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Whitaker L, Etkin Y. The enduring success of the DRIL technique and new advances in dialysis access. J Vasc Surg Cases Innov Tech 2024; 10:101490. [PMID: 38566913 PMCID: PMC10985288 DOI: 10.1016/j.jvscit.2024.101490] [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] [Indexed: 04/04/2024] Open
Affiliation(s)
| | - Yana Etkin
- Northwell, New Hyde Park, NY
- Department of Surgery at Zucker School of Medicine, Manhasset, NY
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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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Weaver ML, Drudi LM, Adams AM, Faria I, Feldman HA, Gudmundsdottir H, Marmor H, Miles MVP, Ochoa B, Ruff SM, Sundland R, Tonelli C, Altieri MS, Cannada LK, Dewan K, Etkin Y, Marmor R, Plichta JK, Reyna C, Tatebe LC, Hicks CW. Implementation of a novel peer review academy by Surgery and the Association of Women Surgeons. Surgery 2024; 175:323-330. [PMID: 37953152 PMCID: PMC10842028 DOI: 10.1016/j.surg.2023.09.050] [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: 04/25/2023] [Revised: 06/28/2023] [Accepted: 09/26/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND A novel Peer Review Academy was developed as a collaborative effort between the Association of Women Surgeons and the journal Surgery to provide formal training in peer review. We aimed to describe the outcomes of this initiative using a mixed methods approach. METHODS We developed a year-long curriculum with monthly online didactic sessions. Women surgical trainee mentees were paired 1:1 with rotating women surgical faculty mentors for 3 formal peer review opportunities. We analyzed pre-course and post-course surveys to evaluate mentee perceptions of the academy and assessed changes in mentee review quality over time with blinded scoring of unedited reviews. Semi-structured interviews were conducted upon course completion. RESULTS Ten women surgical faculty mentors and 10 women surgical trainees from across the United States and Canada successfully completed the Peer Review Academy. There were improvements in the mentees' confidence for all domains of peer review evaluated, including overall confidence in peer review, study novelty, study design, analytic approach, and review formatting (all, P ≤ .02). The mean score of peer review quality increased over time (59.2 ± 10.8 vs 76.5 ± 9.4; P = .02). In semi-structured interviews, important elements were emphasized across the Innovation, Implementation Process, and Individuals Domains, including the values of (1) a comprehensive approach to formal peer review education; (2) mentoring relationships between women faculty and resident surgeons; and (3) increasing diversity in the scientific peer review process. CONCLUSION Our novel Peer Review Academy was feasible on a national scale, resulting in significant qualitative and quantitative improvements in women surgical trainee skillsets, and has the potential to grow and diversify the existing peer review pool.
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Affiliation(s)
- M Libby Weaver
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Laura M Drudi
- Division of Vascular Surgery, Centre Hospitalier de L'Universite de Montreal, Montreal, QC, Canada
| | - Alexandra M Adams
- Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX
| | - Isabella Faria
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA
| | - Hope A Feldman
- Department of General Surgery, Geisinger Medical Center, Danville, PA
| | | | - Hannah Marmor
- Department of Surgery, State University of New York Upstate Medical University, Syracuse, NY
| | - M Victoria P Miles
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Brielle Ochoa
- Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Samantha M Ruff
- Division of Surgical Oncology, The Ohio State University, Columbus, OH
| | | | - Celsa Tonelli
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Maria S Altieri
- Department of Surgery, University of Pennsylvania, Pennsylvania Hospital, Philadelphia, PA
| | - Lisa K Cannada
- Novant Health Fracture Clinic, University of North Carolina-Charlotte School of Medicine, Charlotte, NC
| | - Karuna Dewan
- Department of Otolaryngology, Head and Neck Surgery, Louisiana State University, New Orleans, LA
| | - Yana Etkin
- Division of Vascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Rebecca Marmor
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Chantal Reyna
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Leah C Tatebe
- Department of Surgery, Northwestern University, Chicago, IL
| | - Caitlin W Hicks
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
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Etkin Y, Harris LM, Hicks CW. Bridging the Divide: Addressing Sex Disparities in Vascular Surgery. Semin Vasc Surg 2023; 36:475. [PMID: 38030320 DOI: 10.1053/j.semvascsurg.2023.11.001] [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] [Indexed: 12/01/2023]
Affiliation(s)
- Yana Etkin
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine @Hofstrta/Northwell, Hampstead, NY.
| | - Linda M Harris
- Division of Vascular and Endovascular Surgery, Jacobs School of Medicines & Biomedical Sciences, Buffalo, NY
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore MD
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Kania TA, Noorani A, Juneja A, Demissie S, Singh K, Deitch J, Etkin Y, Landis GS, Schor J. Hemodynamic instability in the immediate postoperative setting after transcarotid artery revascularization. Vascular 2023; 31:1151-1160. [PMID: 35618486 DOI: 10.1177/17085381221105178] [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] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Transcarotid artery revascularization (TCAR) is a relatively recent development in the management of carotid artery occlusive disease, the utilization of which is becoming more prevalent. This study aims to evaluate the timing, prevalence, and types of hemodynamic instability after TCAR. METHODS We performed a retrospective review of all TCAR procedures performed at two tertiary care academic medical centers within a single hospital system from 2017 through 2019. Demographics, comorbidities, preoperative patient factors, procedural details, and postoperative data were collected. Patients were assessed over 24 hours postoperatively for stroke, death, myocardial infarction (MI), and hemodynamic instability at 3, 6, 9, 12, and 24 hour intervals. Hemodynamic instability was defined as any vital sign abnormality which required pharmacological intervention with antihypertensive, vasopressor, and/or anti-arrhythmic agents. The incidence and timing of postoperative complications and hemodynamic instability were recorded. RESULTS During the study period, 76 patients 80 TCAR procedures. Out of 80 procedures, 64 (80.0%) were receiving home antihypertensive medication and 28 (35.0%) were symptomatic lesions preoperatively. Intraoperatively, one patient (1.3%) received atropine, 26 (32.5%) received glycopyrrolate, 76 (95%) underwent predilatation, and 16 (20.0%) underwent postdilatation. Postoperatively, a total of 22 cases (27.5%) required medication for acute control of blood pressure or heart rate, which reached a peak of 19 patients (23.8%) within the first 3 hours, and tapered to nine patients (11.3%) by the 24 hour mark. A total of three patients (3.75%) required initiation of pharmacological management after the three-hour mark. Six patients (7.5%) underwent stroke code workup, 4 (5.0%) of whom were confirmed to have stroke on CT. Average time to neurologic event was 3.9 hours. No patients experienced MI or death. Median ICU and hospital days for unstable patients were two and three, respectively, compared to one and one for stable patients. CONCLUSIONS Hemodynamic instability is common after TCAR and reliably presents at or before postoperative hour 3. Hypo- followed by hyper-tension were the most common manifestations of hemodynamic instability. Regardless, unstable patients and stroke patients were more likely to require longer periods of time in the ICU and in the hospital overall. This may have implications for postoperative ICU resource management when deciding to transfer patients out of a monitored setting. Further study is required to establish relationships between pre- and intra-operative risk factors and outcomes such as hemodynamic instability and/or stroke. At present, one should proceed with careful evaluation of preoperative medications, strict management of postoperative hemodynamics, and clear communication among team members should all be employed to optimize outcomes.
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Affiliation(s)
- Thomas A Kania
- Departgment of Surgery, Staten Island University Hospital, Donald and Barbara Zucker SOM at Hofstra/Northwell, Staten Island, NY, USA
| | - Aaquib Noorani
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Amandeep Juneja
- North Shore University Hospital and Long Island Medical Center, Donald and Barbara Zucker SOM at Hofstra/Northwell, New York, NY, USA
| | - Seleshi Demissie
- Departgment of Surgery, Staten Island University Hospital, Donald and Barbara Zucker SOM at Hofstra/Northwell, Staten Island, NY, USA
| | - Kuldeep Singh
- Division of Vascular Surgery, Staten Island University Hospital, Donald and Barbara Zucker SOM at Hofstra/Northwell, Staten Island, NY, USA
| | - Jonathan Deitch
- Vascular and Endovascular Surgery, Texas Health Resources, Harris Methodist Hospital, Ft. Worth, TX USA
| | - Yana Etkin
- North Shore University Hospital and Long Island Medical Center, Donald and Barbara Zucker SOM at Hofstra/Northwell, New York, NY, USA
| | - Gregg S Landis
- North Shore University Hospital and Long Island Medical Center, Donald and Barbara Zucker SOM at Hofstra/Northwell, New York, NY, USA
| | - Jonathan Schor
- Division of Vascular Surgery, Staten Island University Hospital, Donald and Barbara Zucker SOM at Hofstra/Northwell, Staten Island, NY, USA
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Etkin Y, Iyeke L, Yu G, Ahmed I, Matera P, Aminov J, Kokkosis A, Hastings L, Garg K, Rockman C. Sex disparities in outcomes after carotid artery interventions: A systematic review. Semin Vasc Surg 2023; 36:476-486. [PMID: 38030321 DOI: 10.1053/j.semvascsurg.2023.09.004] [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: 07/28/2023] [Revised: 09/13/2023] [Accepted: 09/28/2023] [Indexed: 12/01/2023]
Abstract
This systematic review aimed to identify sex-specific outcomes in men and women after carotid endarterectomy (CEA) and carotid artery stenting (CAS), including transfemoral and transcarotid. A search of literature published from January 2000 through December 2022 was conducted using key terms attributed to carotid interventions on PubMed. Studies comparing outcome metrics post intervention (ie, myocardial infarction [MI], cerebral vascular accident [CVA] or stroke, and long-term mortality) among male and female patients were reviewed. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Overall, all studies reported low rates of perioperative complications. Among the studies that did not stratify outcomes by the preoperative symptom status, there were no significant sex differences in rates of perioperative strokes or MIs. Two studies, however, noted a higher rate of 30-day mortality in male patients undergoing CEA than in female patients. Analysis of asymptomatic patients undergoing CEA revealed no difference in perioperative MIs (female: 0% to 1.8% v male: 0.4% to 4.3%), similar rates of CVAs (female: 0.8% to 5% v male: 0.8% to 4.9%), and no significant differences in the long-term mortality outcomes. Alternatively, symptomatic patients undergoing CEA reported a higher rate of CVAs in female patients vs. male patients (7.7% v 6.2%) and showed a higher rate of death in female patients (1% v 0.7%). Among studies that did not stratify outcome by symptomatology, there was no difference in the 30-day outcomes between sexes for patients undergoing CAS. Asymptomatic patients undergoing CAS demonstrated similar incident rates across perioperative MIs (female: 0% to 5.9% v male: 0.28% to 3.3%), CVAs (female: 0.5% to 4.1% v male: 0.4% to 6.2%), and long-term mortality outcomes (female: 0% to 1.75% v male: 0.2% to 1.5%). Symptomatic patients undergoing CAS similarly reported higher incidences of perioperative MIs (female: 0.3% to 7.1% v male: 0% to 5.5%), CVAs (female: 0% to 9.9% v male: 0% to 7.6%), and long-term mortality outcomes (female: 0.6% to 7.1% v male: 0.5% to 8.2%). Sex-specific differences in outcomes after major vascular procedures are well recognized. Our review suggests that symptomatic female patients have a higher incidence of neurologic and cardiac events after carotid interventions, but that asymptomatic patients do not.
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Affiliation(s)
- Yana Etkin
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, 1999 Marcus Avenue, Suite 106, Lake Success, NY, 11042.
| | - Lisa Iyeke
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, 1999 Marcus Avenue, Suite 106, Lake Success, NY, 11042
| | - Grace Yu
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, 1999 Marcus Avenue, Suite 106, Lake Success, NY, 11042
| | | | | | - Jonathan Aminov
- Division of Vascular and Endovascular Surgery, Stony Brook University Medical Center, Stony Brook, NY
| | - Angela Kokkosis
- Division of Vascular and Endovascular Surgery, Stony Brook University Medical Center, Stony Brook, NY
| | - Laurel Hastings
- Division of Vascular Surgery, Einstein Medical Center, Philadelphia, PA
| | - Karan Garg
- Division of Vascular Surgery, New York University Langone Medical Center, New York, NY
| | - Caron Rockman
- Division of Vascular Surgery, New York University Langone Medical Center, New York, NY
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Silpe J, Koleilat I, Yu J, Kim YH, Taubenfeld E, Talathi S, Coluccio M, Wang K, Woo K, Etkin Y. Sex disparities in hemodialysis access outcomes: A systematic review. Semin Vasc Surg 2023; 36:560-570. [PMID: 38030330 DOI: 10.1053/j.semvascsurg.2023.10.002] [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: 07/26/2023] [Revised: 10/01/2023] [Accepted: 10/02/2023] [Indexed: 12/01/2023]
Abstract
The goal of this systematic review was to collate and summarize the current literature on hemodialysis access outcomes in females, identify differences between females and men, and provide a foundation for future research. A systematic review of the English-language literature was conducted by searching PubMed and Google Scholar for the following terms: "sex," "hemodialysis access," "arteriovenous fistula," "arteriovenous graft," and "dialysis catheter." Reference lists from the resulting articles were also evaluated to ensure that any and all relevant primary sources were identified. Studies were then screened by two independent reviewers for inclusion. Of 967 total studies, 53 ultimately met inclusion criteria. Females have lower maturation rates; have decreased rates of primary, primary-assisted, and secondary patency; require more procedures per capita to achieve maturation and to maintain fistula patency; are more likely to receive dialysis via an arteriovenous graft or central venous catheter; and require a longer time and potentially more assistive invasive interventions to achieve a mature fistula. Our findings emphasize the urgent need for further research to evaluate and address the causes of these disparities. Discussion with patients undergoing hemodialysis should include these findings to improve patient education, expectations, satisfaction, and outcomes.
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Affiliation(s)
- Jeffrey Silpe
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, 1999 Marcus Avenue, Suite 106b Lake Success, NY.
| | - Issam Koleilat
- Department of Surgery, RWJ Barnabas Health Community Medical Center, Tom's River, NJ
| | - Justin Yu
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, 1999 Marcus Avenue, Suite 106b Lake Success, NY
| | - Young Hun Kim
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, 1999 Marcus Avenue, Suite 106b Lake Success, NY
| | - Ella Taubenfeld
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, 1999 Marcus Avenue, Suite 106b Lake Success, NY
| | - Sonia Talathi
- Division of Vascular and Cardiothoracic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Maria Coluccio
- Division of Vascular and Cardiothoracic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Karissa Wang
- Division of Vascular Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Karen Woo
- Division of Vascular Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Yana Etkin
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, 1999 Marcus Avenue, Suite 106b Lake Success, NY
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Hoffstaetter T, Silpe J, Delijani D, Landis GS, Etkin Y. Sex Disparities in Arteriovenous Fistula Maturation Outcomes. Ann Vasc Surg 2023; 95:197-202. [PMID: 37270092 DOI: 10.1016/j.avsg.2023.05.032] [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] [Received: 02/06/2023] [Revised: 05/21/2023] [Accepted: 05/24/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND The end-stage kidney disease life-plan aims to individualize hemodialysis (HD) access selection in patients requiring renal replacement therapy. Paucity of data on risk factors for poor arteriovenous fistula (AVF) outcomes limits the ability of physicians to guide their patients on this decision. This is especially true for female patients, who are known to have worse AVF outcomes when compared to male patients. The goal of this study was to identify risk factors associated with poor AVF maturation outcomes in female patients that will help guide individualized access selection. METHODS A retrospective review of 1,077 patients that had AVF creation between 2014 and 2021 at an academic medical center was performed. Maturation outcomes were compared between 596 male and 481 female patients. Separate multivariate logistic regression models were created for the male and female cohorts to identify factors associated with unassisted maturation. AVF was considered mature if it was successfully used for HD for 4-week sessions without need for further interventions. Unassisted fistula was defined as an AVF that matured without any interventions. RESULTS The male patients were more likely to receive more distal HD access; 378 (63%) male versus 244 (51%) female patients had radiocephalic AVF, P < 0.001. Maturation outcomes were significantly worse in female patients; 387 (80%) AVFs matured in females and 519 (87%) in male patients, P < 0.001. Similarly, the rate of unassisted maturation was 26% (125) in female patients versus 39% (233) in male patients, P < 0.001. Mean preoperative vein diameters were similar in both groups; 2.8 ± 1.1 mm in male versus 2.7 ± 0.97 mm in female patients, P = 0.17. Multivariate logistic regression analysis of the female patients revealed that Black race (odds ratio [OR]: 0.6, 95% confidence interval [CI]: 0.4-0.9, P = 0.045), radiocephalic AVF (OR: 0.6, 95% CI: 0.4-0.9, P = 0.045), and preoperative vein diameter <2.5 mm (OR: 1.4, 95% CI: 10.33-0.901.1-1.7, P = 0.014) were independent predictors of poor unassisted maturation in this cohort. In male patients, preoperative vein diameter <2.5 mm (OR: 1.4, 95% CI: 1.2-1.7, P < 0.001) and need for HD prior to AVF creation (OR: 0.6, 95% CI: 0.3-0.9, P = 0.018) were independent predictors of poor unassisted maturation. CONCLUSIONS Black women with marginal forearm veins may have worse maturation outcomes, and upper arm HD access should be considered when advising patients on their end-stage kidney disease life-plan.
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Affiliation(s)
- Tabea Hoffstaetter
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Jeffrey Silpe
- Division of Vascular and Endovascular Surgery, Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - David Delijani
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Gregg S Landis
- Division of Vascular and Endovascular Surgery, Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Yana Etkin
- Division of Vascular and Endovascular Surgery, Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY.
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9
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Buzzell M, Chen A, Hoffstaetter T, Thompson DA, George SJ, Landis G, Silpe J, Etkin Y. Early Follow-Up after Arteriovenous Fistula Creation is Associated with Improved Access-Related Outcomes. Ann Vasc Surg 2023; 95:203-209. [PMID: 37121342 DOI: 10.1016/j.avsg.2023.04.013] [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] [Received: 02/02/2023] [Revised: 04/07/2023] [Accepted: 04/12/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Up to 60% of arteriovenous fistulas (AVF) require intervention to assist maturation, which prolongs the time until it can be used for hemodialysis (HD). Current guidelines recommend early postoperative AVF examination to detect and address immaturity to decrease time to maturation. This study evaluates how the timing of postoperative follow-up to assess AVF maturity affects patients' outcomes. METHODS All patients who underwent AVF creation between 2017 and 2021 in an academic medical center were retrospectively reviewed, excluding patients lost to follow-up or not on HD. Outcomes were compared between patients that had delayed follow-up to assess AVF maturity, >8 weeks post surgery, versus early follow-up, <8 weeks post-surgery. AVF evaluation for maturity consisted of physical examination and duplex ultrasound. Primary endpoints were time to first cannulation (interval from AVF creation to first successful cannulation) and time to catheter-free dialysis (interval from AVF creation to central venous catheter removal). RESULTS A total of 400 patients were identified: 111 in the delayed follow-up group and 289 in the early follow-up group. The median time to follow-up was 78 days (interquartile range [IQR], 66-125) in the delayed follow-up group versus 39 days (IQR, 36-47) in the early follow-up group, (P < 0.0001). The maturation rate was 87% in the delayed follow-up group versus 81% in the early follow-up group, (P = 0.1) and both groups had similar rates of interventions to assist maturation (66% vs. 57%, P = 0.2). The early follow-up group had a significantly shorter median time to first cannulation (50 vs. 88 days; P < 0.0001) and shorter time to catheter-free HD (75 vs. 118 days; P <0.0001). At 4 months after AVF creation, the incidence of first cannulation was 74% in the early follow-up group versus 63% in the delayed follow-up group (P = 0.001). Similarly, the incidence of catheter-free dialysis was 65% in the early follow-up group versus 50% in the delayed follow-up group at 4 months postoperatively, (P = 0.036). CONCLUSIONS Early postoperative follow-up for evaluation of fistula maturation is associated with reduced time to first successful cannulation of AVF for HD and reduced time to catheter-free dialysis.
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Affiliation(s)
- Mariah Buzzell
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Adrian Chen
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Tabea Hoffstaetter
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Dane A Thompson
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Sam J George
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Gregg Landis
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Jeffrey Silpe
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Yana Etkin
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY.
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Etkin Y, Woo K, Guidry L. Options for Dialysis and Vascular Access Creation. Surg Clin North Am 2023; 103:673-684. [PMID: 37455031 DOI: 10.1016/j.suc.2023.05.006] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
End-stage kidney disease (ESKD) affects nearly 800,000 patients in the United States. The choice of peritoneal dialysis (PD) versus hemodialysis (HD) should be patient centric. An ESKD Life-Plan is crucial with the goal of creating the right access, for the right patient, at the right time, for the right reason. Complex access should be considered when straightforward access options have been exhausted. Evolving techniques such as percutaneous access for HD and PD should be further investigated. Shared decision-making and palliative care is an essential part of the care of patients with CKD and ESKD..
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Affiliation(s)
- Yana Etkin
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Karen Woo
- Division of Vascular Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, 200 UCLA Medical Plaza Suite 526, Los Angeles, CA 90095, USA.
| | - London Guidry
- Division of Vascular and Endovascular Surgery, Department of Surgery, Louisiana State University Health and Science Center, New Orleans, LA, USA
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11
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Kohiyama M, Hoffstaetter T, Silpe J, Garlapati A, Landis GS, Etkin Y. Trans-radial access for balloon-assisted maturation of arteriovenous fistulas. J Vasc Surg Cases Innov Tech 2023; 9:101133. [PMID: 36970137 PMCID: PMC10033986 DOI: 10.1016/j.jvscit.2023.101133] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 02/02/2023] [Indexed: 02/24/2023] Open
Abstract
Balloon-assisted maturation (BAM) of arteriovenous fistulas has conventionally been performed via direct fistula access. The transradial approach has not been well described for BAM, although its use has been reported throughout the cardiology literature. The purpose of the present study was to assess the outcomes of transradial access for its use with BAM. A retrospective review of 205 patients with transradial access for BAM was performed. One sheath was inserted into the radial artery distal to the anastomosis. We have described the procedural details, complications, and outcomes. The procedure was considered technically successful if transradial access had been established and the AVF had been ballooned with at least one balloon without major complications. The procedure was considered clinically successful if no further interventions had been required for AVF maturation. The average time for BAM via transradial access was 35 ± 20 minutes, with 31 ± 17 mL of contrast used. No access-related perioperative complications, including access site hematoma, symptomatic radial artery occlusion, or fistula thrombosis, had occurred. The technical success rate was 100%, and the rate of clinical success was 78%, with 45 patients requiring additional procedures to achieve maturation. Transradial access is an efficient alternative to trans-fistula access for BAM. It is technically easier and allows for better visualization of the anastomosis.
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12
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Juneja A, Garuthara M, Talathi S, Rao A, Landis G, Etkin Y. Predictors of poor outcomes after lower extremity revascularization for acute limb ischemia. Vascular 2023:17085381231154290. [PMID: 36696536 DOI: 10.1177/17085381231154290] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Acute lower extremity ischemia is one of the most common emergencies in vascular surgery and is a cause of considerable morbidity and mortality. The goal of this study was to evaluate outcomes of revascularization for acute lower extremity ischemia and to determine factors associated with perioperative morbidity and mortality. METHODS A total of 354 patients underwent urgent revascularization for acute lower extremity ischemia at an academic medical center between 2014 and 2019. A retrospective review of patients' demographics, comorbidities, etiology and severity of limb ischemia, and procedural characteristics was recorded. Outcomes, including postoperative complications, perioperative limb loss, and mortality, were analyzed. RESULTS The mean patient age was 69 ± 17 years, and 52% were females. 50% of patients presented with Rutherford Class IIb ischemia. Arterial embolization was the most common cause of limb ischemia, seen in 33% of cases. Open surgical revascularization was performed in 241 (68%) patients, while endovascular and hybrid approaches were utilized in 53 (15%) and 60 (17%) cases, respectively. Postoperative adverse events occurred in 44% of patients, including wound complications (11%), cardiac (5%) and pulmonary (16%) complications, strokes (4%), UTIs (10%), renal failure (14%), bleeding (5%), and compartment syndrome (3%). The rate of unplanned return to the operating room was 21%. Major adverse cardiovascular events were seen in 103 (29%) patients and major adverse limb events were seen in 57 (16%) patients. The median length of stay was 10 days (IQR = 4); 49% patients were discharged to skilled nursing facility and 19% were readmitted within 30 days.The rate of amputation during index admission was 10%, and perioperative mortality was 20%. Gender, tibial runoff, and etiology of limb ischemia were independent predictors of limb loss. Women had lower risk of limb loss than men (OR, 0.11; 95% CI, 0.023, 0.38). Poor tibial runoff (one-vessel or absence of flow below the knee) was a significant predictor of limb loss as compared to three-vessel runoff (OR, 14.92; 95% CI, 1.92, 115.88). Aneurysmal disease (OR, 38.35; 95% CI, 3.54, 42.45) and traumatic injuries (OR, 108.08; 95% CI, 8.21, 159.06) were the strongest predictors of amputation as compared to other etiologies of limb ischemia. Multivariate model identified ESRD (OR, 9.2; 95% CI, 1.8-46.3), degree of ischemia (class IIb or higher vs class IIa; OR, 3.5; 95% CI, 1.2-10.6), and age (OR, 1.5; 95% CI 1.1-2.0 for every 10 years) as independent predictors of perioperative mortality. CONCLUSIONS Urgent revascularization for management of acute limb ischemia is associated with high morbidity and mortality. Elderly patients with ESRD presenting with severely threatened limbs have especially high risk of perioperative mortality and may not be ideal candidates for limb salvage.
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Affiliation(s)
- Amandeep Juneja
- Department of Surgery, Division of Vascular and Endovascular Surgery, 232890Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Melissa Garuthara
- Department of Surgery, Division of Vascular and Endovascular Surgery, 232890Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Sonia Talathi
- Division of Vascular and Endovascular Surgery, 2013Montefiore Medical Center, Bronx, NY, USA
| | - Amit Rao
- Department of Surgery, Division of Vascular and Endovascular Surgery, 232890Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Gregg Landis
- Department of Surgery, Division of Vascular and Endovascular Surgery, 232890Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Yana Etkin
- Department of Surgery, Division of Vascular and Endovascular Surgery, 232890Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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Weaver ML, Sundland R, Adams AM, Faria I, Feldman HA, Gudmundsdottir H, Marmor H, Miles V, Ochoa B, Ruff SM, Tonelli C, Altieri MS, Cannada L, Dewan K, Etkin Y, Marmor R, Plichta JK, Reyna C, Tatebe L, Drudi LM, Hicks CW. The art of peer review: Guidelines to become a credible and constructive peer reviewer. Semin Vasc Surg 2022; 35:470-478. [PMID: 36414364 PMCID: PMC9833278 DOI: 10.1053/j.semvascsurg.2022.10.002] [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: 08/02/2022] [Revised: 09/30/2022] [Accepted: 10/04/2022] [Indexed: 11/07/2022]
Abstract
Peer review is a learned skill set that requires knowledge of study design, review construct, ethical considerations, and general expertise in a field of study. Participating in peer review is a rewarding and valuable experience in which all academic physicians are encouraged to partake. However, formal training opportunities in peer review are limited. In 2021, the Association of Women Surgeons and the journal Surgery collaborated to develop a Peer Review Academy. This academy is a 1-year longitudinal course that offers a select group of young women surgical trainees across all specialties a curriculum of monthly lectures and multiple formal mentored peer review opportunities to assist them in developing the foundation necessary to transition to independent peer review. The trainees and faculty mentors participating in the Association of Women Surgeons-Surgery Peer Review Academy compiled a summary of best peer review practices, which is intended to outline the elements of the skill set necessary to become a proficient peer reviewer.
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Affiliation(s)
- M Libby Weaver
- Division of Vascular and Endovascular Surgery, University of Virginia, 1215 Lee Street, PO Box 800679, Charlottesville, VA, 22908-0679.
| | | | - Alexandra M Adams
- Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX
| | - Isabella Faria
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA
| | - Hope A Feldman
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Hannah Marmor
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Victoria Miles
- Department of Surgery, University of Tennessee College of Medicine, Chattanooga, TN
| | - Brielle Ochoa
- Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Samantha M Ruff
- Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Celsa Tonelli
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Maria S Altieri
- Department of Surgery, University of Pennsylvania, Pennsylvania Hospital, Philadelphia, PA
| | - Lisa Cannada
- Department of Orthopaedics, University of North Carolina, Charlotte, NC
| | - Karuna Dewan
- Department of Otolaryngology, Head and Neck Surgery, Louisiana State University, New Orleans, LA
| | - Yana Etkin
- Division of Vascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Rebecca Marmor
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Chantal Reyna
- Department of Surgery, Crozer Health System, Upland, PA
| | - Leah Tatebe
- Department of Surgery, Northwestern University, Chicago, IL
| | - Laura M Drudi
- Division of Vascular Surgery, Centre Hospital de L'Université de Montréal, Montreal, Quebec, Canada
| | - Caitlin W Hicks
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Etkin Y, Buzzell M, Chen A, Thompson D, Hoffstaetter T, Landis G, Silpe J. Delayed Follow-up Is Associated With Worse Hemodialysis Access-related Outcomes. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.06.052] [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] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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15
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Chhabra JS, Juneja A, Etkin Y, Landis G, Gardener H, Garuthara M, Hoffstaetter T, Oropallo A. The effect of nutrition on stroke risk: A systematic review. Nutr Health 2022; 29:255-267. [PMID: 36040714 DOI: 10.1177/02601060221122218] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: An estimated 33% reduction in cardiovascular events can be achieved when incorporating whole grains, fruits, vegetables, poultry, nuts, and vegetable oils in the diet along with reduced consumption of refined carbohydrates, processed meats, and sugar sweetened beverages. We performed a systematic review to analyze the impact of nutritional intervention on stroke risk, as there is no current consensus concerning dietary recommendation for primary and secondary stroke prevention. Methods: A literature search of the PubMed database from January 2010 to June 2020 was performed using combinations of the following search terms: carotid disease, carotid artery disease, carotid stenosis, carotid intima-media thickness (CIMT), diet, nutrition, micronutrition, embolic stroke, and stroke. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 checklist. Results: 28 studies met our inclusion criteria. Multiple studies showed an inverse relationship between consumption of vegetables and fruits and stroke risk. Vitamin B12 or a combination of B Vitamins was the most common supplement studied in stroke prevention. Only one RCT showed the use of B12 (500 micrograms/day) correlated with lower CIMT at follow up in healthy vegetarians. Discussion: The key findings from this systematic review indicate that adopting a diet rich in fruits and vegetables earlier in life may lower stroke risk compared with meats and fat intake. B vitamins also appear to confer some protection against stroke. However, not enough data exists to support the use of multivitamins, calcium, soy products and other supplements for primary or secondary stroke prevention.
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Affiliation(s)
| | | | - Yana Etkin
- Northwell Health, New Hyde Park, NY, USA
| | | | - Hannah Gardener
- University of Miami Miller School of Medicine, Miami, FL, USA
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Tiwary N, Landis GS, Siegel DN, Etkin Y. Renal arteriovenous fistula associated high-output heart failure treated with embolization. J Vasc Surg Cases Innov Tech 2022; 9:100983. [PMID: 36718216 PMCID: PMC9883246 DOI: 10.1016/j.jvscit.2022.07.012] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 07/18/2022] [Indexed: 02/02/2023] Open
Affiliation(s)
- Nayan Tiwary
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Gregg S. Landis
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - David N. Siegel
- Division of Vascular/Interventional Radiology, Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Yana Etkin
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
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17
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Sura TA, Kohiyama M, Hoffstaetter T, Landis G, Silpe J, Etkin Y. Transposed Brachiobasilic Fistula Versus Arteriovenous Graft as Tertiary Hemodialysis Access in Elderly Patients. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.03.181] [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] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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18
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Silpe JE, Hila R, Landis GS, Etkin Y. Intraparotid facial varix. J Vasc Surg Cases Innov Tech 2022; 8:13-15. [PMID: 35036666 PMCID: PMC8743171 DOI: 10.1016/j.jvscit.2021.08.006] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 08/17/2021] [Indexed: 12/03/2022] Open
Abstract
A 72-year-old man had presented with a 4-day history of progressive left-sided facial swelling associated with pain. The physical examination revealed left facial fullness over the parotid gland without tenderness to palpation. His vital signs and laboratory test findings were within normal limits. A computed tomography scan demonstrated a left facial varix measuring 3.4 cm × 2.8 cm within an unremarkable-appearing parotid gland. Parotidectomy vs close observation were discussed, and the patient decided to pursue nonoperative management. Ultimately, his symptoms were self-limited, and the swelling had resolved within 6 months after the diagnosis. Interval computed tomography demonstrated a thrombosed left facial varix measuring 1.3 cm × 1.1 cm.
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19
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Etkin Y, Silpe J, Mussa FF, Talathi S, Garuthara M, Landis GS. Modified Banding of Arteriovenous Fistulas for the Treatment of Vascular Access Induced Digital Ischaemia. EJVES Vasc Forum 2021; 53:26-29. [PMID: 34849498 PMCID: PMC8609140 DOI: 10.1016/j.ejvsvf.2021.10.017] [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: 04/14/2021] [Revised: 07/03/2021] [Accepted: 10/20/2021] [Indexed: 12/02/2022] Open
Abstract
Objective Vascular access induced digital ischaemia is an uncommon complication of haemodialysis access procedures and is difficult to manage. Several techniques have been described to treat this phenomenon, with variable long term success. Although all of these procedures have been shown to work, they have a significant failure rate, such as persistent high vascular access flow or loss of access. One of the major technical limitations of these techniques is the lack of quantitative data gathered during the procedure to ensure treatment success. In this study, the aim was to describe a novel technique that can improve the success of banding in preserving access and eliminating digital ischaemia. Technique A modified method for arteriovenous fistula banding that incorporates measurements of distal arterial pressure to improve the success of the procedure is described. Results Sixteen patients with vascular access induced digital ischaemia and high-flow vascular access were treated using the technique. All procedures were technically successful. At 30 days, complete symptomatic relief (clinical success) was seen in 81% (n = 13) of patients. There was no access thrombosis or infection in any of the patients at the 30 day follow up. Six month follow up data were available in seven patients. There was no loss of access patency or recurrence of symptoms observed at six months. Conclusion This novel technique is simple and effective and can be used safely as first line therapy for the management of vascular access induced digital ischaemia. Modified banding of arteriovenous fistulas (AVF) is associated with no access thrombosis or infection. Modified AVF banding leads to resolution of vascular access induced ischaemia in the majority of patients. Modified AVF banding is a simple, minimally invasive, and effective technique.
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Affiliation(s)
- Yana Etkin
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Jeffrey Silpe
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Firas F Mussa
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Sonia Talathi
- Division of Vascular Surgery, Department of Surgery, Montefiore Medical Centre, Bronx, NY, USA
| | - Melissa Garuthara
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Gregg S Landis
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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20
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Landis G, Veith F, Neville R, Ascher E, Silpe J, Etkin Y. Polytetrafluoroethylene Bypasses to Tibial Arteries Are a Worthwhile Limb Salvage Procedure: An 18-Year Experience. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.07.026] [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] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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21
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Kania TA, Noorani A, Juneja A, Deitch J, Etkin Y, Landis GS, Schor J. Monitoring of Hemodynamics Associated With Carotid Surgery. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.215] [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] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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22
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Juneja A, Wang D, Rao A, Silpe J, Mussa F, Landis GS, Etkin Y. Balloon-assisted Maturation With Larger Diameter Balloons Should Be First-line Intervention for Nonmaturing Autologous Hemodialysis Access. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.401] [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] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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23
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Ilonzo N, Judelson D, Al-Jundi W, Etkin Y, O'Banion LA, Rivera A, Tinelli G, Bellosta R, Vouyouka A. A review of acute limb ischemia in COVID-positive patients. Semin Vasc Surg 2021; 34:8-12. [PMID: 34144749 PMCID: PMC8167656 DOI: 10.1053/j.semvascsurg.2021.04.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/22/2021] [Accepted: 04/30/2021] [Indexed: 01/08/2023]
Abstract
This literature review discusses the current evidence on acute limb ischemia (ALI) in patients with COVID-19. Throughout the pandemic, these patients have been at increased risk of arterial thrombotic events and subsequent mortality as a result of a hypercoagulable state. The exact mechanism of thrombosis is unknown; however arterial thrombosis may be due to invasion of endothelial cells via angiotensin-converting enzyme 2 (ACE2) receptors, endothelial injury from inflammation, or even free-floating aortic thrombus. Multiple studies have been performed evaluating the medical and surgical management of these patients; the decision to proceed with operative intervention is dependent on the patient's clinical status as it relates to COVID-19 and morbidity of that disease. The interventions afforded typically include anticoagulation in patients undergoing palliation; alternatively, thrombectomy (endovascular and open) is utilized in other patients. There is a high risk of rethrombosis, despite anticoagulation, given persistent endothelial injury from the virus. Postoperative mortality can be high in these patients.
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Affiliation(s)
- Nicole Ilonzo
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, The Mount Sinai Medical Center, 1425 Madison Avenue, 4th Floor, New York, NY 10029.
| | - Dejah Judelson
- Division of Vascular Surgery, University of Massachusetts, Worcester, MA
| | - Wissam Al-Jundi
- Norwich Vascular Centre, Norfolk and Norwich University Hospital, Norwich, UK
| | - Yana Etkin
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | | | - Aksim Rivera
- Division of Vascular Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Giovanni Tinelli
- Unit of Vascular Surgery, Fondazione Policlinico Universitario Gemelli IRCCS-Università Cattolica del Sacro Cuore
| | - Rafaello Bellosta
- Divisions of Vascular Surgery, Department of Cardiovascular Surgery, Fondazione Poliambulanza, Brescia, Italy
| | - Ageliki Vouyouka
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, The Mount Sinai Medical Center, 1425 Madison Avenue, 4th Floor, New York, NY 10029
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Juneja AS, Jain S, Silpe J, Landis GS, Mussa FF, Etkin Y. Scoping review of non-thermal technologies for endovenous ablation for treatment of venous insufficiency. J Cardiovasc Surg (Torino) 2021; 62:413-419. [PMID: 33881285 DOI: 10.23736/s0021-9509.21.11900-7] [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] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The aim of this review article is to compare the outcomes of newer non-thermal endovenous ablation techniques to thermal ablation techniques for the treatment of symptomatic venous insufficiency. EVIDENCE ACQUISITION Three independent reviewers screened PubMed® and EMBASE® databases to identify relevant studies. A total of 1173 articles were identified from database search that met our inclusion criteria. Two articles were identified through reference search. Removal of duplicates from our original search yielded 695 articles. We then screened these articles and assessed 173 full-text articles for eligibility. Subsequent to exclusion, 11 full-text articles were selected for final inclusion. EVIDENCE SYNTHESIS The non-thermal techniques are similar to thermal techniques in terms of a high technical success rate, closure rate at 12 months, change in Venous Clinical Severity Score and change in quality of life after procedure. However, the length of procedure is shorter for non-thermal modalities and patient comfort is improved with lower pain scores. Return to work may also be earlier after non-thermal ablation. The rates of bruising, phlebitis and paresthesia are higher after thermal ablation. CONCLUSIONS The non-thermal modalities are safe and effective in treating venous reflux and have shown improved patient comfort and shorter length of procedure which may make them favorable for use compared to the thermal modalities.
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Affiliation(s)
- Amandeep S Juneja
- Department of Surgery, Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwel, Hempstead, NY, USA
| | - Shelley Jain
- Department of Surgery, Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwel, Hempstead, NY, USA
| | - Jeffrey Silpe
- Department of Surgery, Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwel, Hempstead, NY, USA
| | - Gregg S Landis
- Department of Surgery, Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwel, Hempstead, NY, USA
| | - Firas F Mussa
- Department of Surgery, Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwel, Hempstead, NY, USA
| | - Yana Etkin
- Department of Surgery, Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwel, Hempstead, NY, USA -
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Bolourani S, Rao A, Garlapati A, Silpe J, Mussa F, Landis G, Etkin Y. Can Machine Learning Models Predict Failure Of Maturation Of Arteriovenous Fistula? Ann Vasc Surg 2021. [DOI: 10.1016/j.avsg.2021.01.051] [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] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Landis GS, Veith CK, Jannat H, Juneja A, Etkin Y, Rubin DB, Patel K. Anatomically Coiled Internal Carotid Artery Resulting in Severe Dysphagia and Burning Mouth Syndrome. Ann Vasc Surg 2020; 73:509.e1-509.e4. [PMID: 33333198 DOI: 10.1016/j.avsg.2020.10.044] [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: 09/15/2020] [Revised: 10/21/2020] [Accepted: 10/31/2020] [Indexed: 10/22/2022]
Abstract
This is a report of a 65-year-old female presenting with symptoms of dysphagia due to a coiled left internal carotid artery, treated with resection and primary repair. Dysphagia lusoria is more commonly caused by aortic arch anomalies, aberrant subclavian or common carotid arteries. Internal carotid tortuosity as a cause of severe dysphagia and burning mouth syndrome is highly unusual. A literature review examines the etiology, natural history, and treatment options.
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Affiliation(s)
- Gregg S Landis
- Division of Vascular Surgery, Long Island Jewish Medical Center, New Hyde Park, NY.
| | - Christina K Veith
- Division of Vascular Surgery, Long Island Jewish Medical Center, New Hyde Park, NY
| | - Habiba Jannat
- Division of Vascular Surgery, Long Island Jewish Medical Center, New Hyde Park, NY
| | - Amandeep Juneja
- Division of Vascular Surgery, Long Island Jewish Medical Center, New Hyde Park, NY
| | - Yana Etkin
- Division of Vascular Surgery, Long Island Jewish Medical Center, New Hyde Park, NY
| | - Daniel B Rubin
- Division of Vascular Surgery, Long Island Jewish Medical Center, New Hyde Park, NY
| | - Kiran Patel
- Division of Vascular Surgery, Long Island Jewish Medical Center, New Hyde Park, NY
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Etkin Y, Talathi S, Rao A, Akerman M, Lesser M, Mussa FF, Landis GS. The Role of Duplex Ultrasound in Assessing AVF Maturation. Ann Vasc Surg 2020; 72:315-320. [PMID: 33227470 DOI: 10.1016/j.avsg.2020.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/24/2020] [Accepted: 10/04/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Arteriovenous fistulas (AVFs) are favored for hemodialysis (HD) access. However, in many instances, AVFs fail to mature. We examined the utility of postoperative color duplex ultrasound (CDU) in assessing AVF maturation and determining the need for balloon-assisted maturation (BAM). METHODS A total of 633 patients underwent AVF creation at a single institution from 2015 to 2018. A total of 339 patients (54%) underwent CDU at a median of 8 weeks postoperatively. We collected the following parameters: vein diameter, volume flow (VF), peak systolic velocities in arterial inflow and venous outflow, and presence of stealing branches. A peak systolic velocity ratio (SVR) of ≥2 correlated with ≥50% stenosis in venous outflow, and SVR ≥3 correlated with ≥50% stenosis at the anastomosis. AVFs were considered mature when they were successfully cannulated on dialysis. A generalized linear mixed model (GLMM) was created to compare duplex criteria associated with successful use of AVF (maturation) to those AVFs that required further intervention or failed to mature. Fistulography images, the current gold standard, were compared with findings from CDU studies to determine validity of the duplex ultrasound. RESULTS Of the 339 AVFs with postoperative CDU, 31.3% matured without interventions, 38.3% required BAM, 9.7% thrombosed, and the remaining patients were not yet on HD. Based on GLMM analysis, the probability of AVF maturation increases if CDU demonstrated one of the following: the vein diameter is ≥ 6 (odds ratio [OR] = 38.7), no evidence of stenosis in the venous outflow tract (OR = 35.6), no stealing branches (OR = 21.6) and VF ≥ 675 (OR = 5.0). Fistulography was performed in 195 patents. Sensitivity and specificity for each are as follows: vein diameter (84.3%, 28.6%), stenosis (59.3%, 78.8%), and stealing branches (20.7%, 92.7%). CONCLUSIONS Postoperative CDU should be considered routine to correct anatomical findings that might limit AVF maturation and identify the need for further interventions.
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Affiliation(s)
- Yana Etkin
- Division of Vascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY.
| | - Sonia Talathi
- Division of Vascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY
| | - Amit Rao
- Division of Vascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY
| | - Meredith Akerman
- The Feinstein Institutes of Medical Research/Northwell, Hempstead, NY
| | - Martin Lesser
- The Feinstein Institutes of Medical Research/Northwell, Hempstead, NY
| | - Firas F Mussa
- Division of Vascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY
| | - Gregg S Landis
- Division of Vascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY
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Silpe J, Rao A, Wang B, Mussa F, Landis G, Etkin Y. Sex Differences in Arteriovenous Fistula Maturation. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.08.110] [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] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bolourani S, Patel VM, Etkin Y, Landis G, Mussa F. Risk Factors and Machine Learning-Based Prediction Models for Early Readmission after Thoracoabdominal Aortic Dissection. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.722] [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] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Wang B, Rao A, Pappas K, Silpe J, Garlapati A, Talathi S, Mussa F, Landis GS, Etkin Y. Maturation Rates of Arteriovenous Fistulas Using Small Veins in the Era of Endovascular Interventions. Ann Vasc Surg 2020; 71:208-214. [PMID: 32890643 DOI: 10.1016/j.avsg.2020.08.109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 08/11/2020] [Accepted: 08/12/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Traditional practice suggests the abandonment of veins smaller than 3 mm in diameter for arteriovenous fistula (AVF) creation because of a low rate of maturation. This study aims to show that with balloon-assisted maturation (BAM), undersized veins can be used to create functional AVFs with a high rate of success. METHODS All patients who underwent AVF creation between 2014 and 2018 at a tertiary academic medical center were retrospectively reviewed. The patients without preoperative vein mapping, those who failed to follow-up, and the patients who were not on dialysis were excluded. A fistula was considered to be mature if it was successfully cannulated for dialysis. A total of 596 patients were identified for analysis. The cohort was divided into the small-vein group (SVG, <2.5 mm) and large-vein group (LVG, ≥2.5 mm) based on preoperative vein size. Categorical variables were analyzed with the chi-squared test for their association with maturation status. Continuous variables were analyzed with the Wilcoxon rank sum test. A P-value less than 0.05 was considered significant. RESULTS In the study cohort, 61.9% of the patients were male, with an average age of 62.8 ± 13.7 years, and an average preoperative vein size of 2.9 ± 1.1 mm. With similar demographic distribution, the participants in the SVG (n = 216) had significantly smaller preoperative vein size of 1.9 ± 0.4 mm than the patients in the LVG (n = 380), 3.5 ± 0.8 mm (P = 0.001). There were significantly more radio-cephalic AVFs created in the SVG (77.8% versus 48.7%, P < 0.0001). The overall maturation rate was 83.1% (n = 495), 219 fistulas (36.7%) matured primarily and 276 (46.3%) required interventions. Ninety-one percent of the patients required only 1 or 2 BAMs to achieve maturation. The SVG achieved a maturation rate of 75.9% as compared with 87.1% in the LVG (P = 0.002). A significantly higher number of patients in the SVG required BAM for maturation as compared with the LVG (67.7% versus 49.9%, P = 0.0002); however, there was no difference in the average number of BAMs required for fistula maturation between the groups (1.5 ± 0.8 for the SVG vs. 1.4 ± 0.7 for the LVG). In multivariable logistic regression analysis, vein size ≥2.5 mm (odds ratio (OR) = 2.11, confidence interval (CI): 1.36-3.27, P = 0.0009) and male sex (OR = 2.30, CI: 1.49-3.57, P = 0.0002) were independent predictors of maturation. CONCLUSIONS Small veins can be used for AVF creation with lower but still favorable maturation rates using BAM interventions, especially in male patients. This practice can increase the creation of autogenous dialysis access and potentially reduce complications related to prosthetic dialysis access.
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Affiliation(s)
- Bo Wang
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Amit Rao
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Karalyn Pappas
- The Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY
| | - Jeffrey Silpe
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Avinash Garlapati
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Sonia Talathi
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Firas Mussa
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Gregg S Landis
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Yana Etkin
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY.
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Etkin Y, Conway AM, Silpe J, Qato K, Carroccio A, Manvar-Singh P, Giangola G, Deitch JS, Davila-Santini L, Schor JA, Singh K, Mussa FF, Landis GS. Acute Arterial Thromboembolism in Patients with COVID-19 in the New York City Area. Ann Vasc Surg 2020; 70:290-294. [PMID: 32866580 PMCID: PMC7455233 DOI: 10.1016/j.avsg.2020.08.085] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/16/2020] [Indexed: 01/30/2023]
Abstract
Background Coronavirus disease 2019 (COVID-19) predisposes to arterial and venous thromboembolic complications. We describe the clinical presentation, management, and outcomes of acute arterial ischemia and concomitant infection at the epicenter of cases in the United States. Methods Patients with confirmed COVID-19 infection between March 1, 2020 and May 15, 2020 with an acute arterial thromboembolic event were reviewed. Data collected included demographics, anatomical location of the thromboembolism, treatments, and outcomes. Results Over the 11-week period, the Northwell Health System cared for 12,630 hospitalized patients with COVID-19. A total of 49 patients with arterial thromboembolism and confirmed COVID-19 were identified. The median age was 67 years (58–75) and 37 (76%) were men. The most common preexisting conditions were hypertension (53%) and diabetes (35%). The median D-dimer level was 2,673 ng/mL (723–7,139). The distribution of thromboembolic events included upper 7 (14%) and lower 35 (71%) extremity ischemia, bowel ischemia 2 (4%), and cerebral ischemia 5 (10%). Six patients (12%) had thrombus in multiple locations. Concomitant deep vein thrombosis was found in 8 patients (16%). Twenty-two (45%) patients presented with signs of acute arterial ischemia and were subsequently diagnosed with COVID-19. The remaining 27 (55%) developed ischemia during hospitalization. Revascularization was performed in 13 (27%) patients, primary amputation in 5 (10%), administration of systemic tissue‐ plasminogen activator in 3 (6%), and 28 (57%) were treated with systemic anticoagulation only. The rate of limb loss was 18%. Twenty-one patients (46%) died in the hospital. Twenty-five (51%) were successfully discharged, and 3 patients are still in the hospital. Conclusions While the mechanism of thromboembolic events in patients with COVID-19 remains unclear, the occurrence of such complication is associated with acute arterial ischemia which results in a high limb loss and mortality.
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Affiliation(s)
- Yana Etkin
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY.
| | - Allan M Conway
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Jeffrey Silpe
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Khalil Qato
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Alfio Carroccio
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Pallavi Manvar-Singh
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Gary Giangola
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Jonathan S Deitch
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Luis Davila-Santini
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Jonathan A Schor
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Kuldeep Singh
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Firas F Mussa
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Gregg S Landis
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
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Silpe JE, Rao A, Wang B, Mussa F, Landis GS, Etkin Y. Gender Differences in Arteriovenous Fistula Maturation. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.04.397] [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] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Etkin Y, Chao E. Rare Presentation of Perforated Diverticulitis. Am Surg 2020. [DOI: 10.1177/000313481207801213] [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: 11/16/2022]
Affiliation(s)
- Yana Etkin
- Department of Surgery Montefiore Medical Center Albert Einstein College of Medicine Bronx, New York
| | - Edward Chao
- Department of Surgery Montefiore Medical Center Albert Einstein College of Medicine Bronx, New York
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Fairman AS, Fairman RM, Foley PJ, Etkin Y, Jackson OA, Jackson BM. Is Routine Postoperative Anticoagulation Necessary in All Patients after First Rib Resection for Paget-Schroetter Syndrome? Ann Vasc Surg 2020; 69:217-223. [PMID: 32497616 DOI: 10.1016/j.avsg.2020.05.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 02/26/2020] [Accepted: 05/02/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Definitive treatment of Paget-Schroetter syndrome (PSS) involves first rib resection (FRR), division of the anterior scalene muscle, and resection of the subclavius muscle. This is a single-institution experience with PSS, according to a treatment algorithm of preoperative venogram (accompanied by lysis and percutaneous mechanical thrombectomy as needed) followed by transaxillary FRR. In the later period of this experience, patients have often been discharged on aspirin only, with no plan for anticoagulation postoperatively. We sought to evaluate outcomes in light of this experience and these practice patterns. METHODS Between 2007 and 2018, 125 transaxillary FRRs were performed in 123 patients. All patients presented with documented venous thrombosis, underwent diagnostic venography and-if indicated-lysis and percutaneous mechanical thrombectomy (VPT) before FRR. The patient was not offered FRR if the vein could not be crossed with a wire and patency was not re-established during percutaneous treatment. The experience was divided into early (before 2012, n = 50) and late (n = 75) periods. RESULTS Mean patient age was 28.4 (12-64 years) years. Of the cohort, 33 were high-level competitive athletes, 13 presented with documented pulmonary embolism in addition to local symptoms, and 3 had a cervical rib fused to the first rib. Patients underwent FRR a median of 50 (4 days to 18 years) days after their initial symptoms, and a median of 22 (1 day to 9 months) days after their percutaneous intervention. Postoperative VPT was required in 23 patients and performed a median of 5 (1-137 days) days postoperatively; in 19 of these patients, postoperative VPT was required for postoperative re-thrombosis, whereas in 4 patients, postoperative VPT was planned before FRR due to vein stenosis or residual thrombus. All these patients were prescribed postoperative anticoagulation. No operative venous reconstruction or bypass was performed. Median follow-up time after FRR was 242 days; at last follow-up, 98.4% (123/125) of axillosubclavian veins were patent by duplex ultrasound (and all those patients were asymptomatic). Postoperative anticoagulation was less frequently prescribed in the late experience, with no difference in the rate of early re-thrombosis or follow-up patency. CONCLUSIONS This experience demonstrates 98.4% patency at last follow-up with standard preoperative percutaneous venography and intervention, transaxillary FRR, and postoperative endovascular re-intervention only in cases with persistent symptoms, stenosis, or re-thrombosis. Patients presenting with both acute and chronic PSS did not require surgical venous reconstruction. In the later experience, patients frequently have not been anticoagulated postoperatively. Advantages of this algorithm include the following: (1) the cosmetic benefits of the transaxillary approach, (2) the preoperative assessment of the ability to recanalize the vein to determine which patients will benefit from surgery, (3) the capacity to use thrombolysis preoperatively, and (4) potential elimination of the risk and inconvenience of postoperative anticoagulation.
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Affiliation(s)
- Alexander S Fairman
- University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA.
| | - Ronald M Fairman
- University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Paul J Foley
- University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | | | - Benjamin M Jackson
- University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
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Manvar-Singh P, Segal M, Etkin Y, Dodla R, Landis G, Krishnasastry KV, Frankini L. A rare complication of testicular infarction after femorofemoral bypass highlighting the importance of surgical technique. J Surg Case Rep 2019; 2019:rjz271. [PMID: 31737243 PMCID: PMC6847100 DOI: 10.1093/jscr/rjz271] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 09/02/2019] [Indexed: 11/21/2022] Open
Abstract
We present an interesting case of a 66-year-old male who had acute testicular infarction following a right common femoral artery to left profunda femoris artery bypass with advanced symptoms of claudication. Angiography in the preoperative period demonstrated the extent of peripheral arterial disease present, revealing a calcified aorta, partially occluded left hypogastric artery, occluded left external iliac, common femoral and superficial femoral arteries and an occluded right hypogastric artery. A bypass was performed without any initial complications and subsequent relief of symptoms of claudication and rest pain. Postoperative scrotal pain and follow-up duplex demonstrated lack of perfusion of the testicle necessitating orchiectomy. This case serves to illustrate the importance of preserving collateral vessels as a technical consideration, as well as presenting a rare potential complication.
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Affiliation(s)
- Pallavi Manvar-Singh
- Division of Vascular Surgery, Department of Surgery, Northwell Health, New Hyde Park, NY, USA
| | - Michael Segal
- Department of Surgery, Wyckoff Heights Medical Center, Brooklyn, NY, USA
| | - Yana Etkin
- Division of Vascular Surgery, Department of Surgery, Northwell Health, New Hyde Park, NY, USA
| | - Ranjith Dodla
- Division of Vascular Surgery, Department of Surgery, Northwell Health, New Hyde Park, NY, USA
| | - Gregg Landis
- Division of Vascular Surgery, Department of Surgery, Northwell Health, New Hyde Park, NY, USA
| | | | - Larry Frankini
- Division of Vascular Surgery, Department of Surgery, Northwell Health, New Hyde Park, NY, USA
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Newton DH, Foley PJ, Etkin Y, Fairman RM, Landis G, Woo EY, Jackson BM. Maximizing Proximal Seal Zone in Fenestrated Endografting: Evolution in the Approach to Graft Configuration. J Vasc Surg 2019. [DOI: 10.1016/j.jvs.2019.06.040] [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] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Etkin Y, Talathi S, Wang B, Landis G. Open Repair of Celiac Artery Aneurysm. J Vasc Surg 2019. [DOI: 10.1016/j.jvs.2019.06.039] [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] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Etkin Y, Talathi S, Garuthara M, Wang B, Landis G. VS10. Arteriovenous Fistula Banding for Steal Syndrome With Quantitative Data. J Vasc Surg 2019. [DOI: 10.1016/j.jvs.2019.04.421] [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] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Talathi S, Kline M, Wang B, Landis G, Etkin Y. PC198. Clinical Outcomes After Major Vascular Surgery in Octogenarian and Nonagenarian Patients. J Vasc Surg 2019. [DOI: 10.1016/j.jvs.2019.04.392] [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] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Etkin Y, Wang B, Rao AS, Pappas K, Talathi S, Garuthara M, Landis G. SS32. Maturation Rates of Arteriovenous Fistulas Using Small Veins in the Era of Endovascular Interventions. J Vasc Surg 2019. [DOI: 10.1016/j.jvs.2019.04.424] [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] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Etkin Y, Rao A, Jackson BM, Fishbein JS, Shyta K, Baig H, Landis GS. Infections of Prosthetic Grafts and Patches Used for Infrainguinal Arterial Reconstructions. Ann Vasc Surg 2019; 57:152-159. [DOI: 10.1016/j.avsg.2018.09.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 08/10/2018] [Accepted: 09/09/2018] [Indexed: 11/28/2022]
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Kraev AI, McGinn J, Etkin Y, Turner JW, Landis GS. Improving the Power of the American Society of Anesthesiology Classification System to Risk Stratify Vascular Surgery Patients Based on National Surgical Quality Improvement Project–Defined Functional Status. Ann Vasc Surg 2018; 52:153-157. [DOI: 10.1016/j.avsg.2018.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 02/28/2018] [Accepted: 04/01/2018] [Indexed: 11/28/2022]
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Quatromoni JG, Newton DH, Parikh A, Gaffey A, Damrauer SM, Etkin Y, Foley PJ, Jackson BM. Coronary Drug-Eluting Stents for the Treatment of Threatened Lower Extremity Bypass Grafts: A Single-Institution Case Series. J Vasc Surg 2018. [DOI: 10.1016/j.jvs.2018.05.050] [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] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Etkin Y, Jackson B, Fishbein J, Kissin M, McGinn J, Baig H, Landis G. Risk Factors and Outcomes Associated With Infected Lower Extremity Prosthetic Bypasses and Patches. J Vasc Surg 2017. [DOI: 10.1016/j.jvs.2017.07.095] [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] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Jain V, Etkin Y, Landis G. IP157. Modified Banding of Fistulas for Steal Syndrome With Quantitative Data. J Vasc Surg 2017. [DOI: 10.1016/j.jvs.2017.03.182] [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] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Etkin Y, Jackson BM, Akerman M, Jain V, Policha A, Landis G. PC104 The Role of Duplex Ultrasound in Assessing AVF Maturation. J Vasc Surg 2017. [DOI: 10.1016/j.jvs.2017.03.317] [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] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Etkin Y, Glaser JD, Nation DA, Foley PJ, Wang GJ, Woo EY, Fairman RM, Jackson BM. Retrievable inferior vena cava filters can always be removed using "fall-back" techniques. J Vasc Surg Venous Lymphat Disord 2016; 3:364-369. [PMID: 26992612 DOI: 10.1016/j.jvsv.2015.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [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: 02/13/2015] [Accepted: 04/16/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Retrievable inferior vena cava filters (IVCFs) left in place for a prolonged period can lead to complications including filter migration, fracture, and caval thrombosis. "Fall-back" techniques for IVCF retrieval that can be used when standard snaring is unsuccessful have been recently described. The purpose of this study was to analyze how incorporation of these new techniques affected the outcomes of IVCF retrievals at our institution during the past 5 years. METHODS Data were collected of all patients undergoing IVCF removal by vascular surgeons at a tertiary academic medical center between 2009 and 2013, including demographics and procedural and filter characteristics. A standard technique of snaring the retrieval hook was attempted first in all cases; if this was unsuccessful, a number of fall-back techniques were employed, including the use of endoscopic graspers, 18F sheaths, and snaring a second wire below the collar of the filter to collapse it into the sheath. RESULTS IVCF retrieval was attempted in 275 patients; 3 were excluded intraoperatively because of thrombus in the filter. Most filters (97%) were Günther Tulips (Cook Medical, Bloomington, Ind); 70% had been placed prophylactically before bariatric surgery. A total of 268 filters (98.5%) were retrieved successfully, 213 (79%) by standard snaring and 55 (21%) with fall-back techniques. In patients undergoing fall-back techniques, technical success was achieved 100% of the time. The median time since insertion was significantly longer in the fall-back group (173 days vs 83 days; P < .0001). Four intraoperative complications occurred; fractured wires embolized to the right atrium or pulmonary artery and were successfully removed endovascularly. The majority of the procedures (80%) were performed under sedation in both groups. CONCLUSIONS Incorporation of fall-back techniques may allow 100% technically successful and safe removal of retrievable IVCFs and is especially useful in removing filters with prolonged dwell time.
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Affiliation(s)
- Yana Etkin
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa.
| | - Julia D Glaser
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - David A Nation
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Paul J Foley
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Edward Y Woo
- Department of Vascular Surgery, MedStar Washington Hospital Center, Washington, D.C
| | - Ronald M Fairman
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Benjamin M Jackson
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa
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Etkin Y, Foley PJ, Wang GJ, Guzzo TJ, Roses RE, Fraker DL, Drebin JA, Jackson BM. Successful venous repair and reconstruction for oncologic resections. J Vasc Surg Venous Lymphat Disord 2016; 4:57-63. [DOI: 10.1016/j.jvsv.2015.05.003] [Citation(s) in RCA: 6] [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] [Received: 03/31/2015] [Accepted: 05/12/2015] [Indexed: 12/22/2022]
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Etkin Y, Jackson BM, Woo EY, Foley PJ, Rohrbach JI, Fairman RM, Wang GJ. Trends in Endovascular Aortic Aneurysm Repair Length of Stay over a Decade at a Tertiary Academic Institution. Ann Vasc Surg 2015; 29:1554-8. [PMID: 26253042 DOI: 10.1016/j.avsg.2015.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 07/06/2015] [Accepted: 07/10/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Length of stay (LOS) is used as a quality metric to reduce cost and improve value of delivery of care. We sought to analyze trends in endovascular aortic aneurysm repair (EVAR) LOS at a tertiary academic institution over the last decade. METHODS A retrospective review of prospectively collected data was performed. Infrarenal EVARs from 2001 to 2013 were divided into 3 groups: group I (2001-2004), EVARs were performed as part of clinical trials; group II (2005-2008), EVARs were referred to a tertiary referral center with the most experience with EVAR; group III (2009-2013), EVARs were referred to academic institutions in the presence of severe patient comorbidities. Trends in LOS and correlation with severity of illness (SOI) as based on All Patient Refined Diagnosis Related Groups and admission and/or disposition status were analyzed. LOS index (LOSI) at our institution was then compared with University HealthSystem Consortium (UHC) Hospitals over the past 3 years. RESULTS A total of 1,265 EVARs were performed during this time period: 325 in group I, 547 in group II, and 393 in group III. The median LOS was 4 days (inter quartile range [IQR], 2-6) vs. 3 days (IQR, 2-5) ± 0.28 vs. 4 days (IQR, 3-7), respectively (P < 0.01). Although moderate SOI was fairly constant over time (P = 0.66), major and/or extreme SOI constituted a greater proportion of patients in group I, was reduced in group II, and was again increased in group III, P < 0.01. The complication rate paralleled this pattern (group I, 15.2%; group II, 8.6%; group III, 10.4%; P = 0.02). The percentage of patients discharged to nursing home and/or rehab was 5.7% in group I, 8.2% in group II, 11.5% in group III (P = 0.03). Cases that were performed urgently and/or emergently increased over time: 11.6% in group I, 14.9% in group II, 21.6% in group III (P = 0.01). The risk-adjusted LOSI at our institution was significantly greater (1.25) when compared with UHC hospitals (0.75). CONCLUSIONS Our study suggests a relationship between time period of EVAR, SOI, complications, admission status, and LOS. Attention to these trends could be used to decrease LOS in an increasingly complex patient population.
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Affiliation(s)
- Yana Etkin
- Division of Vascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Benjamin M Jackson
- Division of Vascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Edward Y Woo
- Department of Vascular Surgery, MedStar Health, Washington, DC
| | - Paul J Foley
- Division of Vascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jeffrey I Rohrbach
- Division of Vascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Ronald M Fairman
- Division of Vascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Grace J Wang
- Division of Vascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA.
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Fairman RM, Jackson BM, Wang GJ, Foley PJ, Orlova K, Ramdon A, Etkin Y, Woo E. Upper Extremity Arterial Thrombectomy for Hand Ischemia Is Associated With High In-Hospital Mortality. J Vasc Surg 2015. [DOI: 10.1016/j.jvs.2015.04.092] [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] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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