JVS-vascular insights最新文献

Objective

The aim of this study was to review the most commonly used percutaneous mechanical thrombectomy devices for the treatment of pulmonary embolism today.

Methods

A thorough search of the existing literature was conducted on commonly used percutaneous mechanical thrombectomy devices, most notably Inari Flowtriever, Penumbra’s Indigo Aspiration, and Alphavac. Reported qualitative and quantitative information was abstracted and descriptively reviewed to ascertain the clinical utility and effectiveness of these devices.

Results

Inari Flowtriever is one of the most frequently utilized thrombectomy devices with the most substantive industry-sponsored trial data. Penumbra’s Indigo Aspiration is one of the up-and-coming devices that presents certain caveats in addition to the commonly utilized features of a percutaneous mechanical thrombectomy device, making it a viable alternative. Other newer devices such as Alphavac still lack substantial data, with some other lesser-known devices sporadically used and showing limited, primarily anecdotal evidence.

Conclusions

Each device has its positives and negatives. Data are growing on the clinical utility of these devices as their use is becoming more common. However, the long-term durability and overall cost-effectiveness remains to be determined.

Objective

The COVID-19 pandemic caused significant stress on health care systems, leading to altered care processes (ie, altered treatment algorithms, supply shortages, and personnel shortages). However, the effect of COVID and subsequent altered care processes on many surgical outcomes has not been characterized. In particular, patient outcomes after endovascular aortic repair (EVAR) for ruptured abdominal aortic aneurysm (rAAA) have not been well reported. Using COVID prevalence as a surrogate for altered processes of care, our aim is to determine changes in COVID-negative patient outcomes after EVAR for rAAA.

Methods

Using the Center for Disease Control COVID-19 data, COVID mortality per 3-month quarter was calculated in Florida. The quarters with the three highest mortality rates and three lowest mortality rates were used to establish COVID-heavy and COVID-light timeframes, respectively. Three quarters of 2019 were used for the pre-COVID timeframe for comparison. The Florida Agency for Health Care Administration database was queried using International Classification of Diseases-10 codes to identify patients diagnosed with rAAA who underwent EVAR during each timeframe. COVID-positive patients were excluded. Primary outcomes were in-hospital mortality, morbidity, and length of stay. Stepwise linear and logistic regression with 10-fold cross-validation determined which factors most impacted primary outcomes. Secondary outcomes included individual complication rates.

Results

A total of 316 patients were included. There were no significant differences in surgical volume, demographics, or comorbidities except that more patients had peripheral vascular disease in the COVID-light timeframe compared with the pre-COVID timeframe (P = .01). Mortality, length of stay, and complications were not significantly different per timeframe on univariable analysis. Regression confirmed that timeframe was not significantly associated with any primary outcome.

Conclusions

Despite increased stress on the health care system during the COVID-19 pandemic, outcomes after EVAR for rAAA were unchanged in Florida. These results imply that despite periods of COVID-heavy stress on the health care system, patient care was maintained at the pre-COVID standard of care.

Background

We assessed the skill acquisition, operative competency, and confidence of vascular surgery residents during a limb angioplasty workshop and evaluated their surgical volume and retention rate at 1 year.

Methods

For 3 years (2018-2020), all residents and fellows in their final year of vascular residency at a teaching hospital were enrolled. Five residents in 2018 were enrolled in the control group (apprenticeship model). Twelve residents and fellows from 2019 (training group) and 2020 (coronavirus disease 2019 [COVID-19] group) were trained using the ANGIO Mentor (Simbionix Ltd, Airport City, Israel) in two workshops. The residents were evaluated using the Objective Structured Assessment of Technical Skills, simulator metrics, and a confidence questionnaire. A P value of < .05 was considered statistically significant.

Results

The groups were similar in age, sex, and number of limb angioplasties performed (control group, 25.00 ± 5.52; training group, 23.16 ± 7.44; COVID-19 group, 24.50 ± 8.17; P = .91, Student t test). The residents of the training and COVID-19 groups showed significantly improved Objective Structured Assessment of Technical Skills scores after the first workshop (from 15.5 [interquartile range (IQR), 12.62-19.13] to 29.5 [IQR, 25.25-39.38]; and from 14.50 [IQR, 13.62-15.00] to 23.5 [IQR, 21.87-24]; P < .001]; respectively) and reported confidence improvement (from a median of 3 [IQR, 3-3] to 4 [IQR, 4-5]; P = .01). After 6 months, the retention rate was good. During that semester, each resident performed a median of 10.50 limb angioplasties (IQR, 7.00-13.25 limb angioplasties). The second workshop did not improve either the residents' scores or their confidence. At the end of the year, the control group scored worse than did the training and control groups (control group, 23.50 [IQR, 19.00-24.50]; training group, 37.0 [IQR, 36.50-39.37]; COVID-19 group, 34.75 [IQR, 30.75-38.75]; P = .005, Kruskal-Wallis test). The simulation metrics did not show significant differences among the groups.

Conclusions

A 3-week limb angioplasty workshop can improve residents' skills and confidence. Performing 10 angioplasties per semester is sufficient to ensure the retention rate is good after 6 months, and a second workshop is unnecessary.

Objective

Intravascular ultrasound (IVUS) is a useful adjunct to obtain precise intraluminal measurements during thoracic endovascular aortic repair (TEVAR), but IVUS examination is not routinely used by all surgeons or centers during TEVAR. We sought to identify patient- and system-related factors that influence the decision to use IVUS examination during TEVAR.

Methods

A retrospective review of the Vascular Quality Initiative (VQI) database was performed to identify all patients undergoing TEVAR from 2015 to 2019. Multivariable logistic regression modeling with three-fold repeated cross-validation was performed to identify predictors of IVUS use during TEVAR. Association of IVUS use with contrast volume and radiation exposure was also assessed.

Results

A total of 12,414 patients undergoing TEVAR met the inclusion criteria. Of these, IVUS examination was used in 41.3% of cases (n = 5121). IVUS use was more common in younger patients with fewer comorbidities; however, IVUS examination was also more commonly deployed in symptomatic patients and those with a higher preoperative American Society of Anesthesiology classification. IVUS examination was use in 80% (n = 3385/4213) TEVAR procedures performed for type B aortic dissection, which accounted for 50% of total IVUS use and only 11% of cases during which IVUS examination was not used (n = 822/7293) (P < .01). In multivariable analysis, the strongest independent predictor of IVUS use was aortic dissection (odds ratio, 13.7; 95% confidence interval, 11.7-16.3; P < .001, with aortic aneurysm as the reference). Surgeon years of independent practice experience was not associated with IVUS use, but when accounting for clustering on physicians and geographic regions, these variables explained 15% of the variance observed in the final risk-adjusted model. After adjustment for confounding factors, IVUS use was associated with a significant decrease in fluoroscopy time and contrast volume (both P < .001).

Conclusions

The decision to use IVUS examination during TEVAR is most heavily influenced by aortic pathology. Although surgeon experience was not associated with the decision to use IVUS examination, there was substantial variation in IVUS examination use among individual surgeons and VQI regions. IVUS use was associated with decreased contrast administration and fluoroscopy use but did not appear to have an impact on survival or re-intervention. Although aortic dissection was strongly associated with IVUS use, a significant number of TEVAR for dissection were performed without IVUS examination. Further research is warranted to identify the barriers to IVUS use as well as the risks and benefits of IVUS use during TEVAR so that quality benchmarks can be established and resource use is improved.

Objective

Best practice advisory notifications (BPAs) have become an integral part of many electronic medical record (EMR) systems. These communications alert providers to recommended therapy or screenings for patients depending on factors found within the EMR. Our goal was to evaluate the impact of BPAs on the rate of abdominal aortic aneurysm (AAA) screening in patients who met guidelines for screening in a single-center EMR.

Methods

We reviewed all patients who triggered a BPA alert for AAA screening from December 2018 to December 2021 in a single tertiary academic setting. The BPA alerts the provider when closing the chart when a patient meets the criteria for AAA screening based on the United States Preventive Services Task Force recommendations of screening male patients aged 65 to 75 years with a smoking history. Provider responses to these triggers were analyzed, and the predictors of response to the advisory and its impact on AAA screening for individual patients within 6 months of the alert was evaluated.

Results

Over this period, 1292 patients triggered the BPA for AAA screening. After excluding deceased patients, 1205 patients were included in the final analysis. Providers interacted with rather than dismissed the BPA in 20.4% of patients. The overall screening rate in this patient cohort was 28.28%. Interacting with the BPA significantly increased the odds of being appropriately screened for a AAA (odds ratio, 2.48). A higher number of visits and BPA triggers correlated with increased odds of undergoing screening for AAA (odds ratios, 1.08 and 1.02, respectively). Additionally, patients who underwent screening were younger in age and more often African American as compared with other races. The presence and number of comorbid conditions were not associated with screening rates, although hyperlipidemia was associated with positive response to BPA.

Conclusions

The overall rate of appropriate AAA screening is low, despite the presence of BPAs. Positively interacting with rather than dismissing the BPA is correlated with an increased rate of appropriate AAA screening. Providers were more likely to screen patients if the patient was younger, had more health care system visits, or if the trigger was delivered more often to members of the health care team. Further study is needed to evaluate provider factors that will result in an increased adherence to recommended screening guidelines.

Background/Objective

Chronic venous disease (CVD) affects >25% of adults in developed countries. It is usually a progressive disease; if left untreated, can lead to advanced disease such as venous ulceration. The VenaSeal Spectrum Program compares the VenaSeal closure system (VenaSeal) to the global standards of care for CVD: endothermal ablation and surgical stripping. It also investigates VenaSeal's usefulness for patients with venous leg ulcers (VLUs). A key component of this clinical program was to measure and quantify patient satisfaction with treatments related to discomfort, healing time, and effectiveness, which often has been overlooked in CVD research. This article describes the rationale and design of the VenaSeal Spectrum Program for patients with CVD.

Methods

VenaSeal Spectrum is a prospective, postmarket, clinical trial program reporting outcomes from the periprocedural period through 5 years after treatment with VenaSeal. VenaSeal Spectrum has enrolled 506 participants at 32 sites in 10 countries requiring treatment for symptomatic Clinical, Etiological, Anatomical, and Pathophysiological Classification (CEAP) 2-6 CVD involving the truncal saphenous vein(s). The program is composed of three studies. Two randomized controlled trials compare VenaSeal ablation with either surgical stripping or endovenous thermal ablation in patients with symptomatic CEAP 2-5 disease. A single-arm prospective study investigates participants with active VLUs (CEAP 6) treated with VenaSeal. The unique primary end points for both randomized trials include both periprocedural and postprocedural patient treatment satisfaction measured by a new questionnaire (VenousTSQ) at 30 days post procedure and elimination of clinically relevant superficial truncal reflux in the target vein at index procedure. The primary end point for the VLU study is time to ulcer healing through 12 months. Secondary end points, which are more familiar to clinicians in this disease space, include time to return to work, complication rates, patient-reported outcome measures, and closure rates.

Conclusions

VenaSeal Spectrum is a rigorously designed clinical study program with a large study population and unique patient-centric end points after treatment with VenaSeal for early to advanced symptomatic CVD. The studies report on the safety, effectiveness, and patient experience outcomes including two new primary end points assessing the specific needs of patients with venous insufficiency from the periprocedural period through 5-year follow-up.

Increasing diversity among vascular surgeons and trainees has introduced a growing number of female trainees in vascular surgery, which necessitates the creation of guidelines that both support and protect those wishing to pursue family planning during training. The expectations of long work hours, clinical responsibilities, and radiation exposure associated with surgical training place pregnant trainees at increased risk for complications. These include intrauterine growth restriction, premature delivery, and postpartum depression. It is therefore important to establish guidelines that address the specific risks of training in vascular surgery to prioritize the health and well-being of pregnant trainees. Existing literature and recommendations surrounding support and protections for the pregnant individual and guidelines created for trainees desiring to start a family within other medical societies were reviewed and used to form the foundation for relevant recommendations to guide program directors in vascular surgery. While considering vascular surgery trainees’ unique risks and demands, guidance surrounding radiation exposure, clinical responsibilities, parental leave, and culture paradigms is described to establish minimum recommendations for training programs. Strategies to incorporate a culture of support to protect trainees are necessary to both recruit and retain talent within the field. Integration of this guidance into training programs is a crucial first step toward more successful recruitment of female talent and prevention of burnout and subsequently leading toward successful retention and satisfaction within the specialty.

Background

Vessel sizing has played a pivotal role in guiding balloon and stent selection for coronary interventions, thereby decreasing dissections, vessel stress, and rates of restenosis. Despite its proven benefits in the coronaries, its application in peripheral vascular interventions has remained relatively underexplored.

Methods

This review aims to identify invasive and noninvasive imaging modalities available for sizing peripheral vessels as well as elucidate how vessel sizing is affected by measurement techniques, observer variability, and vessel characteristics.

Results

Traditionally, digital subtraction angiography (DSA) has been the gold standard for guiding vascular interventions. However, emerging techniques such as intravascular ultrasound (IVUS) examination and optical coherence tomography offer alternative approaches to vessel sizing, including assessment of cross-sectional area and minimal effective diameter.

Results

IVUS examination has demonstrated larger vessel diameter measurements and less intraobserver and interobserver variability than DSA. Whereas direct comparisons between IVUS examination and optical coherence tomography in the peripheries has been limited, noninvasive modalities such as computed tomography angiography and magnetic resonance angiography (MRA) provide a three-dimensional approach on vessel sizing, yet their integration into procedural planning remains constrained. Initial studies suggest discrepancies between vessel sizing using CTA and magnetic resonance angiography, warranting further investigation. Moreover, vessel characteristics such as localization and degree of calcification have been shown to influence balloon and stent sizing, highlighting the need for tailored approaches in peripheral vascular intervention.

Conclusions

Overall, although disparities exist between DSA and invasive/noninvasive imaging modalities in peripheral vessel sizing, the long-term implications of these differences on procedural outcomes remain poorly understood. Preliminary evidence suggests an opportunity to enhance procedural success, mitigate restenosis rates, and enhance patient care through improved vessel sizing techniques.