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Indianapolis, IN, United States

Pannucci C.J.,Section of Plastic Surgery | Laird S.,Michigan Surgical Quality Collaborative | Campbell D.A.,University of Michigan | Henke P.K.,Section of Vascular Surgery | Henke P.K.,University of Michigan
Chest | Year: 2014

Background: VTE is the proximate cause of 100,000 deaths in the United States each year. Perioperative VTE risk among surgical patients varies by 20-fold, which highlights the importance of risk stratification to identify high-risk patients, in whom chemoprophylaxis can decrease VTE risk, and low-risk patients, for whom the risk-benefi t relationship of prophylaxis may be unfavorable. Methods: We used data from a statewide surgical quality collaborative for surgical procedures performed between 2010 and 2012. Regression-based techniques identifi ed predictors of 90-day VTE while adjusting for procedural complexity and comorbid conditions. A weighted risk index was created and was validated subsequently in a separate, independent dataset. Results: Data were available for 10,344 patients, who were allocated randomly to a derivation or validation cohort. The 90-day VTE rate was 1.4%; 66.2% of the derivation cohort and 65.5% of the validation cohort received chemoprophylaxis. Seven risk factors were incorporated into a weighted risk index: personal history of VTE, current cancer, sepsis/septic shock/systemic infl ammatory response syndrome, age ≥ 60 years, BMI ≥40 kg/m 2 , male sex, and family history of VTE. Prediction for 90-day VTE was similar in the derivation and validation cohorts (areas under the receiver operator curve, 0.72 and 0.70, respectively). An 18-fold variation in 90-day VTE rate was identified. Conclusions: A weighted risk index quantifi es 90-day VTE risk among surgical patients and identifies an 18-fold variation in VTE risk among the overall surgical population. © 2014 American College of Chest Physicians. Source

Calligaro K.D.,Section of Vascular Surgery
Journal of Vascular Surgery | Year: 2010

The following recommendations for elective vascular interventions should be considered my own personal guidelines and are expected to be controversial (Table I). Patients >80 years old and patients with chronic renal failure have been shown to be high risk or have poor long-term outcomes for many interventions. Prophylactic CEA should be performed only in low risk patients with expected good long-term survival and only when associated with low complications. Prophylactic CEA should not be offered to patients with dialysis-dependent renal failure. CAS should not be recommended for patients ≥80 years old, in patients with chronic renal failure, and if CEA can be performed (exceptions include lesions that are surgically inaccessible or patients with history of neck radiation or prior CEA). Renal artery bypass should not performed in patients ≥80 years old, in patients with moderate or severe chronic renal failure, in low-volume hospitals, or concomitantly with aortic surgery, unless an individual institution show excellent short- and long-term outcomes. Renal artery stenting should rarely be performed and possibly only after prospective randomized studies document its efficacy. Open AAA surgery should not be performed in dialysis-dependent patients ≥80 years old. Open TAA surgery should rarely be performed in patients ≥80 years old unless a center has documented excellent results in these patients. TEVAR alone or with hybrid de-branching operations should not be carried out in poor-risk patients. Infrainguinal arterial bypasses should not performed in patients ≥90 years old and superficial femoral artery endovascular interventions should not performed for limb salvage in patients with poor run-off. Exceptions to the above guidelines exist, especially in extremely good risk patients, in patients with expected excellent long-term survival, or when the proposed procedure is to be performed in a hospital with high volume and with documented excellent results. © 2010 Society for Vascular Surgery. Source

Hull R.D.,University of Calgary | Liang J.,University of Calgary | Bergqvist D.,Section of Vascular Surgery | Yusen R.D.,University of Washington
Thrombosis and Haemostasis | Year: 2014

Surgeons consider the benefit-to-harm ratio when making decisions regarding the use of anticoagulant venous thromboembolism (VTE) prophylaxis. We evaluated the benefit-to-harm ratio of the use of newer anticoagulants as thromboprophylaxis in patients undergoing major orthopaedic surgery using the likelihood of being helped or harmed (LHH), and assessed the effects of variation in the definition of major bleeding on the results. A systematic literature search was performed to identify phase II and phase III studies that compared regulatory authority-approved newer anticoagulants to the low-molecular-weight heparin enoxaparin in patients undergoing major orthopaedic surgery. Analysis of outcomes data estimated the clinical benefit (number-needed-to-treat [NNT] to prevent one symptomatic VTE) and clinical harm (number-needed-to-harm [NNH] or the NNT to cause one major bleeding event) of therapies. We estimated each trial's benefit-to-harm ratio from NNT and NNH values, and expressed this as LHH = (1/NNT)/(1/NNH) = NNH/NNT. Based on reporting of efficacy and safety outcomes, most studies favoured enoxaparin over fondapari-nux, and rivaroxaban over enoxaparin. However, when using the LHH metric, most trials favoured enoxaparin over both fondaparinux and rivaroxaban when they included surgical-site bleeding that did not require reoperation in the definition of major bleeding. The exclusion of bleeding at surgical site which did not require reoperation shifted the benefit-to-harm ratio in favour of the newer agents. Variations in the definitions of major bleeding may change the benefit-to-harm ratio and subsequently affect its interpretation. Clinical trials should attempt to improve the consistency of major bleeding reporting. © Schattauer 2014. Source

Thompson A.M.,Section of Vascular Surgery | Martin K.A.,Yale University | Rzucidlo E.M.,Section of Vascular Surgery
PLoS ONE | Year: 2014

Phenotypic plasticity in vascular smooth muscle cells (VSMC) is necessary for vessel maintenance, repair and adaptation to vascular changes associated with aging. De-differentiated VSMC contribute to pathologies including atherosclerosis and intimal hyperplasia. As resveratrol has been reported to have cardio- protective effects, we investigated its role in VSMC phenotypic modulation. We demonstrated the novel finding that resveratrol promoted VSMC differentiation as measured by contractile protein expression, contractile morphology and contraction in collagen gels. Resveratrol induced VSMC differentiation through stimulation of SirT1 and AMPK. We made the novel finding that low or high dose resveratrol had an initially different mechanism on induction of differentiation. We found that low dose resveratrol stimulated differentiation through SirT1-mediated activation of AKT, whereas high dose resveratrol stimulated differentiation through AMPK-mediated inhibition of the mTORC1 pathway, allowing activation of AKT. The health effects of resveratrol in cardiovascular diseases, cancer and longevity are an area of active research. We have demonstrated a supplemental avenue where-by resveratrol may promote health by maintaining and enhancing plasticity of the vasculature. © 2014 Thompson et al. Source

Tameo M.N.,Section of Vascular Surgery | Dougherty M.J.,Section of Vascular Surgery | Calligaro K.D.,Section of Vascular Surgery
Journal of Vascular Surgery | Year: 2011

Spontaneous dissection of the superior mesenteric artery (SMA) is rare. We report a case of rupture of the SMA after spontaneous dissection in a 51-year-old male who presented with acute onset of abdominal pain and hypotension. The patient was initially treated with intravenous fluid resuscitation and endovascular intervention followed by open surgery. No identifiable cause for dissection was found. The patient was diagnosed as having segmental arterial mediolysis (SAM). The patients' presentation, treatment, outcome, and all relevant imaging, pathologic, and laboratory studies were reviewed. The relevant features of the case and SAM are presented herein. In addition, a review of all available published literature on SAM to date is presented. © 2011 The Society for Vascular Surgery. Source

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