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Desikan SK, Brahmbhatt B, Patel J, Kankaria A, Anagnostakos J, Dux M, Beach K, Gray VL, McDonald T, Crone C, Sikdar S, Sorkin JD, Lal BK. Cognitive impairment in asymptomatic carotid artery stenosis is associated with abnormal segments in the Circle of Willis. J Vasc Surg 2024:S0741-5214(24)01085-1. [PMID: 38710420 DOI: 10.1016/j.jvs.2024.04.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 04/11/2024] [Accepted: 04/24/2024] [Indexed: 05/08/2024]
Abstract
OBJECTIVE Our group has previously demonstrated that patients with asymptomatic carotid artery stenosis (ACAS) demonstrate cognitive impairment. One proposed mechanism for cognitive impairment in patients with ACAS is cerebral hypoperfusion due to flow-restriction. We tested whether the combination of a high-grade carotid stenosis and inadequate cross-collateralization in the Circle of Willis (CoW) resulted in worsened cognitive impairment. METHODS Twenty-four patients with high-grade (≥70% diameter-reducing) ACAS underwent carotid duplex ultrasound, cognitive assessment, and 3D time-of-flight magnetic resonance angiography (MRA). The cognitive battery consisted of nine neuropsychological tests assessing four cognitive domains: learning and recall, attention and working memory, motor and processing speed, and executive function. Raw cognitive scores were converted into standardized T-scores. A structured interpretation of the MRA images was performed with each segment of the CoW categorized as being either normal or abnormal. Abnormal segments of the CoW were defined as segments characterized as narrowed or occluded due to congenital aplasia or hypoplasia, or acquired atherosclerotic stenosis or occlusion. Linear regression was used to estimate the association between the number of abnormal segments in the CoW, and individual cognitive domain scores. Significance was set to p<0.05. RESULTS The mean age of the patients was 66.1 + 9.6 (mean + SD) years and 79.2% (n=19) were male. A significant negative association was found between the number of abnormal segments in the CoW and cognitive scores in the learning and recall (β = -6.5, p = 0.01), and attention and working memory (β = -7.0, p = 0.02) domains. There was a trend suggesting a negative association in the motor and processing speed (β = -2.4, p = 0.35) and executive function (β = -4.5, p = 0.06) domains that did not reach significance. CONCLUSION In patients with high-grade ACAS, the concomitant presence of increasing occlusive disease in the CoW correlates with worse cognitive function. This association was significant in the learning and recall and attention and working memory domains. While motor and processing speed and executive function also declined numerically with increasing abnormal segments in the CoW, the relationship was not significant. Since flow restriction at a carotid stenosis compounded by inadequate collateral compensation across a diseased CoW worsens cerebral perfusion, our findings support the hypothesis that cerebral hypoperfusion underlies the observed cognitive impairment in patients with ACAS.
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Affiliation(s)
- S K Desikan
- Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; Vascular Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - B Brahmbhatt
- Department of Bioengineering, George Mason University, Fairfax, VA, USA
| | - J Patel
- Radiology Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - A Kankaria
- Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; Vascular Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - J Anagnostakos
- Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; Vascular Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - M Dux
- Neuropsychology Section, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - K Beach
- D. Eugene Strandness Vascular Laboratory, Department of Surgery, University of Washington, Seattle, WA, USA
| | - V L Gray
- Department of Physical Therapy and Rehabilitation Science, University of Maryland, Baltimore, MD, USA
| | - T McDonald
- Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; Vascular Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - C Crone
- Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; Vascular Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - S Sikdar
- Department of Bioengineering, George Mason University, Fairfax, VA, USA
| | - J D Sorkin
- Baltimore VA Geriatric Research, Education and Clinical Center, Baltimore, MD, USA; Department of Medicine, Division of Gerontology and Palliative Care, University of Maryland School of Medicine, Baltimore, MD, USA
| | - B K Lal
- Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; Vascular Service, Veterans Affairs Medical Center, Baltimore, MD, USA.
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Turan TN, Lal BK, Meschia JF. Antihypertensive Pharmacotherapy for Patients Undergoing Carotid Revascularization. Ann Vasc Surg 2024; 101:193-194. [PMID: 38171453 PMCID: PMC10957318 DOI: 10.1016/j.avsg.2023.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 11/19/2023] [Indexed: 01/05/2024]
Affiliation(s)
- Tanya N Turan
- Department of Neurology, Medical University of South Carolina, Charleston, SC
| | - Brajesh K Lal
- Department of Vascular Surgery, University of Maryland Medical System, Baltimore, MD
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Paraskevas KI, Dardik A, Schermerhorn ML, Liapis CD, Mansilha A, Lal BK, Gray WA, Brown MM, Myrcha P, Lavie CJ, Zeebregts CJ, Secemsky EA, Saba L, Blecha M, Gurevich V, Silvestrini M, Blinc A, Svetlikov A, Fernandes E Fernandes J, Schneider PA, Gloviczki P, White CJ, AbuRahma AF. Why selective screening for asymptomatic carotid stenosis is currently appropriate: a special report. Expert Rev Cardiovasc Ther 2024; 22:159-165. [PMID: 38480465 DOI: 10.1080/14779072.2024.2330660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/11/2024] [Indexed: 03/19/2024]
Abstract
INTRODUCTION Two of the main reasons recent guidelines do not recommend routine population-wide screening programs for asymptomatic carotid artery stenosis (AsxCS) is that screening could lead to an increase of carotid revascularization procedures and that such mass screening programs may not be cost-effective. Nevertheless, selective screening for AsxCS could have several benefits. This article presents the rationale for such a program. AREAS COVERED The benefits of selective screening for AsxCS include early recognition of AsxCS allowing timely initiation of preventive measures to reduce future myocardial infarction (MI), stroke, cardiac death and cardiovascular (CV) event rates. EXPERT OPINION Mass screening programs for AsxCS are neither clinically effective nor cost-effective. Nevertheless, targeted screening of populations at high risk for AsxCS provides an opportunity to identify these individuals earlier rather than later and to initiate a number of lifestyle measures, risk factor modifications, and intensive medical therapy in order to prevent future strokes and CV events. For patients at 'higher risk of stroke' on best medical treatment, a prophylactic carotid intervention may be considered.
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Affiliation(s)
| | - Alan Dardik
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
- Department of Surgery, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Christos D Liapis
- Department of Vascular Surgery, Athens Vascular Research Center, Athens, Greece
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal
- Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Brajesh K Lal
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, USA
- Department of Vascular Surgery, Baltimore VA Medical Center, Baltimore, USA
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Martin M Brown
- Stroke Research Centre, UCL Institute of Neurology, University College London, London, UK
| | - Piotr Myrcha
- Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, USA
| | - Clark J Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Eric A Secemsky
- Smith Center for Outcomes Research, Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | - Matthew Blecha
- Division of Vascular Surgery, Stritch School of Medicine, Loyola University Chicago, Chicago, IL, USA
| | - Victor Gurevich
- Center of Atherosclerosis and Lipid Disorders, Lab of Microangiopathic Mechanisms of Atherogenesis, Saint-Petersburg State University, Mechnikov, Saint-Petersburgh, Russia
| | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Ales Blinc
- Department of Vascular Diseases, Division of Internal Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Alexei Svetlikov
- Division of Vascular & Endovascular Surgery, North-Western Scientific Clinical Center of Federal Medical Biological Agency, Department of Hospital Surgery, Saint-Petersburg State University, Saint-Petersburg, Russia
| | - Jose Fernandes E Fernandes
- Cardiovascular Center (CCUL), Faculty of Medicine University of Lisbon, Lisbon, Portugal
- Department of Vascular Surgery, Hospital da Luz Torres de Lisboa, Lisbon, Portugal
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA, USA
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Christopher J White
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, USA
| | - Ali F AbuRahma
- Department of Surgery, Division of Vascular and Endovascular Surgery, Charleston Area Medical Center/West Virginia University Health Sciences Center, Charleston, WV, USA
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Hayssen H, Sahoo S, Nguyen P, Mayorga-Carlin M, Siddiqui T, Englum B, Slejko JF, Mullins CD, Yesha Y, Sorkin JD, Lal BK. Ability of Caprini and Padua risk-assessment models to predict venous thromboembolism in a nationwide Veterans Affairs study. J Vasc Surg Venous Lymphat Disord 2024; 12:101693. [PMID: 37838307 PMCID: PMC10922503 DOI: 10.1016/j.jvsv.2023.101693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 09/28/2023] [Accepted: 10/02/2023] [Indexed: 10/16/2023]
Abstract
OBJECTIVE Venous thromboembolism (VTE) is a preventable complication of hospitalization. Risk-stratification is the cornerstone of prevention. The Caprini and Padua are two of the most commonly used risk-assessment models (RAMs) to quantify VTE risk. Both models perform well in select, high-risk cohorts. Although VTE RAMs were designed for use in all hospital admissions, they are mostly tested in select, high-risk cohorts. We aim to evaluate the two RAMs in a large, unselected cohort of patients. METHODS We analyzed consecutive first hospital admissions of 1,252,460 unique surgical and non-surgical patients to 1298 Veterans Affairs facilities nationwide between January 2016 and December 2021. Caprini and Padua scores were generated using the Veterans Affairs' national data repository. We determined the ability of the two RAMs to predict VTE within 90 days of admission. In secondary analyses, we evaluated prediction at 30 and 60 days, in surgical vs non-surgical patients, after excluding patients with upper extremity deep vein thrombosis, in patients hospitalized ≥72 hours, after including all-cause mortality in a composite outcome, and after accounting for prophylaxis in the predictive model. We used area under the receiver operating characteristic curves (AUCs) as the metric of prediction. RESULTS A total of 330,388 (26.4%) surgical and 922,072 (73.6%) non-surgical consecutively hospitalized patients (total N = 1,252,460) were analyzed. Caprini scores ranged from 0 to 28 (median, 4; interquartile range [IQR], 3-6); Padua scores ranged from 0-13 (median, 1; IQR, 1-3). The RAMs showed good calibration and higher scores were associated with higher VTE rates. VTE developed in 35,557 patients (2.8%) within 90 days of admission. The ability of both models to predict 90-day VTE was low (AUCs: Caprini, 0.56; 95% confidence interval [CI], 0.56-0.56; Padua, 0.59; 95% CI, 0.58-0.59). Prediction remained low for surgical (Caprini, 0.54; 95% CI, 0.53-0.54; Padua, 0.56; 95% CI, 0.56-0.57) and non-surgical patients (Caprini, 0.59; 95% CI, 0.58-0.59; Padua, 0.59; 95% CI, 0.59-0.60). There was no clinically meaningful change in predictive performance in any of the sensitivity analyses. CONCLUSIONS Caprini and Padua RAM scores have low ability to predict VTE events in a cohort of unselected consecutive hospitalizations. Improved VTE RAMs must be developed before they can be applied to a general hospital population.
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Affiliation(s)
- Hilary Hayssen
- Department of Surgery, University of Maryland, Baltimore, MD; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD
| | - Shalini Sahoo
- Department of Surgery, University of Maryland, Baltimore, MD; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD
| | - Phuong Nguyen
- Department of Computer Science, University of Miami, Miami, FL
| | - Minerva Mayorga-Carlin
- Department of Surgery, University of Maryland, Baltimore, MD; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD
| | - Tariq Siddiqui
- Surgery Service, Veterans Affairs Medical Center, Baltimore, MD
| | - Brian Englum
- Department of Surgery, University of Maryland, Baltimore, MD
| | - Julia F Slejko
- Department of Health Services Research, University of Maryland, Baltimore, MD
| | - C Daniel Mullins
- Department of Health Services Research, University of Maryland, Baltimore, MD
| | - Yelena Yesha
- Department of Computer Science, University of Miami, Miami, FL
| | - John D Sorkin
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD; Geriatric Research, Education, and Clinical Center, Veterans Affairs Medical Center, Baltimore, MD
| | - Brajesh K Lal
- Department of Surgery, University of Maryland, Baltimore, MD; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD.
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Vemuri C, Gibson KD, Pappas PJ, Sadek M, Ting W, Obi AT, Mouawad NJ, Etkin Y, Gasparis AP, McDonald T, Sahoo S, Sorkin JD, Lal BK. Effect of junctional reflux on the venous clinical severity score in patients with insufficiency of the great saphenous vein (JURY study). J Vasc Surg Venous Lymphat Disord 2024; 12:101700. [PMID: 37956904 PMCID: PMC10939725 DOI: 10.1016/j.jvsv.2023.101700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/29/2023] [Accepted: 10/02/2023] [Indexed: 11/21/2023]
Abstract
OBJECTIVE Effective treatment options are available for chronic venous insufficiency associated with superficial venous reflux. Although many patients with C2 and C3 disease based on the CEAP (Clinical-Etiological-Anatomical-Pathophysiological) classification have combined great saphenous vein (GSV) and saphenofemoral junction (SFJ) reflux, some may not have concomitant SFJ reflux. Several payors have determined that symptom severity in patients without SFJ reflux does not warrant treatment. In patients planned for venous ablation, we tested whether Venous Clinical Severity Scores (VCSS) are equivalent in those with GSV reflux alone compared with those with both GSV and SFJ reflux. METHODS This cross-sectional study was conducted at 10 centers. Inclusion criteria were: candidate for endovenous ablation as determined by treating physician; 18 to 80 years of age; GSV reflux with or without SFJ reflux on ultrasound; and C2 or C3 disease. Exclusion criteria were prior deep vein thrombosis; prior vein ablation on the index limb; ilio-caval obstruction; and renal, hepatic, or heart failure requiring prior hospitalization. An a priori sample size was calculated. We used multiple linear regression (adjusted for patient characteristics) to compare differences in VCSS scores of the two groups at baseline, and to test whether scores were equivalent using a priori equivalence boundaries of +1 and -1. In secondary analyses, we tested differences in VCSS scores in patients with C2 and C3 disease separately. RESULTS A total of 352 patients were enrolled; 64.2% (n = 226) had SFJ reflux, and 35.8% (n = 126) did not. The two groups did not differ by major clinical characteristics. The mean age of the cohort was 53.9 ± 14.3 years; women comprised 74.2%; White patients 85.8%; and body mass index was 27.8 ± 6.1 kg/m2. The VCSS scores in patients with and without SFJ reflux were found to be equivalent; SFJ reflux was not a significant predictor of VCSS score; and mean VCSS scores did not differ significantly (6.4 vs 6.6, respectively, P = .40). In secondary subset analyses, VCSS scores were equivalent between C2 patients with and without SFJ reflux, and VCSS scores of C3 patients with SFJ reflux were lower than those without SFJ reflux. CONCLUSIONS Symptom severity is equivalent in patients with GSV reflux with or without SFJ reflux. The absence of SFJ reflux alone should not determine the treatment paradigm in patients with symptomatic chronic venous insufficiency. Patients with GSV reflux who meet clinical criteria for treatment should have equivalent treatment regardless of whether or not they have SFJ reflux.
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Affiliation(s)
- Chandu Vemuri
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Kathleen D Gibson
- Department of Surgery, Lake Washington Vascular Surgeons, Bellevue, WA
| | - Peter J Pappas
- Department of Surgery, Center for Vein Restoration, Morristown, NJ
| | - Mikel Sadek
- Department of Surgery, NYU Langone Health, New York, NY
| | - Windsor Ting
- Department of Surgery, Mount Sinai, New York, NY
| | - Andrea T Obi
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | - Yana Etkin
- Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Uniondale, NY
| | | | - Tara McDonald
- Department of Surgery, University of Maryland, Baltimore, MD
| | - Shalini Sahoo
- Department of Surgery, University of Maryland, Baltimore, MD
| | - John D Sorkin
- Department of Medicine, University of Maryland, Baltimore, MD
| | - Brajesh K Lal
- Department of Surgery, University of Maryland, Baltimore, MD.
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Paraskevas KI, Brown MM, Lal BK, Myrcha P, Lyden SP, Schneider PA, Poredos P, Mikhailidis DP, Secemsky EA, Musialek P, Mansilha A, Parikh SA, Silvestrini M, Lavie CJ, Dardik A, Blecha M, Liapis CD, Zeebregts CJ, Nederkoorn PJ, Poredos P, Gurevich V, Jawien A, Lanza G, Gray WA, Gupta A, Svetlikov AV, Fernandes E Fernandes J, Nicolaides AN, White CJ, Meschia JF, Cronenwett JL, Schermerhorn ML, AbuRahma AF. Recent advances and controversial issues in the optimal management of asymptomatic carotid stenosis. J Vasc Surg 2024; 79:695-703. [PMID: 37939746 DOI: 10.1016/j.jvs.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 10/29/2023] [Accepted: 11/03/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVE The optimal management of patients with asymptomatic carotid stenosis (AsxCS) is enduringly controversial. We updated our 2021 Expert Review and Position Statement, focusing on recent advances in the diagnosis and management of patients with AsxCS. METHODS A systematic review of the literature was performed up to August 1, 2023, using PubMed/PubMed Central, EMBASE and Scopus. The following keywords were used in various combinations: "asymptomatic carotid stenosis," "carotid endarterectomy" (CEA), "carotid artery stenting" (CAS), and "transcarotid artery revascularization" (TCAR). Areas covered included (i) improvements in best medical treatment (BMT) for patients with AsxCS and declining stroke risk, (ii) technological advances in surgical/endovascular skills/techniques and outcomes, (iii) risk factors, clinical/imaging characteristics and risk prediction models for the identification of high-risk AsxCS patient subgroups, and (iv) the association between cognitive dysfunction and AsxCS. RESULTS BMT is essential for all patients with AsxCS, regardless of whether they will eventually be offered CEA, CAS, or TCAR. Specific patient subgroups at high risk for stroke despite BMT should be considered for a carotid revascularization procedure. These patients include those with severe (≥80%) AsxCS, transcranial Doppler-detected microemboli, plaque echolucency on Duplex ultrasound examination, silent infarcts on brain computed tomography or magnetic resonance angiography scans, decreased cerebrovascular reserve, increased size of juxtaluminal hypoechoic area, AsxCS progression, carotid plaque ulceration, and intraplaque hemorrhage. Treatment of patients with AsxCS should be individualized, taking into consideration individual patient preferences and needs, clinical and imaging characteristics, and cultural, ethnic, and social factors. Solid evidence supporting or refuting an association between AsxCS and cognitive dysfunction is lacking. CONCLUSIONS The optimal management of patients with AsxCS should include BMT for all individuals and a prophylactic carotid revascularization procedure (CEA, CAS, or TCAR) for some asymptomatic patient subgroups, additionally taking into consideration individual patient needs and preference, clinical and imaging characteristics, social and cultural factors, and the available stroke risk prediction models. Future studies should investigate the association between AsxCS with cognitive function and the role of carotid revascularization procedures in the progression or reversal of cognitive dysfunction.
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Affiliation(s)
| | - Martin M Brown
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Brajesh K Lal
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD; Department of Vascular Surgery, Baltimore VA Medical Center, Baltimore, MD; Department of Neurology, Mayo Clinic, Rochester, MN
| | - Piotr Myrcha
- Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Sean P Lyden
- Department of Vascular Surgery, The Cleveland Clinic, Cleveland, OH
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA
| | - Pavel Poredos
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Eric A Secemsky
- Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Piotr Musialek
- Jagiellonian University Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Sahil A Parikh
- Division of Cardiology, Department of Medicine, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY; Center for Interventional Cardiovascular Care and Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA
| | - Alan Dardik
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Chicago, Stritch School of Medicine, Loyola University Health System, Chicago, IL
| | - Christos D Liapis
- Department of Vascular & Endovascular Surgery, Athens Medical Center, Athens, Greece
| | - Clark J Zeebregts
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Amsterdam, the Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Peter Poredos
- Department of Anaesthesiology and Surgical Intensive Care, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Victor Gurevich
- Center of Atherosclerosis, Lab of Microangiopathic Mechanisms of Atherogenesis, Saint-Petersburg State University, North-Western State Medical University n.a. I.I. Mechnikov, Saint Petersburg, Russia
| | - Arkadiusz Jawien
- Department of Vascular Surgery and Angiology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Torun, Poland
| | - Gaetano Lanza
- Department of Surgery, IRCCS Multimedica Hospital, Castellanza, Italy
| | | | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY
| | - Alexei V Svetlikov
- Division of Vascular & Endovascular Surgery, North-Western Scientific Clinical Center of Federal Medical Biological Agency, Department of Hospital Surgery, Saint-Petersburg State University, Saint Petersburg, Russia
| | | | - Andrew N Nicolaides
- Vascular Screening and Diagnostic Center, Nicosia, Cyprus; University of Nicosia Medical School, Nicosia, Cyprus; Department of Vascular Surgery, Imperial College, London, UK
| | - Christopher J White
- Department of Cardiology, Ochsner Clinical School, University of Queensland and Ochsner Health System, New Orleans, LA
| | | | - Jack L Cronenwett
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ali F AbuRahma
- Department of Surgery, Division of Vascular and Endovascular Surgery, Charleston Area Medical Center/West Virginia University Health Sciences Center, Charleston, WV
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Ladner DP, Goldstein AM, Billiar TR, Cameron AM, Carpizo DR, Chu DI, Coopersmith CM, DeMatteo RP, Feng S, Gallagher KA, Gillanders WE, Lal BK, Lipshutz GS, Liu A, Maier RV, Mittendorf EA, Morris AM, Sicklick JK, Velazquez OC, Whitson BA, Wilke LG, Yoon SS, Zeiger MA, Farmer DL, Hwang ES. Transforming the Future of Surgeon-Scientists. Ann Surg 2024; 279:231-239. [PMID: 37916404 DOI: 10.1097/sla.0000000000006148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
OBJECTIVE To create a blueprint for surgical department leaders, academic institutions, and funding agencies to optimally support surgeon-scientists. BACKGROUND Scientific contributions by surgeons have been transformative across many medical disciplines. Surgeon-scientists provide a distinct approach and mindset toward key scientific questions. However, lack of institutional support, pressure for increased clinical productivity, and growing administrative burden are major challenges for the surgeon-scientist, as is the time-consuming nature of surgical training and practice. METHODS An American Surgical Association Research Sustainability Task Force was created to outline a blueprint for sustainable science in surgery. Leaders from top NIH-sponsored departments of surgery engaged in video and in-person meetings between January and April 2023. A strength, weakness, opportunities, threats analysis was performed, and workgroups focused on the roles of surgeons, the department and institutions, and funding agencies. RESULTS Taskforce recommendations: (1) SURGEONS: Growth mindset : identifying research focus, long-term planning, patience/tenacity, team science, collaborations with disparate experts; Skill set : align skills and research, fill critical skill gaps, develop team leadership skills; DEPARTMENT OF SURGERY (DOS): (2) MENTORSHIP: Chair : mentor-mentee matching/regular meetings/accountability, review of junior faculty progress, mentorship training requirement, recognition of mentorship (eg, relative value unit equivalent, awards; Mentor: dedicated time, relevant scientific expertise, extramural funding, experience and/or trained as mentor, trusted advisor; Mentee : enthusiastic/eager, proactive, open to feedback, clear about goals; (3) FINANCIAL SUSTAINABILITY: diversification of research portfolio, identification of matching funding sources, departmental resource awards (eg, T-/P-grants), leveraging of institutional resources, negotiation of formalized/formulaic funds flow investment from academic medical center toward science, philanthropy; (4) STRUCTURAL/STRATEGIC SUPPORT: Structural: grants administrative support, biostats/bioinformatics support, clinical trial and research support, regulatory support, shared departmental laboratory space/equipment; Strategic: hiring diverse surgeon-scientist/scientists faculty across DOS, strategic faculty retention/ recruitment, philanthropy, career development support, progress tracking, grant writing support, DOS-wide research meetings, regular DOS strategic research planning; (5) COMMUNITY AND CULTURE: Community: right mix of faculty, connection surgeon with broad scientific community; Culture: building research infrastructure, financial support for research, projecting importance of research (awards, grand rounds, shoutouts); (6) THE ROLE OF INSTITUTIONS: Foundation: research space co-location, flexible start-up packages, courses/mock study section, awards, diverse institutional mentorship teams; Nurture: institutional infrastructure, funding (eg, endowed chairs), promotion friendly toward surgeon-scientists, surgeon-scientists in institutional leadership positions; Expectations: RVU target relief, salary gap funding, competitive starting salaries, longitudinal salary strategy; (7) THE ROLE OF FUNDING AGENCIES: change surgeon research training paradigm, offer alternate awards to K-awards, increasing salary cap to reflect market reality, time extension for surgeon early-stage investigator status, surgeon representation on study section, focused award strategies for professional societies/foundations. CONCLUSIONS Authentic recommitment from surgeon leaders with intentional and ambitious actions from institutions, corporations, funders, and society is essential in order to reap the essential benefits of surgeon-scientists toward advancements of science.
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Affiliation(s)
| | - Allan M Goldstein
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | | | | | - Daniel I Chu
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | | | | | - Sandy Feng
- Department of Surgery, University of California, San Francisco, CA
| | | | | | - Brajesh K Lal
- Department of Surgery, University of Maryland, Baltimore, MD
| | | | - Annie Liu
- Department of Surgery, Duke University, Durham, NC
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA
| | | | - Arden M Morris
- Department of Surgery, Stanford University, Palo Alto, CA
| | | | | | - Bryan A Whitson
- Department of Surgery, The Ohio State University, Columbus, OH
| | - Lee G Wilke
- Department of Surgery, University of Wisconsin, Madison, WI
| | - Sam S Yoon
- Department of Surgery, Columbia University, New York, NY
| | - Martha A Zeiger
- National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Diana L Farmer
- Department of Surgery, University of California, Davis, CA
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8
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Paraskevas KI, Mikhailidis DP, Ringleb PA, Brown MM, Dardik A, Poredos P, Gray WA, Nicolaides AN, Lal BK, Mansilha A, Antignani PL, de Borst GJ, Cambria RP, Loftus IM, Lavie CJ, Blinc A, Lyden SP, Matsumura JS, Jezovnik MK, Bacharach JM, Meschia JF, Clair DG, Zeebregts CJ, Lanza G, Capoccia L, Spinelli F, Liapis CD, Jawien A, Parikh SA, Svetlikov A, Menyhei G, Davies AH, Musialek P, Roubin G, Stilo F, Sultan S, Proczka RM, Faggioli G, Geroulakos G, Fernandes E Fernandes J, Ricco JB, Saba L, Secemsky EA, Pini R, Myrcha P, Rundek T, Martinelli O, Kakkos SK, Sachar R, Goudot G, Schlachetzki F, Lavenson GS, Ricci S, Topakian R, Millon A, Di Lazzaro V, Silvestrini M, Chaturvedi S, Eckstein HH, Gloviczki P, White CJ. An international, multispecialty, expert-based Delphi Consensus document on controversial issues in the management of patients with asymptomatic and symptomatic carotid stenosis. J Vasc Surg 2024; 79:420-435.e1. [PMID: 37944771 DOI: 10.1016/j.jvs.2023.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/25/2023] [Accepted: 09/25/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE Despite the publication of various national/international guidelines, several questions concerning the management of patients with asymptomatic (AsxCS) and symptomatic (SxCS) carotid stenosis remain unanswered. The aim of this international, multi-specialty, expert-based Delphi Consensus document was to address these issues to help clinicians make decisions when guidelines are unclear. METHODS Fourteen controversial topics were identified. A three-round Delphi Consensus process was performed including 61 experts. The aim of Round 1 was to investigate the differing views and opinions regarding these unresolved topics. In Round 2, clarifications were asked from each participant. In Round 3, the questionnaire was resent to all participants for their final vote. Consensus was reached when ≥75% of experts agreed on a specific response. RESULTS Most experts agreed that: (1) the current periprocedural/in-hospital stroke/death thresholds for performing a carotid intervention should be lowered from 6% to 4% in patients with SxCS and from 3% to 2% in patients with AsxCS; (2) the time threshold for a patient being considered "recently symptomatic" should be reduced from the current definition of "6 months" to 3 months or less; (3) 80% to 99% AsxCS carries a higher risk of stroke compared with 60% to 79% AsxCS; (4) factors beyond the grade of stenosis and symptoms should be added to the indications for revascularization in AsxCS patients (eg, plaque features of vulnerability and silent infarctions on brain computed tomography scans); and (5) shunting should be used selectively, rather than always or never. Consensus could not be reached on the remaining topics due to conflicting, inadequate, or controversial evidence. CONCLUSIONS The present international, multi-specialty expert-based Delphi Consensus document attempted to provide responses to several unanswered/unresolved issues. However, consensus could not be achieved on some topics, highlighting areas requiring future research.
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Affiliation(s)
| | - Dimitri P Mikhailidis
- Division of Surgery and Interventional Science, Department of Surgical Biotechnology, University College London Medical School, University College London (UCL) and Department of Clinical Biochemistry, Royal Free Hospital Campus, UCL, London, United Kingdom
| | | | - Martin M Brown
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Alan Dardik
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Pavel Poredos
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Andrew N Nicolaides
- Vascular Screening and Diagnostic Center, Nicosia, Cyprus; University of Nicosia Medical School, Nicosia, Cyprus; Department of Vascular Surgery, Imperial College, London, United Kingdom
| | - Brajesh K Lal
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD; Department of Vascular Surgery, Baltimore VA Medical Center, Baltimore, MD; Department of Neurology, Mayo Clinic, Rochester, MN
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | | | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston, MA
| | - Ian M Loftus
- St George's Vascular Institute, St George's University London, London, United Kingdom
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA
| | - Ales Blinc
- Division of Internal Medicine, Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Sean P Lyden
- Department of Vascular Surgery, The Cleveland Clinic, Cleveland, OH
| | - Jon S Matsumura
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX
| | - J Michael Bacharach
- Department of Vascular Medicine and Endovascular Intervention, North Central Heart Institute and the Avera Heart Hospital, Sioux Falls, SD
| | | | - Daniel G Clair
- Department of Vascular Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Clark J Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS Multimedica Hospital, Castellanza, Italy
| | - Laura Capoccia
- Vascular Surgery Division, Department of Surgery, SS. Filippo e Nicola Hospital, Avezzano, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Department of Medicine and Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | | | - Arkadiusz Jawien
- Department of Vascular Surgery and Angiology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Sahil A Parikh
- Division of Cardiology, Department of Medicine, New York-Presbyterian Hospital/ Columbia University Irving Medical Center, New York, NY; Center for Interventional Cardiovascular Care and Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Alexei Svetlikov
- Division of Vascular and Endovascular Surgery, North-Western Scientific Clinical Center of Federal Medical Biological Agency of Russia, St Petersburg, Russia
| | - Gabor Menyhei
- Department of Vascular Surgery, University of Pecs, Pecs, Hungary
| | - Alun H Davies
- Department of Surgery and Cancer, Section of Vascular Surgery, Imperial College London, Charing Cross Hospital, London, United Kingdom
| | - Piotr Musialek
- Jagiellonian University Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Gary Roubin
- Department of Cardiology, Cardiovascular Associates of the Southeast/ Brookwood, Baptist Medical Center, Birmingham, AL
| | - Francesco Stilo
- Vascular Surgery Division, Department of Medicine and Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, University of Galway, Galway, Ireland
| | - Robert M Proczka
- First Department of Vascular Surgery, Medicover Hospital, Warsaw, Poland, Lazarski University Faculty of Medicine, Warsaw, Poland
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - George Geroulakos
- Department of Vascular Surgery, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Jose Fernandes E Fernandes
- Faculty of Medicine, Lisbon Academic Medical Center, University of Lisbon, Portugal, Hospital da Luz Torres de Lisboa, Lisbon, Portugal
| | - Jean-Baptiste Ricco
- Department of Vascular Surgery, University Hospital of Toulouse, Toulouse, France
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | - Eric A Secemsky
- Division of Cardiology, Department of Medicine, Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Piotr Myrcha
- Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL
| | - Ombretta Martinelli
- Faculty of Medicine, Sapienza University of Rome, Rome, Italy; Vascular Surgery Unit, "Umberto I." Hospital, Rome, Italy
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Ravish Sachar
- North Carolina Heart and Vascular Hospital, UNC-REX Healthcare, University of North Carolina, Raleigh, NC
| | - Guillaume Goudot
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Université Paris Cité, Paris, France
| | - Felix Schlachetzki
- Department of Neurology, University Hospital of Regensburg, Regensburg, Germany
| | | | - Stefano Ricci
- Neurology Department-Stroke Unit, Gubbio-Gualdo Tadino and Citta di Castello Hospitals, USL Umbria 1, Perugia, Italy
| | - Raffi Topakian
- Department of Neurology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civil de Lyon, Bron, France
| | - Vincenzo Di Lazzaro
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Universita Campus Bio-Medico di Roma, Roma, Italy; Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Mauro Silvestrini
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Seemant Chaturvedi
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Christopher J White
- Department of Medicine and Cardiology, Ochsner Clinical School, University of Queensland, Brisbane, Australia; Department of Cardiology, The John Ochsner Heart and Vascular Institute, New Orleans, LA
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Prior SJ, Chrencik MT, Christensen E, Kundi R, Ryan AS, Addison O, Lal BK. An exercise stress test for contrast-enhanced duplex ultrasound assessment of lower limb muscle perfusion in patients with peripheral arterial disease. J Vasc Surg 2024; 79:397-404. [PMID: 37844848 DOI: 10.1016/j.jvs.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/10/2023] [Accepted: 10/10/2023] [Indexed: 10/18/2023]
Abstract
OBJECTIVE The aim of the present study was to develop a standardized contrast-enhanced duplex ultrasound (CE-DUS) protocol to assess lower-extremity muscle perfusion before and after exercise and determine relationships of perfusion with clinical and functional measures. METHODS CE-DUS (EPIQ 5G, Philips) was used before and immediately after a 10-minute, standardized bout of treadmill walking to compare microvascular perfusion of the gastrocnemius muscle in older (55-82 years) patients with peripheral arterial disease (PAD) (n = 15, mean ankle-brachial index, 0.78 ± 0.04) and controls (n = 13). Microvascular blood volume (MBV) and microvascular flow velocity (MFV) were measured at rest and immediately following treadmill exercise, and the Modified Physical Performance Test (MPPT) was used to assess mobility function. RESULTS In the resting state (pre-exercise), MBV in patients with PAD was not significantly different than normal controls (5.17 ± 0.71 vs 6.20 ± 0.83 arbitrary units (AU) respectively; P = .36); however, after exercise, MBV was ∼40% lower in patients with PAD compared with normal controls (5.85 ± 1.13 vs 9.53 ± 1.31 AU, respectively; P = .04). Conversely, MFV was ∼60% higher in patients with PAD compared with normal controls after exercise (0.180 ± 0.016 vs 0.113 ± 0.018 AU, respectively; P = .01). There was a significant between-group difference in the exercise-induced changes in both MBV and MFV (P ≤ .05). Both basal and exercise MBV directly correlated with MPPT score in the patients with PAD (r = 0.56-0.62; P < .05). CONCLUSIONS This standardized protocol for exercise stress testing of the lower extremities quantifies calf muscle perfusion and elicits perfusion deficits in patients with PAD. This technique objectively quantifies microvascular perfusion deficits that are related to reduced mobility function and could be used to assess therapeutic efficacy in patients with PAD.
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Affiliation(s)
- Steven J Prior
- Department of Kinesiology, University of Maryland School of Public Health, College Park, MD; Department of Veterans Affairs and Baltimore Veterans Affairs Medical Center Geriatric Research, Education and Clinical Center (GRECC), Baltimore, MD; Department of Medicine, Division of Gerontology, Geriatrics and Palliative Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Matthew T Chrencik
- Department of Surgery, Division of Vascular Surgery, University of Maryland School of Medicine and Baltimore Veterans Affairs Medical Center, Baltimore, MD
| | - Eric Christensen
- Department of Veterans Affairs and Baltimore Veterans Affairs Medical Center Geriatric Research, Education and Clinical Center (GRECC), Baltimore, MD; Department of Medicine, Division of Gerontology, Geriatrics and Palliative Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Rishi Kundi
- Department of Surgery, Division of Vascular Surgery, University of Maryland School of Medicine and Baltimore Veterans Affairs Medical Center, Baltimore, MD
| | - Alice S Ryan
- Department of Veterans Affairs and Baltimore Veterans Affairs Medical Center Geriatric Research, Education and Clinical Center (GRECC), Baltimore, MD; Department of Medicine, Division of Gerontology, Geriatrics and Palliative Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Odessa Addison
- Department of Veterans Affairs and Baltimore Veterans Affairs Medical Center Geriatric Research, Education and Clinical Center (GRECC), Baltimore, MD; Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore
| | - Brajesh K Lal
- Department of Surgery, Division of Vascular Surgery, University of Maryland School of Medicine and Baltimore Veterans Affairs Medical Center, Baltimore, MD.
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Fang A, Mayorga-Carlin M, Han P, Cassady S, John T, LaRocco A, Etezadi V, Jones K, Nagarsheth K, Toursavadkohi S, Jeudy J, Anderson D, Griffith B, Sorkin JD, Sarkar R, Lal BK, Cires-Drouet RS. Risk factors and treatment interventions associated with incomplete thrombus resolution and pulmonary hypertension after pulmonary embolism. J Vasc Surg Venous Lymphat Disord 2024; 12:101665. [PMID: 37595746 PMCID: PMC10939011 DOI: 10.1016/j.jvsv.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/23/2023] [Accepted: 08/08/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND Residual pulmonary vascular occlusion (RPVO) affects one half of patients after a pulmonary embolism (PE). The relationship between the risk factors and therapeutic interventions for the development of RPVO and chronic thromboembolic pulmonary hypertension is unknown. METHODS This retrospective review included PE patients within a 26-month period who had baseline and follow-up imaging studies (ie, computed tomography [CT], ventilation/perfusion scans, transthoracic echocardiography) available. We collected the incidence of RPVO, percentage of pulmonary artery occlusion (%PAO), baseline CT %PAO, most recent CT %PAO, and difference between the baseline and most recent %PAO on CT (Δ%PAO). RESULTS A total of 354 patients had imaging reports available; 197 with CT and 315 with transthoracic echocardiography. The median follow-up time was 144 days (interquartile range [IQR], 102-186 days). RPVO was present in 38.9% of the 354 patients. The median Δ%PAO was -10.0% (IQR, -32% to -1.2%). Fewer patients with a provoked PE developed RPVO (P ≤ .01), and the initial troponin level was lower in patients who developed RPVO (P = .03). The initial thrombus was larger in the patients who received advanced intervention vs anticoagulation (baseline CT %PAO: median, 61.2%; [IQR, 27.5%-75.0%] vs median, 12.5% [IQR, 2.5%-40.0%]; P ≤ .0001). Catheter-directed thrombolysis (CDT; median Δ%PAO, -47.5%; IQR, -63.7% to -8.7%) and surgical pulmonary embolectomy (SPE; median Δ%PAO, -42.5; IQR, -68.1% to -18.7%) had the largest thrombus reduction compared with anticoagulation (P = .01). Of the 354 patients, 76 developed pulmonary hypertension; however, only 14 received pulmonary hypertension medications and 12 underwent pulmonary thromboendarterectomy. Cancer (odds ratio [OR], 1.7) and planned prolonged anticoagulation (>1 year; OR, 2.20) increased the risk of RPVO. In contrast, the risk was lower for men (OR, 0.61), patients with recent surgery (OR, 0.33), and patients treated with SPE (OR, 0.42). A larger Δ%PAO was found in men (coefficient, -8.94), patients with a lower body mass index (coefficient, -0.66), patients treated with CDT (coefficient, -18.12), and patients treated with SPE (coefficient, -21.69). A lower Δ%PAO was found in African-American patients (coefficient, 7.31). CONCLUSIONS The use of CDT and SPE showed long-term benefit in thrombus reduction.
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Affiliation(s)
- Adam Fang
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland, Baltimore, MD
| | | | - Paul Han
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Steven Cassady
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Thomas John
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Allison LaRocco
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Vahid Etezadi
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland, Baltimore, MD
| | - Kevin Jones
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD; The R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD
| | | | | | - Jean Jeudy
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland, Baltimore, MD
| | | | | | - John D Sorkin
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD; Baltimore Veterans Affairs Geriatrics Research, Education, and Clinical Center, Baltimore Veterans Affairs Medical Center, Baltimore, MD
| | | | - Brajesh K Lal
- Department of Surgery, University of Maryland, Baltimore, MD; Vascular Service, Baltimore Veterans Affairs Medical Center, Baltimore, MD
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Englum BR, Sahoo S, Mayorga-Carlin M, Hayssen H, Siddiqui T, Turner DJ, Sorkin JD, Lal BK. ASO Visual Abstract: Growing Deficit in New Cancer Diagnoses 2 Years into the COVID-19 Pandemic-A National Multicenter Study. Ann Surg Oncol 2023; 30:8526-8527. [PMID: 37755570 DOI: 10.1245/s10434-023-14290-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Affiliation(s)
- Brian R Englum
- Baltimore VA Medical Center and Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shalini Sahoo
- Baltimore VA Medical Center and Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Minerva Mayorga-Carlin
- Baltimore VA Medical Center and Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Hilary Hayssen
- Baltimore VA Medical Center and Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Tariq Siddiqui
- Baltimore VA Medical Center and Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Douglas J Turner
- Baltimore VA Medical Center and Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - John D Sorkin
- Geriatrics Research, Education, and Clinical Center, Veterans Affairs Medical Center, Baltimore, MD, USA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Brajesh K Lal
- Baltimore VA Medical Center and Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.
- Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA.
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12
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Englum BR, Sahoo S, Mayorga-Carlin M, Hayssen H, Siddiqui T, Turner DJ, Sorkin JD, Lal BK. Growing Deficit in New Cancer Diagnoses 2 Years Into the COVID-19 Pandemic: A National Multicenter Study. Ann Surg Oncol 2023; 30:8509-8518. [PMID: 37695458 PMCID: PMC10939008 DOI: 10.1245/s10434-023-14217-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 08/07/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Large decreases in cancer diagnoses were seen early in the COVID-19 pandemic. However, the evolution of these deficits since the end of 2020 and the advent of widespread vaccination is unknown. METHODS This study examined data from the Veterans Health Administration (VA) from 1 January 2018 through 28 February 2022 and identified patients with screening or diagnostic procedures or new cancer diagnoses for the four most common cancers in the VA health system: prostate, lung, colorectal, and bladder cancers. Monthly procedures and new diagnoses were calculated, and the pre-COVID era (January 2018 to February 2020) was compared with the COVID era (March 2020 to February 2022). RESULTS The study identified 2.5 million patients who underwent a diagnostic or screening procedure related to the four cancers. A new cancer was diagnosed for 317,833 patients. During the first 2 years of the pandemic, VA medical centers performed 13,022 fewer prostate biopsies, 32,348 fewer cystoscopies, and 200,710 fewer colonoscopies than in 2018-2019. These persistent deficits added a cumulative deficit of nearly 19,000 undiagnosed prostate cancers and 3300 to 3700 undiagnosed cancers each for lung, colon, and bladder. Decreased diagnostic and screening procedures correlated with decreased new diagnoses of cancer, particularly cancer of the prostate (R = 0.44) and bladder (R = 0.27). CONCLUSION Disruptions in new diagnoses of four common cancers (prostate, lung, bladder, and colorectal) seen early in the COVID-19 pandemic have persisted for 2 years. Although reductions improved from the early pandemic, new reductions during the Delta and Omicron waves demonstrate the continued impact of the COVID-19 pandemic on cancer care.
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Affiliation(s)
- Brian R Englum
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shalini Sahoo
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Minerva Mayorga-Carlin
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Hilary Hayssen
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Tariq Siddiqui
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Douglas J Turner
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - John D Sorkin
- Geriatrics Research, Education, and Clinical Center, Veterans Affairs Medical Center, Baltimore, MD, USA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Brajesh K Lal
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.
- Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA.
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Sahoo S, Hayssen H, Englum B, Mayorga-Carlin M, Siddiqui T, Nguyen P, Kankaria A, Yesha Y, Sorkin JD, Lal BK. Prediction of bleeding in patients being considered for venous thromboembolism prophylaxis. J Vasc Surg Venous Lymphat Disord 2023; 11:1182-1191.e13. [PMID: 37499868 PMCID: PMC11017967 DOI: 10.1016/j.jvsv.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/28/2023] [Accepted: 07/16/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Venous thromboembolism (pulmonary embolism and deep vein thrombosis) is an important preventable cause of in-hospital death. Prophylaxis with low doses of anticoagulants reduces the incidence of venous thromboembolism but can also cause bleeding. It is, therefore, important to stratify the risk of bleeding for hospitalized patients when considering pharmacologic prophylaxis. The IMPROVE (international medical prevention registry on venous thromboembolism) and Consensus risk assessment models (RAMs) are the two tools available for such patients. Few studies have evaluated their ability to predict bleeding in a large, unselected cohort of patients. We assessed the ability of the IMPROVE and Consensus bleeding RAMs to predict bleeding within 90 days of hospitalization in a comprehensive analysis encompassing all hospitalized patients, regardless of surgical vs nonsurgical status. METHODS We analyzed consecutive first hospital admissions of 1,228,448 unique surgical and nonsurgical patients to 1298 Veterans Affairs facilities nationwide between January 2016 and December 2021. IMPROVE and Consensus scores were generated using data from a repository of their common electronic medical records. We assessed the ability of the two RAMs to predict bleeding within 90 days of admission. We used area under the receiver operating characteristic curves to determine the prediction of bleeding by each RAM. RESULTS Of 1,228,448 hospitalized patients, 324,959 (26.5%) were surgical and 903,489 (73.5%) were nonsurgical. Of these patients, 68,372 (5.6%) had a bleeding event within 90 days of admission. The Consensus RAM scores ranged from -5.60 to -1.21 (median, -4.93; interquartile range, -5.60 to -4.93). The IMPROVE RAM scores ranged from 0 to 22 (median, 3.5; interquartile range, 2.5-5). Both showed good calibration, with higher scores associated with higher bleeding rates. The ability of both RAMs to predict 90-day bleeding was low (area under the receiver operating characteristic curve 0.61 for the IMPROVE RAM and 0.59 for the Consensus RAM). The predictive ability was also low at 30 and 60 days for surgical and nonsurgical patients, patients receiving prophylactic, therapeutic, or no anticoagulation, and patients hospitalized for ≥72 hours. Prediction was also low across different bleeding outcomes (ie, any bleeding, gastrointestinal bleeding, nongastrointestinal bleeding, and bleeding or death). CONCLUSIONS In this large, unselected, nationwide cohort of surgical and nonsurgical hospital admissions, increasing IMPROVE and Consensus bleeding RAM scores were associated with increasing bleeding rates. However, both RAMs had low ability to predict bleeding at 0 to 90 days after admission. Thus, the currently available RAMs require modification and rigorous reevaluation before they can be applied universally.
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Affiliation(s)
- Shalini Sahoo
- Department of Surgery, University of Maryland, Baltimore, MD; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD
| | - Hilary Hayssen
- Department of Surgery, University of Maryland, Baltimore, MD; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD
| | - Brian Englum
- Department of Surgery, University of Maryland, Baltimore, MD
| | - Minerva Mayorga-Carlin
- Department of Surgery, University of Maryland, Baltimore, MD; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD
| | - Tariq Siddiqui
- Surgery Service, Veterans Affairs Medical Center, Baltimore, MD
| | - Phuong Nguyen
- Department of Computer Science, University of Miami, Miami, FL
| | - Aman Kankaria
- Department of Surgery, University of Maryland, Baltimore, MD; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD
| | - Yelena Yesha
- Department of Computer Science, University of Miami, Miami, FL
| | - John D Sorkin
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD; Geriatric Research, Education, and Clinical Center, Veterans Affairs Medical Center, Baltimore, MD
| | - Brajesh K Lal
- Department of Surgery, University of Maryland, Baltimore, MD; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD.
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Lobastov K, Urbanek T, Stepanov E, Lal BK, Marangoni J, Krauss ES, Cronin M, Dengler N, Segal A, Welch HJ, Gianesini S, Chen X, Caprini JA. The Thresholds of Caprini Score Associated With Increased Risk of Venous Thromboembolism Across Different Specialties: A Systematic Review. Ann Surg 2023; 277:929-937. [PMID: 36912040 DOI: 10.1097/sla.0000000000005843] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 02/18/2023] [Indexed: 03/14/2023]
Abstract
OBJECTIVE Estimation of the specific thresholds of the Caprini risk score (CRS) that are associated with the increased incidence of venous thromboembolism (VTE) across different specialties, including identifying the highest level of risk. BACKGROUND Accurate risk assessment remains an important but often challenging aspect of VTE prophylaxis. One well-established risk assessment model is CRS, which has been validated in thousands of patients from many different medical and surgical specialties. METHODS A search of MEDLINE and the Cochrane Library was performed in March 2022. Manuscripts that reported on (1) patients admitted to medical or surgical departments and (2) had their VTE risk assessed by CRS and (3) reported on the correlation between the score and VTE incidence, were included in the analysis. RESULTS A total of 4562 references were identified, and the full text of 202 papers was assessed for eligibility. The correlation between CRS and VTE incidence was reported in 68 studies that enrolled 4,207,895 patients. In all specialties, a significant increase in VTE incidence was observed in patients with a CRS of ≥5. In most specialties thresholds of ≥7, ≥9, and ≥11 to 12 were associated with dramatically increased incidences of VTE. In COVID-19, cancer, trauma, vascular, general, head and neck, and thoracic surgery patients with ≥9 and ≥11 to 12 scores the VTE incidence was extremely high (ranging from 13% to 47%). CONCLUSION The Caprini score is being used increasingly to predict VTE in many medical and surgical specialties. In most cases, the VTE risk for individual patients increases dramatically at a threshold CRS of 7 to 11.
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Affiliation(s)
- Kirill Lobastov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | | | - Eugeniy Stepanov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - Brajesh K Lal
- University of Maryland School of Medicine, Baltimore, MD
| | | | - Eugene S Krauss
- Department of Orthopaedic Surgery, Syosset Hospital, Northwell Health, Syosset, NY
| | - MaryAnne Cronin
- Department of Orthopaedic Surgery, Syosset Hospital, Northwell Health, Syosset, NY
| | - Nancy Dengler
- Department of Orthopaedic Surgery, Syosset Hospital, Northwell Health, Syosset, NY
| | - Ayal Segal
- Department of Orthopaedic Surgery, Syosset Hospital, Northwell Health, Syosset, NY
| | - Harold J Welch
- Division of Vascular Surgery, Lahey Hospital and Medical Center, Burlington, MA
| | | | - Xiaolan Chen
- Department of Respiratory and Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
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Prasad NK, Mayorga-Carlin M, Sahoo S, Englum BR, Turner DJ, Siddiqui T, Lake R, Sorkin JD, Lal BK. Mid-term Surgery Outcomes in Patients With COVID-19: Results From a Nationwide Analysis. Ann Surg 2023; 277:920-928. [PMID: 35762608 PMCID: PMC9794632 DOI: 10.1097/sla.0000000000005515] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Determine mid-term postoperative outcomes among coronavirus disease 2019 (COVID-19)-positive (+) patients compared with those who never tested positive before surgery. BACKGROUND COVID-19 is thought to be associated with prohibitively high rates of postoperative complications. However, prior studies have only evaluated 30-day outcomes, and most did not adjust for demographic, clinical, or procedural characteristics. METHODS We analyzed data from surgeries performed at all Veterans Affairs hospitals between March 2020 and 2021. Kaplan-Meier curves compared trends in mortality and Cox proportional hazards models estimated rates of mortality and pulmonary, thrombotic, and septic postoperative complications between patients with a positive preoperative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test [COVID (+)] and propensity score-matched COVID-negative (-) patients. RESULTS Of 153,741 surgical patients, 4778 COVID (+) were matched to 14,101 COVID (-). COVID (+) status was associated with higher postoperative mortality ( P <0.0001) with a 6-month survival of 94.2% (95% confidence interval: 93.2-95.2) versus 96.0% (95% confidence interval: 95.7.0-96.4) in COVID (-). The highest mortality was in the first 30 postoperative days. Hazards for mortality and postoperative complications in COVID (+) decreased with increasing time between testing COVID (+) and date of surgery. COVID (+) patients undergoing elective surgery had similar rates of mortality, thrombotic and septic complications, but higher rates of pulmonary complications than COVID (-) patients. CONCLUSIONS This is the first report of mid-term outcomes among COVID-19 patients undergoing surgery. COVID-19 is associated with decreased overall and complication-free survival primarily in the early postoperative period, delaying surgery by 5 weeks or more reduces risk of complications. Case urgency has a multiplicative effect on short-term and long-term risk of postoperative mortality and complications.
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Affiliation(s)
- Nikhil K Prasad
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
- Surgery Service, Veterans Affairs Medical Centre, Baltimore, MD
| | - Minerva Mayorga-Carlin
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
- Surgery Service, Veterans Affairs Medical Centre, Baltimore, MD
| | - Shalini Sahoo
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
- Surgery Service, Veterans Affairs Medical Centre, Baltimore, MD
| | - Brian R Englum
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Douglas J. Turner
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
- Surgery Service, Veterans Affairs Medical Centre, Baltimore, MD
| | - Tariq Siddiqui
- Surgery Service, Veterans Affairs Medical Centre, Baltimore, MD
| | - Rachel Lake
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
- Surgery Service, Veterans Affairs Medical Centre, Baltimore, MD
| | - John D Sorkin
- Geriatrics Research, Education, and Clinical Center, Veterans Affairs Medical Centre, Baltimore, MD
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Brajesh K Lal
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
- Surgery Service, Veterans Affairs Medical Centre, Baltimore, MD
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Brott TG, Meschia JF, Lal BK, Chamorro Á, Howard VJ, Howard G. When Will We Have What We Need to Advise Patients How to Manage Their Carotid Stenosis?: Lessons From SPACE-2. Stroke 2023; 54:1452-1456. [PMID: 36942589 PMCID: PMC10133171 DOI: 10.1161/strokeaha.122.042172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
The recently published SPACE-2 trial (Stent-Supported Percutaneous Angioplasty of the Carotid Artery Versus Endarterectomy-2) compared 3 treatments to prevent stroke in patients with asymptomatic carotid stenosis ≥70%: (1) carotid endarterectomy plus best medical treatment (BMT), (2) transfemoral carotid artery stenting plus BMT, or (3) BMT alone. Because of low enrollment, the findings of similar safety and efficacy for carotid endarterectomy, carotid artery stenting, or BMT alone were inconclusive. Publication of the CREST (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial)-2 results should provide level A evidence that has been lacking for 2 to 3 decades, to guide treatment of asymptomatic patients with severe carotid stenosis. For symptomatic patients with ≥70% stenosis, no trials are underway to update the degree of benefit reported for carotid endarterectomy by NASCET (North American Carotid Endarterectomy Trial) and ECST (European Carotid Surgery Trial), published in 1991. Subsequently, the use of cigarettes has plummeted, and major improvements in medical treatments and in carotid revascularization have emerged. These advances have coincided with abrupt decline in the clinical end points necessary for treatment comparisons in procedural trials. One of the advances in the invasive management of carotid disease has been transcarotid artery revascularization, already with limited approval by the US Food and Drug Administration. Establishing safety and efficacy of transcarotid artery revascularization compared with carotid endarterectomy, carotid artery stenting, or BMT alone may be challenging because of enrollment, regulatory, and funding barriers to design and complete an adequately powered randomized trial.
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Affiliation(s)
- Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B., J.F.M.)
| | - James F Meschia
- Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B., J.F.M.)
| | - Brajesh K Lal
- Department of Surgery, University of Maryland, Baltimore (B.K.L.)
| | - Ángel Chamorro
- Department of Neurology, Hospital Clinic, Barcelona, Spain (A.C.)
| | - Virginia J Howard
- Department of Epidemiology (V.J.H.), University of Alabama at Birmingham
| | - George Howard
- Department of Biostatistics (G.H.), University of Alabama at Birmingham
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Hayssen H, Sahoo S, Nguyen P, Mayorga-Carlin M, Siddiqui T, Englum B, Slejko JF, Mullins CD, Yesha Y, Sorkin JD, Lal BK. Ability of Caprini and Padua Risk-Assessment Models to Predict Venous Thromboembolism in a Nationwide Study. medRxiv 2023:2023.03.20.23287506. [PMID: 36993603 PMCID: PMC10055569 DOI: 10.1101/2023.03.20.23287506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
Background Venous thromboembolism (VTE) is a preventable complication of hospitalization. Risk-stratification is the cornerstone of prevention. The Caprini and Padua are the most commonly used risk-assessment models to quantify VTE risk. Both models perform well in select, high-risk cohorts. While VTE risk-stratification is recommended for all hospital admissions, few studies have evaluated the models in a large, unselected cohort of patients. Methods We analyzed consecutive first hospital admissions of 1,252,460 unique surgical and non-surgical patients to 1,298 VA facilities nationwide between January 2016 and December 2021. Caprini and Padua scores were generated using the VA's national data repository. We first assessed the ability of the two RAMs to predict VTE within 90 days of admission. In secondary analyses, we evaluated prediction at 30 and 60 days, in surgical versus non-surgical patients, after excluding patients with upper extremity DVT, in patients hospitalized ≥72 hours, after including all-cause mortality in the composite outcome, and after accounting for prophylaxis in the predictive model. We used area under the receiver-operating characteristic curves (AUC) as the metric of prediction. Results A total of 330,388 (26.4%) surgical and 922,072 (73.6%) non-surgical consecutively hospitalized patients (total n=1,252,460) were analyzed. Caprini scores ranged from 0-28 (median, interquartile range: 4, 3-6); Padua scores ranged from 0-13 (1, 1-3). The RAMs showed good calibration and higher scores were associated with higher VTE rates. VTE developed in 35,557 patients (2.8%) within 90 days of admission. The ability of both models to predict 90-day VTE was low (AUCs: Caprini 0.56 [95% CI 0.56-0.56], Padua 0.59 [0.58-0.59]). Prediction remained low for surgical (Caprini 0.54 [0.53-0.54], Padua 0.56 [0.56-0.57]) and non-surgical patients (Caprini 0.59 [0.58-0.59], Padua 0.59 [0.59-0.60]). There was no clinically meaningful change in predictive performance in patients admitted for ≥72 hours, after excluding upper extremity DVT from the outcome, after including all-cause mortality in the outcome, or after accounting for ongoing VTE prophylaxis. Conclusions Caprini and Padua risk-assessment model scores have low ability to predict VTE events in a cohort of unselected consecutive hospitalizations. Improved VTE risk-assessment models must be developed before they can be applied to a general hospital population.
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Cires-Drouet R, LaRocco A, Soldin D, John T, Toursavadkohi S, Nagarsheth K, Dahi S, Marsella J, Mayorga-Carlin M, Sorkin JD, Jones K, Haase D, Hong SN, Lal BK, Griffith B, Ramani G, Taylor B. Left ventricular systolic dysfunction during acute pulmonary embolism. Thromb Res 2023; 223:1-6. [PMID: 36689804 PMCID: PMC10989403 DOI: 10.1016/j.thromres.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/05/2023] [Accepted: 01/11/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND Heart failure increases the risk of death in acute pulmonary embolism (PE). The role of the left ventricle (LV) in acute PE is not well defined. OBJECTIVE To identify the prevalence of LV systolic dysfunction, morphology, and prognosis of the LV during an acute PE. METHODS Retrospective study (26-months) of patients diagnosed with an acute PE presenting with LV systolic dysfunction at the University of Maryland. RESULTS Among 769 acute PE patients, 78 (10.5 %) had LV systolic dysfunction and 42 (53.8 %) had history of cardiac disease. Patients without history of cardiac disease were younger (mean age [SD] 54.9 [16.8] vs. 62.6 [16.6]; p = 0.04), had a higher BMI (31.2 [12.2] vs. 29.2 [7.7]; p = 0.005), and less hypertension (20 [34.5 %] vs. 38 [65.5 %]; p = 0.0005). A massive PE was most common in patients without history of cardiac disease (8[22.2 %] vs. 2[4.7 %], p = 0.02). There was no difference in clot burden, but right ventricular strain was more frequently seen in patients without history cardiac disease in the initial CT (p = 0.001). The median troponin and lactate were similar in both groups. In 41 patients with follow-up echocardiograms, improvement in LVEF% was observed in patients without cardiac history (median Δ LVEF% [IQR]; 20 [6.2-25.0]). While patients with cardiac disease did not demonstrate similar changes (median Δ LVEF% [IQR]; 0 [-5-17.5]; p = 0.01). In hospital mortality was 12.8 % with no difference between both groups (p = 0.17). CONCLUSION Pulmonary embolism can be associated with LV systolic dysfunction, even in patients without history of cardiac disease.
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Affiliation(s)
| | - Allison LaRocco
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Danielle Soldin
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Thomas John
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | - Siamak Dahi
- Department of Surgery, University of Maryland, Baltimore, MD, USA
| | - Justin Marsella
- Department of Surgery, University of Maryland, Baltimore, MD, USA
| | | | - John D Sorkin
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; Baltimore VA Geriatrics Research, Education, and Clinical Center, Baltimore Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Kevin Jones
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; The R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel Haase
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; The R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Susie N Hong
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Brajesh K Lal
- Department of Surgery, University of Maryland, Baltimore, MD, USA; Vascular Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Bartley Griffith
- Department of Surgery, University of Maryland, Baltimore, MD, USA
| | - Gautam Ramani
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bradley Taylor
- Department of Surgery, University of Maryland, Baltimore, MD, USA
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John PR, Apau OS, Dosi G, Lal BK. Intermittent Pneumatic Compression of the Upper Extremity for Postoperative Deep Venous Thrombosis Prophylaxis: A Pilot Randomized Trial. Am Surg 2023; 89:470-472. [PMID: 33249877 DOI: 10.1177/0003134820954823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Preeti R John
- Department of Surgery, 186153VA Maryland Healthcare System and University of Maryland School of Medicine, MD, USA
| | - Otis S Apau
- Department of Internal Medicine, 158158Meharry Medical College, TN, USA
| | - Garima Dosi
- Department of Surgery, 483907Brigham and Women's Hospital, MA, USA
| | - Brajesh K Lal
- Department of Surgery, 186153VA Maryland Healthcare System and University of Maryland School of Medicine, MD, USA
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20
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Marshall RS, Liebeskind DS, III JH, Edwards LJ, Howard G, Meschia JF, Brott TG, Lal BK, Heck D, Lanzino G, Sangha N, Kashyap VS, Morales CD, Cotton-Samuel D, Rivera AM, Brickman AM, Lazar RM. Cortical Thinning in High-Grade Asymptomatic Carotid Stenosis. J Stroke 2023; 25:92-100. [PMID: 36592969 PMCID: PMC9911846 DOI: 10.5853/jos.2022.02285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 10/17/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND AND PURPOSE High-grade carotid artery stenosis may alter hemodynamics in the ipsilateral hemisphere, but consequences of this effect are poorly understood. Cortical thinning is associated with cognitive impairment in dementia, head trauma, demyelination, and stroke. We hypothesized that hemodynamic impairment, as represented by a relative time-to-peak (TTP) delay on MRI in the hemisphere ipsilateral to the stenosis, would be associated with relative cortical thinning in that hemisphere. METHODS We used baseline MRI data from the NINDS-funded Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis-Hemodynamics (CREST-H) study. Dynamic contrast susceptibility MR perfusion-weighted images were post-processed with quantitative perfusion maps using deconvolution of tissue and arterial signals. The protocol derived a hemispheric TTP delay, calculated by subtraction of voxel values in the hemisphere ipsilateral minus those contralateral to the stenosis. RESULTS Among 110 consecutive patients enrolled in CREST-H to date, 45 (41%) had TTP delay of at least 0.5 seconds and 9 (8.3%) subjects had TTP delay of at least 2.0 seconds, the maximum delay measured. For every 0.25-second increase in TTP delay above 0.5 seconds, there was a 0.006-mm (6 micron) increase in cortical thickness asymmetry. Across the range of hemodynamic impairment, TTP delay independently predicted relative cortical thinning on the side of stenosis, adjusting for age, sex, hypertension, hemisphere, smoking history, low-density lipoprotein cholesterol, and preexisting infarction (P=0.032). CONCLUSIONS Our findings suggest that hemodynamic impairment from high-grade asymptomatic carotid stenosis may structurally alter the cortex supplied by the stenotic carotid artery.
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Affiliation(s)
- Randolph S. Marshall
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA,Correspondence: Randolph S. Marshall Department of Neurology, Columbia University Irving Medical Center, 710 W 168th St, New York, NY 10032, USA Tel: +1-212-305-8389 Fax: +1-212-305-3741 E-mail:
| | - David S. Liebeskind
- Department of Neurology, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Lloyd J. Edwards
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - George Howard
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - Brajesh K. Lal
- Department of Surgery, University of Maryland, Baltimore, MD, USA
| | - Donald Heck
- Department of Radiology, Novant Health Clinical Research, Winston-Salem, NC, USA
| | - Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Navdeep Sangha
- Department of Neurology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Vikram S. Kashyap
- Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Clarissa D. Morales
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Dejania Cotton-Samuel
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Andres M. Rivera
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Adam M. Brickman
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Ronald M. Lazar
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
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Hayssen H, Cires-Drouet R, Englum B, Nguyen P, Sahoo S, Mayorga-Carlin M, Siddiqui T, Turner D, Yesha Y, Sorkin JD, Lal BK. Systematic review of venous thromboembolism risk categories derived from Caprini score. J Vasc Surg Venous Lymphat Disord 2022; 10:1401-1409.e7. [PMID: 35926802 PMCID: PMC9783939 DOI: 10.1016/j.jvsv.2022.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 04/11/2022] [Accepted: 05/03/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Hospital-acquired venous thromboembolism (VTE, including pulmonary embolism [PE] and deep vein thrombosis [DVT]) is a preventable cause of hospital death. The Caprini risk assessment model (RAM) is one of the most commonly used tools to assess VTE risk. The RAM is operationalized in clinical practice by grouping several risk scores into VTE risk categories that drive decisions on prophylaxis. A correlation between increasing Caprini scores and rising VTE risk is well-established. We assessed whether the increasing VTE risk categories assigned on the basis of recommended score ranges also correlate with increasing VTE risk. METHODS We conducted a systematic review of articles that used the Caprini RAM to assign VTE risk categories and that reported corresponding VTE rates. A Medline and EMBASE search retrieved 895 articles, of which 57 fulfilled inclusion criteria. RESULTS Forty-eight (84%) of the articles were cohort studies, 7 (12%) were case-control studies, and 2 (4%) were cross-sectional studies. The populations varied from postsurgical to medical patients. There was variability in the number of VTE risk categories assigned by individual studies (6 used 5 risk categories, 37 used 4, 11 used 3, and 3 used 2), and in the cutoff scores defining the risk categories (scores from 0 alone to 0-10 for the low-risk category; from ≥5 to ≥10 for high risk). The VTE rates reported for similar risk categories also varied across studies (0%-12.3% in the low-risk category; 0%-40% for high risk). The Caprini RAM is designed to assess composite VTE risk; however, two studies reported PE or DVT rates alone, and many of the other studies did not specify the types of DVTs analyzed. The Caprini RAM predicts VTE at 30 days after assessment; however, only 17 studies measured outcomes at 30 days; the remaining studies had either shorter or longer follow-ups (0-180 days). CONCLUSIONS The usefulness of the Caprini RAM is limited by heterogeneity in its implementation across centers. The score-derived VTE risk categorization has significant variability in the number of risk categories being used, the cutpoints used to define the risk categories, the outcome being measured, and the follow-up duration. This factor leads to similar risk categories being associated with different VTE rates, which impacts the clinical and research implications of the results. To enhance generalizability, there is a need for studies that validate the RAM in a broad population of medical and surgical patients, identify standardized risk categories, define risk of DVT and PE as distinct end points, and measure outcomes at standardized follow-up time points.
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Affiliation(s)
- Hilary Hayssen
- Department of Vascular Surgery, University of Maryland, Baltimore, MD; Surgery Service, VA Medical Center, Baltimore, MD
| | | | - Brian Englum
- Department of Vascular Surgery, University of Maryland, Baltimore, MD
| | - Phuong Nguyen
- Department of Computer Science and Electrical Engineering, University of Maryland, Baltimore County, MD
| | - Shalini Sahoo
- Department of Vascular Surgery, University of Maryland, Baltimore, MD; Surgery Service, VA Medical Center, Baltimore, MD
| | - Minerva Mayorga-Carlin
- Department of Vascular Surgery, University of Maryland, Baltimore, MD; Surgery Service, VA Medical Center, Baltimore, MD
| | | | | | - Yelena Yesha
- Department of Computer Science and Electrical Engineering, University of Maryland, Baltimore County, MD; Department of Computer Science, University of Miami, Miami, FL
| | - John D Sorkin
- Department of Medicine, Division of Gerontology and Palliative Care, University of Maryland School of Medicine, Baltimore, MD; Baltimore VA Geriatric Research, Education, and Clinical Center, Baltimore, MD
| | - Brajesh K Lal
- Department of Vascular Surgery, University of Maryland, Baltimore, MD; Surgery Service, VA Medical Center, Baltimore, MD.
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22
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Prasad NK, Englum BR, Mayorga-Carlin M, Turner DJ, Sahoo S, Sorkin JD, Lal BK. Partial COVID-19 vaccination associated with reduction in postoperative mortality and SARS-CoV-2 infection. Am J Surg 2022; 224:1097-1102. [PMID: 35465949 PMCID: PMC8993410 DOI: 10.1016/j.amjsurg.2022.03.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/09/2022] [Accepted: 03/23/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND There are currently no data to guide decisions about delaying surgery to achieve full vaccination. METHODS We analyzed data from patients undergoing surgery at any of the 1,283 VA medical facilities nationwide and compared postoperative complication rates by vaccination status. RESULTS Of 87,073 surgical patients, 20% were fully vaccinated, 15% partially vaccinated, and 65% unvaccinated. Mortality was reduced in full vaccination vs. unvaccinated (Incidence Rate Ratio 0.77, 95% CI [0.62, 0.94]) and partially vaccinated vs. unvaccinated (0.75 [0.60, 0.94]). Postoperative COVID-19 infection was reduced in fully (0.18 [0.12, 0.26]) and partially vaccinated patients (0.34 [0.24, 0.48]). Fully vaccinated compared to partially vaccinated patients, had similar postoperative mortality (1.02, [0.78, 1.33]), but had decreased COVID-19 infection (0.53 [0.32, 0.87]), pneumonia (0.75 [0.62, 0.93]), and pulmonary failure (0.79 [0.68, 0.93]). CONCLUSIONS Full and partial vaccination reduces postoperative complications indicating the importance of any degree of vaccination prior to surgery.
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Affiliation(s)
- Nikhil K Prasad
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Brian R Englum
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Minerva Mayorga-Carlin
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Douglas J Turner
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Shalini Sahoo
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - John D Sorkin
- Baltimore Veterans Affairs Medical Center, Geriatric Research Education and Clinical Center, Baltimore, MD, USA; Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Brajesh K Lal
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA.
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23
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Lal BK, Mayorga-Carlin M, Kashyap V, Jordan W, Mukherjee D, Cambria R, Moore W, Neville RF, Eckstein HH, Sahoo S, Macdonald S, Sorkin JD. Learning curve and proficiency metrics for transcarotid artery revascularization. J Vasc Surg 2022; 75:1966-1976.e1. [PMID: 35063612 PMCID: PMC11057007 DOI: 10.1016/j.jvs.2021.12.073] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 12/22/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND When introduced to a new procedure, physicians improve their performance and reduce their procedural adverse event rates rapidly during the initial cases and then improvement slows, signaling that proficiency has been achieved. Determining when they have acquired proficiency has important implications for procedural innovation, education, credentialing, and patient safety. We analyzed the worldwide experience with transcarotid artery revascularization (TCAR), a hybrid approach to carotid revascularization, to identify the (1) procedural performance measures associated with clinical and technical adverse events; (2) target levels of performance measures that minimize adverse event rates; and (3) number of TCAR cases needed to achieve the target levels for the performance measures. METHODS The patient, lesion, and physician characteristics were collected for each TCAR procedure performed by each physician worldwide in an international quality assurance database. Four procedural performance measures were recorded for each procedure: flow-reversal time, fluoroscopy time, contrast volume, and total skin-to-skin time. Composite clinical adverse events (ie, transient ischemic attack, stroke, myocardial infarction, death) and composite technical adverse events (ie, aborted procedure, conversion to surgery, bleeding, dissection, cranial nerve injury, device failure), occurring within 24 hours were also recorded. Correlations between each performance measure and the clinical and technical adverse event rates were computed. The inflection points in the performance measures were identified at which no further improvements occurred in the adverse event rates. Finally, the minimum number of TCAR cases required to achieve the target performance measure levels was computed. RESULTS A total of 18,240 procedures performed by 1273 physicians were analyzed. Of the 18,240 patients, 34.9% were women and 62.5% were asymptomatic. The flow-reversal time correlated with clinical adverse events adjusted for age, sex, and symptomatic status (R2 = 0.91; P < .0001) and adjusted technical adverse events (R2 = 0.86; P < .0001). The skin-to-skin time correlated with adjusted technical adverse events (R2 = 0.92; P < .0001). A reduction in flow-reversal times to <13.1 minutes and the skin-to-skin time to <81 minutes did not translate into further improvements in the adverse event rates. A minimum of 26 TCAR cases was required to achieve the target flow-reversal time, and a minimum of 15 cases was required to achieve the target skin-to-skin time. CONCLUSIONS The flow-reversal time and skin-to-skin time are appropriate performance measures for establishing the level of expertise of physicians as they acquire skills to perform TCAR. A target time of ≤13.1 minutes for flow-reversal and 81 minutes for skin-to-skin time minimized the adverse event rates. Familiarity with the steps involved in performing TCAR was achieved after ≥15 cases, and minimizing clinical adverse events occurred after ≥26 cases.
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Affiliation(s)
- Brajesh K Lal
- Department of Vascular Surgery, University of Maryland, Baltimore, Md.
| | | | - Vikram Kashyap
- Division of Vascular Surgery, University Hospitals Case Western Reserve University, Cleveland, Ohio
| | - William Jordan
- Department of Vascular Surgery, The University of Alabama at Birmingham, Birmingham, Ala
| | | | - Richard Cambria
- Division of Vascular Surgery, St Elizabeth's Medical Center, Boston, Mass
| | - Wesley Moore
- Division of Vascular Surgery, University of California, Los Angeles, Los Angeles, Calif
| | | | | | - Shalini Sahoo
- Department of Vascular Surgery, University of Maryland, Baltimore, Md
| | | | - John D Sorkin
- Department of Medicine, University of Maryland, Baltimore, Md
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24
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Saba L, Antignani PL, Gupta A, Cau R, Paraskevas KI, Poredos P, Wasserman B, Kamel H, Avgerinos ED, Salgado R, Caobelli F, Aluigi L, Savastano L, Brown M, Hatsukami T, Hussein E, Suri JS, Mansilha A, Wintermark M, Staub D, Montequin JF, Rodriguez RTT, Balu N, Pitha J, Kooi ME, Lal BK, Spence JD, Lanzino G, Marcus HS, Mancini M, Chaturvedi S, Blinc A. International Union of Angiology (IUA) consensus paper on imaging strategies in atherosclerotic carotid artery imaging: From basic strategies to advanced approaches. Atherosclerosis 2022; 354:23-40. [DOI: 10.1016/j.atherosclerosis.2022.06.1014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/10/2022] [Accepted: 06/14/2022] [Indexed: 12/24/2022]
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25
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Englum BR, Prasad NK, Turner DJ, Sorkin JD, Lal BK. Reply to "Cancer treatment in the time of COVID-19 pandemics: A new concern". Cancer 2022; 128:2992-2993. [PMID: 35499669 PMCID: PMC9348373 DOI: 10.1002/cncr.34250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/07/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Brian R Englum
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Nikhil K Prasad
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland.,Surgery Service, Veterans Affairs Medical Center, Baltimore, Maryland
| | - Douglas J Turner
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland.,Surgery Service, Veterans Affairs Medical Center, Baltimore, Maryland
| | - John D Sorkin
- Geriatrics Research, Education, and Clinical Center, Veterans Affairs Medical Center, Baltimore, Maryland.,Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Brajesh K Lal
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland.,Surgery Service, Veterans Affairs Medical Center, Baltimore, Maryland
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26
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Desikan SK, Mayorga-Carlin M, Dux MC, Gray VL, Anagnostakos J, Khan AA, Sikdar S, Barth D, Harper S, Sorkin JD, Lal BK. Lack of association between cognitive impairment and systemic inflammation in asymptomatic carotid stenosis. J Vasc Surg 2022; 75:1643-1650. [PMID: 34921963 PMCID: PMC10939009 DOI: 10.1016/j.jvs.2021.11.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 11/11/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Asymptomatic carotid atherosclerotic stenosis (ACAS) is associated with cognitive impairment. Systemic inflammation occurs in patients with systemic atherosclerosis and is also associated with cognitive impairment. The goal of this study was to determine if cognitive impairment in patients with ACAS is the result of systemic inflammation. METHODS A cross-sectional analysis of 104 patients (63 patients with ACAS, 41 controls) with cognitive function and inflammatory biomarker assessments was performed. Venous blood was assayed for proinflammatory biomarkers (IL-1β, IL-6, IL-6R, IL-8, IL-17, tumor necrosis factor-α, matrix metalloproteinase [MMP]-1, MMP-2, MMP-7, MMP-9, vascular cell adhesion molecule, and high-sensitivity C-reactive protein). The patients also underwent comprehensive cognitive testing to compute five domain-specific cognitive scores per patient. We first assessed the associations between carotid stenosis and cognitive function, and between carotid stenosis and systemic inflammation in separate regression models. We then determined whether cognitive impairments persisted in patients with carotid stenosis after accounting for inflammation by adjusting for inflammatory biomarker levels in a combined model. RESULTS Patients with ACAS and control patients differed in age, race, coronary artery disease prevalence, and education. Stenosis patients had worse cognitive scores in two domains: learning and memory (P = .05) and motor and processing speed (P = .002). Despite adjusting for inflammatory biomarker levels, patients with ACAS still demonstrated deficits in the domains of learning and memory and motor and processing speed. CONCLUSIONS Although systemic atherosclerosis-induced inflammation is a well-recognized cause for cognitive impairment, our data suggest that it is not the primary underlying mechanism behind cognitive impairments seen in ACAS. Cognitive impairments in learning and memory and motor and processing speed seen in patients with ACAS persist after adjusting for systemic inflammation. Thus, alternative mechanisms should be explored to account for the observed functional impairments.
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Affiliation(s)
- Sarasijhaa K Desikan
- Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, Md; Vascular Service, Veterans Affairs Medical Center, Baltimore, Md
| | | | - Moira C Dux
- Neuropsychology Section, Veterans Affairs Medical Center, Baltimore, Md
| | - Vicki L Gray
- Department of Physical Therapy and Rehabilitation Science, University of Maryland, Baltimore, Md
| | - John Anagnostakos
- Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - Amir A Khan
- Department of Bioengineering, George Mason University, Fairfax, Va
| | | | - Dawn Barth
- Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - Sophie Harper
- Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - John D Sorkin
- Baltimore VA Geriatric Research, Education and Clinical Center, Baltimore, Md; Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, Md
| | - Brajesh K Lal
- Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, Md; Vascular Service, Veterans Affairs Medical Center, Baltimore, Md.
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27
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Mayorga-Carlin M, Shaw P, Ozsvath K, Erben Y, Wang G, Sahoo S, Macdonald S, Kashyap VS, Sorkin JD, Lal BK. Transcarotid revascularization outcomes do not differ by patient age or sex. J Vasc Surg 2022; 76:209-219.e2. [PMID: 35358669 DOI: 10.1016/j.jvs.2022.01.141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/30/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Transcarotid artery revascularization (TCAR) is a hybrid approach to carotid revascularization. Limited information is available on the differences in periprocedural complications and performance measures of TCAR for men compared with women and for older vs younger adults. METHODS The patient, lesion, and physician characteristics were collected for all TCAR procedures performed by each physician worldwide in an international quality assurance database between March 3, 2009 and May 7, 2020. Clinical composite (ie, death, stroke, transient ischemic attack, myocardial infarction) and technical composite (ie, aborted procedure, conversion to surgery, bleeding, dissection, cranial nerve injury, device failure) adverse events within 24 hours of the procedure were recorded. Four performance measures were recorded: flow-reversal time, fluoroscopy time, contrast volume, and skin-to-skin time. Poisson regressions were used to assess the effects of age and sex on the incidence of clinical and technical composite adverse events. Linear regressions were used to compare the four performance measures. RESULTS A total of 18,240 TCARs were performed by 1273 physicians; 34.9% of the patients were women and 37.5% were symptomatic. The overall incidence of clinical and technical composite adverse events was low. The adjusted clinical (1.62% [95% confidence interval (CI), 1.17%-2.23%] vs 1.35% [95% CI, 1.01%-1.79%]; P = .22) and technical (7.84% [95% CI, 6.85%-8.97%] vs 7.80% [95% CI, 6.94%-8.77%]; P = .93) composite adverse event rates did not vary for women vs men. The adjusted clinical (P = .65) and technical (P = .55) composite adverse event rates also did not vary by age. The adjusted skin-to-skin time was shorter for the women (76.6 minutes; 95% CI, 74.6-78.6) than for the men (77.7 minutes; 95% CI, 75.7-79.6; P = .002). Significant differences were found by age group for fluoroscopy time, flow-reversal time, and skin-to-skin time, although the magnitude of these differences was small (<1 minute for each). CONCLUSIONS The clinical and technical outcomes of TCAR are not affected by age or sex. We found clinically minor differences in the procedural performance measures when stratified by age and sex. In addition to being safe for younger individuals, TCAR could also be the preferred method for performing carotid stenting in women and older patients, in particular, older women.
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Affiliation(s)
| | - Palma Shaw
- Division of Vascular Surgery, Upstate University, Syracuse, NY
| | - Kathleen Ozsvath
- Division of Vascular Surgery, St. Peter's Health Partners, Troy, NY
| | - Young Erben
- Division of Vascular Surgery, Mayo Clinic, Jacksonville, FL
| | - Grace Wang
- Division of Vascular Surgery, University of Pennsylvania, Philadelphia, PA
| | - Shalini Sahoo
- Division of Vascular Surgery, University of Maryland, Baltimore, MD
| | | | - Vikram S Kashyap
- Division of Vascular Surgery, Case Western Reserve University, Cleveland, OH
| | - John D Sorkin
- Department of Medicine, University of Maryland, Baltimore, MD; Geriatric Research Education and Clinical Center, Baltimore Veterans Affairs Medical Center, Baltimore, MD
| | - Brajesh K Lal
- Division of Vascular Surgery, University of Maryland, Baltimore, MD; Vascular Service, Baltimore Veterans Affairs Medical Center, Baltimore, MD.
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28
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Cires-Drouet R, LaRocco A, Soldin D, John T, Toursavadkohi S, Nagarsheth K, Lal BK, Mayorga-Carlin M, Sorkin J, Jones K, Haase D, Hong-Zohlman SN, Ramani GV, Taylor B. LEFT VENTRICULAR DYSFUNCTION DURING ACUTE PULMONARY EMBOLISM. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02778-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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29
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Englum BR, Prasad NK, Lake RE, Mayorga‐Carlin M, Turner DJ, Siddiqui T, Sorkin JD, Lal BK. Impact of the COVID-19 pandemic on diagnosis of new cancers: A national multicenter study of the Veterans Affairs Healthcare System. Cancer 2022; 128:1048-1056. [PMID: 34866184 PMCID: PMC8837676 DOI: 10.1002/cncr.34011] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/11/2021] [Accepted: 10/07/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic caused disruptions in treatment for cancer. Less is known about its impact on new cancer diagnoses, where delays could cause worsening long-term outcomes. This study quantifies decreases in encounters related to prostate, lung, bladder and colorectal cancers, procedures that facilitate their diagnosis, and new diagnoses of those cancers in the COVID era compared to pre-COVID era. METHODS All encounters at Veterans' Affairs facilities nationwide from 2016 through 2020 were reviewed. The authors quantified trends in new diagnoses of cancer and in procedures facilitating their diagnosis, from January 1, 2018 onward. Using 2018 to 2019 as baseline, reductions in procedures and new cancer diagnoses in 2020 were estimated. Calculated absolute and percentage differences in annual volume and observed-to-expected volume ratios were calculated. Heat maps and funnel plots of volume changes were generated. RESULTS From 2018 through 2020, there were 4.1 million cancer-related encounters, 3.9 million relevant procedures, and 251,647 new cancers diagnosed. Compared to the annual averages in 2018 through 2019, colonoscopies in 2020 decreased by 45% whereas prostate biopsies, chest computed tomography scans, and cystoscopies decreased by 29%, 10%, and 21%, respectively. New cancer diagnoses decreased by 13% to 23%. These drops varied by state and continued to accumulate despite reductions in pandemic-related restrictions. CONCLUSION The authors identified substantial reductions in procedures used to diagnose cancer and subsequent reductions in new diagnoses of cancer across the United States because of the COVID-19 pandemic. A nomogram is provided to identify and resolve these unmet health care needs and avoid worse long-term cancer outcomes. LAY SUMMARY The disruptions due to the COVID-19 pandemic have led to substantial reductions in new cancers being diagnosed. This study quantifies those reductions in a national health care system and offers a method for understanding the backlog of cases and the resources needed to resolve them.
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Affiliation(s)
- Brian R. Englum
- Department of SurgeryUniversity of Maryland School of MedicineBaltimoreMaryland
| | - Nikhil K. Prasad
- Department of SurgeryUniversity of Maryland School of MedicineBaltimoreMaryland
- Surgery ServiceVeterans Affairs Medical CenterBaltimoreMaryland
| | - Rachel E. Lake
- Department of SurgeryUniversity of Maryland School of MedicineBaltimoreMaryland
- Surgery ServiceVeterans Affairs Medical CenterBaltimoreMaryland
| | - Minerva Mayorga‐Carlin
- Department of SurgeryUniversity of Maryland School of MedicineBaltimoreMaryland
- Surgery ServiceVeterans Affairs Medical CenterBaltimoreMaryland
| | - Douglas J. Turner
- Department of SurgeryUniversity of Maryland School of MedicineBaltimoreMaryland
- Surgery ServiceVeterans Affairs Medical CenterBaltimoreMaryland
| | - Tariq Siddiqui
- Department of SurgeryUniversity of Maryland School of MedicineBaltimoreMaryland
- Surgery ServiceVeterans Affairs Medical CenterBaltimoreMaryland
| | - John D. Sorkin
- Geriatrics Research, Education, and Clinical CenterVeterans Affairs Medical CenterBaltimoreMaryland
- Department of MedicineUniversity of Maryland School of MedicineBaltimoreMaryland
| | - Brajesh K. Lal
- Department of SurgeryUniversity of Maryland School of MedicineBaltimoreMaryland
- Surgery ServiceVeterans Affairs Medical CenterBaltimoreMaryland
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30
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Erben Y, Meschia JF, Heck DV, Shawl FA, Mayorga-Carlin M, Howard G, Rosenfield K, Sorkin JD, Brott TG, Lal BK. Safety of the transradial approach to carotid stenting. Catheter Cardiovasc Interv 2022; 99:814-821. [PMID: 34390107 PMCID: PMC8840995 DOI: 10.1002/ccd.29912] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/25/2021] [Accepted: 07/30/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND The multicenter prospective CREST-2 Registry (C2R) provides recent experience in performing carotid artery stenting (CAS) for interventionists to ensure safe performance of CAS. OBJECTIVE To determine the periprocedural safety of CAS performed using a transradial approach relative to CAS performed using a transfemoral approach. METHODS Patients with ≥70% asymptomatic and ≥50% symptomatic carotid stenosis, ≤80 years of age and at standard or high risk for carotid endarterectomy (CEA) are eligible for the C2R. The primary endpoint was a composite of severe access-related complications. Comparisons were made using propensity-score matched logistic regression. RESULTS The mean age of the cohort was 67.6 ± 8.2 years and 1906 (35.1%) were female. Indications for CAS included 4063 (74.9%) for primary atherosclerosis. A total of 2868 (52.8%) cases underwent CAS for asymptomatic disease. Transradial access was used in 213 (3.9%) patients. The transradial cohort had lower use of general anesthesia (1.5% vs. 6.3%, p = 0.007) and higher use of distal embolic protection (96.7% vs. 89.4%, p = 0.0004). There were no significant differences between radial and femoral access groups in terms of a composite of major access-related complications (0% vs. 1.1%) or a composite of periprocedural stroke or death (3.3% vs. 2.4%; OR = 1.4 [confidence intervals 0.6, 3.1]; p = 0.42). CONCLUSION We found no significant differences in rates of major access-related complications or periprocedural stroke or death with CAS performed using transradial compared to transfemoral access. Our results support incorporation of the transradial approach to clinical trials comparing CAS to other revascularization techniques.
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Affiliation(s)
- Young Erben
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL
| | | | - Donald V. Heck
- Novant Health Forsyth Radiological Associates and Triad Radiology Associates, Winston-Salem, NC
| | - Fayaz A. Shawl
- Washington Adventist/White Oak Medical Center, Silver Spring, MD
| | | | - George Howard
- Department of Biostatistics and Epidemiology, School of Public Health, University of Alabama at Birmingham, AL
| | | | - John D. Sorkin
- Baltimore VA Geriatrics Research, Education, and Clinical Center, Baltimore Veterans Affairs Medical Center, Baltimore, MD,University of Maryland School of Medicine, Department of Medicine, Division Gerontology and Geriatrics
| | | | - Brajesh K. Lal
- Department of Neurology, Mayo Clinic, Jacksonville, FL,Department of Vascular Surgery, University of Maryland, Baltimore, MD
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31
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Lal BK, Meschia JF, Jones M, Aronow HD, Lackey A, Lake R, Howard G, Brott TG. Health Screening Program to Enhance Enrollment of Women and Minorities in CREST-2. Stroke 2022; 53:355-361. [PMID: 34983242 PMCID: PMC9512267 DOI: 10.1161/strokeaha.120.033226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE The CREST-2 (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial) consists of 2 parallel randomized stroke prevention trials in patients with asymptomatic high-grade stenosis of the cervical carotid artery. The purpose of this report is to detail the outcomes of a health screening effort to increase trial enrollment of women and minorities. METHODS Life Line screening (LLS) conducts nationwide screening for vascular disease. Screenings within a 50-mile radius of each CREST-2 center were identified for participation in a joint CREST-LLS program over the course of one year (November 2018 to October 2019) whereby patients with an abnormal carotid ultrasound were referred to the local CREST-2 center for further workup, management, and potential consideration for trial enrollment. RESULTS LLS completed the screening of 588 198 individuals in 29 732 zip codes across the United States. Of those, 230 021 individuals were screened at events occurring near a CREST-2 clinical center and 646 (0.3%) were found to have abnormal carotid ultrasound findings. Each of the 646 individuals was contacted by CREST-LLS program staff for permission to be referred to their local CREST-2 center; 200 (31%) consented to be contacted by CREST-2. Of those, 39 (19.5%) agreed to be, and were, evaluated at their local CREST-2 center. High-grade stenosis was confirmed in 27 patients. A total of 3 patients were eligible for the trial and were enrolled, one woman but no racial/ethnic minorities. CONCLUSIONS The LLS program appears to identify community-living individuals with high-grade carotid stenosis through ultrasonography. However, the prevalence of abnormal carotid findings was low. In addition, screening and offering participation into the CREST-2 trial had no substantial impact on the proportion of women and minorities enrolled in the trial. Additional innovative strategies are needed to promote enrollment of diverse patients with carotid stenosis into stroke prevention trials.
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Affiliation(s)
- Brajesh K Lal
- Department of Vascular Surgery, University of Maryland School of Medicine and Baltimore VA Medical Center, Baltimore, MD
| | | | - Michael Jones
- Department of Cardiology, Baptist Health, Lexington, KY
| | - Herbert D Aronow
- Department of Cardiology, Alpert Medical School of Brown University, Providence, RI
| | - Angelica Lackey
- Department of Vascular Surgery, University of Maryland School of Medicine and Baltimore VA Medical Center, Baltimore, MD
| | - Rachel Lake
- Department of Vascular Surgery, University of Maryland School of Medicine and Baltimore VA Medical Center, Baltimore, MD
| | - George Howard
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL
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Prasad NK, Lake R, Englum BR, Turner DJ, Siddiqui T, Mayorga-Carlin M, Sorkin JD, Lal BK. COVID-19 Vaccination Associated With Reduced Postoperative SARS-CoV-2 Infection and Morbidity. Ann Surg 2022; 275:31-36. [PMID: 34417362 PMCID: PMC8678152 DOI: 10.1097/sla.0000000000005176] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the effect of COVID-19 vaccination on postoperative mortality, pulmonary and thrombotic complications, readmissions and hospital lengths of stay among patients undergoing surgery in the United States. BACKGROUND While vaccination prevents COVID-19, little is known about its impact on postoperative complications. METHODS This is a nationwide observational cohort study of all 1,255 Veterans Affairs facilities nationwide. We compared patients undergoing surgery at least 2 weeks after their second dose of the Pfizer BioNTech or Moderna vaccines, to contemporary propensity score matched controls. Primary endpoints were 30-day mortality and postoperative COVID-19 infection. Secondary endpoints were pulmonary or thrombotic complications, readmissions, and hospital lengths of stay. RESULTS 30,681 patients met inclusion criteria. After matching, there were 3,104 in the vaccination group (1,903 received the Pfizer BioNTech, and 1,201 received the Moderna vaccine) and 7,438 controls. Full COVID-19 vaccination was associated with lower rates of postoperative 30-day COVID-19 infection (Incidence Rate Ratio and 95% confidence intervals, 0.09 [0.01,0.44]), pulmonary complications (0.54 [0.39, 0.72]), thrombotic complications (0.68 [0.46, 0.99]) and decreased hospital lengths of stay (0.78 [0.69, 0.89]). Complications were also low in vaccinated patients who tested COVID-19 positive before surgery but events were too few to detect a significant difference compared to controls. CONCLUSION COVID-19 vaccination is associated with lower rates of postoperative morbidity. The benefit is most pronounced among individuals who have never had a COVID-19 infection before surgery.
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Affiliation(s)
- Nikhil K Prasad
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
- Surgery Service, Veterans Affairs Medical Centre, Baltimore, MD
| | - Rachel Lake
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
- Surgery Service, Veterans Affairs Medical Centre, Baltimore, MD
| | - Brian R Englum
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Douglas J Turner
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
- Surgery Service, Veterans Affairs Medical Centre, Baltimore, MD
| | - Tariq Siddiqui
- Surgery Service, Veterans Affairs Medical Centre, Baltimore, MD
| | - Minerva Mayorga-Carlin
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
- Surgery Service, Veterans Affairs Medical Centre, Baltimore, MD
| | - John D Sorkin
- Geriatrics Research, Education, and Clinical Center, Veterans Affairs Medical Centre, Baltimore, MD
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Brajesh K Lal
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
- Surgery Service, Veterans Affairs Medical Centre, Baltimore, MD
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Prasad NK, Englum BR, Turner DJ, Lake R, Siddiqui T, Mayorga-Carlin M, Sorkin JD, Lal BK. A Nation-Wide Review of Elective Surgery and COVID-Surge Capacity. J Surg Res 2021; 267:211-216. [PMID: 34157490 PMCID: PMC8213966 DOI: 10.1016/j.jss.2021.05.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 04/12/2021] [Accepted: 05/02/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND The COVID-19 pandemic has resulted in over 225,000 excess deaths in the United States. A moratorium on elective surgery was placed early in the pandemic to reduce risk to patients and staff and preserve critical care resources. This report evaluates the impact of the elective surgical moratorium on case volumes and intensive care unit (ICU) bed utilization. METHODS This retrospective review used a national convenience sample to correlate trends in the weekly rates of surgical cases at 170 Veterans Affairs Hospitals around the United States from January 1 to September 30, 2020 to national trends in the COVID-19 pandemic. We reviewed data on weekly number of procedures performed and ICU bed usage, stratified by level of urgency (elective, urgent, emergency), and whether an ICU bed was required within 24 hours of surgery. National data on the proportion of COVID-19 positive test results and mortality rates were obtained from the Center for Disease Control website. RESULTS 198,911 unique surgical procedures performed during the study period. The total number of cases performed from January 1 to March 16 was 86,004 compared with 15,699 from March 17 to May 17. The reduction in volume occurred before an increase in the percentage of COVID-19 positive test results and deaths nationally. There was a 91% reduction from baseline in the number of elective surgeries performed allowing 78% of surgical ICU beds to be available for COVID-19 positive patients. CONCLUSION The moratorium on elective surgical cases was timely and effective in creating bed capacity for critically ill COVID-19 patients. Further analyses will allow targeted resource allocation for future pandemic planning.
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Affiliation(s)
- Nikhil K Prasad
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland; Surgery Service, Veterans Affairs Medical Centre, Baltimore, Maryland
| | - Brian R Englum
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Douglas J Turner
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland; Surgery Service, Veterans Affairs Medical Centre, Baltimore, Maryland
| | - Rachel Lake
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland; Surgery Service, Veterans Affairs Medical Centre, Baltimore, Maryland
| | - Tariq Siddiqui
- Surgery Service, Veterans Affairs Medical Centre, Baltimore, Maryland
| | - Minerva Mayorga-Carlin
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland; Surgery Service, Veterans Affairs Medical Centre, Baltimore, Maryland
| | - John D Sorkin
- Geriatrics Research, Education, And Clinical Centre, Veterans Affairs Medical Centre, Baltimore, Maryland; Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Brajesh K Lal
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland; Surgery Service, Veterans Affairs Medical Centre, Baltimore, Maryland.
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Lal BK, Prasad N, Englum B, Lake R, Turner D, Siddiqui T, Carlin M, Sorkin J. National Impact of COVID-19 on Vascular Surgery Services. J Vasc Surg 2021. [PMCID: PMC8376814 DOI: 10.1016/j.jvs.2021.06.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Lazar RM, Wadley VG, Myers T, Jones MR, Heck DV, Clark WM, Marshall RS, Howard VJ, Voeks JH, Manly JJ, Moy CS, Chaturvedi S, Meschia JF, Lal BK, Brott TG, Howard G. Baseline Cognitive Impairment in Patients With Asymptomatic Carotid Stenosis in the CREST-2 Trial. Stroke 2021; 52:3855-3863. [PMID: 34433306 DOI: 10.1161/strokeaha.120.032972] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Studies of carotid artery disease have suggested that high-grade stenosis can affect cognition, even without stroke. The presence and degree of cognitive impairment in such patients have not been reported and compared with a demographically matched population-based cohort. METHODS We studied cognition in 1000 consecutive CREST-2 (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial) patients, a treatment trial for asymptomatic carotid disease. Cognitive assessment was after randomization but before assigned treatment. The cognitive battery was developed in the general population REGARDS Study (Reasons for Geographic and Racial Differences in Stroke), involving Word List Learning Sum, Word List Recall, and Word List fluency for animal names and the letter F. The carotid stenosis patients were >45 years old with ≥70% asymptomatic carotid stenosis and no history of prevalent stroke. The distribution of cognitive performance for the patients was standardized, accounting for age, race, and education using performance from REGARDS, and after further adjustment for hypertension, diabetes, dyslipidemia, and smoking. Using the Wald Test, we tabulated the proportion of Z scores less than the anticipated deviate for the population-based cohort for representative percentiles. RESULTS There were 786 baseline assessments. Mean age was 70 years, 58% men, and 52% right-sided stenosis. The overall Z score for patients was significantly below expected for higher percentiles (P<0.0001 for 50th, 75th, and 95th percentiles) and marginally below expected for the 25th percentile (P=0.015). Lower performance was attributed largely to Word List Recall (P<0.0001 for all percentiles) and for Word List Learning (50th, 75th, and 95th percentiles below expected, P≤0.01). The scores for left versus right carotid disease were similar. CONCLUSIONS Baseline cognition of patients with severe carotid stenosis showed below normal cognition compared to the population-based cohort, controlling for demographic and cardiovascular risk factors. This cohort represents the largest group to date to demonstrate that poorer cognition, especially memory, in this disease. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02089217.
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Affiliation(s)
- Ronald M Lazar
- UAB Evelyn F. McKnight Brain Institute, Department of Neurology, The University of Alabama at Birmingham. (R.M.L., T.M.)
| | - Virginia G Wadley
- Department of Medicine, The University of Alabama at Birmingham. (V.G.W.)
| | - Terina Myers
- UAB Evelyn F. McKnight Brain Institute, Department of Neurology, The University of Alabama at Birmingham. (R.M.L., T.M.)
| | | | - Donald V Heck
- Diagnostic Radiology, Novant Health, Winston-Salem, NC (D.V.H.)
| | - Wayne M Clark
- Department of Neurology, Oregon Health & Science University, Portland (W.M.C.)
| | - Randolph S Marshall
- Department of Neurology, Columbia University Irving Medical Center, New York NY. (R.S.M.)
| | - Virginia J Howard
- Department of Epidemiology, The University of Alabama at Birmingham. (V.J.H.)
| | - Jenifer H Voeks
- Department of Neurology, Medical University of South Carolina, Charleston, SC (J.H.V.)
| | - Jennifer J Manly
- Gertrude H. Sergievsky Center and the Taub Institute for Research in Aging and Alzheimer's Disease, Columbia University Irving Medical Center, New York NY. (J.J.M.)
| | - Claudia S Moy
- Department of Health & Human Services, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (C.S.M.)
| | - Seemant Chaturvedi
- Department of Neurology, University of Maryland School of Medicine, Baltimore. (S.C.)
| | - James F Meschia
- Department of Neurology, Mayo Clinic, Jacksonville, FL (J.F.M., T.G.B.)
| | - Brajesh K Lal
- Department of Surgery, University of Maryland School of Medicine, Baltimore. (B.K.L.)
| | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL (J.F.M., T.G.B.)
| | - George Howard
- Department of Biostatistics, University of Alabama School of Public Health (G.H.)
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Lal BK, Prasad NK, Englum BR, Turner DJ, Siddiqui T, Carlin MM, Lake R, Sorkin JD. Periprocedural complications in patients with SARS-CoV-2 infection compared to those without infection: A nationwide propensity-matched analysis. Am J Surg 2021; 222:431-437. [PMID: 33384154 PMCID: PMC7836786 DOI: 10.1016/j.amjsurg.2020.12.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/09/2020] [Accepted: 12/10/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Reports on emergency surgery performed soon after a COVID-19 infection that are not controlled for premorbid risk-factors show increased 30-day mortality and pulmonary complications. This contributed to a virtual cessation of elective surgery during the pandemic surge. To inform evidence-based guidance on the decisions for surgery during the recovery phase of the pandemic, we compare 30-day outcomes in patients testing positive for COVID-19 before their operation, to contemporary propensity-matched COVID-19 negative patients undergoing the same procedures. METHODS This prospective multicentre study included all patients undergoing surgery at 170 Veterans Health Administration (VA) hospitals across the United States. COVID-19 positive patients were propensity matched to COVID-19 negative patients on demographic and procedural factors. We compared 30-day outcomes between COVID-19 positive and negative patients, and the effect of time from testing positive to the date of procedure (≤10 days, 11-30 days and >30 days) on outcomes. RESULTS Between March 1 and August 15, 2020, 449 COVID-19 positive and 51,238 negative patients met inclusion criteria. Propensity matching yielded 432 COVID-19 positive and 1256 negative patients among whom half underwent elective surgery. Infected patients had longer hospital stays (median seven days), higher rates of pneumonia (20.6%), ventilator requirement (7.6%), acute respiratory distress syndrome (ARDS, 17.1%), septic shock (13.7%), and ischemic stroke (5.8%), while mortality, reoperations and readmissions were not significantly different. Higher odds for ventilation and stroke persisted even when surgery was delayed 11-30 days, and for pneumonia, ARDS, and septic shock >30 days after a positive test. DISCUSSION 30-day pulmonary, septic, and ischaemic complications are increased in COVID-19 positive, compared to propensity score matched negative patients. Odds for several complications persist despite a delay beyond ten days after testing positive. Individualized risk-stratification by pulmonary and atherosclerotic comorbidities should be considered when making decisions for delaying surgery in infected patients.
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Affiliation(s)
- Brajesh K Lal
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA.
| | - Nikhil K Prasad
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Brian R Englum
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Douglas J Turner
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Tariq Siddiqui
- Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Minerva Mayorga Carlin
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Rachel Lake
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - John D Sorkin
- Geriatrics Research, Education, and Clinical Center, Veterans Affairs Medical Center, Baltimore, MD, USA; Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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Saba L, Brinjikji W, Spence JD, Wintermark M, Castillo M, Borst GJD, Yang Q, Yuan C, Buckler A, Edjlali M, Saam T, Saloner D, Lal BK, Capodanno D, Sun J, Balu N, Naylor R, Lugt AVD, Wasserman BA, Kooi ME, Wardlaw J, Gillard J, Lanzino G, Hedin U, Mikulis D, Gupta A, DeMarco JK, Hess C, Goethem JV, Hatsukami T, Rothwell P, Brown MM, Moody AR. Roadmap Consensus on Carotid Artery Plaque Imaging and Impact on Therapy Strategies and Guidelines: An International, Multispecialty, Expert Review and Position Statement. AJNR Am J Neuroradiol 2021; 42:1566-1575. [PMID: 34326105 DOI: 10.3174/ajnr.a7223] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 01/26/2021] [Indexed: 12/19/2022]
Abstract
Current guidelines for primary and secondary prevention of stroke in patients with carotid atherosclerosis are based on the quantification of the degree of stenosis and symptom status. Recent publications have demonstrated that plaque morphology and composition, independent of the degree of stenosis, are important in the risk stratification of carotid atherosclerotic disease. This finding raises the question as to whether current guidelines are adequate or if they should be updated with new evidence, including imaging for plaque phenotyping, risk stratification, and clinical decision-making in addition to the degree of stenosis. To further this discussion, this roadmap consensus article defines the limits of luminal imaging and highlights the current evidence supporting the role of plaque imaging. Furthermore, we identify gaps in current knowledge and suggest steps to generate high-quality evidence, to add relevant information to guidelines currently based on the quantification of stenosis.
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Affiliation(s)
- L Saba
- From the Department of Radiology (L.S.), University of Cagliari, Cagliari, Italy
| | | | - J D Spence
- Stroke Prevention and Atherosclerosis Research Centre (J.D.S.), Robarts Research Institute, Western University, London, Ontario, Canada
| | - M Wintermark
- Department of Neuroradiology (M.W.), Stanford University and Healthcare System, Stanford, California
| | - M Castillo
- Department of Radiology (M.C.), University of North Carolina, Chapel Hill, North Carolina
| | - G J D Borst
- Department of Vascular Surgery (G.J.D.B.), University Medical Center Utrecht, Utrecht, the Netherlands
| | - Q Yang
- Department of Radiology (Q.Y.), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - C Yuan
- Departments of Radiology (C.Y., J.S., N.B.)
| | - A Buckler
- Elucid Bioimaging (A.B.), Boston, Massachusetts
| | - M Edjlali
- Department of Neuroradiology (M.E.), Université Paris-Descartes-Sorbonne-Paris-Cité, IMABRAIN-INSERM-UMR1266, DHU-Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France
| | - T Saam
- Department of Radiology (T.S.), University Hospital, Ludwig Maximilian University of Munich, Munich, Germany.,Radiologisches Zentrum (T.S.), Rosenheim, Germany
| | - D Saloner
- Departments of Radiology and Biomedical Imaging (D.S., C.H.), University of California San Francisco, San Francisco, California
| | - B K Lal
- Department of Vascular Surgery (B.K.L.), University of Maryland School of Medicine, Baltimore, Maryland
| | - D Capodanno
- Division of Cardiology (D.C.), A.O.U. Policlinico "G. Rodolico-San Marco," University of Catania, Italy
| | - J Sun
- Departments of Radiology (C.Y., J.S., N.B.)
| | - N Balu
- Departments of Radiology (C.Y., J.S., N.B.)
| | - R Naylor
- The Leicester Vascular Institute (R.N.), Glenfield Hospital, Leicester, UK
| | - A V D Lugt
- Department of Radiology and Nuclear Medicine (A.v.d.L.), Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - B A Wasserman
- The Russell H. Morgan Department of Radiology and Radiological Science (B.A.W.), Johns Hopkins Hospital, Baltimore, Maryland
| | - M E Kooi
- Department of Radiology and Nuclear Medicine (M.E.K.), CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands
| | - J Wardlaw
- Centre for Clinical Brain Sciences (J.W.), United Kingdom Dementia Research Institute and Edinburgh Imaging, University of Edinburgh, Edinburgh, UK
| | - J Gillard
- Christ's College (J.G.), Cambridge, UK
| | - G Lanzino
- Neurosurgery (G.L.) Mayo Clinic, Rochester, Minnesota
| | - U Hedin
- Department of Molecular Medicine and Surgery (U.H.), Karolinska Institutet, Stockholm, Sweden.,Department of Vascular Surgery (U.H.), Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - D Mikulis
- Joint Department of Medical Imaging and the Functional Neuroimaging Laboratory (D.M.), University Health Network, Toronto, Ontario, Canada
| | - A Gupta
- Department of Radiology (A.G.), Weill Cornell Medical College, New York, New York
| | - J K DeMarco
- Walter Reed National Military Medical Center and Uniformed Services University of the Health Sciences (J.K.D.), Bethesda, Maryland
| | - C Hess
- Departments of Radiology and Biomedical Imaging (D.S., C.H.), University of California San Francisco, San Francisco, California
| | - J V Goethem
- Faculty of Biomedical Sciences (J.V.G.), University of Antwerp, Antwerp, Belgium
| | - T Hatsukami
- Surgery (T.H.), University of Washington, Seattle, Washington
| | - P Rothwell
- Centre for Prevention of Stroke and Dementia (P.R.), Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, UK
| | - M M Brown
- Stroke Research Centre (M.M.B.), Department of Brain Repair and Rehabilitation, University College of London Queen Square Institute of Neurology, University College London, UK
| | - A R Moody
- Department of Medical Imaging (A.R.M.), University of Toronto, Toronto, Ontario, Canada
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Abstract
Background and Purpose Despite a higher incidence of stroke and a more adverse cardiovascular risk factor profile in Blacks and Hispanics compared with Whites, carotid artery revascularization is performed less frequently among these subpopulations. We assessed racial differences in high-grade (≥70% diameter-reducing) carotid stenosis. Methods Consecutive clients in a Nationwide Life Line for-Profit Service to screen for vascular disease, 2005 to 2019 were evaluated in a cross-sectional study. The prevalence of high-grade stenosis, defined by a carotid ultrasound peak systolic velocity of ≥230 cm/s, was assessed. Participants self-identified as White, Black, Hispanic, Asian, Native American, or other. Race/ethnic differences were assessed using Poisson regression. The number of individuals in the United States with high-grade stenosis was estimated by applying prevalence estimates to 2015 US Census population estimates. Results The prevalence of high-grade carotid stenosis was estimated in 6 130 481 individuals. The prevalence of high-grade stenosis was higher with increasing age in all race-sex strata. Generally, Blacks and Hispanics had a lower prevalence of high-grade stenosis compared with Whites, while Native Americans had a higher prevalence. For example, for men aged 55 to 65, the relative risk of stenosis compared with Whites was 0.40 (95% CI, 0.29–0.55) and 0.61 (95% CI, 0.46–0.81) for Blacks and Hispanics, respectively; and 1.53 (95% CI, 1.12–2.10) for Native Americans. When these prevalence estimates were applied to the Census estimates of the US population, an estimated 327 721 individuals have high-grade stenosis, of whom 7% are Black, 7% Hispanic, and 43% women. Conclusions Despite their having a more adverse cardiovascular risk profile, there was a lower prevalence of high-grade carotid artery stenosis for both the Black and Hispanic relative to the White clients. This lower prevalence of high-grade stenosis is a potential contributor to the lower use of carotid revascularization procedures in these minority populations.
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Affiliation(s)
- Brajesh K Lal
- University of Maryland School of Medicine and Baltimore VA Medical Center, Baltimore, MD
| | | | | | | | | | - Angelica Lackey
- University of Maryland School of Medicine and Baltimore VA Medical Center, Baltimore, MD
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Cires-Drouet RS, Nagarsheth K, Kaczorowski DJ, Toursavadkohi S, Deatrick K, Madathil RJ, Jones KM, Liskov S, Fitch J, Sayad M, Pasrija C, Mayorga-Carlin M, Herr D, Sorkin JD, Griffith B, Lal BK, Gammie JS. Catheter-based interventions versus medical and surgical approaches in acute pulmonary embolism. J Vasc Surg Venous Lymphat Disord 2021; 9:1382-1390. [PMID: 33965609 DOI: 10.1016/j.jvsv.2021.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/21/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Catheter-based intervention (CBI) has become an increasingly popular option for treating pulmonary embolism (PE); however, the real benefits are unknown. The purpose of the present study was to compare the outcomes of patients treated with CBI with the outcomes of those treated with medical or surgical approaches. METHODS We performed a retrospective analysis of patients admitted from October 2015 to December 2017 with a diagnosis of acute PE. We compared patients aged ≥18 years with a diagnosis of acute PE treated with CBI against a control group identified by propensity score matching. The control group was divided into those who had undergone surgical pulmonary embolectomy (SPE) as the surgical group and those who had not undergone SPE as the medical group. The primary outcome was mortality (in-hospital and overall mortality). The secondary outcomes were major bleeding, length of hospital stay, thrombus resolution, right ventricle improvement in systolic function and dilatation, and recurrent PE. RESULTS Of the 108 patients, 30 were in the CBI group and 78 were in the control group (62 in the medical group and 16 in the surgical group). The patient characteristics on admission were similar, except for the body mass index, which was greater in the CBI group (P = .03). No difference was found in clinical severity, clot burden, right ventricle function, or biomarkers. Recurrent PE was less frequent in the CBI group than in the medical group (0% vs 6.4%). Otherwise, no significant differences were found in the outcomes between the CBI and medical groups. When CBI was compared with the surgical group, SPE was associated with improved mortality (0% vs 16.6%) but a longer median length of hospital stay (median, 7 days; interquartile range, 3-12 days; vs median, 8 days; interquartile range, 6.5-17 days). CONCLUSIONS The use of CBI reduced the number of recurrent PE events compared with the medically treated patients; however, the mortality was higher than that in the surgical group.
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Affiliation(s)
- Rafael S Cires-Drouet
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Md; Department of Medicine, University of Maryland School of Medicine, Baltimore, Md.
| | - Khanjan Nagarsheth
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - David J Kaczorowski
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - Shahab Toursavadkohi
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Md; Vascular Service, Baltimore Veterans Affairs Medical Center, Baltimore, Md
| | - Kristopher Deatrick
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - Ronson J Madathil
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - Kevin M Jones
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Md
| | - Steven Liskov
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Md
| | - Jeffrey Fitch
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Md
| | - Michelle Sayad
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Md
| | - Chetan Pasrija
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Md
| | | | - Daniel Herr
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - John D Sorkin
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Md; Baltimore Veterans Affairs Geriatrics Research, Education, and Clinical Center, Baltimore Veterans Affairs Medical Center, Baltimore, Md
| | - Bartley Griffith
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - Brajesh K Lal
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Md; Vascular Service, Baltimore Veterans Affairs Medical Center, Baltimore, Md
| | - James S Gammie
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Md
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Aicher BO, Zhang J, Muratoglu SC, Galisteo R, Arai AL, Gray VL, Lal BK, Strickland DK, Ucuzian AA. Moderate aerobic exercise prevents matrix degradation and death in a mouse model of aortic dissection and aneurysm. Am J Physiol Heart Circ Physiol 2021; 320:H1786-H1801. [PMID: 33635167 PMCID: PMC8163659 DOI: 10.1152/ajpheart.00229.2020] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 11/22/2022]
Abstract
Thoracic aortic aneurysm and dissection (TAAD) is a deadly disease characterized by intimal disruption induced by hemodynamic forces of the circulation. The effect of exercise in patients with TAAD is largely unknown. β-Aminopropionitrile (BAPN) is an irreversible inhibitor of lysyl oxidase that induces TAAD in mice. The objective of this study was to investigate the effect of aerobic exercise on BAPN-induced TAAD. Upon weaning, mice were given either BAPN-containing water or standard drinking water and subjected to either conventional cage activity (BAPN-CONV) or forced treadmill exercise (BAPN-EX) for up to 26 wk. Mortality was 23.5% (20/85) for BAPN-CONV mice versus 0% (0/22) for BAPN-EX mice (hazard ratio 3.8; P = 0.01). BAPN induced significant elastic lamina fragmentation and intimal-medial thickening compared with BAPN-untreated controls, and aneurysms were identified in 50% (5/10) of mice that underwent contrast-enhanced CT scanning. Exercise significantly decreased BAPN-induced wall thickening, calculated circumferential wall tension, and lumen diameter, with 0% (0/5) of BAPN-EX demonstrating chronic aortic aneurysm formation on CT scan. Expression of selected genes relevant to vascular diseases was analyzed by qRT-PCR. Notably, exercise normalized BAPN-induced increases in TGF-β pathway-related genes Cd109, Smad4, and Tgfβr1; inflammation-related genes Vcam1, Bcl2a1, Ccr2, Pparg, Il1r1, Il1r1, Itgb2, and Itgax; and vascular injury- and response-related genes Mmp3, Fn1, and Vwf. Additionally, exercise significantly increased elastin expression in BAPN-treated animals compared with controls. This study suggests that moderate aerobic exercise may be safe and effective in preventing the most devastating outcomes in TAAD.NEW & NOTEWORTHY Moderate aerobic exercise was shown to significantly reduce mortality, extracellular matrix degradation, and thoracic aortic aneurysm and dissection formation associated with lysyl oxidase inhibition in a mouse model. Gene expression suggested a reversal of TGF-β, inflammation, and extracellular matrix remodeling pathway dysregulation, along with augmented elastogenesis with exercise.
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MESH Headings
- Aminopropionitrile
- Aortic Dissection/chemically induced
- Aortic Dissection/metabolism
- Aortic Dissection/pathology
- Aortic Dissection/therapy
- Animals
- Aorta, Thoracic/metabolism
- Aorta, Thoracic/pathology
- Aorta, Thoracic/physiopathology
- Aortic Aneurysm, Thoracic/chemically induced
- Aortic Aneurysm, Thoracic/metabolism
- Aortic Aneurysm, Thoracic/pathology
- Aortic Aneurysm, Thoracic/therapy
- Aortic Rupture/chemically induced
- Aortic Rupture/metabolism
- Aortic Rupture/pathology
- Aortic Rupture/prevention & control
- Dilatation, Pathologic
- Disease Models, Animal
- Disease Progression
- Exercise Therapy
- Extracellular Matrix/metabolism
- Extracellular Matrix/pathology
- Extracellular Matrix Proteins/metabolism
- Gene Expression Regulation
- Hemodynamics
- Male
- Mice, Inbred C57BL
- Proteolysis
- Signal Transduction
- Vascular Remodeling
- Mice
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Affiliation(s)
- Brittany O Aicher
- Center for Vascular & Inflammatory Diseases, University of Maryland School of Medicine, Baltimore, Maryland
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jackie Zhang
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Selen C Muratoglu
- Center for Vascular & Inflammatory Diseases, University of Maryland School of Medicine, Baltimore, Maryland
- Department of Physiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Rebeca Galisteo
- Center for Vascular & Inflammatory Diseases, University of Maryland School of Medicine, Baltimore, Maryland
| | - Allison L Arai
- Center for Vascular & Inflammatory Diseases, University of Maryland School of Medicine, Baltimore, Maryland
| | - Vicki L Gray
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, Maryland
| | - Brajesh K Lal
- Center for Vascular & Inflammatory Diseases, University of Maryland School of Medicine, Baltimore, Maryland
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
- Baltimore Veterans Affairs Medical Center, Vascular Service, Baltimore, Maryland
| | - Dudley K Strickland
- Center for Vascular & Inflammatory Diseases, University of Maryland School of Medicine, Baltimore, Maryland
- Department of Physiology, University of Maryland School of Medicine, Baltimore, Maryland
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, Maryland
| | - Areck A Ucuzian
- Center for Vascular & Inflammatory Diseases, University of Maryland School of Medicine, Baltimore, Maryland
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
- Baltimore Veterans Affairs Medical Center, Vascular Service, Baltimore, Maryland
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Prasad NK, Lake R, Englum BR, Turner DJ, Siddiqui T, Mayorga-Carlin M, Sorkin JD, Lal BK. Increased complications in patients who test COVID-19 positive after elective surgery and implications for pre and postoperative screening. Am J Surg 2021; 223:380-387. [PMID: 33894979 PMCID: PMC8045424 DOI: 10.1016/j.amjsurg.2021.04.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 03/30/2021] [Accepted: 04/08/2021] [Indexed: 12/14/2022]
Abstract
Background The COVID-19 pandemic has necessitated the adoption of protocols to minimize risk of periprocedural complications associated with SARS-CoV-2 infection. This typically involves a preoperative symptom screen and nasal swab RT-PCR test for viral RNA. Asymptomatic patients with a negative COVID-19 test are cleared for surgery. However, little is known about the rate of postoperative COVID-19 positivity among elective surgical patients, risk factors for this group and rate of complications. Methods This prospective multicenter study included all patients undergoing elective surgery at 170 Veterans Health Administration (VA) hospitals across the United States. Patients were divided into groups based on first positive COVID-19 test within 30 days after surgery (COVID[-/+]), before surgery (COVID[+/−]) or negative throughout (COVID[−/−]). The cumulative incidence, risk factors for and complications of COVID[-/+], were estimated using univariate analysis, exact matching, and multivariable regression. Results Between March 1 and December 1, 2020 90,093 patients underwent elective surgery. Of these, 60,853 met inclusion criteria, of which 310 (0.5%) were in the COVID[-/+] group. Adjusted multivariable logistic regression identified female sex, end stage renal disease, chronic obstructive pulmonary disease, congestive heart failure, cancer, cirrhosis, and undergoing neurosurgical procedures as risk factors for being in the COVID[-/+] group. After matching on current procedural terminology code and month of procedure, multivariable Poisson regression estimated the complication rate ratio for the COVID[-/+] group vs. COVID[−/−] to be 8.4 (C.I. 4.9–14.4) for pulmonary complications, 3.0 (2.2, 4.1) for major complications, and 2.6 (1.9, 3.4) for any complication. Discussion Despite preoperative COVID-19 screening, there remains a risk of COVID infection within 30 days after elective surgery. This risk is increased for patients with a high comorbidity burden and those undergoing neurosurgical procedures. Higher intensity preoperative screening and closer postoperative monitoring is warranted in such patients because they have a significantly elevated risk of postoperative complications.
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Affiliation(s)
- Nikhil K Prasad
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Rachel Lake
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Brian R Englum
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Douglas J Turner
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Tariq Siddiqui
- Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Minerva Mayorga-Carlin
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - John D Sorkin
- Geriatrics Research, Education, and Clinical Center, Veterans Affairs Medical Center, Baltimore, MD, USA; Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Brajesh K Lal
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA.
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Abstract
Abdominal aortic aneurysms (AAA) are prevalent among older adults and can cause significant morbidity and mortality if not addressed in a timely fashion. Their etiology remains the topic of continued investigation. Known causes include trauma, infection, and inflammatory disorders. Risk factors include cigarette smoking, advanced age, dyslipidemia, hypertension, and coronary artery disease. The pathophysiology of the disease is related to an initial arterial insult causing a cascade of inflammation and extracellular matrix protein breakdown by proteinases leading to arterial wall weakening. When identified early, aneurysms must be monitored for size, growth rate, and other factors which could increase the risk of rupture. Factors predisposing to rupture include size, active smoking, rate of growth, aberrant biomechanical properties of the aneurysmal sac, and female sex. Medical management includes the control of risk factors that may prevent growth, stabilize the aneurysm, and prevent rupture. Surgical management prevents rupture of high risk aneurysms, most commonly predicted by size. Less frequently, surgical management is required when the aneurysm has ruptured. Surgery involves a multidisciplinary approach to evaluate the patient's risk profile and to develop an operative plan involving either an endovascular or an open surgical repair. The patient must be carefully monitored post-operatively for complications and, in the case of endovascular repairs, for endoleaks. AAA management has evolved rapidly in recent years. Technical and technological advances have transformed the diagnosis and treatment of this disease.
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Affiliation(s)
- John Anagnostakos
- Center for Vascular Research, University of Maryland, United States of America
| | - Brajesh K Lal
- Center for Vascular Research, University of Maryland, United States of America; University of Maryland, United States of America; Endovascular Surgery, University of Maryland Medical Center, United States of America; Baltimore VA Medical Center, United States of America.
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43
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Khan AA, Patel J, Desikan S, Chrencik M, Martinez-Delcid J, Caraballo B, Yokemick J, Gray VL, Sorkin JD, Cebral J, Sikdar S, Lal BK. Asymptomatic carotid artery stenosis is associated with cerebral hypoperfusion. J Vasc Surg 2020; 73:1611-1621.e2. [PMID: 33166609 DOI: 10.1016/j.jvs.2020.10.063] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 10/03/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE We have shown that almost 50% of patients with asymptomatic carotid stenosis (ACS) will demonstrate cognitive impairment. Recent evidence has suggested that cerebral hypoperfusion is an important cause of cognitive impairment. Carotid stenosis can restrict blood flow to the brain, with consequent cerebral hypoperfusion. In contrast, cross-hemispheric collateral compensation through the Circle of Willis, and cerebrovascular vasodilation can also mitigate the effects of flow restriction. It is, therefore, critical to develop a clinically relevant measure of net brain perfusion in patients with ACS that could help in risk stratification and in determining the appropriate treatment. To determine whether ACS results in cerebral hypoperfusion, we developed a novel approach to quantify interhemispheric cerebral perfusion differences, measured as the time to peak (TTP) and mean transit time (MTT) delays using perfusion-weighted magnetic resonance imaging (PWI) of the whole brain. To evaluate the utility of using clinical duplex ultrasonography (DUS) to infer brain perfusion, we also assessed the relationship between the PWI findings and ultrasound-based peak systolic velocity (PSV). METHODS Structural and PWI of the brain and magnetic resonance angiography of the carotid arteries were performed in 20 patients with ≥70% ACS. DUS provided the PSV, and magnetic resonance angiography provided plaque geometric measures at the stenosis. Volumetric perfusion maps of the entire brain from PWI were analyzed to obtain the mean interhemispheric differences for the TTP and MTT delays. In addition, the proportion of brain volume that demonstrated a delay in TTP and MTT was also measured. These proportions were measured for increasing severity of perfusion delays (0.5, 1.0, and 2.0 seconds). Finally, perfusion asymmetries on PWI were correlated with the PSV and stenosis features on DUS using Pearson's correlation coefficients. RESULTS Of the 20 patients, 18 had unilateral stenosis (8 right and 10 left) and 2 had bilateral stenoses. The interhemispheric (left-right) TTP delays measured for the whole brain volume identified impaired perfusion in the hemisphere ipsilateral to the stenosis in 16 of the 18 patients. More than 45% of the patients had had ischemia in at least one half of their brain volume, with a TTP delay >0.5 second. The TTP and MTT delays showed strong correlations with PSV. In contrast, the correlations with the percentage of stenosis were weaker. The correlations for the PSV were strongest with the perfusion deficits (TTP and MTT delays) measured for the whole brain using our proposed algorithm (r = 0.80 and r = 0.74, respectively) rather than when measured on a single magnetic resonance angiography slice as performed in current clinical protocols (r = 0.31 and r = 0.58, respectively). CONCLUSIONS Interhemispheric TTP and MTT delay measured for the whole brain using PWI has provided a new tool for assessing cerebral perfusion deficits in patients with ACS. Carotid stenosis was associated with a detectable reduction in ipsilateral brain perfusion compared with the opposite hemisphere in >80% of patients. The PSV measured at the carotid stenosis using ultrasonography correlated with TTP and MTT delays and might serve as a clinically useful surrogate to brain hypoperfusion in these patients.
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Affiliation(s)
- Amir A Khan
- Department of Bioengineering, George Mason University, Fairfax, Va
| | - Jigar Patel
- Imaging Service, Veterans Affairs Maryland Health Care System, Baltimore, Md
| | - Sarasijhaa Desikan
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, Md; Vascular Service, Veterans Affairs Medical Center, Baltimore, Md
| | - Matthew Chrencik
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, Md; Vascular Service, Veterans Affairs Medical Center, Baltimore, Md
| | - Janice Martinez-Delcid
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, Md; Vascular Service, Veterans Affairs Medical Center, Baltimore, Md
| | - Brian Caraballo
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, Md; Vascular Service, Veterans Affairs Medical Center, Baltimore, Md
| | - John Yokemick
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, Md; Vascular Service, Veterans Affairs Medical Center, Baltimore, Md
| | - Vicki L Gray
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, Md
| | - John D Sorkin
- Geriatric Research, Education, and Clinical Center, Baltimore Veterans Affairs Medical Center, Baltimore, Md; Claude D. Pepper Older Americans Independence Center, University of Maryland School of Medicine, Baltimore, Md
| | - Juan Cebral
- Department of Bioengineering, George Mason University, Fairfax, Va
| | | | - Brajesh K Lal
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, Md; Vascular Service, Veterans Affairs Medical Center, Baltimore, Md.
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Lal BK. Defining the future of venous disease through mentorship, innovation, and leadership. J Vasc Surg Venous Lymphat Disord 2020; 8:907-911. [PMID: 33069336 DOI: 10.1016/j.jvsv.2020.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Brajesh K Lal
- Center for Vascular Research and Department of Vascular Surgery, University of Maryland, Baltimore, Md; Vascular Service, Baltimore VA Medical Center, Baltimore, Md.
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45
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Kabnick LS, Sadek M, Bjarnason H, Coleman DM, Dillavou ED, Hingorani AP, Lal BK, Lawrence PF, Malgor R, Puggioni A. Classification and treatment of endothermal heat-induced thrombosis: Recommendations from the American Venous Forum and the Society for Vascular Surgery This Practice Guidelines document has been co-published in Phlebology [DOI: 10.1177/0268355520953759] and Journal of Vascular Surgery: Venous and Lymphatic Disorders [DOI: 10.1016/j.jvsv.2020.06.008]. The publications are identical except for minor stylistic and spelling differences in keeping with each journal's style. The contribution has been published under a Attribution-Non Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0), (https://creativecommons.org/licenses/by-nc-nd/4.0/). Phlebology 2020; 36:8-25. [PMID: 32998622 PMCID: PMC7820569 DOI: 10.1177/0268355520953759] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The American Venous Forum (AVF) and the Society for Vascular Surgery set forth these guidelines for the management of endothermal heat-induced thrombosis (EHIT). The guidelines serve to compile the body of literature on EHIT and to put forth evidence-based recommendations. The guidelines are divided into the following categories: classification of EHIT, risk factors and prevention, and treatment of EHIT. One major feature is to standardize the reporting under one classification system. The Kabnick and Lawrence classification systems are now combined into the AVF EHIT classification system. The novel classification system affords standardization in reporting but also allows continued combined evaluation with the current body of literature. Recommendations codify the use of duplex ultrasound for the diagnosis of EHIT. Risk factor assessments and methods of prevention including mechanical prophylaxis, chemical prophylaxis, and ablation distance are discussed. Treatment guidelines are tailored to the AVF EHIT class (ie, I, II, III, IV). Reference is made to the use of surveillance, antiplatelet therapy, and anticoagulants as deemed indicated, and the recommendations incorporate the use of the novel direct oral anticoagulants. Last, EHIT management as it relates to the great and small saphenous veins is discussed.
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Affiliation(s)
- Lowell S Kabnick
- Atlantic Health System, Morristown Medical Center, Kabnick Vein Center, Morristown, NJ, USA
| | - Mikel Sadek
- Division of Vascular Surgery, NYU Langone Health, New York, NY, USA
| | - Haraldur Bjarnason
- Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, MN, USA
| | - Dawn M Coleman
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Ellen D Dillavou
- Division of Vascular Surgery, Duke University Medical Center, Durham, NC, USA
| | - Anil P Hingorani
- Division of Vascular Surgery, NYU Langone Hospital-Brooklyn, Brooklyn, NY, USA
| | - Brajesh K Lal
- Center for Vascular Research and Department of Vascular Surgery, University of Maryland, and the Vascular Service, Baltimore VA Medical Center, Baltimore, MD, USA
| | - Peter F Lawrence
- Department of Surgery, Division of Vascular Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Rafael Malgor
- Division of Vascular Surgery and Endovascular Therapy, The University of Colorado, Anschutz Medical Center, Aurora, CO, USA
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Gray VL, Desikan SK, Lal BK. Reply. J Vasc Surg 2020; 72:1510-1511. [PMID: 32972595 DOI: 10.1016/j.jvs.2020.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/06/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Vicki L Gray
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, Md
| | - Sarasijhaa K Desikan
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, Md; Vascular Service, Veterans Affairs Medical Center, Baltimore, Md
| | - Brajesh K Lal
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, Md; Vascular Service, Veterans Affairs Medical Center, Baltimore, Md
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Turan TN, Voeks JH, Chimowitz MI, Roldan A, LeMatty T, Haley W, Lopes-Virella M, Chaturvedi S, Jones M, Heck D, Howard G, Lal BK, Meschia JF, Brott TG. Rationale, Design, and Implementation of Intensive Risk Factor Treatment in the CREST2 Trial. Stroke 2020; 51:2960-2971. [PMID: 32951538 DOI: 10.1161/strokeaha.120.030730] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE The CREST2 trial (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis) is comparing intensive medical management (IMM) alone to IMM plus revascularization with carotid endarterectomy or transfemoral carotid artery stenting for preventing stroke or death within 44 days after randomization or ipsilateral ischemic stroke thereafter. There are extensive clinical trial data on outcomes after revascularization of asymptomatic carotid stenosis, but not for IMM. As such, the experimental treatment in CREST2 is IMM, which is described in this article. METHODS IMM consists of aspirin 325 mg/day and intensive risk factor management, primarily targeting systolic blood pressure <130 mm Hg (initially systolic blood pressure <140 mm Hg) and LDL (low-density lipoprotein) cholesterol <70 mg/dL. Secondary risk factor targets focus on tobacco smoking, non-HDL (high-density lipoprotein), HbA1c (hemoglobin A1c), physical activity, and weight. Risk factor management is performed by site personnel and a lifestyle coaching program delivered by telephone. We report interim risk factor data on 1618 patients at baseline and last follow-up through 24 months. RESULTS The mean baseline LDL of 80.5 mg/dL improved to 66.7 mg/dL. The mean baseline systolic blood pressure of 139.7 mm Hg improved to 130.3 mm Hg. The proportion of patients in-target improved from 43% to 61% for systolic blood pressure <130 mm Hg and from 45% to 67% for LDL<70 mg/dL (both changes P<0.001). CONCLUSIONS The rigorous multimodal approach to intensive stroke risk factor management in CREST2 has resulted in significant improvements in risk factor control that will enable a comparison of cutting-edge medical care to revascularization in patients with asymptomatic carotid stenosis. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02089217.
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Affiliation(s)
- Tanya N Turan
- Neurology (T.N.T., J.H.V., M.I.C., A.R., T.L., W.H.), Medical University of South Carolina, Charleston, SC
| | - Jenifer H Voeks
- Neurology (T.N.T., J.H.V., M.I.C., A.R., T.L., W.H.), Medical University of South Carolina, Charleston, SC
| | - Marc I Chimowitz
- Neurology (T.N.T., J.H.V., M.I.C., A.R., T.L., W.H.), Medical University of South Carolina, Charleston, SC
| | - Ana Roldan
- Neurology (T.N.T., J.H.V., M.I.C., A.R., T.L., W.H.), Medical University of South Carolina, Charleston, SC
| | - Todd LeMatty
- Neurology (T.N.T., J.H.V., M.I.C., A.R., T.L., W.H.), Medical University of South Carolina, Charleston, SC
| | - William Haley
- Neurology (T.N.T., J.H.V., M.I.C., A.R., T.L., W.H.), Medical University of South Carolina, Charleston, SC
| | | | - Seemant Chaturvedi
- Medical University of South Carolina, Charleston, SC. Neurology (S.C.), University of Maryland, Baltimore
| | | | - Donald Heck
- Radiology, Novant Health, Winston-Salem, NC (D.H.)
| | - George Howard
- Biostatistics, University of Alabama at Birmingham (G.H.)
| | - Brajesh K Lal
- Vascular Surgery (B.K.L.), University of Maryland, Baltimore
| | | | - Thomas G Brott
- Neurology, Mayo Clinic, Jacksonville, FL (J.F.M., T.G.B.)
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Parsi K, van Rij AM, Meissner MH, Davies AH, Maeseneer MD, Gloviczki P, Benson S, Bottini O, Canata VM, Dinnen P, Gasparis A, Gianesini S, Huber D, Jenkins D, Lal BK, Kabnick L, Lim A, Marston W, Granados AM, Morrison N, Nicolaides A, Paraskevas P, Patel M, Roberts S, Rogan C, Schul MW, Komlos P, Stirling A, Thibault S, Varghese R, Welch HJ, Wittens CHA. Triage of patients with venous and lymphatic diseases during the COVID-19 pandemic - The Venous and Lymphatic Triage and Acuity Scale (VELTAS) : A consensus document of the International Union of Phlebology (UIP), Australasian College of Phlebology (ACP), American Vein and Lymphatic Society (AVLS), American Venous Forum (AVF), European College of Phlebology (ECoP), European Venous Forum (EVF), Interventional Radiology Society of Australasia (IRSA), Latin American Venous Forum, Pan-American Society of Phlebology and Lymphology and the Venous Association of India (VAI) This consensus document has been co-published in Phlebology [DOI: 10.1177/0268355520930884] and Journal of Vascular Surgery: Venous and Lymphatic Disorders [DOI: 10.1016/j.jvsv.2020.05.002]. The publications are identical except for minor stylistic and spelling differences in keeping with each journal's style. The contribution has been published under a Attribution-Non Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0), (https://creativecommons.org/licenses/by-nc-nd/4.0/). Phlebology 2020; 35:550-555. [PMID: 32639862 PMCID: PMC7441329 DOI: 10.1177/0268355520930884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The coronavirus disease 2019 (COVID-19) global pandemic has resulted in diversion of healthcare resources to the management of patients infected with SARS-CoV-2 virus. Elective interventions and surgical procedures in most countries have been postponed and operating room resources have been diverted to manage the pandemic. The Venous and Lymphatic Triage and Acuity Scale was developed to provide an international standard to rationalise and harmonise the management of patients with venous and lymphatic disorders or vascular anomalies. Triage urgency was determined based on clinical assessment of urgency with which a patient would require medical treatment or surgical intervention. Clinical conditions were classified into six categories of: (1) venous thromboembolism (VTE), (2) chronic venous disease, (3) vascular anomalies, (4) venous trauma, (5) venous compression and (6) lymphatic disease. Triage urgency was categorised into four groups and individual conditions were allocated to each class of triage. These included (1) medical emergencies (requiring immediate attendance), example massive pulmonary embolism; (2) urgent (to be seen as soon as possible), example deep vein thrombosis; (3) semi-urgent (to be attended to within 30-90 days), example highly symptomatic chronic venous disease, and (4) discretionary/non-urgent- (to be seen within 6-12 months), example chronic lymphoedema. Venous and Lymphatic Triage and Acuity Scale aims to standardise the triage of patients with venous and lymphatic disease or vascular anomalies by providing an international consensus-based classification of clinical categories and triage urgency. The scale may be used during pandemics such as the current COVID-19 crisis but may also be used as a general framework to classify urgency of the listed conditions.
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Affiliation(s)
- Kurosh Parsi
- International Union of Phlebology
(UIP)
- Australasian College of Phlebology
(ACP)
| | | | - Mark H Meissner
- International Union of Phlebology
(UIP)
- American Venous Forum (AVF)
- American Vein and Lymphatic Society
(AVLS)
| | - Alun H Davies
- Imperial College London, Charing
Cross and St Mary’s Hospital, London, UK
| | | | - Peter Gloviczki
- Division of Vascular and
Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | | | | | | | | | | | | | | | | | - Adrian Lim
- Australasian College of Phlebology
(ACP)
| | | | | | - Nick Morrison
- International Union of Phlebology
(UIP)
- American Vein and Lymphatic Society
(AVLS)
| | | | | | | | | | - Christopher Rogan
- Australasian College of Phlebology
(ACP)
- Interventional Radiology Society
of Australasia (IRSA)
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49
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Cires-Drouet RS, Mayorga-Carlin M, Toursavadkohi S, White R, Redding E, Durham F, Dondero K, Prior SJ, Sorkin JD, Lal BK. Safety of exercise therapy after acute pulmonary embolism. Phlebology 2020; 35:824-832. [PMID: 32720853 DOI: 10.1177/0268355520946625] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The role of exercise therapy after acute pulmonary embolism (PE) is unknown. Exercise therapy is safely used after myocardial infarction and chronic obstructive pulmonary disease. The aim of this study was to investigate the safety of exercise therapy after acute PE. METHODS We implemented a 3-month exercise program after acute PE. Outcomes were death, bleeding, readmissions, recurrent events, changes in peak VO2 and quality of life (QoL). RESULTS A total of 23 patients were enrolled and received anticoagulation; no adverse events were reported during the exercise period. One death, 1 DVT and 5 readmissions were reported due to non-exercise related reasons. Functional capacity improved as evidenced by an increased peak VO2 at 3 months (+3.9 ± 5.6 mL/kg/min; p = 0.05). Improvement in QoL was observed at 6-months on the functional (+17.0 ± 22.6, p = 0.03) and physical health factor scales (+0.9 ± 4.6, p = 0.03). CONCLUSION Exercise therapy is feasible and safe in appropriately anticoagulated patients after PE.
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Affiliation(s)
- Rafael S Cires-Drouet
- Division of Vascular Surgery, Department of Surgery, University of Maryland, Baltimore, MD, USA
| | - Minerva Mayorga-Carlin
- Division of Vascular Surgery, Department of Surgery, University of Maryland, Baltimore, MD, USA
| | - Shahab Toursavadkohi
- Division of Vascular Surgery, Department of Surgery, University of Maryland, Baltimore, MD, USA.,Vascular Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Rachel White
- Division of Vascular Surgery, Department of Surgery, University of Maryland, Baltimore, MD, USA
| | - Emily Redding
- Division of Vascular Surgery, Department of Surgery, University of Maryland, Baltimore, MD, USA
| | - Frederick Durham
- Division of Vascular Surgery, Department of Surgery, University of Maryland, Baltimore, MD, USA
| | - Kathleen Dondero
- Department of Kinesiology, Towson University, Baltimore, MD, USA
| | - Steven J Prior
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.,Baltimore VA Geriatrics Research, Education, and Clinical Center, Baltimore Veterans Affairs Medical Center, Baltimore, MD, USA.,Department of Kinesiology, University of Maryland School of Public Health, College Park, MD, USA
| | - John D Sorkin
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.,Baltimore VA Geriatrics Research, Education, and Clinical Center, Baltimore Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Brajesh K Lal
- Division of Vascular Surgery, Department of Surgery, University of Maryland, Baltimore, MD, USA.,Vascular Service, Veterans Affairs Medical Center, Baltimore, MD, USA
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50
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Lal BK, Kashyap VS, Patel JB, Gutpa A, Chrencik MT, King AH, Khan AA, Buckler A. Novel Application of Artificial Intelligence Algorithms to Develop a Predictive Model for Major Adverse Neurologic Events in Patients With Carotid Atherosclerosis. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.04.306] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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