Effect of frailty syndrome on the outcomes of patients with carotid stenosis.

BACKGROUND: Frailty syndrome confers a greater risk of morbidity and mortality after operative interventions. The aim of the present study was to assess the effect of frailty on the outcomes after carotid interventions, including both carotid endarterectomy (CEA) and carotid artery stenting (CAS). METHODS: We performed an 8-year (2005-2012) retrospective analysis of the National Surgery Quality and Improvement Program database, including patients who had undergone CEA or CAS for carotid artery stenosis. A modified frailty index score was calculated. Frail status was defined as a modified frailty index score of ≥0.27. The outcome measures were inpatient complications, mortality, failure to rescue (FTR), hospital length of stay, and 30-day readmissions. Multivariable regression analysis was performed to study the association between frailty and the perioperative outcomes. RESULTS: The data from 37,875 patients were included. Of the 37,875 patients, 95.7% had undergone CEA, and 27.3% of the patients were frail (27% of the CEA and 26% of the CAS groups had qualified as frail). Overall, 11.7% of the patients had experienced complications, 2.2% had died, and 6.7% had been readmitted after discharge. On regression analysis, after controlling for age, gender, albumin level, type of surgery, and American Society of Anesthesiologists class, frail status was an independent predictor of complications (23.5% vs 7.2%; P < .001), mortality (5.2% vs 1.1%; P = .02), FTR (12.1% vs 4.7%; P = .02), and 30-day readmissions (14.9% vs 3.7%; P = .03). On subanalysis of the patients who had undergone CAS, no association was found between frail status and the occurrence of complications (odds ratio [OR], 1.5; 95% confidence interval [CI], 0.8-3.2), mortality (OR, 1.2; 95% CI, 0.6-2.7), FTR (OR, 0.9; 95% CI, 0.4-2.3), and 30-day readmission rate (OR, 1.1; 95% CI, 0.5-3.1). CONCLUSIONS: Frailty syndrome was associated with morbidity and mortality among patients undergoing surgical interventions for carotid stenosis. In the present study, frailty was associated with significant mortality and morbidity for those who had undergone CEA but not for those who had undergone CAS. However, the present study was not designed to determine the optimal treatment of frail patients. Incorporating frailty status into the treatment algorithm (CEA vs CAS) might provide a more accurate risk assessment and improve patient outcomes.

Frailty Syndrome in Patients with Carotid Disease: Simplifying How We Calculate Frailty.

BACKGROUND: Frailty syndrome is an established predictor of adverse outcomes after carotid surgery. Recently, a modified 5-factor National Surgical Quality Improvement Program frailty index has been used; however, its utility in vascular procedures is unclear. The aim of our study was to compare the 5-factor modified frailty index (mFI-5) with the 11-factor modified frailty index (mFI-11) regarding value and predictive ability for mortality, postoperative infection, and unplanned 30-day readmission. METHODS: The mFI was calculated by dividing the number of factors present for a patient by the number of available factors for which there were no missing data. Spearman rho test was used to assess the correlation between the mFI-5 and mFI-11. Predictive models, using both unadjusted and adjusted logistic regressions, were created for each outcome for carotid endarterectomy using 2005-2012 National Surgical Quality Improvement Program data, the last year all mFI-11 variables existed. RESULTS: A total of 36,000 patients were included with mean age of 74.6 ± 5.9 years, complication rate of 10.7%, mortality rate of 3.1%, and readmission rate of 6.2%. Correlation between mFI-5 and mFI-11 was above 0.9 across all outcomes for patients. mFI-5 had strong predictive ability for mortality, postoperative complications, and 30-day readmission. CONCLUSIONS: The mFI-5 and mFI-11 are equally effective predictors of postoperative outcomes in patients undergoing carotid endarterectomy. mFI-5 is a strong predictor of postoperative complications, mortality, and 30-day readmission.

Management of Abdominal Aortic Aneurysm With Concomitant Acute Cholecystitis in the Era of Endovascular Surgery.

The incidence of symptomatic acute cholecystitis with large (greater than 5.5 cm) abdominal aortic aneurysm is an uncommon occurrence. Guidelines on concomitant repair in this setting remain elusive, particularly in the era of endovascular repair. We present a case of acute cholecystitis in a 79-year-old female presenting to a local rural emergency room with abdominal pain and known abdominal aortic aneurysm (AAA). Abdominal computed tomography (CT) revealed a 5.5 cm infrarenal abdominal aortic aneurysm, significantly greater in size compared to previous imaging, as well as a distended gallbladder with mild wall thickening and cholelithiasis concerning for acute cholecystitis. The two conditions were found to be unrelated to each other, but concerns were raised on appropriate timing of care. Following diagnosis, the patient underwent concomitant treatment of acute cholecystitis and large abdominal aortic aneurysm with laparoscopic and endovascular techniques, respectively. In this report, we take the opportunity to discuss the treatment of patients with AAA and concomitant symptomatic acute cholecystitis.

Removal of an infected pulmonary artery fibroelastoma disguised as a presentation of pulmonary embolism using a percutaneous suction thrombectomy device.

Papillary fibroelastoma (PFE) is a rare, often benign, tumor originating typically in the endocardium and valves, with a preference for the left side of the heart. Although PFEs can appear asymptomatic, in the setting of embolization, they can lead to stroke, acute limb ischemia, and/or mesenteric ischemia. Rarely, PFEs can originate from the pulmonary valve, with the potential for embolic showering into the pulmonary artery, leading to potential right-sided heart outflow obstruction. Treatment has been open surgery in most cases, although treatment of right-sided heart masses with extracorporeal circulatory support extraction systems have been described. Recently, large bore suction thrombectomy devices have become available, typically used for cases of venous thromboembolism. In the present report, we describe a case of a symptomatic infected PFE treated by percutaneous suction thrombectomy using the Inari FlowTriever system (Inari Medical).

Acute Limb Arterial Ischemia Following Iliac Vein Stenting in the Setting of a Frozen Pelvis.

The authors report on a young patient with previous radiation to her pelvis who presented with acute limb ischemia following iliac vein stenting believed to be secondary to extrinsic iliac artery compression in the setting of a frozen pelvis. She underwent revascularization and a trans-femoral amputation, ultimately needing a femoral to femoral artery crossover bypass in order to achieve amputation stump healing. This case describes a potential arterial complication of venous stenting in a previously irradiated field.

Racial and ethnic disparities in lower extremity amputation: Assessing the role of frailty in older adults.

BACKGROUND: Frailty is a state of decreased physiologic reserve contributing to functional decline and is associated with adverse surgical outcomes, particularly in the elderly. Racial disparities have been reported previously both in frail individuals and in limb-salvage patients. Our goal was to assess whether race and ethnicity are disproportionately linked to frailty status in geriatric patients undergoing lower-limb amputation, leading to an increased risk of complications. METHODS: A 3-year analysis was conducted of the National Surgical Quality Improvement Program database and included all geriatric (age ≥65 years) patients who underwent amputation of the lower limb. The frailty index was calculated using the 11-factor modified frailty index with a cutoff limit of 0.27 defined for frail status. Outcomes were 30-day complications, mortality, and readmissions. Multivariate regression analysis was performed. RESULTS: A total of 4,218 geriatric patients underwent surgical amputation of a lower extremity (above knee: 41%; below knee: 59%). Of these patients, 29% were frail, 26% were African American, and 9% were Hispanic. Being African American (odds ratio: 1.6 [1.3-1.9]) and Hispanic (odds ratio: 1.1 [1.05-2.5]) was independently associated with frail status. Frail African Americans had a higher likelihood of 30-day complications (odds ratio: 3.2 [1.9-4.4]) and 30-day readmissions (odds ratio: 2.9 [1.8-3.6]) when compared with nonfrail individuals. Similarly, frail Hispanics had higher 30-day complications (odds ratio: 2.6 [1.9-3.1]) and 30-day readmissions (odds ratio: 1.4 [1.1-2.7]) compared with nonfrail Hispanics/Latinos. CONCLUSION: African American and Hispanic geriatric patients undergoing lower-limb amputation are at increased risk for frailty status and, as a result, increased associated operative complications. These disparities exist regardless of age, sex, comorbid conditions, and location of amputation. Further studies are needed to highlight disparities by race and ethnicity to identify potentially modifiable risk factors, decrease frailty, and improve outcomes.

Factors Associated with Wound Complications after Open Femoral Artery Exposure for Elective Endovascular Abdominal Aortic Aneurysm Repair.

We identified factors that would lead to wound complications after open femoral exposure for endovascular abdominal aortic aneurysm repair (oEVAR). Using the National Surgical Quality Improvement Program dataset (2005-2014), we examined the patients who underwent oEVAR. Patients were stratified on whether they developed postoperative wound complications. Comparisons were made between group with wound complications and those without and adjusted analyses performed to identify variables that independently increased the risk of wound complications. There were 14,868 patients in the study cohort and 2.6% (384 patients) developed wound complications after EVAR. Among those with wound complications, 94% (360 patients) of patients had superficial and deep surgical site infection. Patients who had wound complication were likely to be younger (72.6 vs. 73.7 years old ( p = 0.02), functionally dependent (5.4 vs. 2.5%) ( p < 0.05), smoker (3 vs. 2.4%, p =0.03), female (4 vs. 2.2%), with significantly higher body mass index (31 vs. 28), and more commonly had diabetes (4 vs. 2.4%, p < 0.001) or renal failure (12 vs. 3%, p < 0.001). Although perioperative survival was similar, patients who had wound complications had significantly longer hospital length of stay (LOS) (7.3 ± 12 vs. 3.4 ± 5 days, p < 0.001). Up to 3% patients developed wound complications after open femoral exposure during EVAR with significantly higher LOS and therefore cost utilization.

Perigraft air mimicking infection on CT angiography following open abdominal aortic aneurysm repair.

Aortic graft infection is a feared complication after open abdominal aortic aneurysm repair secondary to its high mortality. Perigraft air is a common finding after open aortic aneurysm repair; however, it is also associated with aortic graft infection. Delineating between graft infection and common postoperative finding is a challenge. This is further complicated by use of hemostatic agents such as Gelfoam, which is also documented to cause perigraft air. Correct diagnosis has crucial implications in management of potential aortic graft infection, which is a vascular emergency. We report a case of perigraft air in a patient status after open aortic aneurysm repair with associated clinical manifestations of infection in whom conservative management and surveillance was selected for treatment. We then discuss the timeline of perigraft air, potential causation, importance of history, and physical examination, and finally, we discuss how specific findings on computed tomography imaging for infection in other areas may be useful in aortic graft infection.

Hypocalcemia-induced seizure: demystifying the calcium paradox.

Calcium is essential for both neurotransmitter release and muscle contraction. Given these important physiological processes, it seems reasonable to assume that hypocalcemia may lead to reduced neuromuscular excitability. Counterintuitively, however, clinical observation has frequently documented hypocalcemia's role in induction of seizures and general excitability processes such as tetany, Chvostek's sign, and bronchospasm. The mechanism of this calcium paradox remains elusive, and very few pathophysiological studies have addressed this conundrum. Nevertheless, several studies primarily addressing other biophysical issues have provided some clues. In this review, we analyze the data of these studies and propose an integrative model to explain this hypocalcemic paradox.