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Zecca F, Faa G, Sanfilippo R, Saba L. How to improve epidemiological trustworthiness concerning abdominal aortic aneurysms. Vascular 2025; 33:520-535. [PMID: 38842081 DOI: 10.1177/17085381241257747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
BackgroundResearch on degenerative abdominal aortic aneurysms (AAA) is hampered by complex pathophysiology, sub-optimal pre-clinical models, and lack of effective medical therapies. In addition, trustworthiness of existing epidemiological data is impaired by elements of ambiguity, inaccuracy, and inconsistency. Our aim is to foster debate concerning the trustworthiness of AAA epidemiological data and to discuss potential solutions.MethodsWe searched the literature from the last five decades for relevant epidemiological data concerning AAA development, rupture, and repair. We then discussed the main issues burdening existing AAA epidemiological figures and proposed suggestions potentially beneficial to AAA diagnosis, prognostication, and management.ResultsRecent data suggest a heterogeneous scenario concerning AAA epidemiology with rates markedly varying by country and study cohorts. Overall, AAA prevalence seems to be decreasing worldwide while mortality is apparently increasing regardless of recent improvements in aortic-repair techniques. Prevalence and mortality are decreasing in high-income countries, whereas low-income countries show an increase in both. However, several pieces of information are missing or outdated, thus systematic renewal is necessary. Current AAA definition and surgical criteria do not consider inter-individual variability of baseline aortic size, further decreasing their reliability.ConclusionsSwitching from flat aortic-size thresholds to relative aortic indices would improve epidemiological trustworthiness regarding AAAs. Aortometry standardization focusing on simplicity, univocity, and accuracy is crucial. A patient-tailored approach integrating clinical data, multi-adjusted indices, and imaging parameters is desirable. Several novel imaging modalities boast promising profiles for investigating the aortic wall. New contrast agents, computational analyses, and artificial intelligence-powered software could provide further improvements.
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Affiliation(s)
- Fabio Zecca
- Department of Radiology, University Hospital "D. Casula", Cagliari, Italy
| | - Gavino Faa
- Department of Pathology, University Hospital "D. Casula", Cagliari, Italy
| | - Roberto Sanfilippo
- Department of Vascular Surgery, University Hospital "D. Casula", Cagliari, Italy
| | - Luca Saba
- Department of Radiology, University Hospital "D. Casula", Cagliari, Italy
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Franco RDL, Iora PH, Massago M, Arruda Beltrame MH, Hatoum US, Giacomin V, Borba IM, Belczak SQ, Staton CA, Dutra ADC, Andrade LD. Geographical disparities in access to surgical treatment and mortality rates from abdominal aortic aneurysms in Brazil: A retrospective longitudinal study. Vasc Med 2024; 29:526-531. [PMID: 38860442 DOI: 10.1177/1358863x241253732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
INTRODUCTION Abdominal aortic aneurysm (AAA) is a growing public health problem, and not all patients have access to surgery when needed. This study aimed to analyze spatiotemporal variations in AAA mortality and surgical procedures in Brazilian intermediate geographic regions and explore the impact of different surgical techniques on operative mortality. METHODS A retrospective longitudinal study was conducted to evaluate AAA mortality from 2008 to 2020 using space-time cube (STC) analysis and the emerging hot spot analysis tool through the Getis-Ord Gi* method. RESULTS There were 34,255 deaths due to AAA, 13,075 surgeries to repair AAA, and a surgical mortality of 14.92%. STC analysis revealed an increase in AAA mortality rates (trend statistic = +1.7693, p = 0.0769) and a significant reduction in AAA surgery rates (trend statistic = -3.8436, p = 0.0001). Analysis of emerging hotspots revealed high AAA mortality rates in the South, Southeast, and Central-West, with a reduction in procedures in São Paulo and Minas Gerais States (Southeast). In the Northeast, there were extensive areas of increasing mortality rates and decreasing procedure rates (cold spots). CONCLUSION AAA mortality increased in several regions of the country while surgery rates decreased, demonstrating the need for implementing public health policies to increase the availability of surgical procedures, particularly in less developed regions with limited access to services.
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Affiliation(s)
- Rogério do Lago Franco
- Medicine Department, State University of Maringá, Maringá, PR, Brazil
- Postgraduate Master Health Sciences Program, State University of Maringá, Maringá, PR, Brazil
| | | | - Miyoko Massago
- Postgraduate Master Health Sciences Program, State University of Maringá, Maringá, PR, Brazil
| | | | - Ualid Saleh Hatoum
- Postgraduate Master Health Sciences Program, State University of Maringá, Maringá, PR, Brazil
| | - Vinicius Giacomin
- Postgraduate Master Health Sciences Program, State University of Maringá, Maringá, PR, Brazil
| | | | | | | | | | - Luciano de Andrade
- Medicine Department, State University of Maringá, Maringá, PR, Brazil
- Postgraduate Master Health Sciences Program, State University of Maringá, Maringá, PR, Brazil
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Magnani AS, de Castro LT, Manta ICKA, Dib VG, Vittorelli LO, Portela FSO, Wolosker N, Teivelis MP. Preoperative evaluation profile of patients undergoing arterial vascular surgery in a tertiary hospital. Clinics (Sao Paulo) 2024; 79:100445. [PMID: 39059143 PMCID: PMC11338055 DOI: 10.1016/j.clinsp.2024.100445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 06/02/2024] [Accepted: 06/27/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Patients with peripheral arterial disease have an increased risk of developing cardiovascular complications in the postoperative period of arterial surgeries known as Major Adverse Cardiac Events (MACE), which includes acute myocardial infarction, heart failure, malignant arrhythmias, and stroke. The preoperative evaluation aims to reduce mortality and the risk of MACE. However, there is no standardized approach to performing them. The aim of this study was to compare the preoperative evaluation conducted by general practitioners with those performed by cardiologists. METHODS This is a retrospective analysis of medical records of patients who underwent elective arterial surgeries from January 2016 to December 2020 at a tertiary hospital in São Paulo, Brazil. The authors compared the preoperative evaluation of these patients according to the initial evaluator (general practitioners vs. cardiologists), assessing patients' clinical factors, mortality, postoperative MACE incidence, rate of requested non-invasive stratification tests, length of hospital stay, among others. RESULTS 281 patients were evaluated: 169 assessed by cardiologists and 112 by general practitioners. Cardiologists requested more non-invasive stratification tests (40.8%) compared to general practitioners (9%) (p < 0.001), with no impact on mortality (8.8% versus 10.7%; p = 0.609) and postoperative MACE incidence (10.6% versus 6.2%; p = 0.209). The total length of hospital stay was longer in the cardiologist group (17.27 versus 11.79 days; p < 0.001). CONCLUSION The increased request for exams didn't have a significant impact on mortality and postoperative MACE incidence, but prolonged the total length of hospital stay. Health managers should consider these findings and ensure appropriate utilization of human and financial resources.
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Affiliation(s)
- Arthur Souza Magnani
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Leandro Teixeira de Castro
- Hospital Municipal da Vila Santa Catarina Dr. Gilson de Cássia Marques de Carvalho; Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Isabela Cristina Kirnew Abud Manta
- Hospital Municipal da Vila Santa Catarina Dr. Gilson de Cássia Marques de Carvalho; Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Viviane Galli Dib
- Hospital Municipal da Vila Santa Catarina Dr. Gilson de Cássia Marques de Carvalho; Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Luiz Otávio Vittorelli
- Hospital Municipal da Vila Santa Catarina Dr. Gilson de Cássia Marques de Carvalho; Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Felipe Soares Oliveira Portela
- Hospital Municipal da Vila Santa Catarina Dr. Gilson de Cássia Marques de Carvalho; Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Nelson Wolosker
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil; Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Marcelo Passos Teivelis
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil; Hospital Municipal da Vila Santa Catarina Dr. Gilson de Cássia Marques de Carvalho; Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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Portela FSO, Rossetti CA, de Souza TF, Magnani AS, da Silva MFA, Portugal MFC, Teivelis MP, Wolosker N, Mendes CDA. Retrospective analysis of 1,203 cases of referral to a quaternary vascular surgery outpatient clinic within the Unified Health System, São Paulo, Brazil. EINSTEIN-SAO PAULO 2024; 22:eAO0676. [PMID: 38808797 PMCID: PMC11155721 DOI: 10.31744/einstein_journal/2024ao0676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 11/27/2023] [Indexed: 05/30/2024] Open
Abstract
OBJECTIVE Through a retrospective analysis of 1,203 cases of referral from primary healthcare units to a specialized quaternary vascular surgical service, the findings of this study revealed a high proportion of inappropriate referrals, which may represent a substantial subutilization of this highly complex service. Consequently, in this study, we aimed to evaluate 1,203 cases of referral to a quaternary vascular surgical service, in São Paulo, Brazil, over a 6-year period, to assess the appropriate need for referral; in addition to the prevalence of surgical indications. METHODS In this retrospective analysis, we reviewed the institutional records of participants referred from Basic Healthcare Units to a vascular surgical service inside the Brazilian Unified Health System, between May 2015 and December 2020. Demographic and clinical data were collected. The participants were stratified, as per the reason for referral to the vascular surgical service, previous imaging studies, and surgical treatment indications. Referral appropriateness and complementary examinations were evaluated for each disease cohort. Finally, the prevalence of cases requiring surgical treatment was defined as the outcome measure. RESULTS Of the 1,203 referrals evaluated, venous disease was the main reason for referral (53%), followed by peripheral arterial disease (19.4%). A considerable proportion of participants had been referred without complementary imaging or after a long duration of undergoing an examination. Referrals were regarded as inappropriate in 517 (43%) cases. Of these, 32 cases (6.2%) had been referred to the vascular surgical service, as the incorrect specialty. The percentage of referred participants who ultimately underwent surgical treatment was 39.92%. Carotid (18%) and peripheral arterial diseases (18.4%) were correlated with a lower prevalence of surgical treatments. CONCLUSION The rate of referral appropriateness to specialized vascular care from primary care settings was low. This may represent a subutilization of quaternary surgical services, with low rates of surgical treatment.
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Affiliation(s)
| | - Carlos Augusto Rossetti
- Faculdade Israelita de Ciências da Saúde Albert EinsteinHospital Israelita Albert EinsteinSão PauloSPBrazil Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Thulio Fernandes de Souza
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Arthur Souza Magnani
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | | | | | - Marcelo Passos Teivelis
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
- Faculdade Israelita de Ciências da Saúde Albert EinsteinHospital Israelita Albert EinsteinSão PauloSPBrazil Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Nelson Wolosker
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
- Faculdade Israelita de Ciências da Saúde Albert EinsteinHospital Israelita Albert EinsteinSão PauloSPBrazil Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Cynthia de Almeida Mendes
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
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Alexandrino da Silva MF, Oliveira Portela FS, Sposato Louzada AC, Teivelis MP, Amaro Junior E, Wolosker N. National Cross-Sectional Epidemiological Analysis of the Impact of Pandemic COVID-19 on Vascular Procedures in Public Health System: 521,069 Procedures Over 4 Years. Ann Vasc Surg 2024; 98:7-17. [PMID: 37717819 DOI: 10.1016/j.avsg.2023.07.103] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/09/2023] [Accepted: 07/19/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND During the COVID-19 pandemic, there was a dramatic increase in healthcare demand. Resources were redirected to care patients with COVID-19. Therefore, surgical treatments were affected, including those of vascular diseases. There are no studies evaluating the whole impact of the COVID-19 pandemic, considering all types of vascular procedures, both elective and urgent, in a large country. The aim of the present study was to analyze the impact on all types of vascular procedures performed in Brazilian public hospitals during the COVID-19 pandemic. METHODS Cross-sectional population-based analysis of publicly available data referring to vascular procedures. Surgeries 2 years before the pandemic onset (2018-2019) and 2 years during pandemic (2020-2021) were included. RESULTS We observed a total of 521,069 procedures. Decrease was observed in elective abdominal aortic aneurysm repairs both open surgery (P = 0.001) and endovascular surgery (P < 0.001), emergency open abdominal repairs (P = 0.005), elective thoracic aortic aneurysm repairs (P = 0.007), elective open peripheral aneurysm repairs (P = 0.038), carotid endarterectomies (P < 0.001) and angioplasties (P = 0.001), open revascularizations for peripheral arterial disease (P < 0.001), surgical treatment of chronic venous disease (P < 0.001) and sympathectomies for hyperhidrosis (P < 0.001). However, there was an increase of lower limb amputations (P = 0.027) and vena cava filter placements (P = 0.005). There was a reduction of almost US$17 million in financial investments. CONCLUSIONS The reorganization of health systems led to a significant reduction in vascular procedures and decrease in financial investments. On the other hand, there was a significant increase in the number of lower limb amputations and vena cava filter placements.
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Affiliation(s)
- Marcelo Fiorelli Alexandrino da Silva
- Department of Vascular Surgery, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil; Faculdade Israelita de Ciências da Saúde Albert Einstein (FICSAE), Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | | | - Andressa Cristina Sposato Louzada
- Department of Vascular Surgery, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil; Faculdade Israelita de Ciências da Saúde Albert Einstein (FICSAE), Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Marcelo Passos Teivelis
- Department of Vascular Surgery, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil; Faculdade Israelita de Ciências da Saúde Albert Einstein (FICSAE), Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Edson Amaro Junior
- Department of Vascular Surgery, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Nelson Wolosker
- Department of Vascular Surgery, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil; Faculdade Israelita de Ciências da Saúde Albert Einstein (FICSAE), Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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Wolosker N, Louzada ACS, Portela FSO, da Silva MFA, Schettino GDPP, Corrêa LH, Juniordata EA, Teivelis MP. Proposed public policies to improve outcomes in vascular surgery: an experts' forum. EINSTEIN-SAO PAULO 2023; 21:eAE0241. [PMID: 37585883 PMCID: PMC10421605 DOI: 10.31744/einstein_journal/2023ae0241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 12/18/2022] [Indexed: 08/18/2023] Open
Abstract
OBJECTIVE To evaluate outcomes of vascular surgeries and identify strategies to improve public vascular care. METHODS This was a descriptive, qualitative, and cross-sectional survey involving 30 specialists of the Hospital Israelita Albert Einstein via Zoom. The outcomes of vascular procedures performed in the Public Health System extracted through Big Data analysis were discussed, and 53 potential strategies to improve public vascular care to improve public vascular care. RESULTS There was a consensus on mandatory reporting of some key complications after complex arterial surgeries, such as stroke after carotid revascularization and amputations after lower limb revascularization. Participants agreed on the recommendation of screening for diabetic feet and infrarenal abdominal aortic aneurysms. The use of Telemedicine as a tool for patient follow-up, auditing of centers for major arterial surgeries, and the concentration of complex arterial surgeries in reference centers were also points of consensus, as well as the need to reduce the values of endovascular materials. Regarding venous surgery, it was suggested that there should be incentives for simultaneous treatment of both limbs in cases of varicose veins of the lower limbs, in addition to the promotion of ultrasound-guided foam sclerotherapy in the public system. CONCLUSION After discussing the data from the Brazilian Public System, proposals were defined for standardizing measures in population health care in the area of vascular surgery. Notification of complications of arterial surgeries is essential in identifying strategies to improve surgical outcomes. Screening of prevalent and/or morbid diseases allows early intervention and prevention of complications. Use of telemedicine in vascular follow-up allows optimizing the use of resources and reducing the burden on health services. Concentrating complex cases in reference hospitals leads to improved surgical outcomes.
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Affiliation(s)
- Nelson Wolosker
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
- Faculdade Israelita de Ciências da Saúde Albert EinsteinHospital Israelita Albert EinsteinSão PauloSPBrazil Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | | | | | | | | | - Lucas Hernandes Corrêa
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Edson Amaro Juniordata
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Marcelo Passos Teivelis
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
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