Workflow and Patient Satisfaction in Treating Peripheral Arterial Disease in the Office-Based Setting.

Contemporary concepts in health-care reform promote a shift in the provision of care away from hospitals in favor of the more cost-effective and efficient use of outpatient facilities including ambulatory surgery centers and office-based procedure centers particularly in the care of cardiovascular disease. This article reviews the experience of patients and specialists in caring for patients with peripheral arterial disease in an office-based care setting.

Initial experience with the ambulatory management of acute iliofemoral deep vein thrombosis with May-Thurner syndrome with percutaneous mechanical thrombectomy, angioplasty and stenting.

OBJECTIVE: Patients undergoing intervention for acute iliofemoral deep vein thrombosis (IFDVT) with May-Thurner syndrome (MTS) typically require inpatient (IP) hospitalization for initial treatment with anticoagulation and management with pharmacomechanical thrombectomy. Direct oral anticoagulants and percutaneous mechanical thrombectomy (PMT) devices offer the opportunity for outpatient (OP) management. We describe our approach with these patients. METHODS: Patients receiving intervention for acute IFDVT from January 2020 through October 2022 were retrospectively reviewed. Patients undergoing unilateral thrombectomy, venous angioplasty, and stenting for IFDVT with MTS comprised the study population and were divided into two groups: (1) patients admitted to the hospital and treated as IPs and (2) patients who underwent therapy as OPs. The two groups were compared regarding demographics, risk factors, procedural success, complications, and follow-up. RESULTS: A total of 92 patients were treated for IFDVT with thrombectomy, angioplasty, and stenting of whom 58 comprised the IP group and 34 the OP group. All 92 patients underwent PMT using the Inari ClotTriever (Inari Medical), intravascular ultrasound, angioplasty, and stenting with 100% technical success. Three patients in the IP group required adjuvant thrombolysis. There was no difference in primary patency of the treated IFDVT segment at 12 months between the two groups (IP, 73.5%; OP, 86.7%; P = .21, log-rank test). CONCLUSIONS: Patients with acute IFDVT and MTS deemed appropriate for thrombectomy and iliac revascularization can be managed with initiation of ambulatory direct oral anticoagulant therapy and subsequent return for ambulatory PMT, angioplasty, and stenting. This approach avoids the expense of IP care and allows for effective use of resources at a time when staffing and supply chain shortages have led to inefficiencies in the provision of IP care for nonemergent conditions.

Percutaneous deep vein arterialization using off-the-shelf devices for chronic limb threatening ischemia.

We present the case of a young man with severe comorbidities who presented with gangrene and rest pain of his right foot. He had already undergone a contralateral below knee amputation for a nonsalvageable left foot due to chronic limb threatening ischemia. We performed percutaneous deep vein arterialization using off-the-shelf devices to attempt limb salvage of his right foot.

Successful left gonadal vein to inferior vena cava bypass for symptomatic May-Thurner syndrome.

We report the management of symptomatic May-Thurner syndrome refractory to endovascular techniques with left gonadal vein to inferior vena cava bypass. The patient's presentation was exceptional-a young individual with end-stage renal disease status post four failed kidney transplants, dwindling options for dialysis access, and an unusable left thigh arteriovenous graft owing to severe lower extremity edema secondary to common iliac vein compression. Postoperatively, swelling was markedly alleviated and the thigh graft was functional. Discussed are endovascular and venous bypass techniques for management of May-Thurner-associated lesions, as well as approaches to end-stage hemodialysis access salvage.

Physical therapy management, surgical treatment, and patient-reported outcomes measures in a prospective observational cohort of patients with neurogenic thoracic outlet syndrome.

OBJECTIVE: To assess the results of physical therapy management and surgical treatment in a prospective observational cohort of patients with neurogenic thoracic outlet syndrome (NTOS) using patient-reported outcomes measures. METHODS: Of 183 new patient referrals from July 1 to December 31, 2015, 150 (82%) met the established clinical diagnostic criteria for NTOS. All patients underwent an initial 6-week physical therapy trial. Those with symptom improvement continued physical therapy, and the remainder underwent surgery (supraclavicular decompression with or without pectoralis minor tenotomy). Pretreatment factors and 7 patient-reported outcomes measures were compared between the physical therapy and surgery groups using t-tests and χ2 analyses. Follow-up results were assessed by changes in 11-item version of Disability of the Arm, Shoulder, and Hand (QuickDASH) scores and patient-rated outcomes. RESULTS: Of the 150 patients, 20 (13%) declined further treatment or follow-up, 40 (27%) obtained satisfactory improvement with physical therapy alone, and 90 (60%) underwent surgery. Slight differences were found between the physical therapy and surgery groups in the mean ± standard error degree of local tenderness to palpation (1.7 ± 0.1 vs 2.0 ± 0.1; P = .032), the number of positive clinical diagnostic criteria (9.0 ± 0.3 vs 10.1 ± 0.1; P = .001), Cervical-Brachial Symptom Questionnaire scores (68.0 ± 4.1 vs 78.0 ± 2.7; P = .045), and Short-Form 12-item physical quality-of-life scores (35.6 ± 1.5 vs 32.0 ± 0.8; P = .019) but not other pretreatment factors. During follow-up (median, 21.1 months for physical therapy and 12.0 months for surgery), the mean change in QuickDASH scores for physical therapy was -15.6 ± 3.0 (-29.5% ± 5.7%) compared with -29.8 ± 2.4 (-47.9% ± 3.6%) for surgery (P = .001). The patient-rated outcomes for surgery were excellent for 27%, good for 36%, fair for 26%, and poor for 11%, with a strong correlation between the percentage of decline in the QuickDASH score and patient-rated outcomes (P < .0001). CONCLUSIONS: The present study has demonstrated contemporary outcomes for physical therapy and surgery in a well-studied cohort of patients with NTOS, reinforcing that surgery can be effective when physical therapy is insufficient, even with substantial pretreatment disability. Substantial symptom improvement can be expected for ∼90% of patients after surgery for NTOS, with treatment outcomes accurately reflected by changes in QuickDASH scores. Within this cohort, it was difficult to identify specific predictive factors for individuals most likely to benefit from physical therapy alone vs surgery.

Influence of Body Weight on Surgical Treatment for Neurogenic Thoracic Outlet Syndrome.

BACKGROUND: Body weight affects outcomes of surgical treatment for various conditions, but its effects on the treatment of neurogenic thoracic outlet syndrome (NTOS) are unknown. The purpose of this study was to evaluate the influence of body weight on technical and functional outcomes of surgical treatment for NTOS. METHODS: A retrospective review of prospectively collected data was conducted for 265 patients who underwent supraclavicular decompression for NTOS between January 1, 2014 and March 31, 2016. Patients were grouped according to 6 standard body mass index (BMI) categories. The influence of BMI on measures of surgical outcome was analyzed using Pearson correlation statistics, analysis of variance (ANOVA), and multivariate logistic regression. RESULTS: Mean patient age was 33.3 ± 0.7 years (range, 12-70), and 208 (78%) patients were women. Mean BMI was 27.2 ± 0.4 (range 16.8-49.9), with 7 underweight (3%), 95 normal (36%), 84 overweight (32%), 47 obese-I (18%), 15 obese-II (6%), and 17 obese-III (6%). There was a slight but significant association between BMI and age (Pearson P < 0.0001, r = 0.264; ANOVA P = 0.0002), but no correlations between BMI and other preoperative variables. There were no differences between BMI groups for intraoperative, immediate postoperative, or 3-month outcomes. Multivariate logistic regression demonstrated that BMI had no significant effect on functional outcome as measured by the extent of improvement in Disability of the Arm, Shoulder, and Hand score at 3 months (P = 0.429). CONCLUSIONS: There was no substantive influence of BMI on preoperative characteristics or intraoperative, postoperative, or 3-month outcomes for patients with NTOS, and no indication of an "obesity paradox" for this condition. Supraclavicular decompression for NTOS achieves similar outcomes across the BMI spectrum.

Associations between clinical diagnostic criteria and pretreatment patient-reported outcomes measures in a prospective observational cohort of patients with neurogenic thoracic outlet syndrome.

OBJECTIVE: Neurogenic thoracic outlet syndrome (NTOS) is caused by dynamic compression of the brachial plexus at the level of the supraclavicular scalene triangle or the subcoracoid (pectoralis minor) space, or both. The purpose of this study was to characterize relationships between 14 clinical diagnostic criteria (CDC) and seven pretreatment patient-reported outcomes measures (PROMs) in a prospective cohort of patients with NTOS. METHODS: There were 183 new patient referrals between July 1 and December 31, 2015, with 150 (82%) meeting an established set of predefined CDC for NTOS. PROMs were evaluated across five domains: pain severity, functional disability, depression, quality of life, and pain catastrophizing. Linear regression and Pearson correlation statistics were used to analyze associations between CDC and PROMs. RESULTS: Mean ± standard error patient age was 37.1 ± 1.1 years (range, 12-66 years), and 107 (71%) were women. Five (3%) had a cervical rib, and 15 (10%) had recurrent NTOS. The most frequently positive CDC were neck or upper extremity pain (99%), upper extremity or hand paresthesia (94%), symptom exacerbation by arm elevation (97%), localized supraclavicular or subcoracoid tenderness to palpation (96%), and a positive 3-minute elevated arm stress test (94%; mean duration, 102.0 ± 5.1 seconds). The number of positive CDC (mean, 9.6 ± 0.1) correlated with the degree of tenderness to palpation and the duration of elevated arm stress test, as well as with PROMs for pain severity, functional disability, depression, physical quality of life, and pain catastrophizing (all P < .0001). PROMs across multiple domains were also strongly correlated with each other. Patients with clinically significant pain catastrophizing exhibited a greater level of functional disability than noncatastrophizing patients (P < .0001). CONCLUSIONS: This study illustrates the relative strengths of 14 CDC and seven PROMs to evaluate patients with NTOS, helping validate the selected CDC and highlighting the potential role of pain catastrophizing in functional disability. This cohort will provide valuable information on the utility of different CDC and PROMs to predict treatment outcomes.

A telephone call 1 week after hospitalization can identify risk factors for vascular surgery readmission.

OBJECTIVE: Compared with other populations, patients who undergo vascular surgery have higher 30-day hospital readmission rates of up to 25%. Postdischarge telephone call assessments have demonstrated utility in patients with significant medical comorbidities and traditionally high readmission rates. Therefore, we hypothesized that a 1-week postdischarge telephone call evaluation can identify risk factors for readmission among vascular surgery patients. METHODS: Patients who underwent a vascular surgery procedure during a 1-year period by a single vascular surgeon at one hospital received a postdischarge telephone call questionnaire to review postoperative pain, surgical site, constitutional symptoms, and follow-up arrangement. The primary outcome measure was frequency of postoperative symptoms as collected on the telephone call questionnaire. The secondary outcome measure was 30-day hospital readmission rates. RESULTS: Among 167 patients, 131 (78%) received a telephone call after discharge. Calls identified pain relieved by prescription medication (odds ratio, 6.67; confidence interval, 0.82-53.81; P = .05) and continued dressing application (odds ratio, 9.55; confidence interval, 0.54-166.6; P = .04) as risk factors for 30-day readmission. The 30-day readmission was not statistically different in patients who were successfully and not successfully contacted with a postdischarge telephone call (8% and 17%, respectively; P = .37). CONCLUSIONS: Vascular surgery patients are at higher risk of 30-day readmission than are patients in other surgical subspecialties. For the majority of patients, implementing a 1-week postdischarge telephone call for short-term follow-up evaluation is feasible and can help identify potential risk factors for hospital readmission within 30 days.

Bone morphogenetic protein-2 decreases microRNA-30b and microRNA-30c to promote vascular smooth muscle cell calcification.

BACKGROUND: Vascular calcification resembles bone formation and involves vascular smooth muscle cell (SMC) transition to an osteoblast-like phenotype to express Runx2, a master osteoblast transcription factor. One possible mechanism by which Runx2 protein expression is induced is downregulation of inhibitory microRNAs (miR). METHODS AND RESULTS: Human coronary artery SMCs (CASMCs) treated with bone morphogenetic protein-2 (BMP-2; 100 ng/mL) demonstrated a 1.7-fold (P<0.02) increase in Runx2 protein expression at 24 hours. A miR microarray and target prediction database analysis independently identified miR-30b and miR-30c (miR-30b-c) as miRs that regulate Runx2 expression. Real-time-polymerase chain reaction confirmed that BMP-2 decreased miR-30b and miR-30c expression. A luciferase reporter assay verified that both miR-30b and miR-30c bind to the 3'-untranslated region of Runx2 mRNA to regulate its expression. CASMCs transfected with antagomirs to downregulate miR-30b-c demonstrated significantly increased Runx2, intracellular calcium deposition, and mineralization. Conversely, forced expression of miR-30b-c by transfection with pre-miR-30b-c prevented the increase in Runx2 expression and mineralization of SMCs. Calcified human coronary arteries demonstrated higher levels of BMP-2 and lower levels of miR-30b than did noncalcified donor coronary arteries. CONCLUSIONS: BMP-2 downregulates miR-30b and miR-30c to increase Runx2 expression in CASMCs and promote mineralization. Strategies that modulate expression of miR-30b and miR-30c may influence vascular calcification.

Pyrazine in supercritical xenon: local number density defined by experiment and calculation.

Toward our goal of using supercritical fluids to study solvent effects in physical and chemical phenomena, we develop a method to spatially define the solvent local number density at the solute in the highly compressible regime of a supercritical fluid. Experimentally, the red shift of the pyrazine n-pi* electronic transition was measured at high dilution in supercritical xenon as a function of pressure from 0 to approximately 24 MPa at two temperatures: one (293.2 K) close to the critical temperature and the other (333.2 K) remote. Computationally, several representative stationary points were located on the potential surfaces for pyrazine and 1, 2, 3, and 4 xenons at the MP2/6-311++G(d,p)/aug-cc-pVTZ-PP level. The vertical n-pi* ((1)B(3u)) transition energies were computed for these geometries using a TDDFT/B3LYP/DGDZVP method. The combination of experiment and quantum chemical computation allows prediction of supercritical xenon bulk densities at which the pyrazine primary solvation shell contains an average of 1, 2, 3, and 4 xenon molecules. These density predictions were achieved by graphical superposition of calculated shifts on the experimental shift versus density curves for 293.2 and 333.2 K. Predicted bulk densities are 0.50, 0.91, 1.85, and 2.50 g cm(-3) for average pyrazine primary solvation shell occupancy by 1, 2, 3, and 4 xenons at 293.2 K. Predicted bulk densities are 0.65, 1.20, 1.85, and 2.50 g cm(-3) for average pyrazine primary solvation shell occupancy by 1, 2, 3, and 4 xenons at 333.2 K. These predictions were evaluated with classical Lennard-Jones molecular dynamics simulations designed to replicate experimental conditions at the two temperatures. The average xenon number within 5.0 A of the pyrazine center-of-mass at the predicted densities is 1.3, 2.1, 3.0, and 4.0 at both simulation temperatures. Our three-component method-absorbance measurement, quantum chemical prediction, and evaluation of prediction with classical molecular dynamics simulation-therefore has a high degree of internal consistency for a system in which the intermolecular interactions are dominated by dispersion forces.