Bruce A. Perler

Does contralateral internal carotid artery occlusion increase the risk of carotid endarterectomy

The results of every carotid endarterectomy performed contralateral to an internal carotid artery occlusion (n = 36) (group I) were compared with those performed contralateral to a patent internal carotid artery (n = 169) (group II) over the last 10 years. The patients in each group were evenly matched with respect to male gender (66% vs 69%); mean age (66.7 vs 65.9 years); and incidence of hypertension (55.6% vs 53.2%), diabetes (16.7% vs 20.1%), and hyperlipidemia (8.3% vs 11.8%). Patients in group I had a higher incidence of previous myocardial infarction (25% vs 11.8%, p less than 0.05) and exertional angina (55.6% vs 29.6%, p less than 0.01). Indications for carotid endarterectomy were equivalent, including stroke (19.4% vs 21.9%), transient ischemic attacks (36.1% vs 35.5%), amaurosis fugax (16.7% vs 11.8%), nonhemispheric symptoms (5.6% vs 8.3%), and asymptomatic stenoses (22.2% vs 22.5%), respectively. Perioperative strokes occurred in one (2.8%) patient in group I and seven (4.1%) patients in group II (NS). Among the patients in group II the incidence of perioperative stroke did not correlate directly with the degree of contralateral ICA stenosis: greater than 90% (4%); 70% to 90% (6.7%); 50% to 70% (8.7%); and less than 50% (2.8%). The operative mortality rate was 0% among patients in group I and 1.2% among patients in group II (NS). Cardiac complications occurred in two (5.6%) patients in group I and nine (5.3%) patients in group II (NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Reduction of in-hospital mortality among California hospitals meeting Leapfrog evidence-based standards for abdominal aortic aneurysm repair

BACKGROUNDnThe Leapfrog Group established evidence-based standards for abdominal aortic aneurysm (AAA) repair, including targets for case volume and perioperative beta-blocker usage. The purpose of this study was to determine whether meeting these benchmarks correlated with improved patient outcomes over time.nnnMETHODSnWe studied California hospitals that responded to consecutive Leapfrog Group Hospital Quality and Safety Surveys between 2000 and 2005. Survey results of compliance with Leapfrog standards were linked to patient outcomes for AAA repair using the California state discharge database for the corresponding years. A random-effects Poisson regression analysis was performed to measure the effect of meeting beta-blocker and case volume standards on hospital mortality and average length of stay after elective open and endovascular AAA repair (EVAR) during the early (2000-2002) and later (2003-2005) phase of Leapfrog implementation.nnnRESULTSnAmong 140 hospitals that performed open AAA repair, 25 (17.4%) met the Leapfrog case volume standard, 32 (22.2%) were compliant with routine perioperative beta-blocker use, 5 hospitals (3.5%) met both criteria, and 78 control hospitals failed to meet either standard. After controlling for temporal differences in hospital and patient characteristics, hospitals that implemented a policy for perioperative beta-blocker usage were found to have an estimated 51% reduction of in-hospital mortality (relative risk, 0.49; 95% confidence interval, 0.24-0.99; P < .05) after open AAA repair cases compared with control hospitals over time. There was no improvement in mortality outcomes over time, however, after open AAA repair in hospitals meeting case volume standards. Among 111 California hospitals in which EVAR was performed, there was an estimated 61% reduction of in-hospital mortality over time (relative risk, 0.39; 95% confidence interval, 0.07-1.80) among hospitals meeting Leapfrog case volume standards compared with control hospitals, although these results did not reach statistical significance. Finally, there was no reduction in length of hospital stay over time after either EVAR or open AAA repair for hospitals meeting Leapfrog standards compared with control hospitals.nnnCONCLUSIONSnThis population-based study supports the effectiveness of meeting Leapfrog AAA repair standards towards improving mortality outcomes over time and suggests that their impact depends upon procedure type. Further studies are needed to help promote the standardization of evidence-based measures that may improve vascular surgery outcomes.

Rotational muscle flaps to treat localized prosthetic graft infection: Long-term follow-up

PURPOSEnThe conventional management of prosthetic graft infection (PGI), including graft excision and extraanatomic revascularization, continues to be associated with substantial morbidity. Rotational muscle flap (RMF) closure of the infected wound, with preservation of the graft, is an alternative, albeit controversial, approach.nnnMETHODSnOver the last 7 years, 22 RMF procedures have been performed to close 19 wounds in 18 patients, ranging in age from 39 to 79 (mean 63.7) years, with PGI. Twenty-one grafts constructed of Dacron (13) or polytetrafluoroethylene (8) were covered in the groin (16), neck (2), or chest (1). The clinical presentations included abscess or purulent drainage in 14 grafts, hemorrhage in three, and infected false aneurysm in two wounds; positive bacterial culture results were obtained in each case.nnnRESULTSnThere was one (5.6%) operative death. Healing was achieved in the 18 wounds of the 17 operative survivors. No patients have been lost to follow-up. Three (17.6%) of these 17 patients had recurrent infection, including one patient who underwent a secondary RMF procedure with graft salvage, one who underwent excision of an occluded graft, and one who underwent excision and extraanatomic bypass and died. Four other patients died 1 to 6 (mean 3) months after RMF closure with healed wounds. Eleven (92%) of the 12 survivors have healed wounds and intact grafts with follow-up ranging from 8 to 83 (mean 39) months. For the entire series 15 (88%) of these 17 patients had healed wounds and intact grafts, with a mean follow-up of 30 months.nnnCONCLUSIONSnThese results suggest that RMF procedures are well tolerated and can achieve acceptable long-term graft salvage in selected patients with PGI.

Vascular Disease in the Elderly Patient

At a time of potentially dramatic changes in health care policy in this country, and in view of the necessity for health care cost containment, physicians are expected to exercise serious introspection in the selection of treatment for the elderly patient with peripheral arterial disease. These decisions should be made while acknowledging that it is the goal of the health-care provider to postpone chronic illness, to maintain vigor, and to slow social and psychological involution. For the elderly patient with an abdominal aortic aneurysm, with significant carotid disease, or with limb-threatening peripheral ischemia, the evidence is compelling that timely surgical intervention in properly selected patients is well tolerated and will satisfy this goal.

Improving surgical outcomes through adoption of evidence-based process measures: Intervention specific or associated with overall hospital quality?

BACKGROUNDnThe Leapfrog Group aims to improve surgical outcomes through promoting hospital adoption of procedure-specific process measures, although it is unclear whether compliance reflects a hospitals overall quality. The purpose of this study was to evaluate whether implementation of Leapfrogs standard for routine beta-blockade was associated with reductions in mortality after open abdominal aortic aneurysm (AAA) repair alone versus other high-risk operations.nnnMETHODSnUsing a 2:1 matched case-control study design, hospitals that had not adopted the beta-blockade standard (n = 72) were compared with hospitals that had implemented this Leapfrog standard (n = 36). Leapfrog survey data were linked to patient outcomes in the California OSHPD database from 2000 to 2005. Random-effects Poisson regression models were used to evaluate in-hospital mortality over time for patients undergoing AAA repair versus esophagectomy, hepatectomy, pancreatectomy, colectomy, gastrectomy, and pulmonary lobectomy.nnnRESULTSnA total of 6,199 AAA repairs, 2,780 esophagectomies, 2,544 hepatectomies, 2,909 pancreatectomies, 57,795 colectomies, 6,267 gastrectomies, and 10,210 lobectomies were analyzed. AAA-associated mortality significantly declined in hospitals that adopted the beta-blocker standard (relative risk [RR]: 0.49; 95% confidence interval [CI]: 0.24-0.97; P < .05). Implementation of this Leapfrog standard had no effect on reducing adjusted mortality rates for other high-risk operations, including esophagectomy (RR: 0.70; 95% CI: 0.25-1.89), hepatectomy (RR: 1.16; 95% CI: 0.32-4.29), pancreatectomy (RR: 0.76; 95% CI: 0.28-2.02), colectomy (RR: 1.12; 95% CI: 0.86-1.44), gastrectomy (RR: 1.17; 95% CI: 0.57-2.43), and lobectomy (RR: 0.98; 95% CI: 0.46-2.08) (all P > .05).nnnCONCLUSIONnCompliance with peri-operative beta-blockade resulted in a significant reduction in mortality after open AAA repair over time, but it had no crossover effect on mortality associated with other high-risk operations in the same hospital. These data suggest that improvements in outcomes resulting from the adoption of evidence-based process measures are procedure specific and do not necessarily reflect overall hospital quality.

Charles Dickens, Coach K, Pogo, and the recent history and future of vascular surgery

It is hard for me to believe that it has been 24 years since I attended my first meeting of the Southern Association for Vascular Surgery, as a guest, in Cerromar Beach, Puerto Rico. I remember that meeting as if it was yesterday. I was struck by how friendly everyone was, famous surgeons whose names I had only read in journals went out of their way to introduce themselves and say hello, the papers were terrific, and the venue was not bad either. I decided then and there that I had to get into this club! Fortunately, I was elected to membership a couple years later. However, never then, or at any time since did I ever expect to be standing here today as the President of this remarkable organization. There is no greater reward in academic medicine then to be recognized and respected by one’s peers, and when I consider the 33 vascular surgeons who have preceded me in this office, I am truly humbled, and I thank you sincerely for this wonderful honor. I would not be standing here today without the help and support of many, many people, too numerous to mention individually, but especially my family: my professional, as well as my nuclear, family. I have been privileged to spend my entire career at one incredible institution, Johns Hopkins, and to work with so many amazing people. To my partners, past and present, and our Fellows, thank you for your support, your professionalism, and your friendship. We have been blessed with two beautiful children who are quickly becoming an outstanding young man and woman. Since I have spent most of my waking hours as a surgeon, and not as a father or husband, my bride, Patti, deserves all the credit for these terrific kids. I love you all very, very much.

Outcomes of nonelective weekend admissions for lower extremity ischemia

OBJECTIVEnA weekend effect has been demonstrated for a number of diagnoses, including many cardiovascular pathologies. Whether patients with lower extremity ischemia admitted over the weekend have inferior outcomes compared with those admitted on a weekday is unknown.nnnMETHODSnNonelective admissions for critical limb ischemia (CLI) and acute limb ischemia (ALI) from lower extremity thrombosis or embolism were identified in the 2005 to 2010 Nationwide Inpatient Sample, and outcomes were compared based on weekend vs weekday admission by using multiple logistic and linear regression.nnnRESULTSnOf the 63,768 patients identified with lower extremity vascular emergencies, 15.4% were admitted during the weekend. Patients admitted on the weekend were less likely to have CLI than those admitted on a weekday (51.2% vs 65.4%; P < .001) and were more likely to have ALI than patients admitted during a weekday (48.8% vs 34.5%; P < .001). Weekend admission was independently associated with a lower likelihood of revascularization (adjusted odds ratio [aOR], 0.90; 95% confidence interval [CI], 0.85-0.95; P < .001), a longer time until revascularization (3.09 days vs 2.75 days; P < .001), an increased likelihood of major amputation (aOR, 1.35; 95% CI, 1.19-1.53; P < .001), in-hospital complications (aOR, 1.18; 95% CI, 1.11-1.25; P < .001), and discharge to a skilled nursing facility (aOR, 1.15; 95% CI, 1.06-1.25; P = .001), and a longer predicted length of stay (10.1 days vs 9.5 days; P < .001). There was no statistically significant association between weekend admission and in-hospital mortality (aOR, 1.15; 95% CI, 1.06-1.25; P = .10).nnnCONCLUSIONSnPatients admitted on the weekend for lower extremity vascular emergencies are significantly more likely to experience adverse outcomes, including major amputation, than patients admitted on a weekday, independent of their presenting diagnosis with ALI or CLI. Further investigation into the etiologies of these differences is needed to address this disparity. These data raise questions about the proper staffing models to optimize urgent treatment of lower extremity vascular emergencies.

The Role of the Surgical Femoropopliteal Bypass in Today's Practice

EPIDEMIOLOGY Among the population of patients presenting with peripheral arterial occlusive disease, the anatomic distribution of atherosclerotic lesions differs somewhat between diabetic and non-diabetic individuals. Non-diabetic patients are more likely to develop a0110-iliac occlusive disease whereas infra inguinal disease, and especially infrapopliteal occlusive disease, is seen more commonly in the diabetiC population. However, among both groups, the femoral-popliteal anatomic segment is clearly the most frequent arterial bed in which arteriosclerotic lesions occur. It is estimated that atherosclerotic disease of the lower extremities affects at least 5% of individuals over the age of 60 and at least 10% of those over the age of 70. Severe limb threatening ischemia, most often secondary to femoral-popliteal-tibial occlusive disease affects at east 50,000 individuals each year in the United States. These epidemiologic observations are reflected in clinical practice since exclusive of carotid endarterectomy, infrainguinal bypass grafts (femoralpopliteal and femoral-tibial) are the most frequently performed operations in peripheral vascular surgery, with nearly 80,000 procedures performed annually in the United States. It is estimated that the percentage of individuals over the age of 65 will increase by more than 70% over the next four decades and those over the age of 85 by 600%. By the year 2030, it is predicted that roughly 7% of the United States population will be age 85 or older. It is therefore clear that femoral-popliteal revascularization represents a significant growth area in medical practice. Patients presenting with femoral-popliteal-tibial occlUSive disease tend to be somewhat older than those presenting with aorto-iliac occlusive disease. Tobacco use, hypertension, and as noted above, diabetes mellitus are risk factors for this pathologic process. There is also a strong association between femoral-popliteal occlusive disease and atherosclerotic disease in the carotid and coronary artery circulations, and in fact, cardiac morbidity is the most common cause of mortality among those who undergo surgical femoral-popliteal reconstructions.

Carotid Endarterectomy: What Are the Real Risks?

1:10 p.lll. Carotid Endarterectomy: What Are the Real Risks? Bruce A. Perler, MD johns Hopkins University School of Medicine Baltimore, MD Carotid endarterectomy (CEA) was first performed in the 1950s, and over the last four decades this procedure has become the most frequently performed peripheral vascular operation in the United States, with more than 150,000 procedures now carried out annually in this counuy. During the late 1980s, however, in view of the rapid growth in the performance of this operation and isolated reports citing excessively high rates of operative mortality and morbidity, CEA came under intense scrutiny and in fact there was a substantial reduction in the number of procedures performed. Subsequently, several randomized prospective clinical trials have confirmed the safety and efficacy of this operation, and as a result there has been dramatic growth in the performance of the procedure over last several years. Most recently, however, the role of CEA has been challenged by the introduction of carotid stenting into clinical practice. While there is increasing interest in and enthUSiasm for carotid stenting, before we can view this therapeutic modality as an acceptable alternative to CEA for the treatment of carotid atherosclerotic disease, it must be proven that it is as safe and effective, and as durable, as CEA.