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Fanaroff AC, Dayoub EJ, Yang L, Schultz K, Ramadan OI, Wang GJ, Damrauer SM, Genovese EA, Secemsky EA, Parikh SA, Nathan AS, Kohi MP, Weinberg MD, Jaff MR, Groeneveld PW, Giri JS. Association Between Diagnosis-to-Limb Revascularization Time and Clinical Outcomes in Outpatients With Chronic Limb-Threatening Ischemia: Insights From the CLIPPER Cohort. J Am Heart Assoc 2024; 13:e033898. [PMID: 38639376 DOI: 10.1161/jaha.123.033898] [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: 01/05/2024] [Accepted: 03/18/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND The extent and consequences of ischemia in patients with chronic limb-threatening ischemia (CLTI) may change rapidly, and delays from diagnosis to revascularization may worsen outcomes. We sought to describe the association between time from diagnosis to endovascular lower extremity revascularization (diagnosis-to-limb revascularization [D2L] time) and clinical outcomes in outpatients with CLTI. METHODS AND RESULTS In the CLIPPER cohort, comprising patients between 66 and 86 years old diagnosed with CLTI betweeen 2010 and 2019, we used Medicare claims data to identify patients who underwent outpatient endovascular revascularization within 180 days of diagnosis. We described the risk-adjusted association between D2L time and clinical outcomes. Among 1 130 065 patients aged between 66 and 86 years with CLTI, 99 221 (8.8%) underwent outpatient endovascular lower extremity revascularization within 180 days of their CLTI diagnosis. Among patients with D2L time <30 days, there was no association between D2L time and all-cause death or major lower extremity amputation. However, among patients with D2L time >30 days, each additional 10-day increase in D2L time was associated with a 2.5% greater risk of major amputation (hazard ratio, 1.025 [95% CI, 1.014-1.036]). There was no association between D2L time and all-cause death. CONCLUSIONS A delay of >30 days from CLTI diagnosis to lower extremity endovascular revascularization was associated with an increased risk of major lower extremity amputation among patients undergoing outpatient endovascular revascularization. Improving systems of care to reduce D2L time could reduce amputations.
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Affiliation(s)
- Alexander C Fanaroff
- Cardiovascular Medicine Division, Perelman School of Medicine University of Pennsylvania Philadelphia PA
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
- Penn Center for Health Incentives and Behavioral Economics University of Pennsylvania Philadelphia PA
| | - Elias J Dayoub
- Cardiovascular Medicine Division, Perelman School of Medicine University of Pennsylvania Philadelphia PA
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
| | - Lin Yang
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
| | - Kaitlyn Schultz
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
| | - Omar I Ramadan
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Grace J Wang
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Scott M Damrauer
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of Medicine University of Pennsylvania Philadelphia PA
- Department of Genetics, Perelman School of Medicine University of Pennsylvania Philadelphia PA
- Corporal Michael J. Crescenz Veterans Affairs Medical Center Philadelphia PA
| | - Elizabeth A Genovese
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Eric A Secemsky
- Smith Center for Cardiovascular Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical School Harvard University Boston MA
| | - Sahil A Parikh
- Division of Cardiology, Vagelos College of Physicians and Surgeons Columbia University New York NY
| | - Ashwin S Nathan
- Cardiovascular Medicine Division, Perelman School of Medicine University of Pennsylvania Philadelphia PA
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
- Corporal Michael J. Crescenz Veterans Affairs Medical Center Philadelphia PA
| | - Maureen P Kohi
- Department of Radiology University of North Carolina Chapel Hill NC
| | | | | | - Peter W Groeneveld
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
- Corporal Michael J. Crescenz Veterans Affairs Medical Center Philadelphia PA
- General Internal Medicine Division, Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Jay S Giri
- Cardiovascular Medicine Division, Perelman School of Medicine University of Pennsylvania Philadelphia PA
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
- Leonard Davis Institute for Health Economics Philadelphia PA
- Corporal Michael J. Crescenz Veterans Affairs Medical Center Philadelphia PA
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Farber A, Siracuse JJ, Giles K, Jones DW, Laskowski IA, Powell RJ, Rosenfield K, Strong MB, White CJ, Doros G, Menard MT. Investigator attitudes on equipoise and practice patterns in the BEST-CLI trial. J Vasc Surg 2024; 79:865-874. [PMID: 38056700 DOI: 10.1016/j.jvs.2023.11.045] [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: 10/31/2023] [Revised: 11/22/2023] [Accepted: 11/28/2023] [Indexed: 12/08/2023]
Abstract
OBJECTIVES There has been significant variability in practice patterns and equipoise regarding treatment approach for chronic limb-threatening ischemia (CLTI). We aimed to assess treatment preferences of Best Endovascular vs Best Surgical Therapy in Patients with CLTI (BEST-CLI) investigators prior to and following the trial. METHODS An electronic 60-question survey was sent to 1180 BEST-CLI investigators in 2022, after trial conclusion and before announcement of results. Investigators' preferences were assessed across clinical scenarios for both open (OPEN) and endovascular (ENDO) revascularization strategies. Vascular surgeon (VS) surgical and ENDO preferences were compared with a 2010 survey administered to prospective investigators before trial funding. RESULTS For the 2022 survey, the response rate was 20.2% and was comprised of VSs (76.3%), interventional cardiologists (11.4%) and interventional radiologists (11.6%). The majority (72.6%) were in academic practice and 39.1% were in practice for >20 years. During initial CLTI work-up, 65.8%, 42.6%, and 55.9% of respondents always or usually ordered an arterial duplex, computed tomography angiography, and vein mapping, respectively. The most common practice distribution between ENDO and OPEN procedures was 70/30. Postoperatively, a majority reported performing routine duplex surveillance of vein bypass (99%), prosthetic bypass (81.9%), and ENDO interventions (86%). A minority reported always or usually using the wound, ischemia, and foot infection (WIfI) criteria (25.8%), GLASS (8.3%), and a risk calculator (14.8%). More than one-half (52.9%) agreed that the statement "no bridges are burned with an ENDO-first approach" was false. Intervention choice was influenced by availability of the operating room or ENDO suite, personal schedule, and personal skill set in 30.1%, 18.0%, and 45.9% of respondents, respectively. Most respondents reported routinely using paclitaxel-coated balloons (88.1%) and stents (67.5%); however, 73.3% altered practice when safety concerns were raised. Among surgeons, 17.8%, 2.9%, and 10.3% reported performing >10 annual alternative autogenous vein bypasses, composite vein composite vein bypasses, and bypasses to pedal targets, respectively. Among all interventionalists, 8%, 24%, and 8% reported performing >10 annual radial access procedures, pedal or tibial access procedures, and pedal loop revascularizations. The majority (89.1%) of respondents felt that CLTI teams improved care; however, only 23.2% had a defined team. The effectiveness of the teamwork at institutions was characterized as highly effective in 42.5%. When comparing responses by VSs to the 2010 survey, there were no changes in preferred treatment based on Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) II classification or conduit preference. In 2022, OPEN surgery was preferred more for a popliteal occlusion. For clinical scenarios, there were no differences except a decreased proportion of respondents who felt there was equipoise for major tissue loss for major tissue loss (43.8% vs 31.2%) and increased ENDO choice for minor tissue loss (17.6% vs 30.8%) (P < .05). CONCLUSIONS There is a wide range of practice patterns among vascular specialists treating CLTI. The majority of investigators in BEST-CLI had experience in both advanced OPEN and ENDO techniques and represent a real-world sample of technical expertise. Over the course of the decade of the BEST-CLI trial, there was overall similar equipoise among VSs.
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Affiliation(s)
- Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA.
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Kristina Giles
- Division of Vascular and Endovascular Surgery, Maine Medical Center, Portland, ME
| | - Douglas W Jones
- Division of Vascular Surgery, UMass Memorial Health, Worcester, MA
| | - Igor A Laskowski
- Division of Vascular and Endovascular Surgery, Westchester Medical Center, Valhalla, NY; Department of Surgery, Section of Vascular Surgery, New York Medical College, Valhalla, NY
| | - Richard J Powell
- Dartmouth Hitchcock Medical Center, Heart and Vascular Center, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Kenneth Rosenfield
- Section of Vascular Medicine and Intervention Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Michael B Strong
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Christopher J White
- Department of Cardiovascular Diseases, The Ochsner Clinical School, University of Queensland, Queensland, Australia
| | | | - Matthew T Menard
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Foley KM, Kennedy KF, Lima FV, Secemsky EA, Banerjee S, Goodney PP, Shishehbor MH, Soukas PA, Hyder ON, Abbott JD, Aronow HD. Treatment Variability Among Patients Hospitalized for Chronic Limb-Threatening Ischemia: An Analysis of the 2016 to 2018 US National Inpatient Sample. J Am Heart Assoc 2024; 13:e030899. [PMID: 38240207 PMCID: PMC11056168 DOI: 10.1161/jaha.123.030899] [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: 08/15/2023] [Accepted: 11/21/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Little is known about treatment variability across US hospitals for patients with chronic limb-threatening ischemia (CLTI). METHODS AND RESULTS Data were collected from the 2016 to 2018 National Inpatient Sample. All patients aged ≥18 years, admitted to nonfederal US hospitals with a primary diagnosis of CLTI, were identified. Patients were classified according to their clinical presentation (rest pain, skin ulceration, or gangrene) and were further characterized according to the treatment strategy used. The primary outcome of interest was variability in CLTI treatment, as characterized by the median odds ratio. The median odds ratio is defined as the likelihood that 2 similar patients would be treated with a given modality at 1 versus another randomly selected hospital. There were 15 896 (weighted n=79 480) hospitalizations identified where CLTI was the primary diagnosis. Medical therapy alone, endovascular revascularization ± amputation, surgical revascularization ± amputation, and amputation alone were used in 4057 (25%), 5390 (34%), 3733 (24%), and 2716 (17%) patients, respectively. After adjusting for both patient- and hospital-related factors, the median odds ratio (95% CI) for medical therapy alone, endovascular revascularization ± amputation, surgical revascularization ± amputation, any revascularization, and amputation alone were 1.28 (1.19-1.38), 1.86 (1.77-1.95), 1.65 (1.55-1.74), 1.37 (1.28-1.45), and 1.42 (1.27-1.55), respectively. CONCLUSIONS Significant variability in CLTI treatment exists across US hospitals and is not fully explained by patient or hospital characteristics.
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Affiliation(s)
- Katelyn M. Foley
- Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown UniversityProvidenceRI
| | | | - Fabio V. Lima
- University of California, San FranciscoSan FranciscoCA
| | | | - Subhash Banerjee
- Baylor Scott & White Cardiology Consultants of Texas – DallasDallasTX
| | | | | | - Peter A. Soukas
- Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown UniversityProvidenceRI
| | - Omar N. Hyder
- Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown UniversityProvidenceRI
| | - J. Dawn Abbott
- Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown UniversityProvidenceRI
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Dakour-Aridi H, Vyas PK, Schermerhorn M, Malas M, Eldrup-Jorgensen J, Cronenwett J, Wang G, Kashyap VS, Motaganahalli RL. Regional variation in patient selection, practice patterns, and outcomes based on techniques for carotid artery revascularization in the Vascular Quality Initiative. J Vasc Surg 2023; 78:687-694.e2. [PMID: 37224893 DOI: 10.1016/j.jvs.2023.05.029] [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: 03/14/2023] [Revised: 05/02/2023] [Accepted: 05/16/2023] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Significant regional variation is known with multiple surgical procedures. This study describes regional variation in carotid revascularization within the Vascular Quality Initiative (VQI). METHODS Data from the VQI carotid endarterectomy (CEA) and carotid artery stenting (CAS) databases from 2016 to 2021 were used. Nineteen geographic VQI regions were divided into three tertiles based on the average annual volume of carotid procedures performed per region (low-volume: 956 cases [range, 144-1382]; medium-volume: 1533 cases [range, 1432-1589]; and high-volume: 1845 cases [range, 1642-2059]). Patients' characteristics, indications for carotid revascularization, practice patterns, and outcomes (perioperative and 1-year stroke/death) of different revascularization techniques were compared between these regional groups. Regression models that adjust for known risk factors and allow for random effects at the center level were used. RESULTS CEA was the most common revascularization procedure (>60%) across all regional groups. Significant regional variation was observed in the practice of CEA such as variability in the use of shunting, drain placement, stump pressure and electroencephalogram monitoring, intraoperative protamine, and patch angioplasty. For transfemoral CAS, high-volume regions had a higher proportion of asymptomatic patients with <80% stenosis (30.5% vs 27.8%) in addition to higher use of local/regional anesthesia (80.4% vs 76.2%), protamine (16.1% vs 11.8%), and completion angiography (81.6% vs 77.6%) during transfemoral carotid artery stenting (TF-CAS) compared with low-volume regions. For transcarotid artery revascularization (TCAR), high-volume regions were less likely to intervene on asymptomatic patients with <80% stenosis (32.2% vs 35.8%) than low-volume regions. They also had a higher proportion of urgent/emergent procedures (13.6% vs 10.4%) and were more likely to use general anesthesia (92.0% vs 82.1%), completion angiography (67.3% vs 63.0%), and poststent ballooning (48.4% vs 36.8%). For each carotid revascularization technique, no significant differences were noted in perioperative and 1-year outcomes between low-, medium-, and high-volume regions. Finally, there were no significant differences in outcomes between TCAR and CEA across the different regional groups. In all regional groups, TCAR was associated with a 40% reduction in perioperative and 1-year stroke/death compared with TF-CAS. CONCLUSIONS Despite significant variation in clinical practices for the management of carotid disease, no regional variation exists in the overall outcomes of carotid interventions. TCAR and CEA continue to show superior outcomes to TF-CAS across all VQI regional groups.
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Affiliation(s)
- Hanaa Dakour-Aridi
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Punit K Vyas
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Marc Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mahmoud Malas
- Division of Vascular & Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA
| | | | - Jack Cronenwett
- The Dartmouth Institute for Health Care Policy and Clinical Practice, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Grace Wang
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Vikram S Kashyap
- Frederik Meijer Heart and Vascular Institute, Corewell Health, Grand Rapids, MI
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN.
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Chowdhury M, Secemsky EA. Atherectomy vs Other Modalities for Treatment During Peripheral Vascular Intervention. Curr Cardiol Rep 2022; 24:869-877. [PMID: 35536534 DOI: 10.1007/s11886-022-01709-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF THE REVIEW Calcified atheroma is frequently encountered in peripheral vascular intervention. Standard treatment with balloon and/or stenting alone does poorly in these cases due to vessel recoil, suboptimal luminal gain, and inadequate stent expansion. In light of the above challenges with angioplasty and stenting for PAD, endovascular atherectomy has emerged as a novel technology for atheroma treatment and removal, offering the benefits of surgical endarterectomy in a minimally invasive percutaneous approach. This review outlines the endovascular atherectomy devices available in clinical practice to date, compares and contrasts their mode of action, summarizes the relevant published data on indication and role of atherectomy over other treatment modalities for PAD, and discusses the future prospective on this emerging technology. RECENT FINDINGS Currently, there are host of peripheral atherectomy devices available with unique mechanism of action and relative advantages and disadvantages. Despite these recent technological advancements, there remains a paucity of data from well-designed studies regarding the superiority of atherectomy as an adjunctive treatment versus standard treatment with balloon and stenting. Emerging data have supported its use to improve patency rates in conjunction with drug-coated balloons. Although associated risks, including distal embolization and perforation, are often marginal, the cost of these devices to the healthcare system necessitates further investment in to establishing level 1 data to support their use. Peripheral atherectomy has the potential to improve limb-related outcomes, potentially through reduced need for bail-out scaffolds and improved drug uptake. Nonetheless, further investment in the evidence foundation supporting these devices versus standard practices is required.
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Affiliation(s)
- Mohsin Chowdhury
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Baker 4, Boston, MA, 02215, USA
| | - Eric A Secemsky
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Baker 4, Boston, MA, 02215, USA.
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Kolossváry E, Ferenci T, Kováts T, Sótonyi P, Szeberin Z, Nemes B, Dósa E, Farkas K, Járai Z. High level of unwarranted clinical variation in the utilisation of lower extremity revascularisation procedures in Hungary (2013–2017). Eur J Vasc Endovasc Surg 2022; 63:874-882. [DOI: 10.1016/j.ejvs.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 03/01/2022] [Accepted: 03/06/2022] [Indexed: 11/30/2022]
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Rates of intervention for claudication versus chronic limb-threatening ischemia in Canada and United States. Ann Vasc Surg 2021; 82:131-143. [PMID: 34902467 DOI: 10.1016/j.avsg.2021.10.068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 10/22/2021] [Accepted: 10/24/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Previous studies have demonstrated important geographic variations in peripheral artery disease (PAD) management despite existing guidelines. We assessed differences in patient characteristics, procedural technique, and outcomes for PAD interventions in Canada vs. United States. METHODS The Vascular Quality Initiative (VQI) was used to identify all patients who underwent endovascular intervention or surgical bypass for PAD between 2010-2019 in Canada and United States. Independent t-test and chi-square test were performed to assess differences between countries in terms of demographic, clinical, and procedural characteristics. The primary outcome was the percentage of interventions performed for claudication vs. chronic limb-threatening ischemia (CLTI). Perioperative outcomes were in-hospital mortality and index limb amputation. The long-term outcome was 1-year amputation-free survival. Univariate/multivariate logistic regression and Cox proportional hazards analysis were performed to investigate associations between region and outcomes. RESULTS 246,770 US patients and 3,467 Canadian patients underwent revascularization for PAD during the study period. There was a higher proportion of endovascular interventions in the US (75.9% vs. 69.2%, OR 1.41 [95% CI 1.31 - 1.51], p < 0.001). American patients were younger with more comorbidities, including hypertension, diabetes, and coronary artery disease. The percentage of interventions performed for claudication was significantly higher in the US (42.3% vs. 35.7%, OR 1.31 [95% CI 1.22 - 1.44], p < 0.001). This persisted after controlling for demographic, clinical, and procedural characteristics (adjusted OR 1.05 [95% CI 1.01 - 1.10], p = 0.02). Perioperative outcomes were similar between countries after adjustment for baseline differences: in-hospital mortality (adjusted OR 1.07 [95% CI 0.69 - 1.62], p = 0.75) and index limb amputation (adjusted OR 0.67 [95% CI 0.43 - 1.07], p = 0.09). However, 1-year amputation-free survival was higher in the US (84.1% vs. 71.0%, HR 1.61 [95% CI 1.47 - 1.76], p < 0.001). Multivariable Cox proportional hazards analysis demonstrated that the factor most strongly associated with index limb amputation or death at 1-year was intervention for CLTI (HR 1.56 [95% CI 1.54 - 1.58], p < 0.001). CONCLUSIONS There are significant variations in PAD management between US and Canada. In particular, a higher proportion of interventions are performed for claudication rather than CLTI in the US compared to Canada. This is an important contributor to the higher 1-year amputation-free survival rate in US patients. Reasons for these differences should be assessed by future studies and evidence-based care may be standardized by targeted quality improvement projects.
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Gandjian M, Sareh S, Premji A, Ugarte R, Tran Z, Bowens N, Benharash P. Racial disparities in surgical management and outcomes of acute limb ischemia in the United States. Surg Open Sci 2021; 6:45-50. [PMID: 34632355 PMCID: PMC8487073 DOI: 10.1016/j.sopen.2021.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 08/22/2021] [Accepted: 08/27/2021] [Indexed: 12/04/2022] Open
Abstract
Background Although significant racial disparities in the surgical management of lower extremity critical limb threatening ischemia have been previously reported, data on disparities in lower extremity acute limb ischemia are lacking. Methods The 2012–2018 National Inpatient Sample was queried for all adult hospitalizations for acute limb ischemia (N = 225,180). Hospital-specific observed-to-expected rates of major lower extremity amputation were tabulated. Multivariable logistic and linear models were developed to assess the impact of race on amputation and revascularization. Results Nonwhite race was associated with significantly increased odds of overall (adjusted odds ratio: 1.16, 95% confidence interval 1.06–1.28) and primary (adjusted odds ratio: 1.34, 95% confidence interval 1.17–1.53) major amputation, decreased odds of revascularization (adjusted odds ratio 0.79, 95% confidence interval 0.73–0.85), but decreased in-hospital mortality (adjusted odds ratio: 0.86, 95% confidence interval 0.74–0.99). The nonwhite group incurred increased adjusted index hospitalization costs (β: +$4,810, 95% confidence interval 3,280-6,350), length of stay (β: + 1.09 days, 95% confidence interval 0.70–1.48), and nonhome discharge (adjusted odds ratio: 1.15, 95% confidence interval 1.06–1.26). Conclusion Significant racial disparities exist in the management of and outcomes of lower extremity acute limb ischemia despite correction for variations in hospital amputation practices and other relevant hospital and patient characteristics. Whether the etiology lies primarily in patient, institution, or healthcare provider–specific factors has not yet been determined. Further studies of race-based disparities in management and outcomes of acute limb ischemia are warranted to provide effective and equitable care to all.
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Affiliation(s)
- Matthew Gandjian
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, Los Angeles, CA.,Department of Surgery, Los Angeles County Harbor-UCLA Medical Center, Torrance, CA
| | - Sohail Sareh
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, Los Angeles, CA.,Department of Surgery, Los Angeles County Harbor-UCLA Medical Center, Torrance, CA
| | - Alykhan Premji
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Ramsey Ugarte
- Department of Surgery, Los Angeles County Harbor-UCLA Medical Center, Torrance, CA
| | - Zachary Tran
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Nina Bowens
- Department of Surgery, Los Angeles County Harbor-UCLA Medical Center, Torrance, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, Los Angeles, CA
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Lodha A, Giannopoulos S, Sumar R, Ratcliffe J, Gorenchtein M, Green P, Rollefson W, Stout CL, Armstrong EJ. Transradial endovascular intervention: Results from the Radial accEss for nAvigation to your CHosen lesion for Peripheral Vascular Intervention (REACH PVI) study. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 36:115-120. [PMID: 34020900 DOI: 10.1016/j.carrev.2021.05.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/04/2021] [Accepted: 05/13/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND/PURPOSE The transradial approach has been proposed as an alternative to traditional transfemoral access for diagnostic and therapeutic purposes in several catheterization procedures. Historically, extended length devices for lower limb endovascular interventions have been limited. The aim of this study was to investigate the acute clinical outcomes of orbital atherectomy (OA) via transradial access (TRA) for the treatment of lower extremity peripheral artery disease (PAD). METHODS/MATERIALS REACH PVI was a multicenter, prospective, observational study (NCT03943160) including subjects with PAD and target lesion morphology appropriate for OA. All patients were followed post-procedure through the first standard of care follow-up visit. RESULTS A total of 50 patients were enrolled. In most cases the indication for intervention was disabling claudication (74.0%). Overall, 50 target lesions were treated, 92.0% of lesions were femoropopliteal and 8.0% were infrapopliteal. The average lesion length was 98.3 ± 87.5 mm and 78.0% of the lesions were severely calcified. Balloon angioplasty was performed in 98.0% of target lesions, while a stent was deployed in 16.0%. Treatment success was 98.0%; in only one case the result was sub-optimal (>30% stenosis with stent placement) and a significant dissection was reported. No serious distal embolization, serious thrombus formation or serious acute vessel closure were observed intra- or post-procedurally. CONCLUSIONS Transradial OA followed by percutaneous transluminal angioplasty for lower extremity PAD is feasible and demonstrates a favorable safety profile. Extended length devices such as the Extended Length Orbital Atherectomy System could further facilitate transradial endovascular procedures by increasing its spectrum of application.
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Affiliation(s)
- Ankur Lodha
- Cardiovascular Institute of the South - Lafayette, Lafayette, LA, United States
| | - Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, United States
| | - Riyaz Sumar
- Arizona Cardiovascular Research Center, Phoenix, AZ, United States
| | | | | | | | | | | | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, United States.
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Creager MA, Matsushita K, Arya S, Beckman JA, Duval S, Goodney PP, Gutierrez JAT, Kaufman JA, Joynt Maddox KE, Pollak AW, Pradhan AD, Whitsel LP. Reducing Nontraumatic Lower-Extremity Amputations by 20% by 2030: Time to Get to Our Feet: A Policy Statement From the American Heart Association. Circulation 2021; 143:e875-e891. [PMID: 33761757 DOI: 10.1161/cir.0000000000000967] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Nontraumatic lower-extremity amputation is a devastating complication of peripheral artery disease (PAD) with a high mortality and medical expenditure. There are ≈150 000 nontraumatic leg amputations every year in the United States, and most cases occur in patients with diabetes. Among patients with diabetes, after an ≈40% decline between 2000 and 2009, the amputation rate increased by 50% from 2009 to 2015. A number of evidence-based diagnostic and therapeutic approaches for PAD can reduce amputation risk. However, their implementation and adherence are suboptimal. Some racial/ethnic groups have an elevated risk of PAD but less access to high-quality vascular care, leading to increased rates of amputation. To stop, and indeed reverse, the increasing trends of amputation, actionable policies that will reduce the incidence of critical limb ischemia and enhance delivery of optimal care are needed. This statement describes the impact of amputation on patients and society, summarizes medical approaches to identify PAD and prevent its progression, and proposes policy solutions to prevent limb amputation. Among the actions recommended are improving public awareness of PAD and greater use of effective PAD management strategies (eg, smoking cessation, use of statins, and foot monitoring/care in patients with diabetes). To facilitate the implementation of these recommendations, we propose several regulatory/legislative and organizational/institutional policies such as adoption of quality measures for PAD care; affordable prevention, diagnosis, and management; regulation of tobacco products; clinical decision support for PAD care; professional education; and dedicated funding opportunities to support PAD research. If these recommendations and proposed policies are implemented, we should be able to achieve the goal of reducing the rate of nontraumatic lower-extremity amputations by 20% by 2030.
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Monaro S, Pinkova J, Ko N, Stromsmoe N, Gullick J. Chronic wound care delivery in wound clinics, community nursing and residential aged care settings: A qualitative analysis using Levine's Conservation Model. J Clin Nurs 2021; 30:1295-1311. [PMID: 33506537 DOI: 10.1111/jocn.15674] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 11/21/2020] [Accepted: 12/13/2020] [Indexed: 11/27/2022]
Abstract
AIMS AND OBJECTIVES To explore patient experience of chronic wound care across diverse models of outpatient wound care delivery. BACKGROUND Chronic wounds represent a significant personal, family and healthcare system burden. Evidence suggests specialist wound clinics are more effective and less expensive, however, most outpatient wound care is delivered by general community nurses. There is little understanding of how patients experience diverse models of wound care delivery and the subsequent impact on their capacity to adapt to imbalances in their internal/external environment. DESIGN Descriptive, qualitative study. METHODS Eighteen patients with chronic wounds from three wound services were engaged in semi-structured interviews. Initial inductive analysis was refined deductively using Levine's Conservation Model. RESULTS Chronic wounds lead to imbalances and subsequent adaptions in energy conservation and personal, social and structural integrity. Nursing process and wound care system responses suggest specialist wound clinics provide access to the right person and care at the right time, with less care variation. The community nursing model is most effective with a small team of nurses and a documented care plan, with specialist wound nurse oversight. Residential aged care facilities emerged as important sites for wound care delivery revealing higher variance in care and less specialist wound oversight. CONCLUSIONS The application of Levine's conservation model provides a theoretical understanding and important insights into the patient experience of nurse and system elements across diverse models of wound care delivery. Specialist oversight by expert wound nurses with the capacity for medical specialist referral is the cornerstone of good wound care. A frequently reviewed wound care plan and skill development for nurses in primary, aged care and community settings are vital. RELEVANCE TO CLINICAL PRACTICE Shared care between specialist and primary care should include evidence-based pain assessment, clear referral pathways, collaborative relationships, telehealth capacity, patient-held wound plans and upskilling of frontline clinicians.
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Affiliation(s)
- Susan Monaro
- Concord Repatriation General Hospital, Sydney, NSW, Australia.,Faculty of Medicine & Health, Susan Wakil School of Nursing & Midwifery, University of Sydney, Camperdown, NSW, Australia
| | - Jana Pinkova
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Natalie Ko
- Concord Repatriation General Hospital, Sydney, NSW, Australia
| | | | - Janice Gullick
- Faculty of Medicine & Health, Susan Wakil School of Nursing & Midwifery, University of Sydney, Camperdown, NSW, Australia
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12
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Contemporary Use of Radial to Peripheral Access for Management of Peripheral Artery Disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-020-00895-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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Cheng TW, Raulli SJ, Farber A, Levin SR, Kalish JA, Jones DW, Rybin D, Doros G, Siracuse JJ. The Association of the Day of the Week with Outcomes of Infrainguinal Lower Extremity Bypass. Ann Vasc Surg 2020; 73:43-50. [PMID: 33370572 DOI: 10.1016/j.avsg.2020.11.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The day of the week (DOW) for performing procedures and operations has been shown to affect clinical and resource utilization outcomes. Limited published data are available on vascular surgery operations. Our primary objective was to assess outcomes by DOW for infrainguinal lower extremity bypass (LEB) performed for claudication or rest pain. The secondary objective was to assess outcomes by DOW for LEBs performed for tissue loss. METHODS The Vascular Quality Initiative was queried from 2003 to 2018 for all elective index infrainguinal LEBs performed for claudication or rest pain. Cases performed for acute limb ischemia as well as concomitant peripheral vascular intervention, nonelective LEBs, sequential grafts, and weekend cases were excluded. LEBs were grouped by DOW: Monday-Tuesday (early weekdays) versus Wednesday-Friday (later weekdays). Baseline data, operative details, and outcomes were collected. Univariate and multivariable analyses were performed. LEBs performed for claudication/rest pain were analyzed together while tissue loss was assessed separately. RESULTS There were 12,084 LEBs identified-44.5% performed on Monday-Tuesday and 55.5% on Wednesday-Friday. Overall, the mean age was 65.6 years, 68.6% were male, and 82.8% were Caucasian. LEBs were performed for claudication in 57.4% of cases. An autogenous great saphenous vein was used in 58.8% of cases, whereas a prosthetic graft was used in 35.1% of cases. The most common bypass origin was the femoral artery (94.1%), and target was the popliteal artery (70.1%). Significant differences between Monday-Tuesday versus Wednesday-Friday, respectively, were mean body mass index (27.8 kg/m2 vs. 28 kg/m2), preoperative aspirin use (74.2% vs. 72.5%), continuous vein harvest technique (41.9% vs. 44%), and mean operative time (mins) (216.2 vs. 222.6) (all P < 0.05). Univariate postoperative outcomes were significantly different between Monday-Tuesday versus Wednesday-Friday, respectively, for mean length of stay (LOS) (days) (3.9 vs. 4.3), cardiac complications (myocardial infarction/dysrhythmia/congestive heart failure) (3.5% vs. 4.9%), stroke (0.3% vs. 0.6%), and respiratory complications (0.8% vs. 1.3%) (all P < 0.05). Multivariable analysis demonstrated that LEBs performed on Wednesday-Friday versus Monday-Tuesday for claudication/rest pain were independently associated with cardiac complications and prolonged LOS. There were also 8,491 LEBs performed for tissue loss which overall had similar findings to LEBs performed for claudication/rest pain such as increased LOS for LEBs performed for tissue loss on Wednesday-Friday (P < 0.001) and similar likeliness for respiratory complication, wound complication, return to the operating room, and mortality (all P > 0.05). However, LEBs performed for tissue loss on Wednesday-Friday versus Monday-Tuesday had similar cardiac complications (P > 0.05). CONCLUSIONS Elective LEBs performed on later weekdays for claudication/rest pain were associated with cardiac complications and prolonged LOS, whereas tissue loss confirmed association with prolonged LOS. Further investigations are needed to identify whether increased resources or allocation of resources should be focused on later weekdays to optimize patient outcomes.
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Affiliation(s)
- Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Stephen J Raulli
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Jeffrey A Kalish
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Douglas W Jones
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Denis Rybin
- Department of Biostatistics, Boston University, School of Public Health, Boston, MA
| | - Gheorghe Doros
- Department of Biostatistics, Boston University, School of Public Health, Boston, MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA.
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14
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Nayak P, Guralnik JM, Polonsky TS, Kibbe MR, Tian L, Zhao L, Criqui MH, Ferrucci L, Li L, Zhang D, McDermott MM. Association of six-minute walk distance with subsequent lower extremity events in peripheral artery disease. Vasc Med 2020; 25:319-327. [DOI: 10.1177/1358863x20901599] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The prognostic significance of the six-minute walk distance for lower extremity events in people with peripheral artery disease (PAD) is unknown. This longitudinal study assessed whether a poorer six-minute walk distance at baseline was associated with higher rates of subsequent lower extremity atherosclerotic disease events in PAD. A total of 369 patients (mean age 69.4 ± 10.0 years; mean ankle–brachial index (ABI) 0.67 ± 0.17; 31% women; 30% black individuals) from Chicago-area medical centers with PAD were enrolled. Participants underwent baseline six-minute walk testing and returned for annual study visits. Lower extremity events consisted of one or more of the following: ABI decline greater than 15% or medical record adjudicated lower extremity revascularization, critical limb ischemia, or amputation. At a mean follow-up of 33.3 months, lower extremity events occurred in 66/123 (53.7%) people in the first (worst) tertile of six-minute walk performance, 55/124 (44.4%) in the second tertile, and 56/122 (45.9%) in the third (best) tertile. After adjusting for age, sex, race, ABI, comorbidities, and other confounders, participants in the first (worst) tertile of six-minute walk distance at baseline had higher rates of lower extremity events during follow-up, compared to those in the best tertile at baseline (HR = 1.74, 95% CI 1.17–2.60, p = 0.0067). Among people with PAD, a poorer six-minute walk distance was associated with higher rates of subsequent lower extremity PAD-related events after adjusting for confounders. Further study is needed to determine whether interventions that improve six-minute walk distance can reduce lower extremity adverse events in people with PAD.
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Affiliation(s)
- Pooja Nayak
- University of Illinois College of Medicine at Chicago, Chicago, IL, USA
| | - Jack M Guralnik
- Department of Epidemiology, University of Maryland, Baltimore, MD, USA
| | | | - Melina R Kibbe
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Lu Tian
- Department of Biomedical Science Data, Stanford University, Palo Alto, CA, USA
| | - Lihui Zhao
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael H Criqui
- Department of Family Medicine and Public Health University of California San Diego, La Jolla, CA, USA
| | - Luigi Ferrucci
- National Institute on Aging Division of Intramural Research, Baltimore, MD, USA
| | - Lingyu Li
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Dongxue Zhang
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mary M McDermott
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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15
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O'Donnell TFX, Verhagen HJ, Pratesi G, Pratesi C, Teijink JAW, Vermassen FEG, Mwipatayi P, Forbes TL, Schermerhorn ML. Female sex is associated with comparable 5-year outcomes after contemporary endovascular aneurysm repair despite more challenging anatomy. J Vasc Surg 2020; 71:1179-1189. [PMID: 31477480 PMCID: PMC7048667 DOI: 10.1016/j.jvs.2019.05.065] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 05/24/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Women with abdominal aortic aneurysms less often meet anatomic criteria for endovascular repair and experience worse perioperative and long-term survival. METHODS We compared long-term survival, aneurysm-related mortality, and rates of endoleaks and reinterventions between male and female patients in the Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE) using 2:1 propensity score matching. RESULTS There were 1130 male patients and 133 female patients, yielding 399 patients after matching (266 male patients, 133 female patients). Female patients were older, with smaller aneurysms, smaller iliac arteries, and shorter, more angulated necks, and they were more often treated outside the device instructions for use (all P < .001). Through 5 years, female patients experienced overall mortality comparable to that of well-matched male patients (34% vs 38%, respectively; hazard ratio, 0.89 [0.61-1.29]; P = .54) and lower aneurysm-related mortality (0% vs 3%; P = .047). Female patients experienced higher rates of any postoperative type IA endoleak through 5 years (10% vs 1%; P < .001) but comparable rates of secondary endovascular procedures (14% vs 16%; P = .40). Female sex was independently associated with significantly higher risk of long-term type IA endoleaks (hazard ratio, 4.8 [1.2-20.8]; P = .04), even after accounting for anatomic factors. No female patient experienced aneurysm rupture during follow-up, and only one female patient underwent conversion to open repair. CONCLUSIONS Despite more challenging anatomy, female patients in the ENGAGE registry had long-term outcomes comparable to those of male patients. However, female patients experienced higher rates of type IA endoleaks. Although standard endovascular aneurysm repair remains a viable solution for most women, whether high-risk patients may be better served with open surgery, custom-made devices, EndoAnchors (Aptus Endosystems, Sunnyvale, Calif), or chimneys is worthy of further study.
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Affiliation(s)
- Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Hence J Verhagen
- Division of Vascular and Endovascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Giovanni Pratesi
- Vascular Surgery, Department of Biomedicine and Prevention, University of Roma Tor Vergata, Rome, Italy
| | - Carlo Pratesi
- Department of Vascular Surgery, University of Florence, Florence, Italy
| | - Joep A W Teijink
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands; Department of Epidemiology, CAPRHI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Frank E G Vermassen
- Department of Vascular Surgery, Universitair Ziekenhuis Gent, Ghent, Belgium
| | - Patrice Mwipatayi
- Department of Vascular Surgery, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Thomas L Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
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Shibutani S, Obara H, Matsubara K, Toya N, Isogai N, Ogino H, Watada S, Asami A, Kudo T, Kanaoka Y, Fujimura N, Harada H, Uchiyama H, Sato Y, Ohki T. Midterm Results of a Japanese Prospective Multicenter Registry of Heparin-Bonded Expanded Polytetrafluoroethylene Grafts for Above-the-Knee Femoropopliteal Bypass. Circ J 2020; 84:501-508. [PMID: 32062636 DOI: 10.1253/circj.cj-19-0908] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND This study prospectively analyzed the midterm results of above-the-knee femoropopliteal bypass (AKb) using bioactive heparin-bonded expanded polytetrafluoroethylene (HB-ePTFE) graft in patients with femoropopliteal occlusive disease.Methods and Results:This prospective, multicenter, non-randomized study reviewed limbs undergoing AKb with HB-ePTFE graft for femoropopliteal lesion in 20 Japanese institutions between July 2014 and October 2017. Primary efficacy endpoints were primary, primary assisted, and secondary graft patency. Safety endpoints included any major adverse limb event and perioperative mortality. During the study period, 120 limbs of 113 patients (mean age, 72.7 years) underwent AKb with HB-ePTFE grafts. A total of 45 patients (37.5%) had critical limb ischemia and 17 (15.0%) were on hemodialysis (HD). Median duration of follow-up was 16 months (range, 1-36 months). Estimated 1- and 2-year primary, primary assisted, and secondary graft patency rates were 89.4% and 82.7%, 89.4% and 87.2%, and 94.7% and 92.5%, respectively. On univariate analysis of 2-year primary graft patency, having 3 run-off vessels, cuffed distal anastomoses, no coronary artery disease, and no chronic kidney disease requiring HD were significantly associated with favorable patency. CONCLUSIONS AKb using HB-ePTFE grafts achieved favorable 2-year graft patency. AKb using HB-ePTFE grafts may therefore be an acceptable, highly effective treatment option for femoropopliteal artery lesions.
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Affiliation(s)
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine
| | | | - Naoki Toya
- Department of Surgery, The Jikei University Kashiwa Hospital
| | - Naoko Isogai
- Department of Surgery, Shonan Kamakura General Hospital
| | | | | | | | - Toshifumi Kudo
- Department of Surgery, Tokyo Medical and Dental University
| | - Yuji Kanaoka
- Department of Surgery, The Jikei University School of Medicine
| | - Naoki Fujimura
- Division of Vascular Surgery, Saiseikai Central Hospital
| | | | | | - Yasunori Sato
- Department of Preventive Medicine and Public Health, Keio University School of Medicine
| | - Takao Ohki
- Department of Surgery, The Jikei University School of Medicine
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17
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Perez NP, Pernat CA, Chang DC. Surgical Disparities: Beyond Non-Modifiable Patient Factors. Health Serv Res 2020. [DOI: 10.1007/978-3-030-28357-5_5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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18
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Abstract
Peripheral vascular intervention (PVI) improves quality of life and reduces major adverse limb events in patients with peripheral arterial disease. PVI is commonly performed via the femoral artery, and the most common adverse periprocedural event is a vascular access complication. Transradial access for PVI has the potential to reduce vascular access complications and improve patient outcomes. Further study is needed to elucidate the risks of stroke, acute kidney injury, and radiation exposure in the setting of transradial PVI. As transradial access for PVI progresses, it will be important to build the evidence base along with procedural experience.
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Affiliation(s)
| | - Sunil V Rao
- Division of Cardiology, Duke Clinical Research Institute, Duke University, 200 Morris Street, Durham, NC 27701, USA
| | - Rajesh V Swaminathan
- Division of Cardiology, Duke Clinical Research Institute, Duke University, 200 Morris Street, Durham, NC 27701, USA
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19
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Humbarger O, Siracuse JJ, Rybin D, Stone DH, Goodney PP, Schermerhorn ML, Farber A, Jones DW. Broad variation in prosthetic conduit use for femoral-popliteal bypass is not justified on the basis of contemporary outcomes favoring autologous great saphenous vein. J Vasc Surg 2019; 70:1514-1523.e2. [DOI: 10.1016/j.jvs.2019.02.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 02/24/2019] [Indexed: 12/12/2022]
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20
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Fereydooni A, Gorecka J, Dardik A. Using the epidemiology of critical limb ischemia to estimate the number of patients amenable to endovascular therapy. Vasc Med 2019; 25:78-87. [PMID: 31621531 DOI: 10.1177/1358863x19878271] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Critical limb ischemia represents the advanced stage of peripheral artery disease, a health problem with increasing prevalence. Critical limb ischemia is associated with significant mortality, limb loss, pain, and diminished health-related quality of life. Public awareness and early diagnosis are necessary for an effective treatment with early risk factor modification, smoking cessation, and exercise therapy. Herein, we present an overview of the epidemiology as well as the clinical stages of the disease, and estimate that there are 6.5 million patients with critical limb ischemia in the US, Europe, and Japan based on global population-based studies. At least 75% of these patients, accounting for approximately 4.8 million patients, are amenable to endovascular therapy.
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Affiliation(s)
- Arash Fereydooni
- Department of Surgery, Division of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Jolanta Gorecka
- Department of Surgery, Division of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Alan Dardik
- Department of Surgery, Division of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT, USA
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21
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Baumgartner I, Norgren L, Fowkes FGR, Mulder H, Patel MR, Berger JS, Jones WS, Rockhold FW, Katona BG, Mahaffey K, Hiatt WR. Cardiovascular Outcomes After Lower Extremity Endovascular or Surgical Revascularization: The EUCLID Trial. J Am Coll Cardiol 2019; 72:1563-1572. [PMID: 30261955 DOI: 10.1016/j.jacc.2018.07.046] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 07/12/2018] [Accepted: 07/23/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Lower extremity revascularization (LER) is a common treatment in patients with peripheral artery disease (PAD), but long-term outcomes are poorly defined. OBJECTIVES The aim was to analyze LER in the EUCLID (Examining Use of tiCagreLor In paD) trial to determine predictors and cardiovascular outcomes. METHODS Patients were grouped according to whether they received a post-randomization LER (n = 1,738) or not (n = 12,147). All variables were assessed for significance in univariable and parsimonious multivariable models. The primary endpoint was myocardial infarction, ischemic stroke, or cardiovascular death; major adverse limb events (MALE) included acute limb ischemia or major amputation. RESULTS A post-randomization LER occurred in 12.5% of patients and was an endovascular LER in 74.7%. Endovascular LERs were performed more often in North America, whereas surgical procedures occurred more frequently in Europe. Independent factors predicting LER were prior and type of prior LER, geographic region, limb symptoms, diabetes, and smoking. A post-randomization LER was associated with an increased risk for the primary endpoint (hazard ratio: 1.60; 95% confidence interval: 1.35 to 1.90; p < 0.0001) and MALE (hazard ratio: 12.0; 95% confidence interval: 9.47 to 15.30; p < 0.0001). Event rates for the primary endpoint after LER were numerically higher in the surgical subgroup, but MALE were similar between surgical and endovascular LER. CONCLUSIONS In the EUCLID trial, LER was most often endovascular. Following LER, there was an increased hazard for the primary endpoint (with higher event rates in the surgical group) and a markedly increased risk for MALE events (with similar event rates between surgical and endovascular LER procedures). (A Study Comparing Cardiovascular Effects of Ticagrelor and Clopidogrel in Patients With Peripheral Artery Disease [EUCLID]; NCT01732822).
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Affiliation(s)
- Iris Baumgartner
- Swiss Cardiovascular Centre, Inselspital, Division of Angiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lars Norgren
- Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - F Gerry R Fowkes
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Hillary Mulder
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Jeffrey S Berger
- Departments of Medicine and Surgery, New York University School of Medicine, New York, New York
| | - W Schuyler Jones
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Frank W Rockhold
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - Kenneth Mahaffey
- Stanford Center for Clinical Research, Stanford University, School of Medicine, Stanford, California
| | - William R Hiatt
- Division of Cardiology and CPC Clinical Research, University of Colorado School of Medicine, Aurora, Colorado.
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22
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Wang LJ, Ergul EA, Mohebali J, Goodney PP, Patel VI, Conrad MF, Eagleton MJ, Clouse WD. Regional variation in use and outcomes of combined carotid endarterectomy and coronary artery bypass. J Vasc Surg 2019; 70:1130-1136. [PMID: 30922761 DOI: 10.1016/j.jvs.2019.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 02/01/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In treating concomitant carotid and coronary disease, some recommend staged carotid endarterectomy (CEA) and coronary artery bypass grafting, whereas others favor the combined approach (CCAB). Pressure to reduce surgical variation and to improve quality is real, yet little is known about how geographic practice differences affect outcomes. Using the Vascular Quality Initiative (VQI), this study evaluated regional variation in use and outcomes of CCAB. METHODS All CCAB procedures in the VQI from 2003 to 2017 were reviewed and stratified into four regions, as defined by the United States Census Bureau. Primary outcomes included perioperative stroke, death, myocardial infarction (MI), and these as composite (SDM). A χ2 analysis was performed. RESULTS There were 1495 CCAB procedures identified, representing 1.8% of the VQI CEAs. Regions included the following: Midwest (MW), 32%; Northeast (NE), 39%; South (S), 25%; and West (W), 4%. Most were male (70%) and white (92%). There was significant regional variation in proportional volume of CCABs to all CEAs (0.7% [W] to 2.5% [MW]; P < .001). Regional variation in patch use (78% [W] to 93% [MW]; P < .001), shunting (29% [W] to 71% [MW]; P < .001), and electroencephalography monitoring (13% [W] to 52% [NE]; P < .001) was also significant. Overall perioperative stroke was 3.6%; death, 3.0%; and SDM, 6.8%. No regional difference was seen in outcomes of mortality (1.5% [MW] to 4.2% [NE]; P = .05), stroke (2.8% [NE] to 4.4% [MW]; P = .52), and MI (0.6% [MW] to 1.8% [W]; P = .62). When the Bonferroni correction was used, there remained no difference in stroke, MI, or SDM across regions, but mortality became significant. Using the Society for Vascular Surgery guidelines for consideration of CCAB, the minority of patients fell within the symptomatic carotid stenosis (SYMP, 15%; n = 218) or severe (≥70%) asymptomatic bilateral carotid disease (BIL, 18%; n = 267) categories. The most common indication was asymptomatic unilateral severe carotid stenosis (UNI, 37%; n = 552). There were no differences in regional outcomes stratified by indication (SYMP, BIL, UNI). Overall, when SYMP and BIL were compared with UNI, UNI had lower rates of stroke (2.4% vs 4.9%; P = .03) but similar MI (0.7% vs 1.2%; P = .40) and mortality (2.2% vs 2.5%; P = .75). CONCLUSIONS Significant variation exists across VQI centers in the use of CCAB. Despite differences in volume and practices, regional perioperative outcomes are similar. UNI is the most commonly used indication and has lower stroke rates relative to SYMP and BIL. CCAB is performed well across the United States, but most patients fall outside of Society for Vascular Surgery guidelines.
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Affiliation(s)
- Linda J Wang
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Emel A Ergul
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Jahan Mohebali
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Virendra I Patel
- Division of Vascular Surgery and Endovascular Interventions, Columbia University Medical Center, New York, NY
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
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Abstract
PURPOSE OF REVIEW This review summarizes the risks of lower extremity amputation associated with critical limb ischemia (CLI) and discusses current therapies that can prevent amputation in CLI. RECENT FINDINGS CLI remains an under-recognized condition associated with high rates of major amputation and disparities in care. Optimal medical therapy can reduce the risk of major adverse cardiovascular and limb events, but revascularization combined with close wound care remains the cornerstone of amputation prevention. Endovascular revascularization has become more common over time and has been associated with a reduction in amputation rates. Ongoing clinical trials will help inform best practices for revascularization strategies and techniques. Vascular care is inconsistent across the USA, with significant variation in access to care revascularization rates and rates of major amputation. Major amputation can be prevented in patients with CLI when optimal medical therapy, lifestyle modification, and revascularization are provided in a multidisciplinary setting.
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Affiliation(s)
| | - Shea E Hogan
- University of Colorado School of Medicine, Aurora, CO, USA
- Denver Health Medical Center, Denver, CO, USA
| | - Ehrin J Armstrong
- University of Colorado School of Medicine, Aurora, CO, USA.
- Veterans Affairs Eastern Colorado Health Care System, Denver, CO, USA.
- Denver VA Medical Center, 1055 Clermont Street, Denver, CO, 80220, USA.
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Mohan S, Flahive JM, Arous EJ, Judelson DR, Aiello FA, Schanzer A, Simons JP. Peripheral atherectomy practice patterns in the United States from the Vascular Quality Initiative. J Vasc Surg 2018; 68:1806-1816. [PMID: 29937287 DOI: 10.1016/j.jvs.2018.03.417] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 03/08/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Peripheral atherectomy has been shown to have technical success in single-arm studies, but clinical advantages over angioplasty and stenting have not been demonstrated, leaving its role unclear. We sought to describe patterns of atherectomy use in a real-world U.S. cohort to understand how it is currently being applied. METHODS The Vascular Quality Initiative was queried to identify all patients who underwent peripheral vascular intervention from January 2010 to September 2016. Descriptive statistics were performed to analyze demographics of the patients, comorbidities, indication, treatment modalities, and lesion characteristics. The intermittent claudication (IC) and critical limb ischemia (CLI) cohorts were analyzed separately. RESULTS Of 85,605 limbs treated, treatment indication was IC in 51% (n = 43,506) and CLI in 49% (n = 42,099). Atherectomy was used in 15% (n = 13,092) of cases, equivalently for IC (15%; n = 6674) and CLI (15%; n = 6418). There was regional variation in use of atherectomy, ranging from a low of 0% in one region to a high of 32% in another region. During the study period, there was a significant increase in the proportion of cases that used atherectomy (11% in 2010 vs 18% in 2016; P < .0001). Compared with nonatherectomy cases, those with atherectomy use had higher incidence of prior peripheral vascular intervention (IC, 55% vs 43% [P < .0001]; CLI, 47% vs 41% [P < .0001]), greater mean number of arteries treated (IC, 1.8 vs 1.6 [P < .0001]; CLI, 2.1 vs 1.7 [P < .0001]), and lower proportion of prior leg bypass (IC, 10% vs 14% [P < .0001]; CLI, 11% vs 17% [P < .0001]). There was lower incidence of failure to cross the lesion (IC, 1% vs 4% [P < .0001]; CLI, 4% vs 7% [P < .0001]) but higher incidence of distal embolization (IC, 1.9% vs 0.8% [P < .0001]; CLI, 3.0% vs 1.4% [P < .0001]) and, in the CLI cohort, arterial perforation (1.4% vs 1.0%; P = .01). CONCLUSIONS Despite a lack of evidence for atherectomy over angioplasty and stenting, its use has increased across the United States from 2010 to 2016. It is applied equally to IC and CLI populations, with no identifiable pattern of comorbidities or lesion characteristics, suggesting that indications are not clearly delineated or agreed on. This study places impetus on further understanding of the optimal role for atherectomy and its long-term clinical benefit in the management of peripheral arterial disease.
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Affiliation(s)
- Sathish Mohan
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass
| | - Julie M Flahive
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass
| | - Edward J Arous
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass
| | - Dejah R Judelson
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass
| | - Francesco A Aiello
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass
| | - Andres Schanzer
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass
| | - Jessica P Simons
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass.
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- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass
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25
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Aimo A, Seghieri C, Nuti S, Emdin M. Building medical knowledge from real world registries: The case of heart failure. IJC HEART & VASCULATURE 2018; 19:98-99. [PMID: 29955669 PMCID: PMC6020859 DOI: 10.1016/j.ijcha.2018.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 03/30/2018] [Indexed: 10/25/2022]
Affiliation(s)
- Alberto Aimo
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Cardiology Division, University of Pisa, Italy
| | - Chiara Seghieri
- Institute of Management, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Sabina Nuti
- Institute of Management, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
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Golledge J, Moxon JV, Rowbotham S, Pinchbeck J, Yip L, Velu R, Quigley F, Jenkins J, Morris DR. Risk of major amputation in patients with intermittent claudication undergoing early revascularization. Br J Surg 2018; 105:699-708. [PMID: 29566427 DOI: 10.1002/bjs.10765] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 09/29/2017] [Accepted: 10/22/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Revascularization is being used increasingly for the treatment of intermittent claudication and yet few studies have reported the long-term outcomes of this strategy. The aim of this study was to compare the long-term outcome of patients with intermittent claudication who underwent revascularization compared with a group initially treated without revascularization. METHODS Patients with symptoms of intermittent claudication and a diagnosis of peripheral arterial disease were recruited from outpatient clinics at three hospitals in Queensland, Australia. Based on variation in the practices of different vascular specialists, patients were either treated by early revascularization or received initial conservative treatment. Patients were followed in outpatient clinics using linked hospital admission record data. The primary outcome was the requirement for major amputation. Kaplan-Meier curves, Cox regression and competing risks analyses were used to compare major amputation rates. RESULTS Some 456 patients were recruited; 178 (39·0 per cent) underwent early revascularization and 278 (61·0 per cent) had initial conservative treatment. Patients were followed for a mean(s.d.) of 5·00(3·37) years. The estimated 5-year major amputation rate was 6·2 and 0·7 per cent in patients undergoing early revascularization and initial conservative treatment respectively (P = 0·003). Early revascularization was associated with an increased requirement for major amputation in models adjusted for other risk factors (relative risk 5·40 to 4·22 in different models). CONCLUSION Patients presenting with intermittent claudication who underwent early revascularization appeared to be at higher risk of amputation than those who had initial conservative treatment.
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Affiliation(s)
- J Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia.,Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia.,Department of Vascular and Endovascular Surgery, Townsville Hospital, Townsville, Queensland, Australia.,Department of Vascular and Endovascular Surgery, Mater Hospital, Townsville, Queensland, Australia
| | - J V Moxon
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia.,Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia
| | - S Rowbotham
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Department of Vascular and Endovascular Surgery, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - J Pinchbeck
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - L Yip
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - R Velu
- Department of Vascular and Endovascular Surgery, Townsville Hospital, Townsville, Queensland, Australia.,Department of Vascular and Endovascular Surgery, Mater Hospital, Townsville, Queensland, Australia
| | - F Quigley
- Department of Vascular and Endovascular Surgery, Mater Hospital, Townsville, Queensland, Australia
| | - J Jenkins
- Department of Vascular and Endovascular Surgery, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - D R Morris
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia.,Nuffield Department of Population Health, University of Oxford, Oxford, UK
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O'Donnell TFX, Powell C, Deery SE, Darling JD, Hughes K, Giles KA, Wang GJ, Schermerhorn ML. Regional variation in racial disparities among patients with peripheral artery disease. J Vasc Surg 2018; 68:519-526. [PMID: 29459014 DOI: 10.1016/j.jvs.2017.10.090] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 10/27/2017] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Prior studies identified significant racial disparities as well as regional variation in outcomes of patients with peripheral artery disease (PAD). We aimed to determine whether regional variation contributes to these racial disparities. METHODS We identified all white or black patients who underwent infrainguinal revascularization or amputation in 15 deidentified regions of the Vascular Quality Initiative between 2003 and 2017. We excluded three regions with <100 procedures. We used multivariable linear regression, allowing clustering at the hospital level to calculate the marginal effects of race and region on adjusted 30-day mortality, major adverse limb events (MALEs), and amputation. We compared long-term outcomes between black and white patients within each region and within patients of each race treated in different regions using multivariable Cox regression. RESULTS We identified 90,418 patients, 15,527 (17%) of whom were black. Patients underwent 31,263 bypasses, 52,462 endovascular interventions, and 6693 amputations. Black patients were younger and less likely to smoke, to have coronary artery disease, or to have chronic obstructive pulmonary disease, but they were more likely to have diabetes, limb-threatening ischemia, dialysis dependence, and hypertension and to be self-insured or on Medicaid (all P < .05). Adjusted 30-day mortality ranged from 1.2% to 2.1% across regions for white patients and 0% to 3.0% for black patients; adjusted 30-day MALE varied from 4.0% to 8.3% for white patients and 2.4% to 8.1% for black patients; and adjusted 30-day amputation rates varied from 0.3% to 1.2% for white patients and 0% to 2.1% for black patients. Black patients experienced significantly different (both higher and lower) adjusted rates of 30-day mortality and amputation than white patients did in several regions (P < .05) but not MALEs. In addition, within each racial group, we found significant variation in the adjusted rates of all outcomes between regions (all P < .01). In adjusted analyses, compared with white patients, black patients experienced consistently lower long-term mortality (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.73-0.88; P < .001) and higher rates of MALEs (HR, 1.15; 95% CI, 1.06-1.25; P < .001) and amputation (HR, 1.33; 95% CI, 1.18-1.51; P < .001), with no statistically significant variation across the regions. However, rates of all long-term outcomes varied within both racial groups across regions. CONCLUSIONS Significant racial disparities exist in outcomes after lower extremity procedures in patients with PAD, with regional variation contributing to perioperative but not long-term outcome disparities. Underperforming regions should use these data to generate quality improvement projects, as understanding the etiology of these disparities is critical to improving the care of all patients with PAD.
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Affiliation(s)
- Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Chloe Powell
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Sarah E Deery
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Jeremy D Darling
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Kakra Hughes
- Division of Cardiothoracic and Vascular Surgery, Howard University Hospital, Washington, D.C
| | - Kristina A Giles
- Division of Vascular Surgery and Endovascular Therapy, University of Florida Health, Gainesville, Fla
| | - Grace J Wang
- Division of Vascular and Endovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
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29
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Jones WS, Patel MR. Antithrombotic Therapy in Peripheral Artery Disease. J Am Coll Cardiol 2018; 71:352-362. [DOI: 10.1016/j.jacc.2017.11.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Revised: 11/06/2017] [Accepted: 11/15/2017] [Indexed: 02/07/2023]
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Armstrong EJ, Ryan MP, Baker ER, Martinsen BJ, Kotlarz H, Gunnarsson C. Risk of major amputation or death among patients with critical limb ischemia initially treated with endovascular intervention, surgical bypass, minor amputation, or conservative management. J Med Econ 2017; 20:1148-1154. [PMID: 28760065 DOI: 10.1080/13696998.2017.1361961] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AIMS Patients with critical limb ischemia (CLI) have an increased risk of major amputation. The initial treatment approach for CLI may significantly impact the subsequent risk of major amputation or death. The objective of this study was to describe the initial treatment approaches of patients with CLI and the limb outcomes associated with each approach. METHODS Data from MarketScan Commercial and Medicare Supplemental Databases from January 2006-December 2014 was utilized. Cohorts of CLI patients were defined as follows: (1) peripheral vascular intervention (PVI); (2) peripheral vascular surgery (PVS); (3) minor amputation without concomitant PVI or PVS (MinAMP); and (4) Patients without PVI, PVS, or MinAMP (conservative therapy). The odds of major amputation or inpatient death were estimated using the Cox proportional hazards model. For those patients requiring a major amputation, the incremental expenditures per member per month (PMPM) were estimated using a gamma log-link model. RESULTS Conservative therapy was associated with significantly higher odds of major amputation or inpatient death compared to patients who underwent minor amputation (1.59-times), PVI (2.08-times), or PVS (2.12-times). Patients treated with an initial strategy of minor amputation also had higher odds of major amputation or inpatient death compared to PVS (1.31-times) or PVI (1.33-times). The estimated incremental expenditures PMPM for patients with a major amputation was $5,165. CONCLUSIONS Revascularization reduces the risk of a major amputation or inpatient death for patients with CLI when compared to conservative therapy. Major amputation is also associated with significantly higher healthcare expenditures.
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Affiliation(s)
| | - Michael P Ryan
- b CTI Clinical Trial and Consulting Services, Inc. , Covington , KY , USA
| | - Erin R Baker
- b CTI Clinical Trial and Consulting Services, Inc. , Covington , KY , USA
| | | | - Harry Kotlarz
- c Cardiovascular Systems, Inc. , St. Paul , MN , USA
| | - Candace Gunnarsson
- b CTI Clinical Trial and Consulting Services, Inc. , Covington , KY , USA
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31
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Soden PA, Zettervall SL, Shean KE, Vouyouka AG, Goodney PP, Mills JL, Hallett JW, Schermerhorn ML. Regional variation in outcomes for lower extremity vascular disease in the Vascular Quality Initiative. J Vasc Surg 2017; 66:810-818. [PMID: 28450103 PMCID: PMC5572773 DOI: 10.1016/j.jvs.2017.01.061] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Accepted: 01/31/2017] [Indexed: 01/30/2023]
Abstract
BACKGROUND Increased focus has been placed on perioperative and long-term outcomes in the treatment of peripheral artery disease (PAD), both for purposes of quality improvement and for assessment of performance at a surgeon and institutional level. This study evaluates regional variation in outcomes after treatment for PAD within the Vascular Quality Initiative (VQI). By describing the variation in practice patterns and outcomes across regions, we hope that each regionally based quality group can select which areas are most important for them to focus on as they will have access to their regional data to compare. METHODS We identified all patients in the VQI who had infrainguinal bypass or endovascular intervention from 2009 to 2014. We compared variation in perioperative and 1-year outcomes stratified by symptom status and revascularization type among the 16 regional groups of the VQI. We analyzed variation in perioperative end points using χ2 analysis, and 1-year end points were analyzed using Kaplan-Meier and life-table analysis. RESULTS We identified 15,338 bypass procedures for symptomatic PAD: 27% for claudication, 59% for chronic limb-threatening ischemia (CLI; 61% of these for tissue loss), and 14% for acute limb ischemia. We identified 33,925 endovascular procedures for symptomatic PAD: 42% for claudication, 48% for CLI (73% of these for tissue loss), and 10% for acute limb ischemia. Thirty-day mortality varied significantly after endovascular intervention for CLI (0.5%-3%; P < .001) but not for claudication (0.0%-0.5%, P = .77) or for bypass for claudication (0.0%-2.6%; P = .37) or CLI (0.0%-5.0%; P = .08). After bypass, rates of >2 units transfused red blood cells (claudication, 0.0%-13% [P < .001]; CLI, 6.9%-27% [P < .001]) varied significantly. In-hospital major amputation was variable after bypass for CLI (0.0%-4.3%; P = .004) but not for claudication (0.0%-0.6%; P = .98), as was postoperative myocardial infarction (claudication, 0.0%-4% [P = .36]; CLI, 0.8%-6% [P = .001]). One-year survival varied significantly for endovascular interventions for claudication (92%-100%; P < .001), bypass for CLI (85%-94% [P < .001]), and endovascular interventions for CLI (77%-96%; P < .001) but not after bypass for claudication (95%-100%; P = .57). CONCLUSIONS In this real-world comparison among VQI regions, we found significant variation in perioperative and 1-year end points for patients with PAD undergoing bypass or endovascular intervention. This study highlights opportunities for quality improvement efforts to reduce variation and to improve outcomes.
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Affiliation(s)
- Peter A Soden
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Sara L Zettervall
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Katie E Shean
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Ageliki G Vouyouka
- Division of Vascular Surgery, Mount Sinai Health Systems, Icahn School of Medicine, New York, NY
| | - Philip P Goodney
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Dartmouth Medical School, Hanover, NH
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, Tex
| | - John W Hallett
- Division of Cardiovascular Surgery, Medical University of South Carolina, Charleston, SC
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
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Data, guidelines, and practice of revascularization for claudication. J Vasc Surg 2017; 66:911-915. [PMID: 28842076 DOI: 10.1016/j.jvs.2017.05.105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 05/12/2017] [Indexed: 01/20/2023]
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Quality and Safety in Health Care, Part XXIII: Bypass Leg Surgery. Clin Nucl Med 2017; 42:444-445. [PMID: 28195910 DOI: 10.1097/rlu.0000000000001584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The efforts of the Vascular Quality Initiative of the Society for Vascular Surgery and its regional groups, including the Vascular Study Group of New England, have been very helpful in furthering medical knowledge in multiple areas of vascular surgery and hopefully in improving quality and safety. One of the areas focused on has been leg bypass surgery. The American College of Surgeons National Surgical Quality Improvement Program has also provided information relevant to leg bypass surgery quality improvement, but there are differences between this program and that from the Vascular Quality Initiative.
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