Journal of Vascular Surgery最新文献

Objective: Peripheral artery disease (PAD) is one of the most prevalent forms of cardiovascular (CV) disease, with many progressing to CV morbidity/death. Adherence to guideline-directed optimal medical therapy (OMT) in PAD is vital. This study evaluated provider adherence to OMT patients with PAD.

Methods: A retrospective cohort study of 3,471 patients with PAD undergoing vascular laboratory imaging between 2017 and 2022 at a single large, academic, tertiary referral center. OMT was defined by 2016 AHA guidelines. Adherence to guidelines was denoted by active prescriptions for antiplatelet and statin. Presence of high-intensity OMT (HIOMT) was defined as prescriptions for an antiplatelet and high-intensity statin. Prevalence and incidence (change to OMT/HIOMT within 60 days of index ABI) were evaluated. Multivariable models were created evaluating predictors of OMT and HIOMT prevalence and incidence.

Results: OMT prevalence was 45.3% while HIOMT prevalence was 23.6% at the time of index vascular laboratory. Incident OMT was 24.3% while incident HIOMT was 11.2% within 60 days. Age, min/max ABI, insurance status, smoking status, and comorbidities were associated with prevalent OMT/HIOMT. Age, gender, min/max ABI, smoking status, and HgbA1c were associated with incident HIOMT. In multivariable models, incident HIOMT was less common for females (OR 0.7; 0.52-0.91) whereas lower ABIs were predictive of HIOMT (OR 0.6; 0.51-0.72).

Conclusions: Despite clear guidelines regarding OMT for patients with atherosclerotic cardiovascular disease, in this real-world study of guideline directed management of PAD, adherence to OMT remains low, especially for HIOMT. Predictors of appropriate HIOMT prescription include lower ABI and non-female sex. Given the high prevalence of PAD, the heterogeneity of caregivers, and the widespread availability of screening, this population should be targeted for better adherence to HIOMT to prevent CV morbidity and death.

Introduction: Strategies to treat co-prevalent carotid and coronary artery disease include carotid endarterectomy (CEA) or stenting (CAS) with coronary artery bypass graft (CABG). There is uncertainty with respect to treatment utilization frequency. The objective of this study is to describe trends in the volume of CABGs performed concurrently with staged or combined CEA/CAS spanning a two-decade period and identify factors associated with utilization.

Methods: A nationally representative cohort was developed using National Inpatient Sample data from 1998 to 2020, identifying patients undergoing concurrent CABG and carotid revascularization. We included patients undergoing either CABG/CEA or CABG/CAS. Sample-weighted volumes of both staged (CABG+CEA/CAS during the same admission) and combined (both procedures on the same day) strategies were used to describe trends. Poisson regression were used to identify factors predicting increased procedure volume. Interactions between strategy and procedure year, and facility CABG volume and strategy were tested.

Results: We analyzed 12,260 patients who underwent CABG with concurrent carotid revascularization, of which 9,702 (79.1%) were staged and 2,558 (20.9%) were combined. In both the staged and combined groups, a significantly greater frequency of patients underwent CEA compared to CAS (97.5% and 91.7%, respectively; p<0.001). In the multivariable model and as time progressed, concurrent volume decreased by 7% per year - a decrease observed across both staged and combined operations. Concurrent procedure volume significantly increased in urban relative to rural hospitals, with urban teaching hospitals reporting higher volume (urban non-teaching hospitals [IRR = 2.06, 95% CI: 1.87, 2.27]; urban teaching hospitals [IRR = 3.01, 95% CI: 2.73, 3.32]). Interactions between strategy, procedure year, and facility CABG volume were not statistically significant.

Conclusions: In a recent 20-year period, utilization of concurrent CABG/CEA and CABG/CAS operations decreased significantly, independent of timing strategy (either staged or combined). Resource allocation and guideline planning should consider the relative frequency of these operations.

Background: Endovascular treatment (EVT) for patients with an occlusive lesion of the femoropopliteal artery is performed worldwide due to its effectiveness. However, lesions in chronic limb-threatening ischemia (CLTI) are complex and a major concern in superficial femoral artery (SFA) EVT. Despite this, a detailed study of SFA EVT, and especially selection of the final device as a drug-coated balloon (DCB) or a stent, has not been performed in patients with CLTI.

Objectives: To compare the clinical outcomes of SFA EVT using a DCB or a stent in patients with CLTI.

Methods: A multicenter retrospective observational study was performed at 21 Japanese centers. Comparisons were made between patients undergoing initial SFA EVT with a DCB or stenting after inverse probability of treatment weighting (IPTW) using the propensity score to control for potential confounding (patient demographics, comorbidities, medications, and procedural details). The primary outcome measure was major adverse limb events (MALE). We adopted cause-specific hazard models, using Fine and Gray's proportional hazards model in which death was treated as a competing risk. Secondary outcome measures were also evaluated: 1) technical success, 2) slow flow, 3) death within 30 days, 4) major adverse events within 30 days, 5) restenosis, 6) target lesion revascularization (TLR), 7) acute occlusion, 8) wound healing, 9) major amputation, and 10) all-cause mortality.

Results: The study included 900 CLTI cases that underwent EVT with a DCB (n=458) or stenting (n=442) and had a median follow-up period of 17.5 (interquartile range, 6.2-31.9) months. The DCB group had a lower risk of MALE than the stent group, with a hazard ratio of .68 (95% confidence interval (CI), .52-.89; P=.005). Subsequent analysis for the secondary outcome measures demonstrated that the DCB group had a higher prevalence of postprocedural slow flow and a lower incidence rate of acute occlusion (both P < .005 after Bonferroni correction).

Conclusions: DCB angioplasty had a lower risk of MALE than stenting. These results suggest that a DCB might be more beneficial in initial SFA intervention in patients with CLTI.

Objective: Chronic limb-threatening ischemia (CLTI) patients typically undergo revascularization as the standard treatment. However, some still require major amputations post-revascularization. Since revascularization is invasive and costly, avoiding it may benefit patients with low likelihoods of wound healing. The Global Vascular Guidelines suggest primary amputation for patients unsuited to revascularization. While previous research has linked frailty to limb prognosis, skeletal and bone frailties impact survival rather than limb outcomes. This study examines the association between sciatic nerve atrophy and limb prognosis in CLTI patients.

Methods: This single-center, retrospective study included patients with tissue loss CLTI who underwent successful revascularizations at Kyushu Medical Center (2015-2020). Sciatic nerve cross-sectional areas (CSAs) were measured using CT scans above the bifurcation of the tibial and peroneal nerves. The CSA cutoff value for predicting wound healing was established using receiver operating characteristic analysis. Patients were grouped based on whether their CSA was larger (normal) or smaller (atrophy) than CSA cutoff value. Outcomes assessed included wound healing rates, amputation-free survival (AFS), and overall survival (OS).

Results: Among 188 patients (226 limbs), the mean sciatic nerve CSA was 27.5 ± 0.7 mm². A CSA cutoff of 23.6 mm² (AUC (area under the curve) = 0.81; sensitivity = 0.85; specificity = 0.71) was identified. Patients were categorized into normal (n = 147) and atrophy (n = 79) groups. The atrophy group had higher rates of non-ambulatory status (38% vs 23%, P = .029), ischemic heart disease (47% vs 28%, P = .008), cerebrovascular disease (50% vs 35%, P = .045), end-stage renal disease (55% vs 37%, P = .024), and lower serum albumin (3.3 ± 0.06 vs 3.6 ± 0.05, P = 0.001). Six-month wound healing rates were 87.3% in the normal group versus 27.3% in the atrophy group (P < .001). Three-year AFS was 59.3% in the normal group versus 20.0% in the atrophy group (P < .001), and 3-year OS was 71.3% versus 57.8% (P = .022). Factors associated with impaired wound healing included age (HR = 1.01, P = .045), low serum albumin (HR = 1.80, P = .001), ischemic heart disease (HR = 1.75, P = .002), end-stage renal disease (HR = 1.71, P = .002), and sciatic nerve atrophy (HR = 5.21, P < .001). Multivariate analysis identified age (HR = 1.02, P = .012) and sciatic nerve atrophy (HR = 5.08, P < .001) as independent risk factors for impaired wound healing after revascularizations.

Conclusion: Sciatic nerve atrophy correlates with poorer wound healing, AFS, and OS in CLTI patients. Sciatic nerve assessment may guide decisions regarding limb salvage eligibility.

Objective: Length of stay (LOS) is a key quality metric for the Society for Vascular Surgery's Vascular Quality Initiative (VQI). In 2021, our hospital was an outlier for 'prolonged LOS' after carotid endarterectomy (CEA >1 day, 67% vs target 21%) and endovascular aortic aneurysm repair (EVAR >2 days, 36% vs target 22%). In response, we launched a quality improvement (QI) initiative to reduce LOS following elective CEA and EVAR.

Methods: We completed a retrospective review of all CEA and EVAR cases (1/2021 to 3/2022) using data obtained from VQI. During the intervention phase (4/2022 to 7/2023), a multidisciplinary team defined the problem state, refined workflows, used Plan-Do-Study-Act method to address key drivers, and maintained a prospective database of patients and LOS outcomes. Preoperative interventions educated patient stakeholders (e.g., nurses, case managers, trainees) on LOS benchmarks, communicated expected discharge date and time to patients/families, and screened all patients for high-risk discharge, leading to prolonged LOS. After surgery, recovery protocols were standardized, including Foley catheter removal midnight POD0 and physical therapy evaluation morning POD1. Primary outcomes, rates of prolonged LOS and mean LOS (days, hours), and secondary outcomes (discharge within 1 day, readmission, mortality) were compared pre and post-intervention.

Results: Overall, 120 patients were included (48 CEA, 72 EVAR) with 52 (22 CEA, 31 EVAR) pre-intervention and 67 (26 CEA, 41 EVAR) post-intervention. Over the intervention, rate of prolonged LOS significantly decreased from 50% to 15% for CEA (P=.01) and 26% to 7% for EVAR (P=.03). While mean LOS decreased for CEA from 2.2 ± 3.1 days to 1.2 ± 0.5 days (52.7 ± 75.7 hours to 27.7 ± 12.0 hours) and for EVAR from 2.3 ± 1.8 days to 1.5 ± 1.5 days (55.1 ± 43.2 hours to 36.9 ± 35.5 hours). Patients discharged within 1 day from surgery significantly increased from 50% to 85% for CEA and 45% to 76% for EVAR (both P=.01). Balancing measures of 30-day readmission and mortality did not significantly increase following our intervention with three readmissions overall and no deaths in either cohort. Our Fall 2023 VQI Regional Report confirmed these findings with reduced LOS for CEA and EVAR below regional and national targets.

Conclusions: VQI benchmarking identifies system-wide, surgeon-specific QI opportunities. Through engaging multidisciplinary teams and implementing patient-centric interventions across the care continuum, we successfully reduced LOS for CEA and EVAR below VQI targets.