Dalibor Kubelik

Wait times among patients with symptomatic carotid artery stenosis requiring carotid endarterectomy for stroke prevention

BACKGROUND Current Canadian and international guidelines suggest patients with transient ischemic attack (TIA) or nondisabling stroke and ipsilateral internal carotid artery stenosis of 50% to 99% should be offered carotid endarterectomy (CEA) ≤ 2 weeks of the incident TIA or stroke. The objective of the study was to identify whether these goals are being met and the factors that most influence wait times. METHODS Patients who underwent CEA at the Ottawa Hospital for symptomatic carotid artery stenosis from 2008 to 2010 were identified. Time intervals based on the dates of initial symptoms, referral to and visit with a vascular surgeon, the decision to operate, and the date of surgery were recorded for each patient. The influence of various factors on wait times was explored, including age, sex, type of index event, referring physician, distance from the surgical center, degree of stenosis, and surgeon assigned. RESULTS Of the 117 patients who underwent CEA, 92 (78.6%) were symptomatic. The median time from onset of symptoms to surgery for all patients was 79 days (interquartile range [IQR], 34-161). The shortest wait times were observed in stroke patients (49 [IQR, 27-81] days) and inpatient referrals (66 [IQR, 25-103] days). Only 7 of the 92 symptomatic patients (8%) received care within the recommended 2 weeks. The median surgical wait time for all patients was 14 days (IQR, 8-25 days). In the multivariable analysis, significant predictors of longer wait times included retinal TIA (P = .003), outpatient referrals (P = .004), and distance from the center (P = .008). Patients who presented to the emergency department had the shortest delays in seeing a vascular surgeon and subsequently undergoing CEA (P < .0001). There was no difference between surgeons for wait times to be seen in the clinic; however, there were significant differences among surgeons once the decision was made to proceed with CEA. CONCLUSIONS Our wait times for CEA currently do not fall within the recommended 2-week guideline nor does it appear feasible within the current system. Important factors contributing to delays include outpatient referrals, living farther from the hospital, and presenting with a retinal TIA (amaurosis fugax). Our findings also suggest better scheduling practices once a decision is made to operate can modestly improve overall and surgical wait times for CEA.

Internal iliac coverage during endovascular repair of abdominal aortic aneurysms is a safe option: A preliminary study

Endovascular aneurysm repairs lacking suitable common iliac artery landing zones occasionally require graft limb extension into the external iliac artery, covering the internal iliac artery origin. The purpose of this study was to assess incidence of type II endoleak following simple coverage of internal iliac artery without embolization during endovascular aneurysm repair. Three hundred eighty-nine endovascular aneurysm repairs performed by a single surgeon (2004–2015) were reviewed. Twenty-seven patients underwent simple internal iliac artery coverage. Type II endoleak was assessed from operative reports and follow-up computed tomography imaging. No patient suffered type II endoleak from a covered internal iliac artery in post-operative computed tomography scans. Follow-up ranged from 0.5 to 9 years. No severe pelvic ischemic complications were observed. In conclusion, for selected cases internal iliac artery coverage without embolization is a safe alternative to embolization in endovascular aneurysm repairs, where the graft must be extended into the external iliac artery.

Practice Variation in Spontaneous Breathing Trial Performance and Reporting

Background. Spontaneous breathing trials (SBTs) are standard of care in assessing extubation readiness; however, there are no universally accepted guidelines regarding their precise performance and reporting. Objective. To investigate variability in SBT practice across centres. Methods. Data from 680 patients undergoing 931 SBTs from eight North American centres from the Weaning and Variability Evaluation (WAVE) observational study were examined. SBT performance was analyzed with respect to ventilatory support, oxygen requirements, and sedation level using the Richmond Agitation Scale Score (RASS). The incidence of use of clinical extubation criteria and changes in physiologic parameters during an SBT were assessed. Results. The majority (80% and 78%) of SBTs used 5 cmH2O of ventilator support, although there was variability. A significant range in oxygenation was observed. RASS scores were variable, with RASS 0 ranging from 29% to 86% and 22% of SBTs performed in sedated patients (RASS < −2). Clinical extubation criteria were heterogeneous among centres. On average, there was no change in physiological variables during SBTs. Conclusion. The present study highlights variation in SBT performance and documentation across and within sites. With their impact on the accuracy of outcome prediction, these results support efforts to further clarify and standardize optimal SBT technique.

Early vs. late tracheostomy in intensive care settings: Impact on ICU and hospital costs

Introduction: Up to 12% of the 800,000 patients who undergo mechanical ventilation in the United States every year require tracheostomies. A recent systematic review showed that early tracheostomy was associated with better outcomes: more ventilator‐free days, shorter ICU stays, less sedation and reduced long‐term mortality. However, the financial impact of early tracheostomies remain unknown. Objectives: To conduct a cost‐analysis on the timing of tracheostomy in mechanically ventilated patients. Methods: We extracted individual length of hospital stay and length of ICU stay data from the studies included in the systematic review from Hosokawa et al. We also searched for any recent randomized control trials on the topic that were published after this review. The weighted length of stay was estimated using a random effects model. Average daily hospital and ICU costs per patients were obtained from a cost study by Kahn et al. We estimated hospital and ICU costs by multiplying LOS with respective average daily cost per patient. We calculated difference in costs by subtracting hospital costs, ICU costs and total direct variable costs from early tracheotomy to late tracheotomy. 95% confidence intervals were estimated using bootstrap re‐sampling procedures with 1000 iterations. Results: The average weighted cost of ICU stay in patients with an early tracheostomy was

Endovascular Repair of a Chronic AV Fistula Presenting as Post-Partum High Output Heart Failure

4316 less when compared to patients with late tracheostomy (95% CI: 403–8229). Subgroup analysis revealed that very early tracheostomies (<4 days) cost on average

Quality Improvement in Timing and Delivery of Carotid Endarterectomies at The Ottawa Hospital: Is the Pendulum Swinging Too Far?

3672 USD less than late tracheostomies (95% CI: –1309, 10,294) and that early tracheostomies (<10 days but >4) cost on average

Dynamic Assessment of Fluid Responsiveness in Surgical ICU Patients Through Stroke Volume Variation is Associated With Decreased Length of Stay and Costs: A Systematic Review and Meta-Analysis

6385 USD less than late tracheostomies (95% CI: –4396–17,165). Conclusion: This study shows that early tracheostomy can significantly reduce direct variable and likely total hospital costs in the intensive care unit based on length of stay alone. This is in addition to the already shown benefits of early tracheostomy in terms of ventilator dependent days, reduced length of stays, decreased pain, and improved communication. Further prospective studies on this topic are needed to prove the cost‐effectiveness of early tracheostomy in the critically ill population. HighlightsEarly tracheostomy reduces ICU & hospital costs.Early tracheostomy reduces ICU length of stay.Findings are consistent after sensitivity analysis.

Characteristics, Outcomes, and Cost Patterns of High-Cost Patients in the Intensive Care Unit

Introduction Acute injury to the large vessels is the most feared of diagnoses for a spinal surgeon, but far more common is the delayed presentation of arteriovenous fistula (AVF) formation. The mean time to diagnosis of an AV fistula in this scenario is just over 1 month. Treatment can include both open and endovascular repair. Report This study presents a case of an otherwise healthy 39-year-old woman who initially presented with orthopnea, leg edema, and a presumptive diagnosis of post-partum cardiomyopathy. Cardiac investigations revealed high output cardiac failure and an abdominal CT scan confirmed an arterial venous fistula from the left common iliac artery to left common iliac vein. The patient maintained a cardiac output three times normal prior to her definitive treatment. This high flow physiology caused unique challenges for the endovascular procedure as the stent graft collapsed and distorted toward the iliac side wall. The AV fistula was eventually covered successfully and post-operative studies show no further fistula and normal cardiac function. This case demonstrates an unanticipated effect of very high flows of stent graft deployment. Discussion Extreme high flow AV fistulas can present as unexpected challenges to endovascular repair. These issues may be ameliorated by techniques such as controlled hypotension, adenosine, ventricular pacing, or proximal balloon occlusion.

Ultrasound Surveillance Following Carotid Endarterectomy: Prudent or Pointless?

ICH, Intracranial hemorrhage; MI, myocardial infarction; N/A, not applicable. ICH and MI were significantly increased among patients who underwent CEA within 2 days of symptom onset (Fisher exact test, P 1⁄4 .05). Stroke rate was nonsignificantly increased in patients who received CEA within 2 days of symptoms (Fisher exact test, P 1⁄4 .32). Values are reported as number (%). Sean A. Crawford, MD, Matthew G. Doyle, PhD, Cristina H. Amon, ScD, MS, P Eng, Thomas L. Forbes, MD, FRCSC. Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada; Division of Vascular Surgery, University Health Network, Peter Munk Cardiac Centre, University of Toronto, Toronto, Ontario, Canada; Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada

Rivaroxaban Plus Aspirin Versus Standard Dual Antiplatelet Therapy Following Angioplasty for Lower Extremity Peripheral Arterial Disease in Patients With Critical Limb Ischemia and Claudication (RIVAL-PAD): 12-Month Results of a Randomized Trial

Static indices, such as the central venous pressure, have proven to be inaccurate predictors of fluid responsiveness. An emerging approach uses dynamic assessment of fluid responsiveness (FT-DYN), such as stroke volume variation (SVV) or surrogate dynamic variables, as more accurate measures of volume status. Recent work has demonstrated that goal-directed therapy guided by FT-DYN was associated with reduced intensive care unit (ICU) mortality; however, no study has specifically assessed this in surgical ICU patients. This study aimed to conduct a systematic review and meta-analysis on the impact of employing FT-DYN in the perioperative care of surgical ICU patients on length of stay in the ICU. As secondary objectives, we performed a cost analysis of FT-DYN and assessed the impact of FT-DYN versus standard care on hospital length of stay and mortality. We identified all randomized controlled trials (RCTs) through MEDLINE, EMBASE, and CENTRAL that examined adult patients in the ICU who were randomized to standard care or to FT-DYN from inception to September 2017. Two investigators independently reviewed search results, identified appropriate studies, and extracted data using standardized spreadsheets. A random effect meta-analysis was carried out. Eleven RCTs were included with a total of 1015 patients. The incorporation of FT-DYN through SVV in surgical patients led to shorter ICU length of stay (weighted mean difference [WMD], −1.43d; 95% confidence interval [CI], −2.09 to −0.78), shorter hospital length of stay (WMD, −1.96d; 95% CI, −2.34 to −1.59), and trended toward improved mortality (odds ratio, 0.55; 95% CI, 0.30-1.03). There was a decrease in daily ICU-related costs per patient for those who received FT-DYN in the perioperative period (WMD, US