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Pre-emptive Sac Management to Prevent Type II Endoleaks in High-Risk Patients. J Vasc Interv Radiol 2024:S1051-0443(24)00008-3. [PMID: 38218220 DOI: 10.1016/j.jvir.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 01/03/2024] [Indexed: 01/15/2024] Open
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Optimal Medical Management in Patients undergoing Peripheral Vascular Interventions for Chronic Limb Threatening Ischemia is associated with Improved Outcomes. J Vasc Surg 2023:S0741-5214(23)01068-6. [PMID: 37150486 DOI: 10.1016/j.jvs.2023.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 04/13/2023] [Accepted: 04/14/2023] [Indexed: 05/09/2023]
Abstract
OBJECTIVE Optimizing medical management and risk factor modification are underutilized strategies in patients with chronic limb threatening ischemia (CLTI), despite evidence of improved outcomes. The Vascular Quality Initiative (VQI) registry is a tool to improve quality of vascular care. In this study, we used the VQI to evaluate trends in medical management in CLTI patients undergoing peripheral vascular interventions (PVI), and the impact of changes in management on overall survival (OS), amputation-free survival (AFS) and limb salvage (LS). METHODS Patients undergoing index PVI for CLTI between 2012-2016, with at least 24-month follow-up were identified from the national VQI registry. Patient details including smoking status and medication use, OS, LS, and AFS were analyzed with linear-by-linear association, t-test and logistic regression. RESULTS 12,370 PVI were completed in 11,466 patients. There was a significant increase in infrapopliteal interventions (29.8% → 39.0%; P < .001) and PVI performed for tissue loss (TL) (59.1% → 66.5%; P < .001). The percentage of current smokers at time of PVI decreased (36.2% → 30.7%; P = .036). At discharge, statins were initiated in 25%, aspirin in 45% and P2Y12 therapy in 58% of patients not receiving these medications prior to PVI. Over the course of follow-up, dual antiplatelet (DAPT) (41.1% → 48.0%; P < .001), ACE-inhibitor (46.2% → 51.3%; P < .001), and statin (70.4% → 77.5%; P < .001) use increased. Combined DAPT, ACE-inhibitor and statin use increased from 33.6% → 39.6% (P=<.001). Significant improvement in 24-month OS and AFS was noted (OS, 90.9% → 93.7%; P = .002: AFS, 81.2% → 83.1%; P = .046) but not LS (89.6% → 89.0%; P = .83). Combined therapy with P2Y12 inhibitors, statins and ACE-inhibitors was an independent predictor of improved OS (HR 0.61; 0.39 - 0.96, P = .034). DAPT was independent predictor of improved LS (HR 0.83; 0.79 - 0.87, P < .007). CONCLUSION Antiplatelet, ACE-inhibitor and statin use increased over the study period and was associated with improved OS and AFS. Limb salvage trends did not change significantly over time, possibly due to inclusion of patients with higher disease burden or inadequate medical management. Medical management, although improved, remained far from optimal and represents an area for continued development.
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Effect of a Decision Aid on Agreement Between Patient Preferences and Repair Type for Abdominal Aortic Aneurysm: A Randomized Clinical Trial. JAMA Surg 2022; 157:e222935. [PMID: 35947375 PMCID: PMC9366657 DOI: 10.1001/jamasurg.2022.2935] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 05/04/2022] [Indexed: 12/19/2022]
Abstract
Importance Patients with abdominal aortic aneurysm (AAA) can choose open repair or endovascular repair (EVAR). While EVAR is less invasive, it requires lifelong surveillance and more frequent aneurysm-related reinterventions than open repair. A decision aid may help patients receive their preferred type of AAA repair. Objective To determine the effect of a decision aid on agreement between patient preference for AAA repair type and the repair type they receive. Design, Setting, and Participants In this cluster randomized trial, 235 patients were randomized at 22 VA vascular surgery clinics. All patients had AAAs greater than 5.0 cm in diameter and were candidates for both open repair and EVAR. Data were collected from August 2017 to December 2020, and data were analyzed from December 2020 to June 2021. Interventions Presurgical consultation using a decision aid vs usual care. Main Outcomes and Measures The primary outcome was the proportion of patients who had agreement between their preference and their repair type, measured using χ2 analyses, κ statistics, and adjusted odds ratios. Results Of 235 included patients, 234 (99.6%) were male, and the mean (SD) age was 73 (5.9) years. A total of 126 patients were enrolled in the decision aid group, and 109 were enrolled in the control group. Within 2 years after enrollment, 192 (81.7%) underwent repair. Patients were similar between the decision aid and control groups by age, sex, aneurysm size, iliac artery involvement, and Charlson Comorbidity Index score. Patients preferred EVAR over open repair in both groups (96 of 122 [79%] in the decision aid group; 81 of 106 [76%] in the control group; P = .60). Patients in the decision aid group were more likely to receive their preferred repair type than patients in the control group (95% agreement [93 of 98] vs 86% agreement [81 of 94]; P = .03), and κ statistics were higher in the decision aid group (κ = 0.78; 95% CI, 0.60-0.95) compared with the control group (κ = 0.53; 95% CI, 0.32-0.74). Adjusted models confirmed this association (odds ratio of agreement in the decision aid group relative to control group, 2.93; 95% CI, 1.10-7.70). Conclusions and Relevance Patients exposed to a decision aid were more likely to receive their preferred AAA repair type, suggesting that decision aids can help better align patient preferences and treatments in major cardiovascular procedures. Trial Registration ClinicalTrials.gov Identifier: NCT03115346.
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Statins Save Limbs in Patients With Chronic Limb Threatening Ischemia and End Stage Renal Disease. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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No Vitamin K Antagonists for Patients with Abdominal Aortic Aneurysms or Peripheral Arterial Disease? Are We There yet? Eur J Vasc Endovasc Surg 2021; 62:275. [PMID: 33994305 DOI: 10.1016/j.ejvs.2021.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/06/2021] [Accepted: 04/07/2021] [Indexed: 10/21/2022]
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Ruptured abdominal aortic aneurysm in an 11-year-old with multiple peripheral artery aneurysms. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2020; 6:539-542. [PMID: 33134637 PMCID: PMC7588751 DOI: 10.1016/j.jvscit.2020.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/23/2020] [Indexed: 11/25/2022]
Abstract
Pediatric abdominal aortic aneurysms (AAAs) are rarely encountered in clinical practice. The combination of a pediatric AAA in a patient with multiple peripheral artery aneurysms is even more rare. We report the management of an 11-year-old boy who presented with a ruptured AAA who also had multiple peripheral arterial aneurysms. Infectious, genetic, and inflammatory workup was negative, classifying this aneurysm as congenital.
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The selection of patients for ambulatory endovascular aneurysm repair of elective asymptomatic abdominal aortic aneurysm. J Vasc Surg 2020; 72:1347-1353. [DOI: 10.1016/j.jvs.2020.01.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 01/17/2020] [Indexed: 11/27/2022]
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P2Y12 Inhibitor Monotherapy Is Superior to Aspirin Monotherapy in Chronic Limb-Threatening Ischemia Postendovascular Intervention. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.04.411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Evaluation of Balloon Angioplasty, Stenting, and Atherectomy in the Treatment of Infrapopliteal Disease for Chronic Limb-Threatening Ischemia. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.04.261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Paclitaxel and Mortality: Where Are We now? Eur J Vasc Endovasc Surg 2020; 60:230. [PMID: 32265112 DOI: 10.1016/j.ejvs.2020.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 03/10/2020] [Indexed: 11/30/2022]
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A simplified method of pre-emptive perigraft aortic sac embolization to prevent type II endoleak using the Excluder endograft. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2019; 5:509-511. [PMID: 31763510 PMCID: PMC6861731 DOI: 10.1016/j.jvscit.2019.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 09/23/2019] [Indexed: 11/23/2022]
Abstract
Pre-emptive, nonselective perigraft embolization of abdominal aortic aneurysm sac to reduce the risk of type II endoleak has been previously reported with a percutaneous technique using contralateral access with resheathing for coiling. The approach has been modified to simplify the procedure and to eliminate unnecessary sheath exchanges.
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Successful treatment of a ruptured profunda femoris artery aneurysm in association with fibromuscular dysplasia. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2019; 5:485-487. [PMID: 31763504 PMCID: PMC6859280 DOI: 10.1016/j.jvscit.2019.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 08/07/2019] [Indexed: 11/23/2022]
Abstract
Fibromuscular dysplasia is rarely reported in the infra-inguinal arteries. We report a case of an 86-year-old woman who presented with a ruptured profunda femoris artery aneurysm who was found to have angiographic findings of fibromuscular dysplasia in the bilateral deep femoral arteries and bilateral renal arteries. The rupture was treated successfully with a balloon-expandable covered stent.
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High plateletcrit is associated with early loss of patency after open and endovascular interventions for chronic limb ischemia. J Vasc Surg 2019; 71:2089-2097. [PMID: 31708302 DOI: 10.1016/j.jvs.2019.08.258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 08/16/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Plateletcrit (PCT) reflects the total platelet mass in blood and can be calculated from a complete blood count. We examined the effect of PCT on outcomes of endovascular and open interventions for chronic limb ischemia. METHODS Patients who underwent revascularization for chronic limb ischemia (Rutherford categories 3-6) between June 2001 and December 2014 were retrospectively identified. PCT on admission was recorded. Patients and limbs were divided into tertiles of low (0.046-0.211), medium (0.212-0.271), and high (0.272-0.842) PCT. Patency, limb salvage, major adverse limb events, major adverse cardiac events, and survival rates were calculated using Kaplan-Meier analysis and compared with log-rank test. Cox regression analysis was used for multivariate analysis. RESULTS A total of 1431 limbs (1210 patients) were identified and divided into low PCT (477 limbs in 407 patients), medium PCT (477 limbs in 407 patients), and high PCT (477 limbs in 396 patients) groups. The patients in the high tertile were 2 years older that the patients in the other two tertiles (P = .009). Five-year primary patency was 65% ± 3% in the low-PCT group compared with 55% ± 3% and 51% ± 3% in the medium and high PCT groups, respectively (P = .004). Five-year secondary patency was 81% ± 2% in the low PCT group compared with 82% ± 2% and 72% ± 3% in the medium and high PCT groups, respectively (P = .02). Five-year limb salvage rate was 86% ± 2% in the low PCT group compared with 79% ± 3% and 74% ± 3% in the medium PCT and high PCT groups, respectively (P = .004). Multivariate regression analysis showed that low PCT was independently associated with primary patency after endovascular interventions (hazard ratio, 0.67 [0.47-0.95]; P = .02) but not after open interventions (hazard ratio, 0.72 [0.43-1.21]; P = .21). CONCLUSIONS High PCT is associated with poor patency and limb salvage rates after interventions for lower extremity chronic limb ischemia. Multivariate regression analysis confirmed association of low PCT with improved primary patency after endovascular interventions but not after open interventions. High PCT may be a marker of increased platelet reactivity and could be used to identify patients at high risk for early thrombosis and failure after interventions.
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Angiotensin Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers (ACEI/ARB) are Associated with Improved Limb Salvage after Infrapopliteal Interventions for Critical Limb Ischemia. Ann Vasc Surg 2019; 63:275-286. [PMID: 31626938 DOI: 10.1016/j.avsg.2019.08.093] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/08/2019] [Accepted: 08/14/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Angiotensin-converting enzyme Inhibitors and Angiotensin II Receptor Blockers (ACEI/ARB) reduce the risk of cardiovascular events and mortality in patients with peripheral arterial disease (PAD). However, their effect on limb-specific outcomes is unclear. The objective of this study is to assess the effect of ACEI/ARB on patency and limb salvage in patients undergoing interventions for critical limb ischemia (CLI). METHODS Patients undergoing infrainguinal revascularization for CLI (Rutherford 4-6) between 06/2001 and 12/2014 were retrospectively identified. Primary Patency (PP), Secondary Patency (SP), Limb Salvage (LS), major adverse cardiac events (MACE), and survival rates were calculated using Kaplan-Meier. Multivariate analysis was performed using Cox regression. RESULTS A total of 755 limbs in 611 patients (311 ACEI/ARB, 300 No ACEI/ARB) were identified. Hypertension (86% vs. 70%, P < 0.001), diabetes (68% vs. 55%, P = 0.001) and statin use (61% vs. 45%, P < 0.001) were significantly greater in the ACEI/ARB group. Interventions were performed mostly for tissue loss (83% ACEI/ARB vs. 84% No ACEI/ARB, P = 0.73). Comparing ACEI/ARB versus No ACEI/ARB, in femoropopliteal interventions, 60-month PP (54% vs. 55%, P = 0.47), SP (76% vs. 75%, P = 0.83) and LS (84% vs. 87%, P = 0.36) were not significantly different. In infrapopliteal interventions, 60-month PP (45% vs. 46%, P = 0.66) and SP (62% vs. 75%, P = 0.96) were not significantly different. LS was significantly greater in ACEI/ARB (75%), as compared to No ACEI/ARB (61%) (P = 0.005). Cox regression identified diabetes (HR 2.4 (1.4-4.1), P = 0.002), ESRD (HR 3.5 (2.1-5.7), P < 0.001), hypertension (HR 0.4 (0.2-0.6), P < 0.001), and ACEI/ARB (HR 0.6 (0.4-0.9), P = 0.03), as factors independently associated with LS after infrapopliteal interventions. Freedom from MACE (ACEI/ARB 37% vs. 32%, P = 0.82) and overall survival (ACEI/ARB 42% vs. 35% No ACEI/ARB, P = 0.84) were not significantly different. CONCLUSIONS ACEI/ARB is associated with improved limb salvage in CLI patients undergoing infrapopliteal interventions, but not after femoropopliteal interventions. ACEI/ARB had no impact on patency rates. They were also associated with a trend toward improved survival and freedom from MACE. Our findings suggest that the use of ACEI/ARB may improve outcomes in the high-risk CLI patient population.
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Foley Catheter Use in Endovascular Aneurysm Repair. J Vasc Surg 2019. [DOI: 10.1016/j.jvs.2019.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Metformin Is Associated with Improved Survival and Decreased Cardiac Events with No Impact on Patency and Limb Salvage after Revascularization for Peripheral Arterial Disease. Ann Vasc Surg 2019; 55:63-77. [DOI: 10.1016/j.avsg.2018.05.054] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 05/15/2018] [Accepted: 05/22/2018] [Indexed: 12/27/2022]
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Acute kidney injury after non-cardiovascular surgery: risk factors and impact on development of chronic kidney disease and long-term mortality. Curr Med Res Opin 2018; 34:1829-1837. [PMID: 29613817 DOI: 10.1080/03007995.2018.1459527] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To identify factors associated with acute kidney injury (AKI) and its progression to chronic kidney disease (CKD) in a non-cardiac/non-vascular surgery setting. METHODS This study examined the Veterans Affairs Surgical Quality database for surgical entries between 2000-2014. Demographics, comorbidities, laboratory findings and hospital outcomes were assessed. The primary end-point was the occurrence of AKI, defined as an increase of ≥0.3 mg/dL, 48 h post-operatively. Major adverse cardiac event (MACE) was defined as the composite first occurrence of myocardial infarction, cardiac arrest, and death in 30 days (secondary end-point) and was compared between two groups. Rates of progression to CKD in 1 year and long-term survival were examined. MAIN OUTCOME MEASURES Occurrence of AKI 48 h post-operatively. RESULTS AKI was documented in 8.5% of patients. Age, diabetes, and chronic obstructive pulmonary disease, chronic kidney disease, platelet count, serum albumin level, and duration of surgery were identified as independent predictors of AKI. In total, 6.4% patients developed MACE, which was more frequent in patients with AKI (p < .001). Age and pre-operative hematocrit <30% were independent predictors of progression to CKD. Pre-operative hematocrit with a cut-off value of 30% was the only modifiable factor to predict the long-term survival. CONCLUSION Development of AKI is associated with increased odds of various post-operative complications and long-term renal insufficiency and mortality.
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The Selection of Patients for Ambulatory Endovascular Aneurysm Repair. J Vasc Surg 2018. [DOI: 10.1016/j.jvs.2018.05.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Long-term Durability of Infrainguinal Endovascular and Open Revascularization for Disabling Claudication. Ann Vasc Surg 2018; 51:55-64. [DOI: 10.1016/j.avsg.2018.02.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 02/14/2018] [Accepted: 02/19/2018] [Indexed: 12/01/2022]
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Neutrophil-lymphocyte ratio is a marker of survival and cardiac complications rather than patency following revascularization of lower extremities. Vasc Med 2018; 23:437-444. [PMID: 29848209 DOI: 10.1177/1358863x18774623] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The neutrophil-lymphocyte ratio (NLR), as a marker of inflammation, is associated with the severity of peripheral artery disease (PAD). The role of the NLR on predicting future complications after elective revascularization for patients with PAD remains unknown. We aimed to examine the role of the NLR in the development of major adverse limb events (MALE) and the long-term mortality of these patients. We evaluated 1708 revascularization procedures from May 2001 to December 2015 at the Veterans Affairs Western New York Healthcare System from a prospectively maintained vascular database that included demographics, comorbidities and pre-procedural medications. Peri-procedural laboratory findings including complete blood cell count and metabolic panel were further retrieved from the electronic health record. The NLR was calculated, and the patients were categorized into tertiles according to NLR cut-off points. Multivariate Cox regression analysis was performed to determine MALE and 10-year mortality. The primary endpoint of the study was MALE, and the secondary endpoint included 10-year mortality. A total of 1228 patients were included for final analyses. Patients in the third NLR tertile were more likely to experience MALE during the follow-up period ( p<0.001). In addition, fewer patients in tertile 3 survived over the follow-up period compared to tertiles 1 and 2 ( p<0.0001). Patients in tertile 3 tended to be older with a higher frequency of hypertension, diabetes, chronic kidney disease, coronary artery disease and congestive heart failure. Our multivariate analysis demonstrated that the NLR was independently associated with higher rates of MALE in the affected vessels following revascularization procedures. Similarly, the NLR was revealed to be an independent predictor of higher long-term mortality in these patients.
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Should Multiple Vessels be Recanalised for Tissue Loss Irrespective of Pedal Anatomy and Angiosome? Eur J Vasc Endovasc Surg 2018; 55:528. [DOI: 10.1016/j.ejvs.2018.01.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 01/23/2018] [Indexed: 10/18/2022]
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Metformin Is Associated With Improved Survival and Decreased Cardiac Events With No Impact on Patency and Limb Salvage After Revascularization for Chronic Limb Ischemia. J Vasc Surg 2017. [DOI: 10.1016/j.jvs.2017.07.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Commentary on "Robotic Arch Catheter Placement Reduces Cerebral Embolisation During Thoracic Endovascular Aortic Repair (TEVAR)". Eur J Vasc Endovasc Surg 2017; 53:370. [PMID: 28161278 DOI: 10.1016/j.ejvs.2017.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 01/05/2017] [Indexed: 10/20/2022]
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Preoperative Risk Factor Profiling to Identify Candidates for Endovascular Aneurysm Repair in Ambulatory Surgery Centers. J Vasc Surg 2016. [DOI: 10.1016/j.jvs.2016.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Recanalization of Concomitant Iliac Artery and Common Femoral Artery Occlusions Using an Antegrade Hybrid (Open/Endovascular) Approach. Vasc Endovascular Surg 2016; 41:130-4. [PMID: 17463203 DOI: 10.1177/1538574406298084] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The endovascular treatment of patients with bulky iliofemoral occlusions usually requires a femoral endarterectomy, coupled with iliac recanalization. This requires crossing the occlusions with a guidewire, which is usually attempted in a retrograde fashion. If this fails, then a surgical inflow procedure is necessary. Antegrade crossing of an iliac occlusion either from the contralateral femoral or transbrachial approach and retrieval of the guidewire during the ensuing femoral endarterectomy obviates the need for luminal reentry, ensures inflow by endovascular recanalization of the iliac artery, and avoids the need for surgical bypass. This underused technique should be considered in such situations, and its details are described.
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Stent-Related Iliac Artery and Iliac Vein Infections: Two Unreported Presentations and Review of the Literature. J Endovasc Ther 2016; 8:202-9. [PMID: 11357983 DOI: 10.1177/152660280100800217] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: To discuss the presentation, diagnosis, and treatment of stent-related infections on the basis of 2 new cases and historical review. Case Reports: Two previously unreported cases of vascular stent infection are presented with a summary of cases from the literature. One case involved an iliac artery stent infection secondary to a remote bacteremia 6 months after stent placement. The other case was an early iliac vein stent infection, a previously unreported site of this complication. Both cases were diagnosed by use of computed tomography and were treated surgically after medical management failed. Both patients survived. Conclusions: A high index of suspicion is necessary for the diagnosis of stent infections, and an aggressive treatment is usually necessary for survival. Prophylactic antibiotics should definitely be considered in cases involving repeat interventions and prolonged catheterization, as well as before bacteremia-inducing therapies.
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Total Percutaneous Endovascular Repair of Abdominal Aortic Aneurysms Using Perclose ProGlide Closure Devices. J Endovasc Ther 2016; 14:184-8. [PMID: 17484534 DOI: 10.1177/152660280701400210] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Purpose: To describe a technique for access site closure in percutaneous abdominal aortic aneurysm (AAA) repair using double Perclose ProGlide devices to overcome the problems associated with the bulky delivery system and braided suture of the antecedent (Prostar) device. Technique: After obtaining guidewire access, 2 Perclose ProGlide sutures are deployed at 90° to each other. The appropriate sheaths are placed over the stiff guidewires. After the stent-graft procedure is completed, an assistant holds pressure while the knots are tightened with the stiff guidewire still in the artery. Once the second knot is tightened with the knot pusher and after confirming adequate hemostasis, the wire is removed, pressure is applied, and heparin reversed. This method has been used in 17 consecutive patients (age range 65–85 years) undergoing endovascular AAA repair. One patient needed patch angioplasty and 2 required small incisions for additional suture placements (81% primary success rate for total percutaneous repair, 90% success rate for all sites). Conclusion: We have found the double Perclose ProGlide technique to be easy to use, safe, and feasible for total percutaneous AAA repair. More experience with longer follow-up is needed to assess its potential to replace the Perclose Prostar closure device for total percutaneous AAA repairs.
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Abstract
Scrotal necrosis is an extremely rare complication following endovascular abdominal aortic aneurysm repair. Sloughing of scrotal skin and penile necrosis owing to therapeutic hypogastric artery occlusion for endoluminal aortoiliac aneurysm repair have been documented. We present herein one case of scrotal necrosis following endovascular abdominal aortic aneurysm repair. The presentation of combined scrotal necrosis, buttock ischemia, lower extremity livedo reticularis, and left blue toes with palpable pulses in the posterior tibial and dorsalis pedis arteries suggested that microembolization during endovascular aneurysm repair was the major cause of the devastating ischemic complications in this patient.
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Poorer limb salvage in African American men with chronic limb ischemia is due to advanced clinical stage and higher anatomic complexity at presentation. J Vasc Surg 2016; 63:1318-24. [PMID: 27005751 DOI: 10.1016/j.jvs.2015.11.052] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 11/18/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE African Americans (AAs) with symptomatic peripheral arterial disease (PAD) have been reported to have fewer revascularization attempts and poorer patency and limb salvage (LS) rates than Caucasians (CAUs). This study compared the outcomes between AA and CAU men with chronic limb ischemia. METHODS All AA and CAU men who underwent treatment for symptomatic PAD between November 1, 2003, and May 31, 2012, were included. Patency rates, LS, major adverse cardiovascular and limb events, amputation-free survival, and survival were compared before and after propensity score matching and with multivariate (Cox regression) analysis. RESULTS Of the 834 men (1062 limbs), 107 were AA (137 limbs) and 727 were CAU (925 limbs). AAs were more likely to have insulin-dependent diabetes mellitus, hypertension, dialysis dependence, lower albumin levels, and critical limb ischemia (73% vs 61%; P = .006), whereas CAUs had more coronary artery disease, dyslipidemia, and chronic obstructive pulmonary disease. In patients with critical limb ischemia, primary amputation rates (10.9% vs 7.2%; P = .209) were similar between groups; however, infrapopliteal interventions were more frequent in AAs (62.6% vs 44.3%; P = .004). Perioperative morbidity and mortality rates were similar. Mean follow-up was 38.5 ± 28.9 months (range, 0-119 months). Patency rates, major adverse limb and cardiovascular events, amputation-free survival, and survival were similar in AAs and CAUs; however, the LS rate was significantly lower in AA (73% ± 6% vs 83% ± 2%; P = .048), mainly due to the difference in the endovascular-treated group (5-year LS, 69% ± 7% in AAs vs 84% ± 2% in CAUs; P = .025). All outcomes were similar in propensity score-matched cohorts. In multivariate analysis, insulin-dependent diabetes mellitus, gangrene, poor functional capacity, dialysis-dependence, and need for infrapopliteal revascularization were independently associated with limb loss, whereas race was not. CONCLUSIONS AA men with symptomatic PAD were found to have lower LS rates than CAUs. However, this was likely due to presenting with advanced ischemia or with poor prognostic factors that are independently associated with limb loss.
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Factors That Impact Cost and Clinical Outcomes With Endovascular Aortic Repair (EVAR). J Vasc Surg 2015. [DOI: 10.1016/j.jvs.2015.06.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Endoscopic Vein Harvest (EVH) Does Not Negatively Impact Patency of Great Saphenous Vein (GSV) Lower Extremity Bypass. J Vasc Surg 2015. [DOI: 10.1016/j.jvs.2015.06.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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The Effect of Adding Functional Classification to ASA Status for Predicting 30-Day Mortality. Anesth Analg 2015; 121:110-116. [DOI: 10.1213/ane.0000000000000740] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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PC40. Impact of Graft Cost and Reimbursement on Hospital Contribution Margin in EVAR Patients. J Vasc Surg 2015. [DOI: 10.1016/j.jvs.2015.04.244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Costs of repair of abdominal aortic aneurysm with different devices in a multicenter randomized trial. J Vasc Surg 2015; 61:59-65. [DOI: 10.1016/j.jvs.2014.08.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 08/01/2014] [Indexed: 10/24/2022]
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The validity of the VA surgical risk tool in predicting postoperative mortality among octogenarians. Am J Surg 2014; 209:274-9. [PMID: 25457253 DOI: 10.1016/j.amjsurg.2014.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 06/26/2014] [Accepted: 07/15/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND To examine the validity of Veterans Affair-VA risk assessment tool in predicting the perioperative and overall mortality among octogenarians. METHODS This is a single-institution retrospective observational study, in which the clinical information of 1,618 octogenarians were extracted from the VA Surgical Quality Improvement Program database. VA risk assessment tool and ASA classification were used to predict the probability of postoperative mortality and morbidity. Multiple risk groups were compared for mortality using multiple logistic regressions. RESULTS There were 570 survivors and 1,048 nonsurvivors. VA risk tool strongly predicted perioperative 30-day mortality in receiver operator characteristic curve analysis (area under the curve: .82 ± .02). The power of this tool, while acceptable, was less in predicting overall mortality (area under the curve: .68 ± .01). Age, dialysis, a history of congestive heart failure, functional status, transfusion, and weight loss were also associated with increased rate of death within 30 days. CONCLUSIONS VA risk tool predicted both perioperative and overall mortality. Relatively strong power of this tool in predicting overall mortality may be unique to this age group because of their advanced age.
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PS162. Outcomes and Costs Associated With Secondary Amputation (SA) Following Endovascular Intervention (EVI) Without Healing and Primary Amputation (PA) in the Treatment of Patients With Critical Limb Ischemia (CLI) and Tissue Loss (TL). J Vasc Surg 2014. [DOI: 10.1016/j.jvs.2014.03.162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Statin use is associated with improved overall survival without affecting patency and limb salvage rates following open or endovascular revascularization. Vasc Med 2014; 19:86-93. [DOI: 10.1177/1358863x14528271] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The aim of the study was to determine statin drug association with patency, limb salvage rates and survival after revascularization in patients with chronic limb ischemia. We retrospectively reviewed all patients who underwent revascularization for intermittent claudication or critical limb ischemia between 05/2001 and 12/2009. Patients were grouped based on statin therapy at the time of revascularization. Early postoperative outcomes as well as patency, limb salvage, and survival rates were compared between groups. Of 717 patients, 397 (55.4%) were on statins. The incidence of major adverse cardiac events (MACE) was significantly lower in the statin group. Patency and limb salvage rates were similar; however, survival was significantly better in the statin group. Non-statin use, coronary artery disease, chronic pulmonary obstructive disease, renal insufficiency, critical limb ischemia, and age >70 years were found to be independently associated with decreased survival. Statin use was associated with improved survival, but not with long-term patency and limb salvage.
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Functional Capacity as a Significant Independent Predictor of Postoperative Mortality for Octogenarian ASA-III Patients. J Gerontol A Biol Sci Med Sci 2014; 69:1229-35. [DOI: 10.1093/gerona/glu062] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Similar Outcomes in African American Compared with Caucasian Men with Chronic Limb Ischemia in an Equal Access to Care Setting. J Vasc Surg 2013. [DOI: 10.1016/j.jvs.2013.07.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Low levels of high-density lipoproteins are associated with acute kidney injury following revascularization for chronic limb ischemia. Ren Fail 2013; 35:838-44. [DOI: 10.3109/0886022x.2013.801271] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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Impact of Tissue Loss on Limb Salvage After Revascularization. J Vasc Surg 2013. [DOI: 10.1016/j.jvs.2013.02.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Commentary regarding "A multicentric experience with open surgical repair and endovascular exclusion of popliteal artery aneurysms". Eur J Vasc Endovasc Surg 2013; 45:528-30. [PMID: 23540802 DOI: 10.1016/j.ejvs.2013.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 03/05/2013] [Indexed: 10/27/2022]
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Commentary: Endovascular Therapy Should Be the First Line of Treatment in Patients With Severe (TASC II C or D) Aortoiliac Occlusive Disease. J Endovasc Ther 2013; 20:74-9. [DOI: 10.1583/12-4014c.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Ambulatory Percutaneous Endovascular Abdominal Aortic Aneurysm Repair. J Vasc Surg 2013. [DOI: 10.1016/j.jvs.2012.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Procedural trends in the treatment of peripheral arterial disease by insurer status in New York State. J Am Coll Surg 2012; 215:311-321.e1. [PMID: 22901510 DOI: 10.1016/j.jamcollsurg.2012.05.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Revised: 04/12/2012] [Accepted: 05/10/2012] [Indexed: 01/24/2023]
Abstract
BACKGROUND Type or lack of insurance may affect access to care, treatment, and outcomes. We evaluated trends for surgical management of all peripheral arterial disease (PAD) in-hospital admissions by insurer status in New York State. STUDY DESIGN Statewide Planning and Research Cooperative System (SPARCS) data were obtained and cross-referenced for diagnostic and procedure codes. Data from 2001 to 2002 were averaged and used as a baseline. Change in indication, volume of admissions, procedures, and amputations were calculated for the years 2003 to 2008 and were analyzed by insurer status. RESULTS There were 83,949 admissions. Endovascular intervention (EVI) increased tremendously for all indications and was used equally in the insured and uninsured. Among critical limb ischemia admissions, patients with private insurance were significantly more likely to be admitted for rest pain and significantly less likely to be admitted for gangrene (p < 0.001). Admission for gangrene declined for all. As EVI increased, amputation decreased and was significantly lowest in patients with private insurance (p < 0.001). Amputation was significantly higher in Medicaid than other insured (Medicaid vs private, p < 0.001; Medicaid vs Medicare, p = 0.003), but comparable to the uninsured (p = 0.08). Age greater than 65 years and low socioeconomic class or minority status were significant risks for gangrene (p = 0.014; p < 0.001) and ultimate amputation (p = 0.05; p < 0.001). Lack of insurance may pose a similar risk. CONCLUSIONS EVI increased tremendously and was used without disparity across insurer status. Amputation declined steadily and may have been related to increased EVI or to decreased admission for gangrene. Advanced age, low socioeconomic class or minority status, and lack of insurance negatively affect presentation and limb salvage. Universal health care may be beneficial in improving outcomes but must address root causes for delayed presentation.
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Low Levels of High-Density Lipoproteins Are Associated With Acute Kidney Injury Following Revascularization for Chronic Limb Ischemia. J Vasc Surg 2012. [DOI: 10.1016/j.jvs.2012.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Long-term limb salvage and survival after endovascular and open revascularization for critical limb ischemia after adoption of endovascular-first approach by vascular surgeons. J Vasc Surg 2012; 56:361-71. [DOI: 10.1016/j.jvs.2012.01.054] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Revised: 01/18/2012] [Accepted: 01/18/2012] [Indexed: 10/28/2022]
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RR14. Spinal Cord Injury after Hybrid Endovascular Repair of Thoracoabdominal Aortic Aneurysms in the North American Complex Abdominal Aortic Debranching (NACAAD) Registry. J Vasc Surg 2012. [DOI: 10.1016/j.jvs.2012.03.223] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Commentary: A New Approach to Treating Infected Vascular Reconstructions:The Hybrid EndoVAC Technique. J Endovasc Ther 2011; 18:674-5. [DOI: 10.1583/11-3465c.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Long-Term Limb Salvage and Survival Following Endovascular and Open Revascularization for Critical Limb Ischemia After Adoption of Endovascular-First Approach by Vascular Surgeons. J Vasc Surg 2011. [DOI: 10.1016/j.jvs.2011.06.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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