a measure of physician market competition) for each U.S region as defined by the U.S Department of Health and Human Services. Logistic regression was used to examine the association of degree of carotid stenosis at revascularization with HHI stratified by symptomatology, adjusting for age, sex, race, insurance, and revascularization modality. RESULTS: Of 92,243 carotid interventions, 57,094 (61.9%) were performed for ACAS and 35,149 (38.1%) were performed for symptomatic carotid stenosis (SCAS). ACAS patients undergoing revascularization for moderate-grade stenosis were significantly less likely to be aspirin (85.6% vs. 86.3%), clopidogrel (41.3% vs. 45.1%), dual anti-platelet therapy (35.9% vs. 39.2%) and systemic anticoagulants (10.9 vs. 11.7%) compared to high-grade stenosis (all P < 0.05). Multivariable analysis demonstrated that decreased local market competition was independently associated with a lower odds of revascularization for moderate versus high-grade ACAS (odds ratio OR: 0.99 per 10 point increase in HHI, 95% confidence interval CI: 0.98-0.99). There was no association of local market competition with degree of carotid stenosis at time of revascularization among patients with SCAS (OR: 1.00 per 10 point increase in HHI, 95% CI: 0.99-1.00). Among ACAS patients, patients with moderate-grade stenosis had a higher odds ratio of in-hospital stroke or death compared to patients with high-grade stenosis (OR: 1.22, 95% CI 1.03-1.45). This association was not redemonstrated in the SCAS group (OR: 0.92, 95% CI: 0.80-1.06). CONCLUSIONS: Increased local market competition is associated with a lower threshold for revascularization of ACAS. There is no association between regional market competition and revascularization threshold for SCAS. These findings, combined with the significantly increased risk of perioperative stroke/death among moderate-grade ACAS patients, suggest that competition among proceduralists may result in a higher tolerance for increased operative risk in patients who might otherwise be reasonable candidates for surveillance.
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Estenose das Carótidas , Endarterectomia das Carótidas , Acidente Vascular Cerebral , Humanos , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/cirurgia , Constrição Patológica/etiologia , Resultado do Tratamento , Endarterectomia das Carótidas/efeitos adversos , Stents/efeitos adversos , Acidente Vascular Cerebral/prevenção & controle , Acidente Vascular Cerebral/complicações , Fatores de Risco , Medição de Risco , Estudos RetrospectivosRESUMO
OBJECTIVE: Distal revascularization and interval ligation (DRIL) is an effective approach to the management of hemodialysis access-related ischemia that offers both symptom relief and access salvage. The great saphenous vein (GSV) has been the most commonly used conduit. However, the use of an ipsilateral arm vein will allow for performance of the operation with the patient under regional anesthesia and might result in lower harvest site morbidity than the GSV. We sought to determine the suitability of DRIL using an arm vein compared with a GSV conduit. METHODS: All patients who had undergone DRIL from 2008 to 2019 were retrospectively identified in the electronic medical records. The characteristics and outcomes of those with an arm vein vs a GSV conduit were compared using the Wilcoxon log-rank and χ2 tests. Access patency was examined using Kaplan-Meier methods, with censoring at lost to follow-up or death. RESULTS: A total of 66 patients who had undergone DRIL for hand ischemia were included in the present study. An arm vein conduit was used in 40 patients (median age, 65 years; 25% male) and a GSV conduit in 26 patients (median age, 58 years; 19% male). No significant differences in comorbidities were found between the two groups, with the exception of diabetes mellitus (arm vein group, 78%; GSV group, 50% GSV; P = .02). No difference in the ischemia stage at presentation was present between the groups, with most patients presenting with stage 3 ischemia. Also, no differences in patency of hemodialysis access after DRIL between the two groups were found (P = .96). At 12 and 24 months after DRIL, 86.9% (95% confidence interval [CI], 68.3%-94.9%) and 82.0% (95% CI, 61.3%-92.3%) of patients with an arm vein conduit had access patency compared with 93.8% (95% CI, 63.2%-99.1%) and 76.9% (95% CI, 43.0%-92.2%) of those with a GSV conduit, respectively. All but one patient had symptom resolution. The incidence of wound complications was significantly greater in the GSV group than in the arm vein group (46% vs 11%; P = .003). DRIL bypass had remained patent in all but one patient in each group, with a median follow-up of 18 months (range, 1-112 months) in the arm vein conduit group and 15 months (range, 0.25-105 months) in the GSV conduit group. CONCLUSIONS: DRIL procedures using an arm vein have advantages over those performed with the GSV. In our series, symptom resolution and access salvage were similar but distinctly fewer wound complications had occurred in the arm vein group. Additionally, the use of an arm vein conduit avoids the need for general anesthesia. If an ipsilateral arm vein is available, it should be the conduit of choice when performing DRIL.
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Derivação Arteriovenosa Cirúrgica/efeitos adversos , Implante de Prótese Vascular/efeitos adversos , Isquemia/cirurgia , Diálise Renal , Extremidade Superior/irrigação sanguínea , Enxerto Vascular , Veias/transplante , Idoso , Registros Eletrônicos de Saúde , Feminino , Humanos , Isquemia/diagnóstico por imagem , Isquemia/etiologia , Isquemia/fisiopatologia , Ligadura , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Fluxo Sanguíneo Regional , Estudos Retrospectivos , Fatores de Risco , Veia Safena/transplante , Fatores de Tempo , Resultado do Tratamento , Enxerto Vascular/efeitos adversos , Grau de Desobstrução VascularRESUMO
OBJECTIVES: Selecting optimal hemodialysis access in elderly patients remains challenging, particularly in those requiring new options after failed initial access. We sought to describe the outcomes of redo hemodialysis access in elderly patients. METHODS: All patients aged ≥65 undergoing hemodialysis access placement from 2014-2019 were retrospectively identified in the electronic medical record. Characteristics and outcomes of those with initial versus redo access were compared. Patency was depicted utilizing Kaplan-Meier methods, with censoring at loss to follow-up or death, and unadjusted Cox regression. RESULTS: Overall, 211 elderly patients undergoing 257 procedures were included in the study. Of these, 116 (45.1%) were redo access procedures. There were no demographic or comorbidity differences between the two groups with the exception of central venous stenosis which was more common in the redo cohort (27.2% vs. 6.4%, P < 0.001). 91.5% of initial, vs. 60.3% of redo, procedures were arteriovenous fistulas (P < 0.001). Distribution of fistula type differed between the two groups with first time and redo procedures of 25.5% vs. 6.9% radiocephalic, 28.4% vs. 7.8% brachiocephalic, and 35.5% vs. 37.1% brachiobasilic respectively (P < 0.001). At 12 and 24 months, 63.6% and 44.0% of first-time accesses remained patent vs. 51% and 29.0% of redo accesses (HR 1.37, 95% CI 1.05-1.80, P = 0.02). However, there was no difference in primary patency between redo grafts and fistulas (48.7% fistulas vs. 55.0% grafts at 12 months, P = 0.47). CONCLUSIONS: These results demonstrate acceptable outcomes of redo access in elderly patients. There is no evidence from this study that prosthetic grafts are preferential, suggesting elderly patients with meaningful life expectancy who require redo access should be offered autogenous options when possible.
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Derivação Arteriovenosa Cirúrgica , Implante de Prótese Vascular , Falência Renal Crônica/terapia , Diálise Renal , Grau de Desobstrução Vascular , Fatores Etários , Idoso , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Implante de Prótese Vascular/efeitos adversos , Tomada de Decisão Clínica , Registros Eletrônicos de Saúde , Feminino , Humanos , Falência Renal Crônica/diagnóstico , Masculino , Reoperação , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Local market competition has been previously associated with more aggressive surgical decision-making. For example, more local competition for organs is associated with acceptance of lower quality kidney offers in transplant surgery. We hypothesized that market competition would be associated with the size of an abdominal aortic aneurysm (AAA) at the time of elective endovascular aneurysm repair (EVAR). METHODS: We included all elective EVARs reported in the Vascular Quality Initiative database (2012-2018). Small AAAs were defined as a maximum diameter <5.5 cm in men or <5.0 cm in women. We calculated the Herfindahl-Hirschman Index (HHI), a measure of physician market concentration (higher HHI = less market competition), for each US census region. Multilevel regression was used to examine the association between the size of AAA at EVAR and HHI, clustering by region. RESULTS: Of 37,914 EVARs performed, 15,379 (40.6%) were for small AAAs. There was significant variation in proportion of EVARs performed for small AAAs across regions (P < 0.001). The South had both the highest proportion of EVARs for small AAAs (44.2%) as well as the highest market competition (HHI 50), whereas the West had the lowest proportion of EVARs for small AAAs (35.0%) and the lowest market competition (HHI 107). Adjusting for patient characteristics, each 10 unit increase in HHI was associated with a 0.1 mm larger maximum AAA diameter at the time of EVAR (95% CI 0.04-0.24 mm, P = 0.005). CONCLUSIONS: Physician market concentration is independently associated with AAA diameter at time of elective EVAR. These data suggest that physician decision-making for EVAR is impacted by market competition.
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Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/tendências , Competição Econômica/tendências , Procedimentos Endovasculares/tendências , Setor de Assistência à Saúde/tendências , Disparidades em Assistência à Saúde/tendências , Padrões de Prática Médica/tendências , Cirurgiões/tendências , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/economia , Aneurisma da Aorta Abdominal/epidemiologia , Implante de Prótese Vascular/economia , Tomada de Decisão Clínica , Bases de Dados Factuais , Procedimentos Endovasculares/economia , Feminino , Setor de Assistência à Saúde/economia , Disparidades em Assistência à Saúde/economia , Humanos , Masculino , Seleção de Pacientes , Padrões de Prática Médica/economia , Cirurgiões/economia , Estados Unidos/epidemiologiaRESUMO
Steatotic donor livers (SDLs) (macrosteatosis ≥30%) represent a possible donor pool expansion, but are frequently discarded due to a historical association with mortality and graft loss. However, changes in recipient/donor demographics, allocation policy, and clinical protocols might have altered utilization and outcomes of SDLs. We used Scientific Registry of Transplant Recipients data from 2005 to 2017 and adjusted multilevel regression to quantify temporal trends in discard rates (logistic) and posttransplant outcomes (Cox) of SDLs, accounting for Organ Procurement Organization-level variation. Of 4346 recovered SDLs, 58.0% were discarded in 2005, versus only 43.1% in 2017 (P < .001). SDLs were always substantially more likely discarded versus non-SDLs, although this difference decreased over time (adjusted odds ratio in 2005-2007:13.15 15.2817.74 ; 2008-2011:11.77 13.4115.29 ; 2012-2014:9.87 11.3713.10 ; 2015-2017:7.79 8.8910.15 , P < .001 for all). Conversely, posttransplant outcomes of recipients of SDLs improved over time: recipients of SDLs from 2012 to 2017 had 46% lower risk of mortality (adjusted hazard ratio [aHR]: 0.43 0.540.68 , P < .001) and 47% lower risk of graft loss (aHR: 0.42 0.530.67 , P < .001) compared to 2005 to 2011. In fact, in 2012 to 2017, recipients of SDLs had equivalent mortality (aHR: 0.90 1.041.21 , P = .6) and graft loss (aHR: 0.90 1.041.20 , P = .6) to recipients of non-SDLs. Increasing utilization of SDLs might be a reasonable strategy to expand the donor pool.
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Transplante de Fígado , Obtenção de Tecidos e Órgãos , Sobrevivência de Enxerto , Humanos , Doadores Vivos , Sistema de Registros , Fatores de Risco , Doadores de Tecidos , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: To determine if the association of frailty and waitlist mortality varies by candidate age. BACKGROUND: Frailty, a construct developed in geriatrics, is a state of decreased physiologic reserve, and is associated with mortality while awaiting liver transplantation (LT). However, older candidates have high comorbidity burden and less physiologic reserve, so the relationship between frailty and waitlist mortality may vary by candidate age. METHODS: We studied adults listed for LT at 2 transplant centers. The liver frailty index (grip strength, chair stands, balance) was measured at evaluation, with frailty defined as liver frailty index â≥â4.5. We compared the prevalence of frailty in older (≥65 yr) and younger (18-64 yr) candidates. We studied the association between frailty, age, interaction between the 2, and waitlist mortality using competing risks regression adjusted for sex, BMI, and MELDNa. RESULTS: Among 882 LT candidates, 16.6% wereâ≥â65 years. Older candidates were more likely to be frail (33.3% vs 21.7%, P = 0.002). Older age [adjusted subhazard ratio (aSHR): 2.16, 95% CI: 1.51-3.09, P < 0.001] and frailty (aSHR: 1.92, 95% CI: 1.38-2.67, P < 0.001) were independently associated with higher risk of waitlist mortality. However, the association between waitlist mortality and frailty did not vary by candidate age (aSHR of frailty for younger patients: 1.90, 95% CI: 1.28-2.80, P = 0.001; aSHR of frailty for older patients: 1.98, 95% CI: 1.07-3.67, P = 0.03; P interaction = 0.9). CONCLUSIONS: Older candidates experienced higher rates of frailty than younger candidates. However, regardless of age, frailty was associated with nearly 2-fold increased risk of waitlist mortality. Our data support the applicability of the frailty concept to the whole LT population and can guide the development of prehabilitation programs targeting frailty in LT patients of all ages.
Assuntos
Doença Hepática Terminal/cirurgia , Fragilidade/epidemiologia , Transplante de Fígado/mortalidade , Medição de Risco/métodos , Listas de Espera/mortalidade , Idoso , Doença Hepática Terminal/mortalidade , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologiaRESUMO
With implementation of the Kidney Allocation System, the growth of kidney paired donation programs, and advances in desensitization and immunosuppression, the outlook for "untransplantable" kidney transplantation candidates has never been more promising. The Kidney Allocation System prioritized compatible matches for candidates with calculated panel-reactive antibody levels of 98%, 99%, or 100% and broadened allocation of non-A1 and non-A1-B subgroup kidneys to blood group type B candidates. Concurrently, the growth of kidney paired donation programs and use of incompatible transplantation as part of kidney paired donation to achieve "more compatible" kidney transplantation has improved options for candidates with an incompatible living donor. Finally, advances in desensitization and immunosuppression have strengthened the ability to manage donor-specific antibodies and antibody-mediated rejection. Although no patient should be labeled "untransplantable" due to blood group type or donor-specific antibody, all candidates should be provided with individualized and realistic counseling regarding their anticipated wait times for deceased donor or kidney paired donation matching, with early referral to expert centers when needed. In this Perspective, we consider blood group type ABO incompatibility, HLA antigen incompatibility, antibody-mediated rejection, kidney paired donation, and recent developments in incompatible transplantation in more depth and recommend an approach to the sensitized candidate.
Assuntos
Incompatibilidade de Grupos Sanguíneos/imunologia , Antígenos HLA/imunologia , Histocompatibilidade/imunologia , Transplante de Rim/métodos , Sistema ABO de Grupos Sanguíneos/imunologia , Dessensibilização Imunológica/métodos , Doação Dirigida de Tecido , Seleção do Doador , Humanos , Doadores Vivos , Obtenção de Tecidos e ÓrgãosRESUMO
RATIONALE & OBJECTIVE: Risk factors for kidney failure are the basis of live kidney donor candidate evaluation. We quantified risk for end-stage kidney disease (ESKD) by the biological relationship of the donor to the recipient, a risk factor that is not addressed by current clinical practice guidelines. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: A cohort of 143,750 US kidney donors between 1987 and 2017. EXPOSURE: Biological relationship of donor and recipient. OUTCOME: ESKD. Donors' records were linked to national dialysis and transplantation registries to ascertain development of the outcome. ANALYTIC APPROACH: Donors were observed over a median of 12 (interquartile range, 6-18; maximum, 30) years. Survival analysis methods that account for the competing risk for death were used. RESULTS: Risk for ESKD varied by orders of magnitude across donor-recipient relationship categories. For Asian donors, risks compared with unrelated donors were 259.4-fold greater for identical twins (95% CI, 19.5-3445.6), 4.7-fold greater for full siblings (95% CI, 0.5-41.0), 3.5-fold greater for offspring (95% CI, 0.6-39.5), 1.0 for parents, and 1.0 for half-sibling or other biological relatives. For black donors, risks were 22.5-fold greater for identical twin donors (95% CI, 4.7-107.0), 4.1-fold for full siblings (95% CI, 2.1-7.8), 2.7-fold for offspring (95% CI, 1.4-5.4), 3.1-fold for parents (95% CI, 1.4-6.8), and 1.3-fold for half-sibling or other biological relatives (95% CI, 0.5-3.3). For white donors, risks were 3.5-fold greater for identical twin donors (95% CI, 0.5-25.3), 2.0-fold for full siblings (95% CI, 1.4-2.8), 1.4-fold for offspring (95% CI, 0.9-2.3), 2.9-fold for parents (95% CI, 2.0-4.1), and 0.8-fold for half-sibling or other biological relatives (95% CI, 0.3-1.6). LIMITATIONS: Insufficient sample size in some race and relationship groups. Absence of data for family history of kidney disease for donors biologically unrelated to their recipients. CONCLUSIONS: Marked differences in risk for ESKD across types of donor-recipient relationship were observed for Asian, black, and white donors. These findings warrant further validation with more robust data to better inform clinical practice guidelines.
Assuntos
Relações Interpessoais , Falência Renal Crônica/cirurgia , Transplante de Rim , Doadores Vivos/psicologia , Sistema de Registros , Transplantados/psicologia , Adulto , Etnicidade , Feminino , Seguimentos , Sobrevivência de Enxerto , Humanos , Incidência , Falência Renal Crônica/etnologia , Masculino , Pessoa de Meia-Idade , Nefrectomia , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: Transfemoral carotid artery stenting (CAS) has been validated as an acceptable alternative to carotid endarterectomy in patients at high risk for open surgery. There are variable sex- and age-based differences in transfemoral CAS outcomes of published randomized controlled trials. The aim of our study was to evaluate sex-based differences in perioperative outcomes after transfemoral CAS performed in octogenarians. METHODS: The National Surgical Quality Improvement Program targeted vascular module was queried for all patients ≥80 years of age who underwent transfemoral CAS between 2011 and 2017. Symptomatic status was defined as a history of prior ipsilateral stroke, transient ischemic attack, or amaurosis fugax. The primary outcome was a composite outcome of perioperative (30-day) stroke or death. Outcomes were compared for male vs female patients and stratified by symptomatic status using univariate and multivariable logistic regression analyses adjusting for emergent status, symptomatic status, comorbidities, and use of an embolic protection device. RESULTS: Overall, there were 143 patients ≥80 years of age who underwent transfemoral CAS during the study period, including 95 men (66.4%) and 48 women (33.6%). Race (white, 88.0% vs 85.4%), symptomatic status (30.9% vs 29.2%), and degree of stenosis (severe, 71.6% vs 62.5%) were not significantly different for men vs women (P ≥ .27). Periprocedural stroke/death occurred in six men (6.4%) vs two women (4.2%; P = .59) and did not significantly differ when stratified according to symptomatic (6.9% vs 7.1%; P = .98) and asymptomatic (6.2% vs 2.9%; P = .49) status. Based on multivariable analysis, independent factors associated with the composite end point included emergent vs elective status (adjusted odds ratio OR [aOR], 20.3; 95% confidence interval [CI], 2.25-183) and failure to use an embolic protection device (aOR, 2.86; 95% CI, 1.59-50.0). Sex was not significantly associated with the primary outcome after risk adjustment (aOR, 0.81; 95% CI, 0.28-3.28). CONCLUSIONS: We found no sex-based differences in risk of perioperative stroke/death among patients ≥80 years of age undergoing transfemoral CAS. Our study validates previous studies showing a high rate of perioperative complications after transfemoral CAS in octogenarians and suggests that the decision to use this technology in older patients should be determined by patients' anatomic and medical risk factors irrespective of sex.
Assuntos
Estenose das Carótidas/cirurgia , Procedimentos Endovasculares/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Idoso de 80 Anos ou mais , Artérias Carótidas/anatomia & histologia , Artérias Carótidas/cirurgia , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/métodos , Feminino , Artéria Femoral/cirurgia , Mortalidade Hospitalar , Humanos , Masculino , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Medição de Risco/estatística & dados numéricos , Fatores de Risco , Fatores Sexuais , Stents/efeitos adversos , Acidente Vascular Cerebral/etiologia , Resultado do TratamentoRESUMO
OBJECTIVE: Guidelines from the Society for Vascular Surgery and the Choosing Wisely campaign recommend that peripheral vascular interventions (PVIs) be limited to claudication patients with lifestyle-limiting symptoms only after a failed trial of medical and exercise therapy. We sought to explore practice patterns and physician characteristics associated with early PVI after a new claudication diagnosis to evaluate adherence to these guidelines. METHODS: We used 100% Medicare fee-for-service claims to identify patients diagnosed with claudication for the first time between 2015 and 2017. Early PVI was defined as an aortoiliac or femoropopliteal PVI performed within 6 months of initial claudication diagnosis. A physician-level PVI utilization rate was calculated for physicians who diagnosed >10 claudication patients and performed at least one PVI (regardless of indication) during the study period. Hierarchical multivariable logistic regression was used to identify physician-level factors associated with early PVI. RESULTS: Of 194,974 patients who had a first-time diagnosis of claudication during the study period, 6286 (3.2%) underwent early PVI. Among the 5664 physicians included in the analysis, the median physician-level early PVI rate was low at 0% (range, 0%-58.3%). However, there were 320 physicians (5.6%) who had an early PVI rate ≥14% (≥2 standard deviations above the mean). After accounting for patient characteristics, a higher percentage of services delivered in ambulatory surgery center or office settings was associated with higher PVI utilization (vs 0%-22%; 23%-47%: adjusted odds ratio [aOR], 1.23; 48%-68%: aOR, 1.49; 69%-100%: aOR, 1.72; all P < .05). Other risk-adjusted physician factors independently associated with high PVI utilization included male sex (aOR, 2.04), fewer years in practice (vs ≥31 years; 11-20 years: aOR, 1.23; 21-30 years: aOR, 1.13), rural location (aOR, 1.25), and lower volume claudication practice (vs ≥30 patients diagnosed during study period; ≤17 patients: aOR, 1.30; 18-29 patients: aOR, 1.35; all P < .05). CONCLUSIONS: Outlier physicians with a high early PVI rate for patients newly diagnosed with claudication are identifiable using a claims-based practice pattern measure. Given the shared Society for Vascular Surgery and Choosing Wisely initiative goal to avoid interventions for first-line treatment of claudication, confidential data-sharing programs using national benchmarks and educational guidance may be useful to address high utilization in the management of claudication.
Assuntos
Procedimentos Endovasculares/tendências , Claudicação Intermitente/terapia , Avaliação de Processos e Resultados em Cuidados de Saúde/tendências , Doença Arterial Periférica/terapia , Padrões de Prática Médica/tendências , Procedimentos Desnecessários/tendências , Demandas Administrativas em Assistência à Saúde , Idoso , Bases de Dados Factuais , Planos de Pagamento por Serviço Prestado , Feminino , Fidelidade a Diretrizes/tendências , Humanos , Claudicação Intermitente/diagnóstico por imagem , Claudicação Intermitente/fisiopatologia , Masculino , Medicare , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/fisiopatologia , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
Simple (Bosniak I) renal cysts are considered acceptable in living kidney donor selection in terms of cancer risk. However, they tend to increase in number and size over time and might compromise renal function in donors. To clarify their implications for long-term renal function, we characterized the prevalence of renal cysts in 454 individuals who donated at our center from 2000 to 2007. We estimated the association between the presence of cysts in the kidney remaining after nephrectomy (ie, retained cysts) and postdonation eGFR trajectory using mixed-effects linear regression. Donors with retained cysts (N = 86) were older (P < .001) and had slightly lower predonation eGFR (median 94 vs 98 mL/min/1.73 m2 , P < .01) than those without cysts. Over a median 7.8 years, donors with retained cysts had lower baseline eGFR (-8.7 -5.6 -2.3 mL/min/1.73 m2 , P < .01) but similar yearly change in eGFR (-0.4 0.02 0.4 mL/min/1.73 m2 , P = .2) compared to those without retained cysts. Adjusting for predonation characteristics, there was no difference in baseline eGFR (P = .6) or yearly change in eGFR (P > .9). There continued to be no evidence of an association when we considered retained cyst(s) ≥10 mm or multiple retained cysts (all P > .05). These findings reaffirm current practices of accepting candidates with simple renal cysts for donor nephrectomy.
Assuntos
Cistos , Doenças Renais Císticas , Falência Renal Crônica , Transplante de Rim , Cistos/etiologia , Taxa de Filtração Glomerular , Humanos , Rim , Doenças Renais Císticas/cirurgia , Falência Renal Crônica/cirurgia , Doadores Vivos , Nefrectomia , Estudos RetrospectivosRESUMO
BACKGROUND: The prevalence of obesity is increasing in the United States. The treatment of end-stage renal disease (ESRD) via hemodialysis spans the spectrum of body mass index (BMI). This study examines the impact of BMI on outcomes of autogenous fistulas for hemodialysis access in a large population-based cohort of patients. METHODS: A retrospective study of all patients in the prospectively maintained United States Renal Database System who initiated hemodialysis between 2007 and 2014 was performed. Chi-squared test, t-tests, Kaplan-Meier estimates, log-rank tests, multivariable logistic and Cox regression analysis were employed to evaluate access maturation, interventions, patency, and mortality. RESULTS: There were 300,778 patients studied. Of these, 9,394 (3.1%) were underweight, 87,351 (29.1%) were normal weight, 86,101 (28.6%) were overweight, 57,047 (19%) were obese class I, 31,077 (10.3%) were obese class II, and 29,808 (9.9%) were obese class III. There was no significant difference in maturation for patients who were underweight (adjusted hazard ratio [aHR] 0.97, 95% CI 0.89-1.06, P = 0.48), overweight (aHR 1.01, 95% CI 0.97-1.05, P = 0.66), obese class I (aHR 1.05, 95% CI 0.99-1.09, P = 0.22), or obese class II (aHR 1.01, 95% CI 0.94-1.05, P = 0.98 relative to normal weight. However, there was a 6% decrease in maturation for obese class III patients (aHR 0.94, 95% CI 0.89-0.99, P = 0.02) compared to normal weight patients. Primary (aHR 0.93, 95% CI 0.91-0.96, P < 0.001), primary assisted (aHR 0.90, 95% CI 0.88-0.93, P < 0.001), and secondary patency (aHR 0.89, 95% CI 0.86-0.92, P < 0.001) were lower for underweight compared to normal weight patients. There was 8%, 10%, and 7% decrease in primary (aHR 0.92, 95% CI 0.90-0.93, P < 0.001), primary assisted (aHR 0.90, 95% CI 0.88-0.92, P < 0.001), and secondary patency (aHR 0.93, 95% CI 0.91-0.94, P < 0.001) respectively for patients in obese class III compared to patients with normal weight. There was an increase in patient survival with increasing BMI. CONCLUSIONS: In this population-based cohort of hemodialysis-dependent patients, severe obesity was associated with a decrease in fistula maturation. Extremes of BMI were associated with lower patency, but higher BMI was associated with better patient survival. Obese patients nearing ESRD might require earlier referral for arteriovenous fistula (AVF) placement in order to allow for maturation and AVF use at incident hemodialysis.
Assuntos
Derivação Arteriovenosa Cirúrgica , Índice de Massa Corporal , Nefropatias/terapia , Obesidade/diagnóstico , Diálise Renal , Idoso , Idoso de 80 Anos ou mais , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/mortalidade , Bases de Dados Factuais , Feminino , Humanos , Nefropatias/diagnóstico , Nefropatias/mortalidade , Masculino , Pessoa de Meia-Idade , Obesidade/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Magreza/diagnóstico , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Grau de Desobstrução VascularRESUMO
Deceased donor kidney transplantation (DDKT) rates for highly sensitized (HS) candidates increased early after implementation of the Kidney Allocation System (KAS) in 2014. However, this may represent a bolus effect, and a granular investigation of the current state of DDKT for HS candidates remains lacking. We studied 270 722 DDKT candidates from the SRTR from 12/4/2011 to 12/3/2014 ("pre-KAS") and 12/4/2014 to 12/3/2017 ("post-KAS"), analyzing DDKT rates for HS candidates using adjusted negative binomial regression. Post-KAS, candidates with the highest levels of sensitization had an increased DDKT rate compared with pre-KAS (cPRA 98% adjusted incidence rate ratio [aIRR]:1.27 1.772.46 P = .001, cPRA 99% aIRR:3.18 4.365.98 P < .001, cPRA 99.5-99.9% aIRR:16.91 24.2934.89 P < .001, and cPRA 99.9%+ aIRR:8.79 11.5815.26 P < .001). To determine whether these changes produced more equitable access to DDKT, we compared DDKT rates of HS to non-HS candidates (cPRA 0-79%). Post-KAS, cPRA, 98% candidates had an equivalent DDKT rate (aIRR:0.65 0.941.36 , P = .8) to non-HS candidates, whereas 99% candidates had a higher DDKT rate (aIRR:1.19 1.682.38 , P = .02). Although cPRA 99.5-99.9% candidates had an increased DDKT rate (aIRR:2.46 3.504.98 , P < .001) compared to non-HS candidates, cPRA 99.9%+ candidates had a significantly lower DDKT rate (aIRR:0.29 0.400.56 , P < .001). KAS has improved access to DDKT for HS candidates, although substantial imbalance exists between cPRA 99.5-99.9% and 99.9%+ candidates.
Assuntos
Falência Renal Crônica/mortalidade , Falência Renal Crônica/cirurgia , Transplante de Rim , Doadores de Tecidos , Listas de Espera , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Taxa de SobrevidaRESUMO
A recent study reported that kidney transplant recipients of offspring living donors had higher graft loss and mortality. This seemed counterintuitive, given the excellent HLA matching and younger age of offspring donors; we were concerned about residual confounding and other study design issues. We used Scientific Registry of Transplant Recipients data 2001-2016 to evaluate death-censored graft failure (DCGF) and mortality for recipients of offspring versus nonoffspring living donor kidneys, using Cox regression models with interaction terms. Recipients of offspring kidneys had lower DCGF than recipients of nonoffspring kidneys (15-year cumulative incidence 21.2% vs 26.1%, P < .001). This association remained after adjustment for recipient and transplant factors (adjusted hazard ratio [aHR] = 0.73 0.770.82 , P < .001), and was attenuated among African American donors (aHR 0.77 0.850.95 ; interaction: P = .01) and female recipients (aHR 0.77 0.840.91 , P < .001). Although offspring kidney recipients had higher mortality (15-year mortality 56.4% vs 37.2%, P < .001), this largely disappeared with adjustment for recipient age alone (aHR = 1.02 1.061.10 , P = .002) and was nonsignificant after further adjustment for other recipient characteristics (aHR = 0.93 0.971.01 , P = .1). Kidneys from offspring donors provided lower graft failure and comparable mortality. An otherwise eligible donor should not be dismissed because they are the offspring of the recipient, and we encourage continued individualized counseling for potential donors.