Mariel Rivero

Factors that affect cost and clinical outcome of endovascular aortic repair for abdominal aortic aneurysm

Objective: This study evaluated the effect of indication for use (IFU), additional graft components, and percutaneous closure of endovascular aortic repair (PEVAR) on clinical outcomes and cost of endovascular aortic repair (EVAR). Methods: Clinical and financial data were obtained for all elective EVARs completed at a university‐affiliated medical center between January 2012 and June 2013. Data were analyzed by χ2, Student t‐test for independent samples, and Kaplan‐Meier survival. Results: There were 67 elective EVARs. Additional cuffs/extensions were used in 37%, increasing the baseline graft cost by 36% (P < .001), total costs by 20% (P < .001), and negatively affecting the contribution margin. Aortic neck IFU (P = .02), failure of the index graft to seal the neck (P = .02), and need for an additional cuff (P = .008) were related to the need for reintervention for type Ia endoleak for graft B (Excluder; W. L. Gore and Associates, Flagstaff, Ariz), whereas limb IFU was related to the need for additional limb extension for graft A (Powerlink; Endologix, Irvine, Calif; P < .001). Limb extension (P = .06) and failure of the index graft to provide an adequate seal (P < .001) were associated with reintervention for type Ib endoleak. Reintervention‐free rates at 24 months were 96% for graft A and 94% for graft B (P =.54), but different patterns in reintervention emerged: graft A required reoperation early (<2 months) then stabilized; graft B did not require reintervention until 24 months, but rates increased substantially by 25 months. PEVAR was attempted in 61 (91%): 49 (73%) bilaterally, 7 (10%) unilaterally, and 5 (8%) failed. The mean number of closure devices was four (range, 1–9):

Cardiopulmonary Complications of Hemodialysis Access

1000 (3.5% of total cost). Bilateral PEVAR was associated with shorter operating time than unilateral PEVAR/failed PEVAR (P < .001) and lower operating room use costs (P = .005) and total hospital costs (P = .003) than failed PEVAR. The contribution margin was higher for bilateral PEVAR than unilateral PEVAR/failed PEVAR (P = .005). Patients with bilateral PEVAR and unilateral PEVAR were more often discharged on postoperative day 1 than those with failed PEVAR (P = .002). Hospital length of stay (P = .49), operating room duration (P = .31), and total costs (P = .72) were similar for unsuccessful PEVAR and EVAR completed with cutdown. Conclusions: Higher rates of reintervention occurred when EVAR was performed outside of IFU guidelines or when additional components were needed. Additions raised graft costs significantly above baseline. Notable differences in graft performance in complex anatomy and varied patterns of reoperation could be useful in the graft selection process to improve outcome and contain costs. Bilateral PEVAR was associated with lower costs and postoperative day 1 discharge. Attempting PEVAR may be reasonable unless there is serious concern for failure.

Poorer limb salvage in African American men with chronic limb ischemia is due to advanced clinical stage and higher anatomic complexity at presentation

Cardiovascular complications are the leading cause of morbidity and mortality in patients with end-stage renal disease (ESRD). The etiology and pathogenesis of the cardiovascular issues are multifactorial. Patients with chronic kidney disease (CKD) demonstrate altered pulmonary and cardiac status even prior to beginning hemodialysis, as compared to non-CKD patients. Factors, other than the typical comorbidities, have been implicated as playing a role in the higher than expected rate of cardiovascular complications in the CKD population, including volume overload, anemia, and uremia. Interestingly, arteriovenous (AV) access construction is also associated with an increased risk of cardiovascular death. Renal transplant has been shown to drastically improve the clinical picture, even if the access is not ligated. This chapter discusses the cardiopulmonary limitations of hemodialysis access.