Incidence of Procedure-Related Complications in Patients Treated With Atherectomy in the Femoropopliteal and Tibial Vessels in the Vascular Quality Initiative.

PURPOSE: To compare procedural complications in patients undergoing atherectomy plus angioplasty (A+A) and plain balloon angioplasty (POBA). MATERIALS AND METHODS: Patients in the Vascular Quality Initiative (VQI) registry undergoing first-time peripheral vascular intervention (PVI) were included. Those undergoing aortoiliac or pedal interventions, primary stenting, or hybrid procedures were excluded. Patients were stratified by lesion location (femoropopliteal [FP] or tibial [TIB]). The primary outcomes were target vessel dissection, distal embolization, and provisional stent placement. Secondary outcomes included postoperative complications and the need for subsequent interventions. RESULTS: 12 499 patients undergoing FP (49.6% A+A) and 6736 patients undergoing TIB (17.0% A+A) interventions were identified. In the FP group, A+A was associated with greater intraoperative target vessel dissection (4.5% vs 2.6%, p<0.001), distal embolization (1.5% vs 0.7%, p =0.001), and provisional stent placement (1.5% vs 0%, p<0.001); and greater postoperative target vessel dissection (4.2% vs 2.0%, p<0.001) and distal embolization (0.9% vs 0.4%, p=0.034). In the TIB group, A+A was associated with fewer intraoperative vessel dissection (0.8% vs 2.3%, p=0.011) but greater provisional stent placement (0.3% vs 0%, p<0.001). TIB A+A was also associated with higher rates of technical success (97.6% vs 95.1%, p<0.001). CONCLUSIONS: Atherectomy was associated with increased procedural-related complications in femoropopliteal, but not in tibial vessels. Future studies addressing lesion morphology, device design, and technique may help define its role in peripheral vascular interventions.

Review of Malpractice Litigation in the Diagnosis and Treatment of Venous & Lymphatic Disease.

BACKGROUND: Malpractice claims involving nonthrombotic venous and lymphatic diseases and interventions have not been reported previously. We investigated common reasons for litigation, medical specialties involved, patient injuries, and case outcomes in malpractice litigation involving venous and lymphatic disease. METHODS: Litigation cases entered into the Westlaw database from June 8th, 1984 to February 15th, 2018 were analyzed. Search terms included relevant words and phrases related to nonthrombotic venous, thoracic outlet syndrome, and lymphatic disease and treatment. Data on physician specialty, malpractice claims, and patient injuries jury outcomes, amount awarded to the plaintiff, and jury fees were collected and compared for each category. RESULTS: A total of 144 cases were identified. 41 cases involved varicose veins, 11 spider veins, 35 thoracic outlet syndrome (TOS), 17 other venous diseases, and 40 lymphatic diseases. Physician defendants were frequently vascular surgeons (23%) and general surgeons (15%). The majority of litigation claims involved "post-procedure complication" (77%), "lack of informed consent" (25%), "failure to diagnose & treat" (15%), and "intraoperative complications" (13%). The most common injuries were skin damage (27.8%), nerve damage (25%), and lymphedema (24%). Patient death occurred in 6% of cases. Out of venous malpractice cases with post-procedure complications, stab phlebectomy (27%) was the most common intervention followed by foam sclerotherapy (21%), rib resection (21%), laser spider vein removal (5%), and endovenous laser ablation therapy (EVLT)(3%). Of varicose vein cases, 15% included deep vein thrombosis or pulmonary embolism as post-procedure complications. In TOS rib resections, 65% of cases referenced nerve damage and 12% involved arterial injury. For lymphatic disease cases, general surgeons were frequently identified defendants (25%). Lymphedema (93%) and lymphangitis (7%) occurred as post-procedure complications after breast, gynecologic, orthopedic, and radiation procedures. A majority of complications occurred after breast cases (40%). Verdicts overall ruled in favor of the defendant in 71% (102/144) of cases and the plaintiff in 20% (29/144) of cases. Out of cases ruled in favor of the plaintiff, 31% were lymphatics, 24% varicose veins, and 24% TOS cases. Only 8% (12/144) of cases were settled and one outcome was unknown. The mean award was $820,193 (standard deviation SD $1,226,008, Range $12,853 - $6,500,000). CONCLUSIONS: The majority of venous and lymphatic litigation cases involve claims of post-procedure complications. Venous complications occurred after open and endovascular treatment of varicose veins, spider vein treatment, and surgical management of TOS. Lymphedema occurred after breast, oncology, and orthopedic procedures. These cases reflect opportunities for intervention to help potentially prevent litigation.

Initiation of hemodialysis at one month following fistulogram in patients with advanced kidney disease.

OBJECTIVE: Previous studies have demonstrated that low contrast volume used in access-related interventions had limited effects on the progression of chronic kidney disease (CKD) after fistulography, but studies are limited and heterogeneous. We sought to evaluate the rate of and factors associated with progression to dialysis (HD) within 1 month after fistulography for patients with advanced CKD. METHODS: A single-institution retrospective cohort analysis of patients with CKD stage IV and V, not yet on HD, undergoing fistulography from 1 January 2014 to 31 December 2018 was performed. The primary outcome was progression to HD within 1 month. Additional variables and the association with the primary outcome such as medical comorbidities, contrast type or volume were assessed. RESULTS: A total of 34 patients underwent 41 fistulograms prior to HD initiation. Progression to HD within 1 month of fistulogram occurred in seven patients (all CKD V). The mean time between fistulogram and HD was 271 days for 31 of 34 patients who ultimately progressed to HD. Those with CKD IV began HD in 549 days on average, while those with CKD V began HD in 190 days on average. Three patients had not initiated HD at a mean of 539 days of follow-up. The only factors associated with progression to HD within 1 month included use of isovue (p = .005) and elevated contrast volume, with a mean of 40 mL (p = .027). CONCLUSION: Although none of the patients with CKD IV required HD within 1 month after fistulogram, the use of larger iodinated contrast volume was associated with progression to HD within 1 month of fistulography for patients with CKD V. Further studies should investigate the safety of iodinated and alternative (e.g., carbon dioxide) contrast media in fistulography or duplex-based HD access procedures for CKD patients, especially CKD V, not yet on HD.

The current state of vascular surgery presence and educational content in Google and YouTube internet search results.

BACKGROUND: Information on the internet regarding vascular disease has not been extensively assessed. Our goal was to compile and appraise the information available via Google and YouTube searches regarding various topics of interest for vascular surgeons (VS) and related procedures with a focus on the role of the VS. METHODS: The Google and YouTube platforms were independently queried for 25 keywords/phrases relating to common vascular diagnoses and procedures by two separate researchers from March to July 2019. Paid advertisements or a Society for Vascular Surgery (SVS) webpage or affiliated video in the first 25 results was documented. Results were reviewed for information regarding the responsible medical specialty and the target audience, and disease-related information (screening, risk factors, risk reduction, diagnostic testing, operative treatment, alternative treatment, follow-up, complications, and recovery). RESULTS: From the Google search, 357 unique domains of 1241 total webpages were identified with 75% directed toward the public. An SVS page was present in 56% of the first-page results and least likely to be present in searches for claudication, gangrene, carotid stent, rib resection, and thrombolysis. VS were mentioned as referral physicians in 56% of the 68% of websites that mentioned a specialty, endovascular specialists/interventional radiology in 20%, and cardiothoracic surgeons in 19%. Only 4% of the websites contained information from all categories, with the greatest number for aortic dissection. Advertisements were present in 18% of all searches (most commonly for "varicose vein," "varicose vein surgery," and "inferior vena cava filter"). From YouTube, 1247 search results (613 unique videos) were evaluated with 64% directed toward the public. An SVS affiliated video was present in 36% of searches. In the 47% of videos where a specialty was mentioned, 56% mentioned VS, interventional radiology in 10%, and cardiothoracic surgeons in 7%. Only 0.24% of the videos contained information from all categories. The greatest number of content categories was in videos related to peripheral arterial disease. Across both platforms, dialysis access searches yielded results with the least number of content categories. CONCLUSIONS: Patient-related information regarding vascular surgical topics is readily available on the internet, but the content is highly variable and not comprehensive. Only half of the searches mention VS as the referral physician of choice or authority for these medical conditions. Further efforts should focus on developing the online presence of vascular surgery, improving the quality of education of vascular disease on the internet, and directing patients to the vascular specialists to treat these conditions.

Unhealthful Food-and-Beverage Advertising in Subway Stations: Targeted Marketing, Vulnerable Groups, Dietary Intake, and Poor Health.

Unhealthful food-and-beverage advertising often targets vulnerable groups. The extent of such advertising in subway stations has not been reported and it is not clear how ad placement may relate to subway ridership or community demographics, or what the implications might be for diets and diet-related health in surrounding communities. Riding all subway lines (n = 7) in the Bronx, NY, USA, investigators systematically assessed all print ads (n = 1586) in all stations (n = 68) in 2012. Data about subway ridership came from the Metropolitan Transportation Authority. Demographic data on surrounding residential areas came from the U.S. Census Bureau. Data on dietary intake and diet-related conditions came from a city health-department survey. There were no ads promoting "more-healthful" food-or-beverage items (i.e., fruits, vegetables, whole grains, nuts, water or milk). There were many ads for "less-healthful" items (e.g., candies, chips, sugary cereals, frozen pizzas, "energy" drinks, coffee confections, hard alcohol, and beer). Ad placement did not relate to the number of riders entering at stations. Instead, exposure to food-or-beverage ads generally, and to "less-healthful" ads particularly (specifically ads in Spanish, directed at youth, and/or featuring minorities), was directly correlated with poverty, lower high-school graduation rates, higher percentages of Hispanics, and/or higher percentages of children in surrounding residential areas. Correlations were robust to sensitivity analyses. Additional analyses suggested correlations between ad exposures and sugary-drink consumption, fruit-and-vegetable intake, and diabetes, hypertension, and high-cholesterol rates. Subway-station ads for "less-healthful" items were located disproportionately in areas home to vulnerable populations facing diet and diet-related-health challenges. The fact that uneven ad placement did not relate to total rider counts suggests ads were not directed at the largest possible audiences but rather targeted to specific groups.

Urban farmers' markets: accessibility, offerings, and produce variety, quality, and price compared to nearby stores.

Most food-environment research has focused narrowly on select stores and restaurants. There has been comparatively less attention to non-storefront food sources like farmers' markets (FMs), particularly in urban communities. The objective of the present study was to assess FMs' potential contribution to an urban food environment in terms of specific foods offered, and compare FM accessibility as well as produce variety, quality, and price to that of nearby stores. Investigators conducted a detailed cross-sectional assessment of all FMs in Bronx County, NY, and of the nearest store(s) selling produce within a half-mile walking distance (up to two stores per FM). The study included 26 FMs and 44 stores. Investigators assessed accessibility (locations of FMs and stores relative to each other, and hours of operation for each), variety (the number and type of all food items offered at FMs and all fresh produce items offered at stores), quality (where produce items were grown and if they were organic), and price (including any sales prices or promotional discounts). Analyses included frequencies, proportions, and variable distributions, as well as mixed-effect regressions, paired t-tests, and signed rank tests to compare FMs to stores. Geographic information systems (GIS) allowed for mapping of FM and store locations and determining street-network distances between them. The mean distance between FMs and the nearest store selling fresh produce was 0.15 miles (range 0.02-0.36 miles). FMs were open substantially fewer months, days, and hours than stores. FMs offered 26.4 fewer fresh produce items on average than stores (p values <0.02). FM produce items were more frequently local and organic, but often tended toward less-common/more-exotic and heirloom varieties. FMs were more expensive on average (p values <0.001 for pairwise comparisons to stores) - even for more-commonplace and "conventional" produce - especially when discounts or sales prices were considered. Fully, 32.8% of what FMs offered was not fresh produce at all but refined or processed products (e.g., jams, pies, cakes, cookies, donuts, juice drinks). FMs may offer many items not optimal for good nutrition and health, and carry less-varied, less-common fresh produce in neighborhoods that already have access to stores with cheaper prices and overwhelmingly more hours of operation.

Review of Malpractice Lawsuits in the Diagnosis and Management of Aortic Aneurysms and Aortic Dissections.

OBJECTIVE: Aortic aneurysms and dissections are prevalent causes of morbidity and mortality. The management of aortic pathologies may be called into question in malpractice suits. Malpractice claims were analyzed to understand common reasons for litigation, medical specialties involved, patient injuries, and outcomes. METHODS: Litigation cases in the Westlaw database from September 1st, 1987 to October 23 rd, 2019 were analyzed. Search terms included "aortic aneurysm" and "aortic dissection." Data on plaintiff, defendant, litigation claims, patient injuries, misdiagnoses, and case outcomes were collected and compared for aortic aneurysms, aortic dissections, and overall cases. RESULTS: A total of 346 cases were identified, 196 involving aortic aneurysms and 150 aortic dissections. Physician defendants were emergency medicine (29%), cardiology (20%), internal medicine (14%), radiology (11%), cardiothoracic (10%) and vascular surgery (10%). Litigation claims included "failure to diagnose and treat" (61%), "delayed diagnosis and treatment" (21%), "post-operative complications after open repair" (10%) and "negligent post-operative care" (10%). Patients with aneurysms presented with abdominal (63%) and back pain (37%), while dissections presented with chest pain (78%), abdominal pain (15%), and shortness of breath (14%). Misdiagnoses included gastrointestinal (12%), other cardiovascular (9%), and musculoskeletal conditions (9%), but many were not specified (58%). Overall, 83% of cases were wrongful death suits. Injuries included loss of consortium (23%), emotional distress (19%), and bleeding (17%). In 53% of the cases, the jury ruled in favor of the defendant. 25% of cases ruled for the plaintiff. 22% of cases resulted in a settlement. The mean rewarded for each case was $1,644,590.66 (SD: $5,939,134.58; Range: $17,500-$68,035,462). CONCLUSION: For aortic pathologies, post-operative complications were not prominent among the reasons why suits were brought forth. This suggests improvements in education across all involved medical specialties may allow for improved diagnostic accuracy and efficient treatment, which could then translate to a decrease in associated litigation cases.

Race and Ethnicity and Satisfaction With Communication in the Intensive Care Unit.

PURPOSE: Racial and ethnic minority patients receive poorer quality end-of-life (EoL) care compared with white patients. Differences in quality of communication (QOC) with clinicians may contribute to these disparities. We measured differences in satisfaction with communication in the intensive care unit (ICU) by race and ethnicity. MATERIALS AND METHODS: This is a cross-sectional survey of family members of patients in ICUs of an academic medical center serving a diverse urban population using The Family Satisfaction with the ICU (FS-ICU) and QOC scales. RESULTS: One hundred surveys were completed (18.8% white, non-Hispanic; 34.4% black, non-Hispanic; 31.3% Hispanic; 15.6% other race/ethnicity). Mean FS-ICU score was 84.2 (standard deviation [SD] 20.5) for white patients, 83.3 (SD 16.2) for black patients, 82.7 (SD 17.8) for Hispanic or Latino patients, and 80.9 (SD 18.8) for patients with other race/ethnicity (Kruskal-Wallis, P = .92). Differences remained insignificant when controlling for patient and respondent characteristics. The QOC scale was not scored due to nonresponse levels on questions about EoL communication. CONCLUSIONS: Uniformly high ratings may have been influenced by avoidance of EoL discussion. This study is inconclusive regarding whether QOC influences disparities in EoL care since quality of EoL communication was not captured.