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2.
Ann Vasc Surg ; 52: 153-157, 2018 Oct.
Article in English | MEDLINE | ID: mdl-29885432

ABSTRACT

BACKGROUND: Recently published reports have shown that the American Society of Anesthesiology (ASA) classification system has limited applicability in vascular surgery patients. Most patients undergoing vascular procedures are designated as ASA class III, limiting discrimination in preoperative risk assessment. The 2006 National Surgical Quality Improvement Project (NSQIP), containing over 170,000 surgical cases, demonstrated that functional status is an important predictor of mortality. We propose that dividing ASA class III into 2 subgroups, based on NSQIP-defined functional status, improves the predictive value of the ASA scheme. METHODS: The 2006 NSQIP database was queried for ASA class III patients undergoing vascular surgery procedures. Patients were divided into groups IIIA and IIIB based on independent or dependent (partial or complete) functional status, respectively. Difference in 30-day survival between subgroups was evaluated using Kaplan-Meier and logistic regression analyses. Differences in postoperative morbidity and length of stay were compared using the unpaired t-test. RESULTS: ASA class III patients having undergone vascular surgery procedures numbered 11,555 (68%). Of those 9,913 (85.7%) patients were independent (IIIA), and 1,642 (14.3%) were dependent (IIIB). Mean 30-day mortality was 1.3% in subgroup IIIA, and 6.5% in IIIB (logrank P < 0.001, χ2, 137.8). Mean lengths of stay between subgroups IIIA and IIIB were 5.4 and 13.2 days (P < 0.001). The risk of NSQIP-defined postoperative complications was 0.16 in IIIA and 0.32 in IIIB (P < 0.001). CONCLUSIONS: A 5-fold difference in mortality was observed between patients who were functionally independent and dependent. A significant increase in length of stay and incidence of postoperative complications was also observed in subgroup IIIB. Subdividing ASA class III vascular surgery patients markedly improves the value of the ASA classification system. Given the "high-risk" nature of patients with vascular disease, the addition of functional status to the preoperative assessment will assist in predicting outcomes in this patient population.


Subject(s)
Decision Support Techniques , Health Status Indicators , Vascular Diseases/surgery , Vascular Surgical Procedures , Clinical Decision-Making , Databases, Factual , Health Status , Humans , Incidence , Length of Stay , Postoperative Complications/mortality , Predictive Value of Tests , Retrospective Studies , Risk Assessment , Risk Factors , Time Factors , Treatment Outcome , United States/epidemiology , Vascular Diseases/diagnosis , Vascular Diseases/mortality , Vascular Diseases/physiopathology , Vascular Surgical Procedures/adverse effects , Vascular Surgical Procedures/mortality
4.
J Am Coll Surg ; 222(6): 992-1000.e1, 2016 06.
Article in English | MEDLINE | ID: mdl-27118714

ABSTRACT

BACKGROUND: Our goal was to develop a predictive model that identifies how preoperative risk factors and perioperative complications lead to mortality after anatomic pulmonary resections. STUDY DESIGN: This was a retrospective cohort study. The American College of Surgeons NSQIP database was examined for all patients undergoing elective lobectomies for cancer from 2005 through 2012. Fifty-eight pre- and intraoperative risk factors and 13 complications were considered for their impact on perioperative mortality within 30 days of surgery. Multivariate logistic regression and a logistic regression model using least absolute shrinkage and selection operator (LASSO) selection methods were used to identify preoperative risk factors that were significant for predicting mortality, either through or independent of complications. Only factors that were significant under both the multivariate logistic regression and LASSO-selected models were considered to be validated for the final model. RESULTS: There were 6,435 lobectomies identified. After multivariate logistic regression modeling, 28 risk factors and 5 complications were found to be predictors for mortality. This was then tested against the LASSO method. There were 7 factors shared between the LASSO and multivariate logistic regressions that predicted mortality based on comorbidity: age (p = 0.007), male sex (p = 0.011), open lobectomy (p = 0.001), preoperative dyspnea at rest (p < 0.001), preoperative dyspnea on exertion (p = 0.003), preoperative dysnatremia (serum sodium <135 mEq/L or >145 mEq/L) (p = 0.011), and preoperative anemia (p = 0.002). Of these, 3 variables predicted mortality independent of any complications: dyspnea at rest, dyspnea on exertion, and dysnatremia. CONCLUSIONS: The clinical factors that predict postoperative complications and mortality are multiple and not necessarily aligned. Efforts to improve quality after anatomic pulmonary resections should focus on mechanisms to address both types of adverse outcomes.


Subject(s)
Lung Neoplasms/surgery , Pneumonectomy/mortality , Postoperative Complications/etiology , Adult , Aged , Aged, 80 and over , Databases, Factual , Female , Humans , Logistic Models , Lung Neoplasms/mortality , Male , Middle Aged , Postoperative Complications/mortality , Preoperative Period , Retrospective Studies , Risk Factors , Treatment Outcome
5.
Interact Cardiovasc Thorac Surg ; 15(3): 514-5, 2012 Sep.
Article in English | MEDLINE | ID: mdl-22645294

ABSTRACT

A 64-year old male with a prior medical history of bladder transitional cell carcinoma treated with a cystoprostatectomy and adjuvant platinum-based chemotherapy 10 years earlier underwent a surveillance positron emission tomography (PET) scan that revealed a metabolically active 2-cm nodule in the superior mediastinum, anterior to the origin of the innominate artery. The lesion was removed due to concerns of metastatic disease using a cervical mediastinoscope. Final pathology revealed an ectopic mediastinal parathyroid adenoma. The combination of the rare presentation, uncommon surgical approach and pathology makes this case unique.


Subject(s)
Carcinoma, Transitional Cell/secondary , Fluorodeoxyglucose F18 , Mediastinal Neoplasms/secondary , Parathyroid Neoplasms/diagnostic imaging , Positron-Emission Tomography/methods , Urinary Bladder Neoplasms/pathology , Carcinoma, Transitional Cell/complications , Carcinoma, Transitional Cell/diagnosis , Diagnosis, Differential , Humans , Male , Mediastinal Neoplasms/complications , Mediastinal Neoplasms/diagnostic imaging , Middle Aged , Parathyroid Neoplasms/complications , Radiopharmaceuticals , Urinary Bladder Neoplasms/complications , Urinary Bladder Neoplasms/diagnostic imaging
6.
Vascular ; 20(1): 46-8, 2012 Feb.
Article in English | MEDLINE | ID: mdl-22328621

ABSTRACT

Degenerative arterial aneurysms can occur in any vascular territory. However, they are exceedingly rare in the axillary artery. Complications of axillary artery aneurysms may result in acute vascular insufficiency and neurological deficits. Prompt treatment should be employed in the management of this condition. We report a case of an atraumatic degenerative axillary artery aneurysm that was treated with transaxillary open surgical bypass.


Subject(s)
Aneurysm/surgery , Axillary Artery/surgery , Blood Vessel Prosthesis Implantation , Aged, 80 and over , Aneurysm/diagnostic imaging , Axillary Artery/diagnostic imaging , Brachial Artery/surgery , Female , Humans , Tomography, X-Ray Computed , Treatment Outcome
7.
J Vasc Surg ; 54(5): 1475-7, 2011 Nov.
Article in English | MEDLINE | ID: mdl-21723062

ABSTRACT

Fungal arterial infections are well-described entities resulting in direct invasion of the arterial wall or embolic occlusion of small and medium-sized arteries. However, acute occlusion of large vessels such as the aorta by fungal material is exceedingly rare. A 53-year-old woman presented with acute bilateral lower extremity ischemia. She had a history of fungal endocarditis requiring two prosthetic mitral valve replacements; the last episode was 7 months before the current admission. Imaging studies revealed that she had an acute infrarenal aortic occlusion, with evidence of multiple end-organ emboli. After transfemoral thromboembolectomy, perfusion was restored to her lower extremities with minor neurologic sequelae. She ultimately responded to intravenous antifungal agents.


Subject(s)
Aorta/microbiology , Arterial Occlusive Diseases/microbiology , Candida albicans/pathogenicity , Candidiasis/microbiology , Embolism/microbiology , Endocarditis/microbiology , Ischemia/microbiology , Lower Extremity/blood supply , Acute Disease , Antifungal Agents/administration & dosage , Aortography/methods , Arterial Occlusive Diseases/diagnostic imaging , Arterial Occlusive Diseases/therapy , Candida albicans/isolation & purification , Candidiasis/diagnosis , Candidiasis/therapy , Embolectomy , Embolism/diagnostic imaging , Embolism/therapy , Endocarditis/therapy , Female , Heart Valve Prosthesis Implantation , Humans , Ischemia/diagnostic imaging , Ischemia/therapy , Middle Aged , Tomography, X-Ray Computed , Treatment Outcome
8.
J Am Coll Surg ; 206(4): 645-53, 2008 Apr.
Article in English | MEDLINE | ID: mdl-18387469

ABSTRACT

BACKGROUND: Two decade-old studies of cardiopulmonary bypass (CPB) patients documented a 25% to 35% incidence of postoperative hyperbilirubinemia, associated with increased in-hospital morbidity and mortality. Longterm consequences of this complication are unknown. STUDY DESIGN: Medical records of CPB patients were reviewed. Mortality was ascertained through the National Death Index. Proportional hazards determined important factors in post-CPB survival. Logistic regression delineated predictors of hyperbilirubinemia. Kaplan-Meier and Mantel-Cox log-rank survival analyses compared hyperbilirubinemia groups. RESULTS: Bilirubin levels were followed in 826 (59.7%) patients. Bilirubin was normal in 570 (69.0%) patients (group 1), it was 1.4 to 2.8 mg/dL in 184 (22.3%) patients (group 2), and it exceeded 2.8 mg/dL in 72 (8.7%) patients (group 3). Elevated bilirubin was associated with decreased body mass index, congestive heart failure, heparin before operation, postoperative transfusion requirement, bleeding, and renal failure. In-hospital mortality was 4.3% in group 2 and 25.0% in group 3, compared with 0.9% in group 1 (p<0.001). Two-year crude survival was 95.8% in group 1, 84.8% in group 2, and 62.5% in group 3 (p<0.001). Multivariable predictors of longterm mortality were older age, history of stroke, emergency operation, increased duration of cardiopulmonary bypass, respiratory failure, and elevated bilirubin. Compared with survival in group 1, there was a 1.7-fold decrease in group 2 2-year survival (95% CI 0.9 to 3.0; p=0.09) and a 3.8-fold decrease in group 3 survival (95% CI 2.0 to 7.2; p<0.001). CONCLUSIONS: Postoperative bilirubin elevation in CPB patients is common and deadly. The predictive power of hyperbilirubinemia is similar to that of respiratory failure. The cause of postbypass hyperbilirubinemia is unknown and is probably multifactorial. Additional prospective studies are warranted.


Subject(s)
Cardiopulmonary Bypass/adverse effects , Hyperbilirubinemia/etiology , Aged , Aged, 80 and over , Bilirubin/blood , Female , Hospital Mortality , Humans , Male , Middle Aged , Morbidity , Postoperative Period , Predictive Value of Tests , Retrospective Studies , Survival Analysis , Time Factors , Treatment Outcome
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