The Society of Thoracic Surgeons General Thoracic Surgery Database has grown to more than 500,000 case records. Clinical research supported by the database is increasingly used to advance patient ...outcomes. This research review from the General Thoracic Surgery Database in 2014 and 2015 discusses 6 recent publications and an ongoing study on longitudinal outcomes in lung cancer surgery from The Society of Thoracic Surgeons Task Force for Linked Registries and Longitudinal Follow-up. A lack of database variables specific for certain uncommon procedures limits the ability to study these operations; inclusion of clinical descriptors for selected infrequent but clinically important thoracic disorders is suggested.
Drug-eluting stent failures were associated with various clinical factors. However, the clinical impact of stent deployment technique was unknown. This study was designed to evaluate the frequency ...and impact of suboptimal percutaneous coronary intervention on long-term outcomes of 1,557 patients treated with sirolimus-eluting stents (SESs) in 41 US hospitals. All steps of the interventional procedure were scrutinized by an independent core laboratory to determine the occurrence of geographic miss (GM). GM included longitudinal (LGM; injured or diseased segment not covered by SES) or axial GM (balloon-artery size ratio <0.9 or >1.3) mismatches. Patients with and without GM were stratified (GM vs no-GM group). Patients, investigators, and the independent clinical event adjudication committee were blind to study group assignments. The primary end point was 1-year target-vessel revascularization (TVR) rate. Incidences and predictors of GM and safety outcomes were secondary end points. GM occurred in 943 patients (66.5%): 47.6% had LGM, 35.2% had axial GM, and 16.5% had both. One-year TVR rates were 5.1% in the GM group versus 2.5% in the no-GM group (p = 0.025). TVR was 6.1% in the LGM versus 2.6% in the no-LGM subgroups (p = 0.001). The association of GM with 1-year TVR was independent of clinical or anatomic factors (hazard ratio 2.0, 95% confidence interval 1.0 to 4.02, p = 0.05). There was a 3-fold increase in myocardial infarction rates associated with GM (2.4% vs 0.8%; p = 0.04). In conclusion, GM occurred frequently during SES implantation and was associated with increased risk of TVR and myocardial infarction at 1 year. These results emphasized the need for improvement in contemporary percutaneous coronary intervention practices and technologies.
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.
Virtually all sites in the human body can host lesions that simulate neoplasms, and many of these "pseudotumors" can simulate neoplasms on all levels of analysis-- clinical, radiologic, and ...pathologic-- thus they represent particular diagnostic pitfalls for the pathologist that can ultimately lead to therapeutic misdirection. This book provides the pathologist with detailed morphologic descriptions and diagnostic guidance in recognizing these neoplastic mimics as they occur in the skin. In addition, descriptions and diagnostic guidance are provided for the range of skin lesions that may mimic benign masses but are in fact neoplastic. This analysis of diagnostic mimics guides the pathologist through recognizing and distinguishing the unusual variants, morphologic anomalies and misleading features that may easily lead to an inaccurate interpretation and missed diagnosis. The book emphasizes imaging and clinical correlations throughout to support the pathologist as consultant to the diagnostic and clinical management team. Every pathologist who sees skin cases will find this book a valuable working tool to ensure accurate diagnosis.
Background Led by the American College of Surgeons Trauma Quality Improvement Program, performance improvement efforts have expanded to regional and national levels. The American College of Surgeons ...Trauma Quality Improvement Program recommends 5 audit filters to identify records with erroneous data, and the Georgia Committee on Trauma instituted standardized audit filter analysis in all Level I and II trauma centers in the state. Study Design Audit filter reports were performed from July 2013 to September 2014. Records were reviewed to determine whether there was erroneous data abstraction. Percent yield was defined as number of errors divided by number of charts captured. Results Twelve centers submitted complete datasets. During 15 months, 21,115 patient records were subjected to analysis. Audit filter captured 2,901 (14%) records and review yielded 549 (2.5%) records with erroneous data. Audit filter 1 had the highest number of records identified and audit filter 3 had the highest percent yield. Individual center error rates ranged from 0.4% to 5.2%. When comparing quarters 1 and 2 with quarters 4 and 5, there were 7 of 12 centers with substantial decreases in error rates. The most common missed complications were pneumonia, urinary tract infection, and acute renal failure. The most common missed comorbidities were hypertension, diabetes, and substance abuse. Conclusions In Georgia, the prevalence of erroneous data in trauma registries varies among centers, leading to heterogeneity in data quality, and suggests that targeted educational opportunities exist at the institutional level. Standardized audit filter assessment improved data quality in the majority of participating centers.
Objective Coverage of celiac artery (CA) during thoracic endovascular aortic aneurysm repair (TEVAR) has been performed to extend the distal seal zone for which preliminary results and short-term ...follow-up have been reported. We aim to show the outcomes up to 81 months after CA coverage during TEVAR. Methods Patients undergoing TEVAR with coverage of the CA origin from 2005 to 2013 were retrospectively analyzed. Points of analysis include indications for covering the CA, demonstration of collateral circulation between the CA and superior mesenteric artery (SMA), anatomic features of the distal landing zone, rate of reintervention, technical success, presence of clinical ischemic symptoms after the procedure, and mortality. Results During the 9-year period, 366 patients underwent TEVAR, 18 (5%) of whom had CA coverage. Eleven (61%) had TEVAR with CA coverage due to a thoracic aneurysm, three (17%) had thoracic aortic dissection related to aneurysm, and four (22%) had previous TEVAR with a type Ib endoleak (EL) requiring distal coverage. Mesenteric angiography in preparation for TEVAR with CA coverage diagnosed a critical SMA stenosis in one patient that was treated with stenting before the index procedure. At the conclusion of the indicated procedure, two patients (11%) had a type Ia EL and two patients (11%) had a type Ib EL. Three of the type I ELs required reintervention. Two patients (11%) had a type II EL, both of which were managed with observation and resolved. Reintervention was required in 27% of patients. Postoperative complications included visceral ischemia in 2 (11%), weight loss in 1 (5%), spinal cord ischemia in 2 (11%), a cerebrovascular event in 1 (6%), and death in 1 (6%). The mean follow-up period was 38 months (range, 0.5-81 months). Conclusions This analysis of outcomes up to 81 months supports the suitability of covering the CA in selected patients for extending the distal landing zone to the visceral aortic level above the SMA or when alternative branch vessel treatment is unavailable. Preoperative angiographic evaluation of the mesenteric collaterals and early postoperative surveillance may limit postoperative complications. Once the CA is covered, new symptoms do not develop unless the SMA is compromised.
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.
Introduction Size threshold for operative repair of abdominal aortic aneurysms (AAAs) has been determined based on risks and outcomes of open repair vs surveillance. The influence of endovascular ...aneurysm repair (EVAR) on this threshold is less established. The purpose of this study is to determine whether long-term outcomes following EVAR are affected by maximum diameter at the time of treatment. Methods Patients undergoing EVAR with modular stent grafts from 2000 to 2011 were identified from a prospectively maintained database and stratified by maximum aortic diameter at the time of repair: small (4.0-4.9 cm), medium (5.0-5.9 cm), and large (≥6.0 cm). Comparisons of demographics, indications for repair, perioperative complications, and long-term outcomes were made using analysis of variance, χ 2 , and Kaplan-Meier plots. Results Seven hundred forty patients were identified: 157 (21.2%) small, 374 (50.5%) medium, and 209 (28.2%) large. Patients differed by mean age (69.3 ± 8.09, 71.7 ± 8.55, and 73.6 ± 8.77 years for small, medium, and large, respectively; P < .001), coronary artery disease (42% small, 57% medium, 51.2% large; P = .01), prior coronary angioplasty (14.6% small, 18.2% medium, 9.6% large; P = .02), congestive heart failure (5.7% small, 15.2% medium, 19.6% large; P = .01), prior vascular surgery (7% small, 15.8% medium, 10% large; P = .016), and chronic obstructive pulmonary disease (21% small, 27% medium, 33% large; P = .038). Small AAAs were more frequently symptomatic (19.7% small, 7.5% medium, 8.1% large; P < .001). There was no difference in perioperative complication rates ( P = .399), expansion ≥5 mm (2.6% small, 5.6% medium, 7.2% large; P = .148), or all-type endoleak (40.8% small, 41.7% medium, 44.5% large; P = .73). Small AAAs developed fewer type I endoleaks (5.1% vs 6.95% medium and 14.8% large; P = .001). Compared with small AAAs, both medium ( P = .39) and large ( P < .001) required secondary intervention more frequently, with hazard ratios of 2.32 (95% confidence interval, 1.045-5.156) and 4.74 (95% confidence interval, 2.115-10.637), respectively. Ten-year survival was 72%, 63.1%, and 49.8% in the small, medium, and large groups, respectively ( P < .001) with one rupture-related death after EVAR in the large group. All-cause mortality differed among the 75- to 84-year-old patients (30.4% small, 51.6% medium, 55.7% large; P = .017). Conclusions EVAR for small AAAs shows improved long-term outcomes than for age-matched patients with larger aneurysms.
Background Spinal cord ischemia (SCI) remains a significant concern in patients undergoing endovascular repair involving the thoracic aorta (thoracic endovascular aortic repair TEVAR). Perioperative ...lumbar spinal drainage has been widely practiced for open repair, but there is no consensus treatment protocol using lumbar drainage for SCI associated with TEVAR. This study analyzes the efficacy of an institutional protocol using selective lumbar drainage reserved for patients experiencing SCI following TEVAR. Methods A prospectively maintained registry was reviewed to identify all patients who underwent TEVAR from January 2000 through June 2010. Preoperative characteristics, intraoperative details, and outcomes, including neurologic deficit and mortality at 30 days and 1 year were determined based on reporting standards. Patients developing symptoms of SCI in the postoperative setting were compared with those without neurologic symptoms. SCI patients who received selective lumbar drainage were grouped based on resolution of neurologic function, with risk factors and outcomes of these subgroups analyzed with χ2 , t test, logistic regression, and analysis of variance (ANOVA). Results Two hundred seventy-eight TEVARs were performed on 251 patients. Twelve patients accounting for 12 TEVARs were excluded from analysis: 5 patients experienced SCI preoperatively, 4 patients were drained preoperatively, 2 expired intraoperatively, and 1 procedure was aborted. Of the remaining 266 procedures in 239 patients, 16 (6.0%) developed SCI within the 30-day postoperative period. Risk factors for SCI reaching statistical significance included length of aortic coverage ( P = .036), existence of infrarenal aortic pathology ( P = .026), and history of stroke ( P = .043). Stent graft coverage of the left subclavian artery origin was required in 28.9% (n = 77) and was not associated with SCI ( P = .52). Ten of 16 post-TEVAR SCI patients received selective postoperative lumbar drains and were categorized based on resolution of symptoms into complete resolution (n = 3; 30%), partial resolution (n = 4; 40%), and no resolution (n = 3; 30%). No patient characteristics or risk factors reached significance in comparison of lumbar drained patients and nondrained patients. All seven drained patients without complete resolution of SCI died within the first year after surgery, while all three of the complete responders survived ( P = .017). In patients with SCI, increased all-cause mortality was observed at 1 year (56.3% vs 20.4%; P = .003). Conclusions A protocol utilizing selective postoperative lumbar spinal drainage can be used safely for patients developing SCI after TEVAR with acceptably low permanent neurologic deficit, although overall survival of patients experiencing SCI after TEVAR is diminished relative to non-SCI patients.
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