Journal of vascular surgery
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Readmissions after complex vascular surgery are not well studied. We sought to determine the rate of readmission after thoracic and thoracoabdominal aortic aneurysm repair (TAA/TAAAR) at our institution and to identify risk factors for and costs of readmission. ⋯ Early readmissions after TAA/TAAA repair are frequent and often occur at hospitals other than the index institution. Risk factors for readmission include open repair and postoperative pneumonia but not pre-existing patient comorbidities. Readmissions to nonindex hospitals were related to medical morbidities that were associated with fewer interventions and lower costs compared with the index hospital. Focusing on preoperative risk factors in this group of patients may not lead to reduction in readmissions. Minimizing nonsurgical complications may reduce post-TAA/TAAAR readmissions and the high costs associated with repeat care.
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Multicenter Study Clinical Trial
Results of the United States multicenter prospective study evaluating the Zenith fenestrated endovascular graft for treatment of juxtarenal abdominal aortic aneurysms.
This study reports the results of a prospective, multicenter trial designed to evaluate the safety and effectiveness of the Zenith fenestrated endovascular graft (Cook Medical, Bloomington, Ind) for treatment of juxtarenal abdominal aortic aneurysms (AAAs). ⋯ This prospective study demonstrates that endovascular repair of juxtarenal AAAs with the Zenith fenestrated AAA stent graft is safe and effective. Mortality and morbidity are low in properly selected patients treated in centers with experience in these procedures.
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Comparative Study
A comparison of open surgery versus endovascular repair of unstable ruptured abdominal aortic aneurysms.
Two randomized trials to date have compared open surgery (OS) and endovascular (EVAR) repair for ruptured abdominal aortic aneurysm (rAAA); however, neither addressed optimal management of unstable patients. Single-center reports have produced conflicting data regarding the superiority of one vs the other, with the lack of statistical power due to low patient numbers. Furthermore, previous studies have not delineated between the outcomes of stable patients with a contained rupture vs those patients with instability. Our objective was to compare 30-day outcomes in patients undergoing OS vs EVAR for all rAAAs, focusing specifically on patients with instability. ⋯ Approximately one-third of patients treated for rAAA undergo EVAR in NSQIP participating hospitals. Not surprisingly, unstable patients have less favorable outcomes. In both stable and unstable rAAA patients, EVAR is associated with a diminished 30-day mortality and morbidity.
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The Surgical Care Improvement Project (SCIP) is a national initiative to reduce surgical complications, including postoperative surgical site infection (SSI), through protocol-driven antibiotic usage. This study aimed to determine the effect SCIP guidelines have had on in-hospital SSIs after open vascular procedures. ⋯ Implementation of SCIP guidelines has made no significant effect on the incidence of in-hospital SSIs in open vascular operations; rather, an increase in SSI rates in open AAA repairs was observed. Patient-centered, bundled approaches to care, rather than current SCIP practices, may further decrease SSI rates in vascular patients undergoing open procedures.
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Comparative Study
Use of three-dimensional contrast-enhanced duplex ultrasound imaging during endovascular aneurysm repair.
Iodinated contrast during endovascular aneurysm repair (EVAR) is used with caution in patients with chronic kidney disease. Contrast-enhanced ultrasound (CEUS) imaging using nonnephrotoxic sulphur hexafluoride microbubble contrast is a novel imaging modality that accurately identifies and characterizes endoleaks during EVAR follow-up. We report our initial experience of using three-dimensional (3D) CEUS imaging intraoperatively as completion imaging after endograft deployment. Our aim was to compare intraoperative 3D CEUS against uniplanar angiography in the detection of endoleak, stent deformity, and renal artery perfusion during EVAR. ⋯ 3D CEUS imaging detected endoleaks not seen on uniplanar digital subtraction angiography, including a clinically important type I endoleak, and was also more sensitive than 2D CEUS imaging for the detection of the source of endoleak. This technology has the potential to supplement or replace digital subtraction angiography for completion imaging to reduce the use of x-ray contrast. Intraoperative 3D CEUS has been applied to allow safe EVAR with ultralow or no iodinated contrast usage in selected cases, without compromising completion imaging.