High-risk Vascular Surgery Patients Research Articles

Palliative Care Consults and Frailty Screening in High-Risk Vascular Surgery Patients

Palliative care has increasingly been integrated into the management of high-risk surgery because of the beneficial effect on patient quality of life. However, the utilization of palliative care in vascular surgery remains unclear due to a lack of data. The purpose of this study was to determine the palliative care consult rate in high-risk vascular surgery patients. A retrospective chart review was performed at a single Veteran Affairs Medical Center from 2013 to 2021. High-risk vascular surgery patients were identified by using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) risk score of >4%, which predicted 30-day mortality. Patient demographics, operative procedures, and clinical outcomes were collected. A total of 126 patients underwent a high-risk vascular surgery operation. The surgical procedures consisted of 78 amputations, 19 bypasses, 18 endovascular aneurysm repair/stents, and 11 thrombectomy/arterial repair. Palliative care was consulted in 44 patients (35%) during the hospitalization: 8 patients (18%) had preoperative consults, whereas 36 patients (82%) had postoperative consults. The overall 30-day mortality was 15%, and the 1-year mortality rate was 34%. The 30-day and 1-year mortality rates were higher in those patients who received palliative care consultation (36% and 64%, respectively) compared with those without consult (0% and 21%, respectively). The palliative care consults had a higher referral rate in more frail patients, by Revised Analysis Index (RAI): n = 13 of 57 (23%) nonfrail (RAI <20), n = 14 of 44 (32%) frail (RAI = 21-32), and n = 17 of 25 (68%) very frail (RAI >33). The majority of the palliative care consults were obtained for goals of care discussion (80%) compared with withdrawal of care (20%). Palliative care is generally underused for vascular surgery patients, but our data demonstrated a palliative care consult rate of 35% in high-risk vascular surgery patients. A frailty screening program can further stratify high-risk vascular surgery patients who would benefit from an early palliative care consult.

Predisposition of functional genetic variants of A-kinase anchoring protein 10 toward acquired repolarization disorders in high-risk vascular surgery patients

PurposeWe aimed at assessing the predisposition of A-kinase anchoring protein 10 (AKAP10) polymorphism toward acquired repolarization disorders in high-risk vascular surgery patients.Patients and methodsOne hundred adult patients (age =44–85 years), scheduled for an elective high-risk “open” vascular surgery procedure, were recruited. The electrocardiogram Holter monitor was used to assess repolarization stability from the beginning of the operation up to 24 hours afterward. The AKAP10 gene rs203462 polymorphism and cardiac complications were analyzed.ResultsRepolarization disturbances defined as QT interval duration corrected for heart rate (QTc) interval prolongation >500 ms and QTc interval dispersion >65 ms were recorded in 46 patients. A model of multivariate logistic regression showed that only the presence of allele G of the AKAP10 polymorphism was an independent risk factor for repolarization disturbances in the perioperative period (odds ratio =14.35; 95% CI =4.65–44.23; p<0.0001).ConclusionWhen the acquired QTc interval prolongation or QTc dispersion is associated with AKAP10 polymorphism, it may remain clinically silent.

Randomized Controlled Trial of Negative Pressure Wound Therapy for High-Risk Groin Wounds in Lower Extremity Revascularization

Revascularization of the lower extremity requiring groin incision is associated with a high rate of surgical site infection (SSI). The objective of this study was to assess the effect of negative pressure wound therapy (NPWT) on rates of infection following primary closure of high-risk groin wounds in vascular surgery patients undergoing lower limb revascularization. We performed a randomized controlled trial at an academic tertiary medical center. High-risk groin wounds were defined as having previous femoral artery cutdown, body mass index >30 kg/m2, or major or minor ischemic tissue loss. We randomized patients to NPWT or standard group once the surgical incision was primarily closed. The primary outcome of the study was overall 30-day groin SSI. Our secondary outcomes were length of stay, readmissions, reoperations, amputations, and mortality. A total of 101 patients were randomized during 13 months. Criteria for inclusion were previous femoral artery cutdown in 24%, >30 kg/m2 body mass index in 36%, and ischemic tissue loss in 40%. The most common revascularization procedure performed was femoral to distal bypass (51%), followed by femoral to femoral artery bypass (20%) and other (29%). Primary outcome of 30-day SSI showed a lower trend but was nonsignificant in the NPWT group (11%) compared with the standard dressing group (19%; P = .24). There was one in-hospital SSI in both groups (P = .96). Length of hospital stay was significantly shorter for the NPWT group compared with the standard group (6.4 days vs 8.9 days; P = .01). We found a trend toward lower groin SSI in high-risk vascular surgery patients treated with NPWT compared with standard dressing. The NPWT group had significantly shorter length of hospital stay than the standard group. Our study was underpowered because of lower than expected infection rates.

Hospitalist-vascular surgery comanagement: effects on complications and mortality

ABSTRACTObjectives: Hospitalized vascular surgery patients have multiple severe comorbidities, poor functional status, and high perioperative cardiac risk. Thus they may be ideal patients for a collaborative care model. However, there is little evidence for a comanagement model on clinical outcomes.Methods: The two-year pre-post study consisted of a comanagement model where a hospitalist actively participated in the medical care of American Society of Anesthesiologist Physical Status Classification scale 3 or 4 vascular surgery patients. Outcomes were in-hospital mortality, length of stay, 30-day readmission rate, pain scores, and patient safety metrics.Results: With comanagement, patient complications decreased from 3.5 to 2.2 events per 1000 patients. (p = 0.045). Mortality decreased from 2.01% to 1.00% (p = 0.049), corresponding to a decrease in the risk-adjusted observed to expected mortality rate ratio from 1.22 to 0.53 (p = 0.01). Patient reported pain scores improved; more patients in the comanagement cohort expressed no pain (72% vs 82.8%; p = 0.01) and there were reductions in reports of mild and moderate pain. There was no significant difference in the risk-adjusted length of stay (observed to expected ratio 0.83 to 0.88 for the pre-intervention and comanagement groups, respectively, p = 0.48). The 30-day readmission rate was unchanged (21.9 vs 20.6% p = 0.44). Patients in the intervention period were more clinically complex, as evidenced by the greater case mix index (2.21 vs 2.44).Conclusions: After two years of implementation, our comanagement service reduced complications, mortality, and pain scores among high-risk vascular surgery patients.

Effect of Hydroxyethyl Starch on Outcomes in High-Risk Vascular Surgery Patients: A Retrospective Analysis.

To assess the effect of using hydroxyethyl starch (HES) for intraoperative fluid therapy on outcomes in high-risk vascular surgery patients. Retrospective case series. Single-center academic hospital. The study included 1,395 adult vascular surgery patients with peripheral vascular disease. Retrospective review of hospital databases. Outcomes were compared between patients who were intraoperatively administered HES (Voluven [Fresenius Kabi, Bad Homburg, Germany] or Pentaspan [Bristol-Myers Squibb Canada, Montreal, Quebec, Canada]) versus patients who received only crystalloids during their procedure. Logistic regression was used to assess for association between these groups and mortality (in-hospital, 30-day), intensive care unit admission, hemodialysis requirement, vasopressor requirement, and ventilator requirement. Overall, 796 patients had complete fluid records and were included in the analysis. After adjustment for potential confounders, receiving an HES solution was associated with increased likelihood of 30-day mortality (odds ratio [OR] 2.11, 95% confidence interval [CI] 1.05-3.80), postoperative requirement for hemodialysis (OR 6.17, 95% CI 1.09-35.10), intensive care unit admission (OR 3.52, 95% CI 2.15-5.74), and mechanical ventilation (OR 3.16, 95% CI 1.84-5.41). Intraoperative administration of HES was associated with an increased likelihood of adverse outcomes compared with use of crystalloids alone.

Physiological POSSUM as an Indicator for Long-term Survival in Vascular Surgery

We investigated whether the POSSUM physiology score, originally designed as an indicator for 30-day mortality for comparative audit, could be used as an indicator of long-term survival in vascular surgery practice. Data from 184 different vascular procedures conducted between 1989 and 2000, containing survival data for each patient of 10 years or longer, were analysed retrospectively. Parameters collected were the pre-operative physiological and the operative severity POSSUM score, gender, and type of procedure. Multivariate analyses were performed using Cox regression method and, on the basis of their physiological POSSUM score grouping, Kaplan-Meier analysis was performed for estimation of overall survival. Both an increase in physiological POSSUM score (hazard ratio [HR] 1.050, 95% confidence interval [CI] 1.031 to 1.070) and one of its components, age (HR 1.025, 95% CI 1.006 to 1.045; p = 0.009), were shown to be indicators of long-term all-cause mortality. The sample's mean physiological POSSUM score of 21 was then used as a cut-off point to categorise low and high-risk vascular surgery patients. Median survival in the low-risk group was 70 months (95% CI 56-86 months), whereas in the high-risk group this was 17 months (95% CI 3-31 months). The physiological POSSUM score, including patient age, is an indicator of long-term survival of patients with vascular disease. This may help in choosing the appropriate vascular intervention.

Abstract 193: Primary Care Utilization Reduces Risk of Readmission among High-Risk Vascular Surgery Patients: Coordinating of Post-Discharge Care Matters

Objectives: Readmissions are a common and costly occurrence following high-risk surgical procedures, but may be avoided if problems are identified early in the post-discharge period. We hypothesized that routine follow-up with a primary care provider (PCP) might reduce 30-day readmissions following a high-risk vascular surgery procedure, thoracic aortic aneurysm (TAA) repair. Methods: We conducted a retrospective cohort study of 42,935 Medicare beneficiaries who were discharged home from US hospitals following open TAA repair in 2003-2010. Primary care utilization was determined within 307 hospital referral regions described by the Dartmouth Atlas, as well as using a 20% sample of Medicare claims for outpatient primary care services within 30-days following TAA repair. We used hierarchical regression models, adjusted for patient and regional level differences, to examine the relationship between primary care utilization with 30-day readmission &amp; mortality following TAA repair. Results: 8,429 (20%) patients were readmitted within 30-days after open TAA repair, and more than 42% of readmissions occurred by 11 days post discharge. Among patients discharged following an uncomplicated hospital course, follow-up with a PCP within 30-days significantly reduced the risk of readmissions (Figure). Even after adjusting for differences in age, race, gender, and complications, PCP follow-up reduced the likelihood of 30-day readmission following TAA repair by over 30% (OR: 0.69; 95%CI: 0.49-0.97; P&lt;0.05). As with most major surgical procedures, readmissions following TAA repair were more likely to occur among patients experiencing postoperative complications (21% vs. 19%, P&lt;0.01). Finally, readmissions were less likely to occur in hospital referral regions with high primary care utilization as compared to regions with low rates of primary care utilization (19.4% high vs. 23.6% low; P&lt;0.01). Conclusions: Medicare recipients discharged following open TAA repair were significantly less likely to be readmitted in regions with high primary care utilization and when primary care follow-up occurred after surgery. These results highlight the need for better coordination of care between surgeons and primary care providers, and suggest an opportunity to focus quality improvement efforts to limit readmission.

RETRACTED: Influence of continuous perioperative beta-blockade in combination with phosphodiesterase inhibition on haemodynamics and myocardial ischaemia in high-risk vascular surgery patients

We sought to assess the intra- and postoperative haemodynamic effects of continuous perioperative beta-adrenergic blockade combined with phosphodiesterase (PDE) III inhibition and its potential benefits in limiting perioperative myocardial ischaemia in high-risk vascular surgery patients. Seventy-five patients were randomly assigned to receive tight heart rate (HR) control by a continuous infusion of: esmolol in combination with the PDE III inhibitor enoximone (esmolol+enoximone group), esmolol infusion alone (esmolol group), or standard therapy (control group) for a period of 48 h. Myocardial ischaemia and dysfunction were detected by serial plasma Troponin T (TnT) and B-type natriuretic peptide (BNP) measurements. Cardiac index (CI) increased significantly only in esmolol+enoximone-treated patients [CI: from 2.4 (0.2) litre min(-1) m(-2) at baseline to 3.2 (0.2) litre min(-1) m(-2) at 24 h after surgery; P=0.001] and was significantly higher than in the esmolol [CI: from 2.5 (0.2) litre min(-1) m(-2) at baseline to 2.6 (0.2) litre min(-1) m(-2) at 24 h; P=0.18] and the control groups [CI: from 2.4 (0.2) litre min(-1) m(-2) at baseline to 2.7 (0.2) litre min(-1) m(-2) at 24 h; P=0.13]. A significant postoperative release of TnT was detected only in control patients. Plasma BNP levels increased towards the end of surgery in all patients. Peak plasma BNP concentrations were significantly higher in control patients [293 (98) pg ml(-1)] than in esmolol [118 (71) pg ml(-1)] and in esmolol+enoximone-treated patients [78 (21) pg ml(-1)]. Inotropic therapy with the PDE III inhibitor enoximone combined with tight HR control by a continuous infusion of esmolol improved cardiac function and reduced myocardial ischaemia in high-risk vascular surgery patients. CLINICAL TRIAL REGISTRATION INFORMATION-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00348101.

Perioperative myocardial ischemic injury in high-risk vascular surgery patients: Incidence and clinical significance in a prospective clinical trial

Perioperative myocardial ischemic injury in high-risk vascular surgery patients: Incidence and clinical significance in a prospective clinical trial

Perioperative myocardial ischemic injury in high-risk vascular surgery patients: Incidence and clinical significance in a prospective clinical trial

The purpose of this study was to assess prospectively the incidence, health care resource utilization, and economic burden associated with perioperative myocardial ischemic injury (PMII) in high-risk patients undergoing noncardiac vascular surgery. Two hundred thirty-six patients consented to participate in a pharmacoeconomic substudy as part of a randomized, multicenter clinical trial. Patients were assessed for myocardial ischemic injury by using clinical, biochemical, and electrocardiographic criteria. PMII was defined as fatal or nonfatal myocardial infarction, new or worsened congestive heart failure, or new arrhythmias. Resource utilization parameters were compared for patients with and without PMII. Patients underwent the following index procedures: open abdominal aortic aneurysm repair (n = 44), bypass for aortoiliac disease (n = 29), bypass for femoropopliteal disease (n = 62), bypass for femorotibial disease (n = 71), extra-anatomic bypass (n = 23), and miscellaneous (n = 7). Patients undergoing carotid endarterectomy or only endovascular interventions were excluded. The incremental cost of PMII was estimated by applying the average costs (adjusted to 2004 US dollars) of the hospital ward (dollar 700.00/d) or intensive care unit (dollar 2500.00/d) to the length of stay differences for patients with and without PMII. The overall mortality was 3.4% (8/236), and 7 of 8 deaths were related to PMII. PMII occurred in 42 (17.8%) of 236 patients: 22 myocardial infarctions, 11 congestive heart failures, and 12 new arrhythmias (3 patients had 2 PMII events). There was no evidence of differences in the incidence of PMII among the various index procedures. PMII was associated with a dramatic increase in resource utilization. The mean length of stay was 16.8 and 10.0 days for patients with and without PMII, respectively (P < .001). Intensive care unit care was required by 35 (83.3%) of 42 patients with and 121 (62.4%) of 194 patients without PMII (P < .009). The mean intensive care unit length of stay was 6.6 and 3.7 days for patients with and without PMII, respectively (P < .009). Ten (23.8%) of 42 patients with and 20 (10.3%) of 194 patients without PMII returned to the emergency department for care after discharge (P < .02). In modern vascular surgery practice, PMII remains common despite the availability of beta-blockers and other preventative strategies. PMII is associated with dramatic increases in resource utilization and cost. The increase in resource utilization associated with PMII resulted in an estimated incremental cost per patient of dollar 9980.00. If 250,000 high-risk open vascular operations are performed annually in the United States, the economic burden of PMII in these procedures alone approximates dollar 444 million. Strategies to decrease PMII incidence and severity should be evaluated in large-scale prospective trials.

Haemodynamic stability under spinal ropivacaine in high risk vascular surgery patients

Haemodynamic stability under spinal ropivacaine in high risk vascular surgery patients

Haemodynamic stability under spinal ropivacaine in high risk vascular surgery patients

Haemodynamic stability under spinal ropivacaine in high risk vascular surgery patients

The Effect of Heart Rate Control on Myocardial Ischemia Among High-Risk Patients After Vascular Surgery

Patients undergoing vascular surgery have a high risk of suffering major postoperative cardiac events.Preoperative myocardial ischemia as detected by Holter monitoring identifies a high-risk subgroup whose postoperative ischemia, similarly detected, seems to herald major cardiac events. In this study, we determined whether systematic, patient-specific postoperative heart rate control with beta-adrenergic blocker therapy decreases the incidence of postoperative ischemia among high-risk vascular surgery patients. A total of 26 of 150 patients who underwent elective vascular surgery and were monitored preoperatively by 24-h Holter were found to have significant myocardial ischemia as defined by ST-segment depression. The minimal heart rate at which this ST-segment depression occurred was identified (ischemic threshold), and these 26 patients were then randomized to receive continuous IV beta-blockade with esmolol or placebo plus usual medical therapy, aiming to reduce the postoperative heart rate to 20% below the ischemic threshold. All patients were monitored by Holter for 48 h postoperatively. Postoperative Holter readings were analyzed for the incidence of ischemia and for the number of hours during which heart rate was controlled below the ischemia threshold. Patients had a median of two episodes of preoperative ischemia lasting a median of 30 min (range 1-155 min). A total of 15 patients were randomized to receive esmolol, and 11 were randomized to receive placebo. The two groups were comparable with respect to clinical characteristics and incidence and duration of preoperative ischemia. Ischemia persisted in the postoperative period in 8 of 11 placebo patients (73%), but only 5 of 15 esmolol patients (33%) (P < 0.05). Of the 15 esmolol patients, 9 had mean heart rates below the ischemic threshold, and all 9 had no postoperative ischemia. A total of 4 of 11 placebo patients had mean heart rates below the ischemic threshold, and 3 of the 4 had no postoperative ischemia. There were two postoperative cardiac events among patients who had postoperative ischemia (one placebo, one esmolol) and whose mean heart rates exceeded the ischemic threshold. Our data suggest that patient-specific, strict heart rate control aiming for a predefined target based on individual preoperative ischemic threshold was associated with a significant reduction and frequent elimination of postoperative myocardial ischemia among high-risk patients and provide a rationale for a larger trial to examine this strategy's effect on cardiac risk. Implications: Patients who undergo peripheral vascular surgery often experience transient cardiac complications and/or permanent heart damage just after surgery because of inadequate myocardial blood flow. In this study, we identified patients at high risk of cardiac complications after vascular surgery and showed that if their heart rate was carefully controlled for 48 h after surgery, myocardial ischemia, a common marker of heart injury, was markedly reduced. (Anesth Analg 1999;88:477-82)

Cardiac risk stratification for high-risk vascular surgery.

The best strategy for cardiac risk assessment before high-risk vascular surgery remains controversial. A cardiac risk stratification protocol was evaluated in patients undergoing high-risk vascular surgery. Our investigation paralleled the elaboration of the American College of Cardiology/ American Heart Association (ACC/AHA) Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery and is highly comparable to the proposed guidelines. A cardiac risk stratification protocol was evaluated prospectively in 203 patients scheduled for aortic surgery. Key points of the study were cardiac mortality/morbidity and cost-effectiveness. Patients were stratified into low (n = 101), intermediate (n = 79), and high (n = 23) cardiac risk after clinical predictors. After stratification, the degree of estimated functional capacity assessed by treadmill exercise and daily living activities and expressed by metabolic equivalents (METs) was critical for further cardiac evaluation. In intermediate-risk patients with an estimated functional capacity < 5 METs and in all high-risk patients, noninvasive cardiac testing and/or subsequent medical care were performed. Noninvasive testing was considered necessary in 41 patients, coronary angiography in 7, and myocardial revascularization in 1. Overall hospital mortality was 3.5%. Cardiac mortality and morbidity were 1% and 12.4%, respectively. Cardiac risk stratification for high-risk vascular surgery patients, according to a protocol similar to the ACC/AHA Guidelines for Cardiovascular Evaluation for Noncardiac Surgery, demonstrated excellent clinical outcome. This approach appears to be a safe and economical strategy for preoperative cardiac evaluation.