Mark C. Wyers

Mesenteric revascularization: management and outcomes in the United States, 1988-2006.

BACKGROUND Recent reports have suggested that angioplasty, with and without stenting (PTA/S), may have a lower perioperative mortality rate than open surgery for revascularization of acute (AMI) and chronic mesenteric ischemia (CMI). It is unclear if there has been nationwide adoption of this methodology or whether there is actually a mortality benefit. METHODS We identified all patients undergoing surgical (bypass, endarterectomy, or embolectomy) or PTA/S mesenteric revascularization from the Nationwide Inpatient Sample from 1988 to 2006. A diagnosis by International Classification of Diseases, 9th Revisioncoding of AMI or CMI was required for inclusion. We evaluated trends in management during this period and compared in-hospital death and complications between surgical bypass and PTA/S for the years 2000 to 2006. RESULTS From 1988 to 2006, there were 6342 PTA/S and 16,071 open surgical repairs overall. PTA/S increased steadily, surpassing all surgery for CMI in 2002. PTA/S for AMI has also increased and surpassed bypass in 2002 but has not surpassed all surgical procedures for AMI even in 2006. The mortality rate was lower after PTA/S than after bypass for CMI (3.7% vs 13%, P < .01) and AMI (16% vs 28%, P < .01). Bowel resection was more common after bypass than PTA/S for CMI (7% vs 3%, P < .01). This subgroup showed an increased in-hospital mortality rate for both repair types (54% and 25%, respectively). CONCLUSION PTA/S is being used with increasing frequency for revascularization of CMI and AMI. The lower in-hospital mortality rate for patients, as they are currently being selected, shows that PTA/S is appropriate therapy for selected patients with CMI. Longitudinal data are needed to determine the durability of this benefit. The greater proportion of patients undergoing bowel resection with bypass for AMI suggests a more advanced level of ischemia in this group, making comparison with PTA/S difficult. However, PTA/S may be useful in selected patients with AMI and appropriate anatomy. Further data with greater detail regarding symptomatology and anatomy will clarify appropriate patient selection.

Acute Mesenteric Ischemia: Diagnostic Approach and Surgical Treatment

Mortality related to acute mesenteric arterial occlusion remains very high. Patient survival is dependent on prompt recognition and revascularization before ischemia progresses to intestinal gangrene. Biphasic computed tomography angiography has surpassed angiography as the diagnostic test of choice due to its ability to define the arterial anatomy and to evaluate secondary signs of mesenteric ischemia. Unlike chronic mesenteric ischemia, the treatment of acute arterial mesenteric ischemia, either embolic or thrombotic, remains largely surgical. This is due to the emergent need for revascularization combined with a careful evaluation of the intestines. Endovascular techniques remain useful, however, and can save precious time in the treatment of these challenging patients if integrated into a treatment pathway combined with definitive surgical treatment. A new hybrid endovascular-surgical treatment for the treatment of acute mesenteric thrombosis is described.

Trends in the national outcomes and costs for claudication and limb threatening ischemia: Angioplasty vs bypass graft

PURPOSE Debate exists as to the benefit of angioplasty vs bypass graft in the treatment of lower extremity peripheral vascular disease. The associated costs are poorly defined in the literature. We sought to determine national estimates for the costs, utilization, and outcomes of angioplasty and bypass graft for the treatment of both claudication and limb threat. METHODS We searched the Nationwide Inpatient Sample (NIS) database (1999-2007), identifying patients who had an identifiable International Classification of Disease (ICD)-9 diagnosis code of atherosclerotic disease (claudication [440.21] or limb threat [440.22-440.24]). Of these, only patients who underwent intervention of angioplasty ± stent (percutaneous transluminal angioplasty [PTA; 39.50-39.90]), peripheral bypass graft (BPG; 39.29) or aortofemoral bypass (ABF; 39.25) were included. We compared demographics, costs, and comorbidities, as well as multivariable-adjusted outcomes of in-hospital mortality and major amputation. Additionally, we used the New Jersey State Inpatient and Ambulatory databases in order to better understand the influence of outpatient procedures on current volume and trends. RESULTS There were 563,143 patients identified (PTA: 38%, BPG: 50%, ABF: 6%; 5.1%: multiple procedure codes). Patients who had PTA and BPG were similar in age (70.4 vs 69.5 years) but older than patients who had ABF (61.8 years, P < .01). Patients who underwent PTA were more often women (PTA: 46%, BPG: 42%, ABF: 45.2%; P < .01). Average costs for PTA increased over 60% for claudication between 2001 and 2007 (

Body Mass Index: Surgical Site Infections and Mortality after Lower Extremity Bypass from the National Surgical Quality Improvement Program 2005—2007

8670 to

Gender differences in abdominal aortic aneurysm presentation, repair, and mortality in the Vascular Study Group of New England

14,084) and limb threat (

Population-Based Outcomes Following Endovascular and Open Repair of Ruptured Abdominal Aortic Aneurysms

13,903 to

Open and endovascular repair of type B aortic dissection in the Nationwide Inpatient Sample.

23,196). For BPG, average costs increased 36% for both claudication (

Endovascular repair of abdominal aortic aneurysm without preoperative arteriography.

9322 to

Results for primary bypass versus primary angioplasty/stent for intermittent claudication due to superficial femoral artery occlusive disease

12,681) and limb threat (

Risk factors for readmission after lower extremity bypass in the American College of Surgeons National Surgery Quality Improvement Program

16,795 to