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1.
J Endovasc Ther ; : 15266028241246162, 2024 Apr 12.
Article in English | MEDLINE | ID: mdl-38606923

ABSTRACT

PURPOSE: We performed a large-scale comparison of patients treated for acute limb ischemia (ALI) in the pre-COVID (2017-2019) and COVID (2020-2022) eras to evaluate changes in interventional strategies and compare factors associated with adverse outcomes. We sought to characterize patient outcomes in an evolving ALI treatment algorithm in response to pandemic-associated presentation delays and rapid technological advancements in mechanical thrombectomy (MT). METHODS: Using the TriNetX global research network, we conducted a multicenter query across 80 health care organizations (HCOs) spanning 4 countries for patients treated for ALI. Propensity score matching was performed to account for comorbidities. Risk of adverse outcomes within 30 days was calculated for each era, including re-intervention (RI30), major/minor amputation, and death. Patients were then stratified by initial intervention: open revascularization (OR), MT, or catheter-directed thrombolysis and adjunctive endovascular procedures alone (CDT/EP). Risk of adverse outcomes was compared between treatment groups of the same era. RESULTS: After propensity score matching, the pre-COVID era and COVID era cohorts included 7344 patients each. COVID era patients experienced a statistically significant higher risk of 30-day mortality (RR=1.211, p=0.027). Mechanical thrombectomy interventions were performed more frequently in the COVID era (RR=1.314, p<0.0001). Comparing outcomes between treatment groups, MT patients required RI30 more than OR patients (pre-COVID: RR=2.074, p=0.006; COVID: RR=1.600, p=0.025). Open revascularization patients had higher 30-day mortality (pre-COVID: RR=2.368, p<0.0001; COVID: RR=2.013, p<0.0001) and major amputations (pre-COVID: RR=2.432, p<0.0001; COVID: RR=2.176, p<0.0001) than CDT/EP. Pre-COVID CDT/EP patients were at higher risk for RI30 (RR=1.449, p=0.005) and minor amputations (RR=1.500, p=0.010) than OR. The MT group had higher major amputation rates than CDT/EP (pre-COVID: RR=2.043, p=0.019; COVID: RR=1.914, p=0.007). COVID-era MT patients had greater 30-day mortality (RR=1.706, p=0.031) and RI30 (RR=1.544, p=0.029) than CDT/EP. CONCLUSION: Significant shifts toward an MT-based approach have been observed in the last 3 years. Although MT required more RI30 than OR, there was no associated consequence of mortality and limb salvage. The increased mortality seen among COVID-era patients could be explained by delayed presentation, as well as poorly understood pro-thrombogenic or pro-inflammatory mechanisms related to the first waves of COVID. More research is necessary to determine an optimal treatment algorithm. CLINICAL IMPACT: Comorbid risk factors and severity of ischemia must be carefully considered before selecting an interventional strategy to prevent adverse outcomes and maximize limb salvage. Open revascularization strategies are associated with increased mortality and limb loss compared to less-invasive thrombolytic therapy alone. Mechanical thrombectomy (MT)-based approaches have been increasingly used in the last 3 years. Patients receiving MT are more likely to require reintervention within 30 days.

2.
Vascular ; : 17085381241240679, 2024 Mar 23.
Article in English | MEDLINE | ID: mdl-38520224

ABSTRACT

OBJECTIVE: The COVID-19 pandemic has drastically altered the medical landscape. Various strategies have been employed to preserve hospital beds, personal protective equipment, and other resources to accommodate the surges of COVID-19 positive patients, hospital overcapacities, and staffing shortages. This has had a dramatic effect on vascular surgical practice. The objective of this study is to analyze the impact of the COVID-19 pandemic on surgical delays and adverse outcomes for patients with chronic venous disease scheduled to undergo elective operations. METHODS: The Vascular Surgery COVID-19 Collaborative (VASCC) was founded in March 2020 to evaluate the outcomes of patients with vascular disease whose operations were delayed. Modules were developed by vascular surgeon working groups and tested before implementation. A data analysis of outcomes of patients with chronic venous disease whose surgeries were postponed during the COVID-19 pandemic from March 2020 through February 2021 was performed for this study. RESULTS: A total of 150 patients from 12 institutions in the United States were included in the study. Indications for venous intervention were: 85.3% varicose veins, 10.7% varicose veins with venous ulceration, and 4.0% lipodermatosclerosis. One hundred two surgeries had successfully been completed at the time of data entry. The average length of the delay was 91 days, with a median of 78 days. Delays for venous ulceration procedures ranged from 38 to 208 days. No patients required an emergent intervention due to their venous disease, and no patients experienced major adverse events following their delayed surgeries. CONCLUSIONS: Interventions may be safely delayed for patients with venous disease requiring elective surgical intervention during the COVID-19 pandemic. This finding supports the American College of Surgeons' recommendations for the management of elective vascular surgical procedures. Office-based labs may be safe locations for continued treatment when resources are limited. Although the interventions can be safely postponed, the negative impact on quality of life warrants further investigation.

3.
Tex Heart Inst J ; 50(2)2023 03 01.
Article in English | MEDLINE | ID: mdl-36996381

ABSTRACT

Thoracic endovascular aortic repair has become the preferred modality of treatment of complicated type B aortic dissections. However, persistent pressurization of the false lumen can lead to negative aortic remodeling with aneurysmal dilation. Described herein is the coil embolization technique that can be used to manage this complication and a review of the literature on the recent development of management options.


Subject(s)
Aortic Aneurysm, Thoracic , Aortic Dissection , Blood Vessel Prosthesis Implantation , Endovascular Procedures , Humans , Treatment Outcome , Aortography/methods , Retrospective Studies , Aortic Aneurysm, Thoracic/diagnosis , Aortic Aneurysm, Thoracic/surgery , Aortic Dissection/diagnostic imaging , Aortic Dissection/surgery , Stents
5.
J Vasc Surg Cases Innov Tech ; 7(4): 627-629, 2021 Dec.
Article in English | MEDLINE | ID: mdl-34693090

ABSTRACT

Mobile thrombus of the nonaneurysmal, nonatherosclerotic aorta is a rare condition but presents with catastrophic embolic events. We describe two cases that demonstrate differences in presentation and treatment strategies. We review the literature to discuss initial management as well as surgical options. However, due to the limited number of cases, no definitive guidelines for management exist.

7.
Proc (Bayl Univ Med Cent) ; 33(4): 666-667, 2020 Aug 12.
Article in English | MEDLINE | ID: mdl-33100564

ABSTRACT

Thrombotic complications such as venous thromboembolism, ischemic stroke, and myocardial infarction have emerged as causes of significant morbidity and mortality in patients infected with COVID-19. We present a 32-year-old man who developed a large saddle pulmonary embolus secondary to COVID-19 infection and underwent successful bilateral percutaneous pulmonary artery mechanical thrombectomy.

8.
J Vasc Surg Cases Innov Tech ; 5(2): 132-135, 2019 Jun.
Article in English | MEDLINE | ID: mdl-31193401

ABSTRACT

Mycotic pseudoaneurysms (MPs) rarely affect the aortic arch vessels and usually require surgical resection for definitive treatment. In this case, a 58-year-old woman developed a bleeding innominate artery MP after primary lung cancer resection complicated by an infected chest wound. Because of her previous surgery, irradiation, and chest wall reconstruction, she was not a candidate for open resection. A hybrid endovascular approach successfully excluded her innominate artery MP through placement of an aortic arch stent graft. Cerebral circulation was maintained through a periscoped left common carotid artery stent graft to the descending thoracic aorta graft, which supplied a left-to-right carotid-carotid bypass.

9.
Am J Public Health ; 108(9): 1109, 2018 09.
Article in English | MEDLINE | ID: mdl-30088993
11.
Perioper Med (Lond) ; 6: 23, 2017.
Article in English | MEDLINE | ID: mdl-29238570

ABSTRACT

BACKGROUND: The ASA physical classification score has a major impact on the observed/expected (O/E) mortality ratio in the NSQIP General Vascular Mortality Model. The difference in predicted mortality is greatest between ASAs 3 and 4. We hypothesized under-classified ASA scores significantly affect the O/E mortality. METHODS: We conducted a retrospective review of NSQIP essential surgery cases from January 2014 to December 2014 (n = 1264) with mortality sub-analysis (n = 33) at our institution. We recorded transfer and emergency status and independently calculated the ASA score for mortalities using published definitions. A random sample of 50 survivors and 10 emergency survivors were reviewed and ASA recalculated. We performed statistical modeling to simulate the effects of ASA misclassifications. Statistical analysis was performed using JMP 10 and SAS 9.4. RESULTS: ASA was under-classified in 18.2% of mortalities, most commonly ASAs 3 and 4. Sixteen percent of ASA 3 survivors were misclassified, including 60% in the emergency subgroup (p < 0.05 vs. elective cases). Patients transferred from other institutions were more likely to be emergency cases than non-transferred patients (43.5 vs. 7.84%, p < 0.05). Transferred patients had a higher proportion of ASAs 3-5 vs. ASAs 1-2 compared with non-transfers (84.38 vs. 49.76%, p < 0.05) Simulation data showed ASA misclassification underestimated predicted mortality by 2.5 deaths on average. CONCLUSION: ASA misclassification significantly impacts O/E mortality. With accurate ASA classification, observed mortality would not have exceeded expected mortality in our institution. Education regarding the impact of ASA scoring is critical to ensure accurate O/E mortality data at hospitals using NSQIP to assess surgical quality.

14.
Lancet ; 381(9864): 385-93, 2013 Feb 02.
Article in English | MEDLINE | ID: mdl-23218813

ABSTRACT

BACKGROUND: Enteral nutrition (EN) is recommended for patients in the intensive-care unit (ICU), but it does not consistently achieve nutritional goals. We assessed whether delivery of 100% of the energy target from days 4 to 8 in the ICU with EN plus supplemental parenteral nutrition (SPN) could optimise clinical outcome. METHODS: This randomised controlled trial was undertaken in two centres in Switzerland. We enrolled patients on day 3 of admission to the ICU who had received less than 60% of their energy target from EN, were expected to stay for longer than 5 days, and to survive for longer than 7 days. We calculated energy targets with indirect calorimetry on day 3, or if not possible, set targets as 25 and 30 kcal per kg of ideal bodyweight a day for women and men, respectively. Patients were randomly assigned (1:1) by a computer-generated randomisation sequence to receive EN or SPN. The primary outcome was occurrence of nosocomial infection after cessation of intervention (day 8), measured until end of follow-up (day 28), analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00802503. FINDINGS: We randomly assigned 153 patients to SPN and 152 to EN. 30 patients discontinued before the study end. Mean energy delivery between day 4 and 8 was 28 kcal/kg per day (SD 5) for the SPN group (103% [SD 18%] of energy target), compared with 20 kcal/kg per day (7) for the EN group (77% [27%]). Between days 9 and 28, 41 (27%) of 153 patients in the SPN group had a nosocomial infection compared with 58 (38%) of 152 patients in the EN group (hazard ratio 0·65, 95% CI 0·43-0·97; p=0·0338), and the SPN group had a lower mean number of nosocomial infections per patient (-0·42 [-0·79 to -0·05]; p=0·0248). INTERPRETATION: Individually optimised energy supplementation with SPN starting 4 days after ICU admission could reduce nosocomial infections and should be considered as a strategy to improve clinical outcome in patients in the ICU for whom EN is insufficient. FUNDING: Foundation Nutrition 2000Plus, ICU Quality Funds, Baxter, and Fresenius Kabi.


Subject(s)
Critical Illness/therapy , Parenteral Nutrition , Cross Infection/prevention & control , Dietary Proteins , Energy Intake , Enteral Nutrition , Female , Humans , Intensive Care Units , Male , Middle Aged
15.
J Pediatr Surg ; 47(11): 2123-5, 2012 Nov.
Article in English | MEDLINE | ID: mdl-23164008

ABSTRACT

Although it rarely occurs in children, acute arterial thromboembolism can cause significant morbidity and mortality. Rapid diagnosis and prompt treatment can increase the chances of survival with a functional limb. We describe the case of a 10-year-old boy with acute bilateral lower extremity ischemia due to arterial thromboemboli originating from a rare cancer. We discuss diagnosis of and treatment strategies for acute arterial thromboembolism in the pediatric population, as well as the rare cancer the patient was diagnosed with.


Subject(s)
Carcinoma/diagnosis , Iliac Artery , Nuclear Proteins/genetics , Oncogene Proteins/genetics , Peripheral Vascular Diseases/etiology , Popliteal Artery , Thoracic Neoplasms/diagnosis , Thromboembolism/etiology , Acute Disease , Carcinoma/complications , Carcinoma/genetics , Child , Fatal Outcome , Genetic Markers , Humans , Iliac Artery/diagnostic imaging , Iliac Artery/pathology , Male , Neoplasm Proteins , Peripheral Vascular Diseases/diagnosis , Popliteal Artery/diagnostic imaging , Popliteal Artery/pathology , Radiography , Thoracic Neoplasms/complications , Thoracic Neoplasms/genetics , Thromboembolism/diagnosis
16.
Prev Med ; 55(5): 351-2, 2012 Nov.
Article in English | MEDLINE | ID: mdl-23122058
19.
Prev Med ; 55(3): 161-2, 2012 Sep.
Article in English | MEDLINE | ID: mdl-22963883
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