AbstractObjectiveTo evaluate the safety and effectiveness of infrainguinal artery revascularization via atherectomy supplemented with other endovascular techniques in an office endovascular center ...(OEC) setting. MethodsA retrospective study was conducted examining 352 lower extremity atherectomy revascularization procedures between 2011 and 2016 at an OEC by five board-certified vascular surgeons. Patients received laser atherectomy or orbital atherectomy followed by angioplasty or angioplasty and stent placement as needed. Reintervention was indicated based on evidence of clinical symptoms and imaging studies. Demographics, vessel-specific data, treatment information, and outcome of procedures were recorded. Data analysis was carried out using Kaplan-Meier survival curves. ResultsLower extremity atherectomy was carried out in 282 patients in 352 limbs with average age of 69 ± 11 years. Technical success of <30% residual stenosis by angiogram was achieved in 571/594 vessels treated. Within 30 days of procedure, 23/352 limbs required major amputation resulting from pre-existing disease, ranging from 3 Rutherford class 4, 17 Rutherford class 5, to 3 Rutherford class 6 limbs. No 30-day mortality was noted. The primary patency of the 571 treated vessels at 12 months was 90%, and 84% at 29 months. The patency of treated vessels that reached >50% stenosis on follow-up and required reintervention (51/571 vessels) or did not require reintervention (79/571) was 72% and 87% at 23 months' follow-up, respectively, with no difference in risk of occlusion identified ( P = .181). There was a significantly increased risk of occlusion for vessels treated with laser atherectomy as compared with orbital atherectomy (odds ratio, 2.552; 95% confidence interval, 1.375-4.735; P = .003). No significant difference in risk of occlusion was found between treatment with atherectomy and angioplasty (466/571 vessels) compared with atherectomy, angioplasty, and stenting (102/571) with secondary patency of 90% and 85% at 6 months' follow-up, respectively. There was no difference in patency between claudicants and patients with critical limb ischemia. ConclusionsAtherectomy in conjunction with angioplasty and/or stenting has satisfactory patency with minimal complications when the procedure is carried out in an OEC. Asymptomatic >50% restenosis of treated vessels does not warrant reintervention unless the patient presents with clinical symptoms. Various atherectomy devices may result in different outcomes.
Future of vascular surgery is in the office Jain, Krishna M., MD; Munn, John, MD; Rummel, Mark, MD ...
Journal of vascular surgery,
02/2010, Letnik:
51, Številka:
2
Journal Article
Recenzirano
Odprti dostop
Objective The practice of vascular surgery is under pressure from various specialties and payers. Our group started office-based procedures in May 2007. This article reports our study of the effect ...of this change on our case volume, office revenue, and the financial impact on the health care system. Methods Between May 1, 2006, and April 30, 2007 (period 1), and between June 1, 2007, and May 31 2008 (period 2), 3041 and 3351 cases, respectively, were performed. In period 1, only venous cases could be done in the office. Before arteriogram, serum levels of urea nitrogen and creatinine were obtained. The number of percutaneous cases done in the hospital and office setting was analyzed, and revenue was calculated based on the 2008 Medicare fee schedule for our region. Amputation and mortality rates at 30 days were documented. Hospital DRG payment schedule was obtained. Results In period 1, 670 (22% of total) percutaneous procedures were performed compared with 1502 (44.8%) in period 2, a twofold increase. In period 1, 1.5% of total cases were done in the office compared with 31% in period 2. There was a fivefold increase in revenue from these procedures. No deaths or amputations occurred as a result of procedures performed in the office. No anesthesiologist's expense and minimal preprocedural expenses were incurred. Total payment by Medicare, DRG payment to the hospital, and the physician component were higher in all the cases. Conclusions A vascular surgery practice can benefit from office-based procedures. Procedures can be done safely. It results in an increase in the number of percutaneous procedures and revenue with a significant savings to the health care system. Surgeons can control their schedule. Every vascular surgeon should consider doing these procedures in office.
Office-based endovascular suite is safe for most procedures Jain, Krishna, MD; Munn, John, MD; Rummel, Mark C., MD ...
Journal of vascular surgery,
2014, January 2014, 2014-Jan, 2014-01-00, 20140101, Letnik:
59, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Objective This study was conducted to identify the safety of endovascular procedures in the office endovascular suite and to assess patient satisfaction in this setting. Methods Between May 22, 2007, ...and December 31, 2012, 2822 patients underwent 6458 percutaneous procedures in an office-based endovascular suite. Demographics of the patients, complications, hospital transfers, and 30-day mortality were documented in a prospective manner. Follow-up calls were made, and a satisfaction survey was conducted. Almost all dialysis procedures were done under local anesthesia and peripheral arterial procedures under conscious sedation. All patients, except those undergoing catheter removals, received hydrocodone and acetaminophen (5/325 mg), diazepam (5-10 mg), and one dose of an oral antibiotic preprocedure and three doses postprocedure. Patients who required conscious sedation received fentanyl and midazolam. Conscious sedation was used almost exclusively in patients having an arterial procedure. Measurements of blood urea nitrogen, creatinine, international normalized ratio, and partial thromboplastin time were performed before peripheral arteriograms. All other patients had no preoperative laboratory tests. Patients considered high risk (American Society of Anesthesiologists Physical Status Classification 4), those who could not tolerate the procedure with mild to moderate conscious sedation, patients with a previous bad experience, or patients who weighed >400 pounds were not candidates for office based procedures. Results There were 54 total complications (0.8%): venous, 2.2%; aortogram without interventions, 1%; aortogram with interventions, 2.7%; fistulogram, 0.5%; catheters, 0.3%; and venous filter-related, 2%. Twenty-six patients required hospital transfer from the office. Ten patients needed an operative intervention because of a complication. No procedure-related deaths occurred. There were 18 deaths in a 30-day period. Of patients surveyed, 99% indicated that they would come back to the office for needed procedures. Conclusions When appropriately screened, almost all peripheral interventions can be performed in the office with minimal complications. For dialysis patients, outpatient intervention has a very low complication rate and is the mainstay of treatment to keep the dialysis access patent. Venous insufficiency, when managed in the office setting, also has a low complication rate. Office-based procedural settings should be seriously considered for percutaneous interventions for arterial, venous, and dialysis-related procedures.
Abstract The CHA2 DS2 -VASC score is a well-validated stratification tool that predicts the risk of thromboembolism and stroke in patients with non-valvular atrial fibrillation. Several studies have ...examined its application as a predictor of mortality in clinical applications other than atrial fibrillation. However, there are current no studies examining its use as an outcome prediction tool in a population of patients with implantable cardiac defibrillators (ICDs). In this study, we examined data from 2,258 patients who underwent ICD device implantation at the hospitals of the University of Pittsburgh Medical Center from February 2002 to April 2014 (median follow up 5.1 years) and examined the impact of their CHA2 DS2 -VASC score at the time of device implantation on all-cause mortality. Survival curves based on CHA2 DS2 -VASC scores were generated using the Kaplan-Meier method and were adjusted for unbalanced covariates using the Cox Proportional Hazards model. The mean CHA2 DS2 -VASC score was 3.15 ± 1.52 (range 1-8, mode 3). The CHA2 DS2 -VASC score predicted all-cause mortality in a significant and dose-dependent fashion. Analyzing the population by quartiles revealed increasing all-cause mortality from Q1 to Q4 (p <0.001). Using a Cox multivariate model adjusting for ejection fraction, BMI, serum creatinine, hemoglobin level, and QRS width, the CHA2 DS2 -VASC score remained a strong predictor of all-cause mortality (HR=1.26 per 1 point increase, 95% confidence interval 1.20 – 1.32). In conclusion, the CHA2 DS2 -VASC score is a simple tool that highly predicts all-cause mortality in ICD patients.
The shift in employment options for vascular surgeons in the current era of major health care reform is being widely debated. After the decision to seek hospital employment or independent practice, ...the choice of then practicing in a single-specialty or a multispecialty practice remains a difficult decision. Although the trend is toward medium-sized to large-sized groups, only 1.2% of medical practices currently have >11 physicians. Barring the large multispecialty groups, such as Kaiser Permanente, Cleveland Clinic, or Mayo Clinic, most vascular practices are constituted as small groups. Which format prospers will depend on adroit management of financial and intellectual capital and nimbleness in adapting to rapidly changing market conditions. In this report, two practicing vascular surgeons debate the merits of single or multispecialty practice, with a commentary to follow.
Changing practice paradigms: Negotiating your future Satiani, Bhagwan B., MD, MBA; Motew, Stephen J., MD; Darling, R. Clem, MD ...
Journal of vascular surgery,
04/2012, Letnik:
55, Številka:
4
Journal Article
Recenzirano
Odprti dostop
There are many recent and ongoing changes in the practice of medicine from a business standpoint as well as in overall practice management. Economic and lifestyle desires have pushed many physicians ...to a decision point of whether or not to join a large multispecialty group or to sell their practice and become an employee of a hospital system. There are advantages and disadvantages to both options; however, deciding on the most appropriate path for each individual can be a daunting task. At our recent breakfast session at the vascular annual meeting in Chicago, Illinois, in June 2011, we brought to light these topics to try and help enlighten physicians on which option may be right for them. There is no single answer/option that will fit every practice, but discussion for various practice management designs are outlined and critiqued. This article cannot fully discuss each view in the allotted space, but it is designed to encourage thought and discussion among the vascular surgical community as a whole.
•Hemophagocytic lymphohistiocytosis (HLH)-like toxicities occur after CAR T-cells•This is now termed immune effector cell (IEC) associated HLH-like syndrome (IEC-HS)•Independent of cytokine release ...syndrome (CRS) and neurotoxicity, IEC-HS can be fatal•Consensus for identification and grading of IEC-HS has been developed by experts•Treatment, supportive care, and future research are imperative to improving outcomes of IEC-HS
T cell-mediated hyperinflammatory responses, such as cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS), are now well-established toxicities of chimeric antigen receptor (CAR) T cell therapy. As the field of CAR T cells advances, however, there is increasing recognition that hemophagocytic lymphohistiocytosis (HLH)-like toxicities following CAR T cell infusion are occurring broadly across patient populations and CAR T cell constructs. Importantly, these HLH-like toxicities are often not as directly associated with CRS and/or its severity as initially described. This emergent toxicity, however ill-defined, is associated with life-threatening complications, creating an urgent need for improved identification and optimal management. With the goal of improving patient outcomes and formulating a framework to characterize and study this HLH-like syndrome, we established an American Society for Transplantation and Cellular Therapy panel composed of experts in primary and secondary HLH, pediatric and adult HLH, infectious disease, rheumatology and hematology, oncology, and cellular therapy. Through this effort, we provide an overview of the underlying biology of classical primary and secondary HLH, explore its relationship with similar manifestations following CAR T cell infusions, and propose the term “immune effector cell-associated HLH-like syndrome (IEC-HS)” to describe this emergent toxicity. We also delineate a framework for identifying IEC-HS and put forward a grading schema that can be used to assess severity and facilitate cross-trial comparisons. Additionally, given the critical need to optimize outcomes for patients experiencing IEC-HS, we provide insight into potential treatment approaches and strategies to optimize supportive care and delineate alternate etiologies that should be considered in a patient presenting with IEC-HS. By collectively defining IEC-HS as a hyperinflammatory toxicity, we can now embark on further study of the pathophysiology underlying this toxicity profile and make strides toward a more comprehensive assessment and treatment approach.
To evaluate the technique and outcomes of deep anterior lamellar keratoplasty (DALK) combined with phacoemulsification for corneal opacity with coexisting cataract.
Cornea Service, Dr. Rajendra ...Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.
Cohort study.
Eyes with cataract of varied nucleus grade and with different corneal pathologies were selected. Modified triple procedures were performed in all eyes.
Twenty eyes were evaluated. The corrected distance visual acuity (CDVA) after 3 months was 20/60 or better in 18 eyes. One eye had 20/80 CDVA as a result of perioperative and postoperative complications. One graft became opaque after postoperative infection.
Simultaneous DALK with phacoemulsification was feasible in eyes with coexisting corneal and lenticular pathology, and the outcomes were encouraging.
No author has a financial or proprietary interest in any material or method mentioned.
PDF
