Objective Patients with vascular disease often have multisystem atherosclerosis and multiple comorbidities requiring comprehensive interdisciplinary specialty care. Consultation is a critical ...component of a tertiary vascular surgery practice, but analysis of this service is under-reported in the literature. After-hours inpatient consultations and interhospital transfers are associated with urgent patient care. Methods A retrospective analysis of vascular surgery consultations was carried out from January 1, 2013, to December 31, 2013. Consultations included inpatient services, the emergency department, surgical and medical intensive care unit, and interhospital transfers. Data analysis included number of consults, time of consultation (during hours, 0700-1859; after hours, 1900-0659), referring service, nature, and outcome of consultation. Consultations were then classified as urgent if vascular surgical intervention was required as an intraoperative consultation, within 24 hours, or during the same hospitalization. Patients without a same-hospital vascular surgical intervention were classified as nonurgent. Results During a 1-year period, 823 independent consult requests of 749 patients were analyzed. It was found that 57.8% of after-hours consults resulted in urgent patient care ( P = .003); 29.7% of medicine, 33.3% of medical intensive care unit, 41.9% of trauma surgery, and 60% of emergency department after-hours consultations were urgent; 73% of surgery and 79.2% of interhospital after-hours consults required urgent vascular surgical intervention. Extremity ischemia, aortic disease, and iatrogenic consults accounted for 44.8%, 20.4%, and 11.1% of after-hours consults, with 57.9%, 56.4%, and 70% requiring urgent vascular surgical intervention, respectively. Conclusions After-hours consultations are not always associated with an urgent vascular surgical intervention. Nonurgent after-hours consultations are requested more frequently from some services and may present an opportunity for education that could improve workflow of the vascular workforce.
Abstract Objective The purpose of this study was to evaluate outcomes of iliac vein stents placed for iliocaval venous obstruction (ICVO) and to determine if routine follow-up surveillance is ...warranted on the basis of timing of stent failure. Methods All patients who underwent iliac vein stenting from 2003 to 2015 were identified from a prospectively maintained registry. Demographics of the patients, venous risk factors, prior venous interventions, indications, imaging, anatomic location of the ICVO, operative findings, procedural success, complications, and clinical follow-up were recorded. Clinical and ultrasound surveillance was performed at first postoperative follow-up and at routine subsequent intervals. Continuous data were analyzed with Student t -tests or Mann-Whitney U test, and frequency data were analyzed with χ2 analysis or Fisher exact test. Primary patency was analyzed using Kaplan-Meier survival analysis. Results Seventy-four limbs in 70 patients who underwent iliac vein stenting for ICVO were identified; 36 limbs (48.6%) were stented for nonthrombotic venous compression (stent-VC), and 38 limbs (51.4%) were stented for venous thrombosis (stent-VT). Twenty-seven limbs (71.1%) of the stent-VT group were treated for acute venous thrombosis requiring lysis followed by stenting for underlying venous lesions. The median number of follow-up visits for the stent-VC and stent-VT groups was two (interquartile range IQR, 1-4) and two (IQR, 1-3), whereas the mean length of follow-up was 19.6 ± 29.5 months and 19.8 ± 26.5 months ( P = .972), respectively. During the first 6 months, one limb (2.8% n = 36) in the stent-VC group occluded, whereas 13.2% (5/38) of the limbs in the stent-VT group occluded. In the stent-VT group, 57% of limbs (4 of 7) with acute venous thrombosis requiring thrombolytic therapy had limb occlusion at >6 months (median, 18.1 months; IQR, 16.6-30.1). Overall patency rates for the stent-VC and stent-VT groups were 97.2% (1/36) and 73.7% (10/38) at 36 months (standard error, ≤10%; P = .001), respectively. Conclusions Iliac vein stents placed for nonthrombotic iliac vein compression had statistically higher patency than those placed for venous thrombosis, with few stent failures, all occurring within 6 months. Iliac vein stents placed for venous thrombosis continued with stent failure after 6 months and may benefit from extended surveillance.
Objective This report describes the pilot of a free comprehensive national screening program for venous disease. Methods The screening process consisted of a venous thromboembolism (VTE) risk ...assessment, abbreviated duplex examination for venous obstruction and reflux, inspection for signs of chronic venous insufficiency (CVI), and an exit interview. Physicians coordinating the screenings were members of the American Venous Forum. Results Seventeen institutions screened 476 people (mean, 28 per site; range, 6 to 71). Mean age was 60 years (range, 40 to 91 years), with 78% women and 68% with a body mass index of ≥25. If placed in a situation conducive for VTE, 22 participants (5%) were low risk, 87 (18%) were moderate risk, 186 (39%) were high risk, and 179 (38%) were at very high risk. In 26 people (6%), one or more segments had venous obstruction, and 190 (40%) had one or more segments of venous reflux in the lower extremities. Varicose veins were present in 32%, edema without skin changes in 11%, skin changes attributable to venous disease in 8%, and healed or active venous stasis ulcer in 1.3% (CEAP classification 2, 3, 4, 5, and 6, respectively). Increasing age and increasing deep venous thrombosis risk score significantly correlated with increasing clinical classification, r = 0.09, P = .04, and r = 0.16, P = .0004, respectively. Those participants with reflux in one or more segments were significantly more likely to have a higher clinical classification compared with those with no reflux ( P = .0001). Conclusion The first comprehensive national screening for venous disease was performed. Participants were informed of their risk for VTE if placed in a situation conducive to VTE, screened for evidence of obstruction, reflux, and CVI, and empowered to share their results with their primary care provider.
Background The Venous Clinical Severity Score (VCSS) was designed and validated as an objective measure of disease severity in patients with chronic venous disease (CVD). Recently, a revision of the ...VCSS (rVCSS) was performed to resolve ambiguity in the clinical descriptors and improve clarity and ease of use. This new revised VCSS requires validation to determine its repeatability and reproducibility in clinical evaluation of patients with varying levels of CVD. Methods A prospective multicenter protocol was designed to enroll patients undergoing evaluation for CVD at venous practices with experience using the original VCSS. At the time of initial evaluation, two clinicians independently assessed both lower extremities to determine the rVCSS and the CEAP clinical score. Between 1 and 6 weeks, patients returned and received repeat assessment of the rVCSS by the same two clinicians independently. Patients were excluded if any venous intervention occurred between the two separate evaluation visits. Scores were compared to determine inter- and intra-observer variability overall and within each CEAP clinical class. Results Seven centers enrolled a total of 136 limbs yielding 248 paired evaluations for interobserver variability and 258 paired evaluations for intraobserver variability. The mean interobserver rVCSS difference was 1.4 ± 1.7 and the mean intraobserver variability was 1.3 ± 1.6. Statistical assessment with weighted kappa yielded good repeatability (κ = 0.68; P < .0001) and good reproducibility (κ = 0.72; P < .000001) for the rVCSS. The rVCSS correlated well with the CEAP clinical class with significant differences between rVCSS in increasing classes. ( P < .0001). Conclusions In this multicenter evaluation, the rVCSS was demonstrated to be a reliable and reproducible instrument for documentation of the severity of symptoms in patients with lower extremity venous insufficiency.
Objective Despite the established guidelines, there is not a clear consensus about how to manage antiplatelet therapy after carotid surgery. It is a common practice in vascular surgery to use the ...combination of aspirin and clopidogrel in the treatment of such patients. In this work, we analyzed the impact on long-term survival of antiplatelet therapy in patients treated for carotid stenosis at a single institution over a 10-year period. Methods Outcomes of 471 patients who underwent carotid intervention (1999-2008) were analyzed. Discharge prescription summaries were retrieved, and patients were divided into two groups according to their antiplatelet regimen: aspirin-only group and aspirin plus clopidogrel group. Only patients with a minimum of 30 days of confirmed antiplatelet therapy were included. All-cause mortality during follow-up represented the primary outcome, whereas stroke and bleeding at 30 days and during follow-up represented secondary end points. When local records were sparse, the Social Security Death Index was queried to confirm mortality. The International Classification of Diseases, 9th Revision (ICD-9 codes), was reviewed for treatment related to a bleeding condition. Results When divided by indication, there was an increased mortality rate in patients with asymptomatic carotid disease receiving dual antiplatelet therapy as compared with aspirin alone (47% vs 40%; P = .05). Patients with symptomatic carotid disease had a nonsignificant decrease in all-cause mortality if they received dual antiplatelet therapy (38% vs 39%; P = .53). In a subgroup analysis, there was a significant increase in the rate of all-cause mortality among patients older than 75 years receiving dual antiplatelet therapy for asymptomatic carotid disease (82% vs 56%; P = .001), whereas there was a nonsignificant decrease in mortality in patients older than 75 years receiving dual antiplatelet therapy for symptomatic carotid disease (47% vs 63%; P = .50). There was no difference in secondary outcomes (stroke and bleeding) regardless of the indication or the antiplatelet therapy. Conclusions In this retrospective, single-institution study, the use of dual antiplatelet therapy (aspirin plus clopidogrel) in patients intervened for asymptomatic carotid disease was related to increased all-cause mortality, whereas it did not significantly influence the outcome in patients with symptomatic carotid disease.
Introduction Since the development of endovascular aneurysm repair (EVAR), there remains concerns regarding its durability, need for secondary procedures, and associated long-term morbidity. We ...compared these two approaches to evaluate secondary interventions and their respective long-term durability. Methods All patients who had undergone endovascular and open abdominal aortic aneurysm (AAA) repair were identified from a prospectively maintained registry. Health system charts, medical communication, and national death indexes were reviewed. Secondary interventions were classified as vascular (aortic graft or remote) and nonvascular (incisional or gastrointestinal). Results Between July 1985 and September 2009, 1908 patients underwent 1986 AAA repair procedures (EVAR = 1066; open = 920). Patients were followed up to 290 months (mean 27.6 ± 35.9) and identified with 427 surgical encounters (EVAR 233% to 21.9%; open 194% to 21.1%). Most encounters (338% to 74.6%) were related to vascular disease: 178 (EVAR = 131; open = 47) related to the aortic graft; 160 (EVAR = 93; open = 67) were related to nonaortic vascular disease. The remaining 89 surgical encounters included incisional hernias, small bowel obstruction, intra-abdominal abscesses, and wound dehiscence requiring operation. Of these 89 encounters (EVAR = 9; open = 80), 44 patients required surgical intervention and 36 required hospitalization without surgical procedure. Over the period of 100 months, the all-cause mortality rate was 25.2% after EVAR and 39.1% after open repair. One-year survival was 88.0% (SE 0.01) and 85.0% (SE 0.01), while 5-year survival was 58.0% (SE 0.02) and 53.0% (SE 0.02) for EVAR and open repair, respectively (log-rank P value < .0164). Seven-year survival was 46% (SE 0.03) for EVAR and 36% (SE 0.03) for open AAA repair. Conclusion EVAR requires more late secondary vascular interventions than open AAA repair, but patients who undergo open repair have more nonvascular long-term morbidity. Long-term survival is better after EVAR compared to open repair in this selected patient group.
Objective Success rates vary for the retrieval of inferior vena cava filters (IVCFs). The optimal retrieval time and factors influencing retrieval success remain unproven. This study aims to ...determine optimal time and evaluate factors related to successful IVCF retrieval. Methods An institutional prospectively maintained database was reviewed for all IVCF retrieval attempts from 2006 to 2012. Patient demographics, comorbidities, indications for procedure, placement technique, IVCF type, presence of angulation, and time to retrieval were evaluated with respect to success or failure of retrieval. Statistical analyses ( t -test, χ2 , correlations, and Kaplan-Meier plots) were performed comparing successful and unsuccessful retrievals. Results Of 121 attempted IVCF retrievals, 92 (76%) were successful and 29 (24%) were unsuccessful. There were no significant differences between the successful and unsuccessful attempts in terms of patient demographics, comorbidities, indications for procedure, placement technique, or IVCF type, which included 93 Celect (77%) and 28 Gunther Tulip (23%). Time since IVCF placement was significantly different ( P = .025) between the successful and unsuccessful retrieval groups (medians were 105 7-368 and 162 43-379 days, respectively). Time since IVCF placement greater than 117 days correlated significantly with unsuccessful IVCF retrieval (R = 0.218; P = .017; odds ratio, 2.88; P = .02). Angulation greater than 20 degrees on anteroposterior radiograph was noted in seven of 29 (24%) unsuccessful retrievals compared with seven of 92 (8%) successful retrievals and was significant ( P = .012). Conclusions Cook Gunther Tulip and Celect IVCF retrieval is most likely to be successful within 3 to 4 months of placement. Unsuccessful retrieval attempts are more likely to occur when IVCF position is angulated.
Complications of inferior vena cava filters Passman, Marc A., MD
Journal of vascular surgery. Venous and lymphatic disorders (New York, NY),
01/2017, Letnik:
5, Številka:
1
Journal Article
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