Mary Emmett

The correlation of aortic neck length to early and late outcomes in endovascular aneurysm repair patients

BACKGROUND Initially, patients with a short angulated aortic neck were considered unfit for endovascular aneurysm repair (EVAR). Recently, however, more liberal use of EVAR has been advocated. This study analyzes the correlation of aortic neck length to early and late outcomes. METHODS We analyzed 238 patients who underwent EVAR during a recent 7-year period. All patients were followed up clinically and underwent postoperative duplex ultrasound imaging or computed tomography angiography, which were repeated every 6 months. Aortic neck length was classified into >or=15 mm (L1, n = 195), 10 to <15 mm (L2, n = 24), and <10 mm (L3, n = 17). Kaplan-Meier methods were used to estimate freedom from late endoleak, early and late reintervention, and survival. RESULTS Analyzed were 49 Ancure, 47 AneuRx, 104 Excluder, and 38 Zenith grafts. The mean follow-up was 24.7 months (range, 1-87 months). The initial technical success was 99%. The perioperative complication rates for groups L1, L2, and L3 were 13%, 21%, and 24%, respectively (P = .289). Proximal type I early endoleaks occurred in 12%, 42%, and 53% in groups L1, L2, and L3, respectively (P < .001). Intraoperative proximal aortic cuffs were needed to seal proximal type I endoleaks in 10%, 38%, and 47% in L1, L2, and L3 groups, respectively (P < .0001). However, the rate of late reintervention was comparable in all groups. Postoperatively, the size of the abdominal aortic aneurysm decreased or remained unchanged in 95%, 94%, and 88% in L1, L2, and L3, respectively (P = .660). Rates of freedom from late type I endoleak at 1, 2, and 3 years were 84%, 82%, and 80% for L1; 68%, 54%, and 54% for L2; and 71%, 71%, and 53% for L3 (P = .0263). Rates of freedom from late intervention at 1, 2, and 3 years were 96%, 94%, and 92% for L1; and 94%, 83%, and 83% for L2; and 93%, 93%, and 93% for L3 (P = .5334). CONCLUSIONS EVAR can be used for patients with a short aortic neck; however, it was associated with a significantly higher rate of early and late type I endoleaks, resulting in an increased use of proximal aortic cuffs for sealing the endoleaks.

Optimal carotid duplex velocity criteria for defining the severity of carotid in-stent restenosis

BACKGROUND The optimal duplex ultrasound (DUS) velocity criteria to determine in-stent carotid restenosis are controversial. We previously reported the optimal DUS velocities for >or=30% in-stent restenosis. This prospective study will further define the optimal velocities in detecting various severities of in-stent restenosis: >or=30%, >or=50%, and 80% to 99%. METHODS The analysis included 144 patients who underwent carotid artery stenting as a part of clinical trials. All patients had completion arteriograms and underwent postoperative carotid DUS imaging, which was repeated at 1 month and every 6 months thereafter. Patients with peak systolic velocities (PSVs) of the internal carotid artery (ICA) of >or=130 cm/s underwent carotid computed tomography (CT)/angiogram. The PSVs and end-diastolic velocities of the ICA and common carotid artery (CCA) and the PSV of the ICA/CCA ratios were recorded. Receiver operating characteristic curve (ROC) analysis was used to determine the optimal velocity criteria for the diagnosis of >or=30, >or=50, and >or=80% restenosis. RESULTS The mean follow-up was 20 months (range, 1-78 months). Available for analysis were 215 pairs of imaging (DUS vs CTA/angiography) studies. The accuracy of CTA vs carotid arteriogram was confirmed in a subset of 22 patients (kappa = 0.81). The ROC analysis demonstrated that an ICA PSV of >or=154 cm/s was optimal for >or=30% stenosis with a sensitivity of 99%, specificity of 89%, positive-predictive value (PPV) of 96%, negative-predictive value (NPV) of 97%, and overall accuracy (OA) of 96%. An ICA EDV of 42 cm/s had sensitivity, specificity, PPV, NPV, and OA in detecting >or=30% stenosis of 86%, 62%, 87%, 60%, and 80%, respectively. An ICA PSV of >or=224 cm/s was optimal for >50% stenosis with a sensitivity of 99%, specificity of 90%, PPV of 99%, NPV of 90%, and OA of 98%. An ICA EDV of 88 cm/s had sensitivity, specificity, PPV, NPV, and OA in detecting >or=50% stenosis of 96%, 100%, 100%, 100%, 53%, and 96%. An ICA/CCA ratio of 3.439 had sensitivity, specificity, PPV, NPV, and OA in detecting >or=50% stenosis of 96%, 100%, 100%, 100%, 58%, and 96%, respectively. An ICA PSV of >or=325 cm/s was optimal for >80% stenosis with a sensitivity of 100%, specificity of 99%, PPV of 100%, NPV of 88%, and OA of 99%. An ICA EDV of 119 cm/sec had sensitivity, specificity, PPV, NPV, and OA in detecting >or=80% stenosis of 99%, 100%, 100%, 100%, 75%, and 99%, respectively. The PSV of the stented artery was a better predictor for in-stent restenosis than the end-diastolic velocity or ICA/CCA ratio. CONCLUSION The optimal DUS velocity criteria for in-stent restenosis of >or=30%, >or=50%, and >or=80% were the PSVs of 154, 224, and 325 cm/s, respectively.

Critical appraisal of the Carotid Duplex Consensus criteria in the diagnosis of carotid artery stenosis

BACKGROUND Clinicians have relied on published institutional experience for interpreting carotid duplex ultrasound studies (CDUS). This study will validate the ultrasound imaging consensus criteria published in 2003. METHODS The CDUS and angiography results of 376 carotid arteries were analyzed. Receiver-operating characteristic (ROCs) curves were used to compare peak systolic velocities (PSVs), end-diastolic velocities (EDVs) of the internal carotid artery (ICA), and ICA/common carotid (CCA) ratios in detecting < 50%, 50% to 69% (ICA PSV of 125-230 cm/s), and 70% to 99% (PSV of ≥ 230 cm/s) stenosis according to the consensus criteria. RESULTS The consensus criteria uses a PSV of 125 to 230 cm/s for detecting angiographic stenosis of 50% to 69%, which has a sensitivity of 93%, specificity of 68%, and overall accuracy of 85%. A PSV of ≥ 230 cm/s for ≥ 70% stenosis had a sensitivity of 99%, specificity of 86%, and overall accuracy of 95%. ROC curves showed that the ICA PSV was significantly better (area under the curve [AUC], 0.97) than EDV (AUC, 0.94) or ICA/CCA ratio (AUC, 0.84; P = .036) in detecting ≥ 70% stenosis and ≥ 50% stenosis. Pearson correlations showed a statistical difference between the correlation of PSV with angiography (0.833; 95% confidence interval [CI], 0.8-0.86), EDV with angiography (0.755; 95% CI, 0.71-0.80), and ICA/CCA systolic ratio with angiography (0.601; 95% CI, 0.53-0.66; P < .0001) in detecting 70% to 99% stenosis. Adding the EDV values or the ratios to the PSV values did not improve accuracy. The consensus criteria for diagnosing 50% to 69% stenosis can be significantly improved by using an ICA PSV of 140 to 230 cm/s, with a sensitivity of 94%, specificity of 92%, and overall accuracy of 92%. CONCLUSIONS The consensus criteria can be accurately used for diagnosing ≥ 70% stenosis; however, the accuracy can be improved for detecting 50% to 69% stenosis if the ICA PSV is changed to 140 to < 230 cm/s.

Prospective randomized trial of routine versus selective shunting in carotid endarterectomy based on stump pressure

BACKGROUND The use of shunting in carotid endarterectomy (CEA) is controversial. This randomized trial compared the results of routine (RS) vs selective shunting (SS) based on stump pressure (SP). METHODS Two-hundred CEA patients under general anesthesia were randomized into RS (98 patients) or SS (102 patients), where shunting was used only if systolic SP (SSP) was <40 mm Hg. Clinical and demographic characteristics were comparable in both groups. Patients underwent immediate and 30-day postoperative duplex ultrasound follow-up. Analysis was by intention-to-treat. RESULTS Of 102 SS patients, 29 (28%) received shunting. Indications for CEA were similar (42% symptomatic for RS; 47% for SS, P = .458). The mean internal carotid artery diameter was comparable (5.5 vs 5.5 mm, P = .685). Mean preoperative ipsilateral and contralateral stenosis was 76% and 38% for RS (P = .268) vs 78% and 40% for SS (P = .528). Mean preoperative ipsilateral and contralateral stenosis was 79% and 56% in the shunted (P = .634) vs 78% and 34% in the nonshunted subgroup of SS patients (P = .002). The mean SSP was 55.9 mm Hg in RS vs 56.2 for SS (P = .915). The mean SSP was 33 mm Hg in the shunted vs 65 in the nonshunted subgroup (P < .0001). Mean clamp time in the nonshunted subgroup of SS was 32 minutes. Mean shunt time was 35 minutes in RS and 33 in SS (P = .354). Mean operative time was 113 minutes for RS and 109 for SS (P = .252), and 111 minutes in shunted and 108 in the nonshunted subgroup (P = .586). Mean arteriotomy length was 4.4 cm for RS and 4.2 for SS (P = .213). Perioperative stroke rate was 0% for RS vs 2% for SS (one major and one minor stroke, both related to carotid thrombosis; P = .498). No patients died perioperatively. Combined perioperative transient ischemic attack (TIA) and stroke rates were 2% in RS vs 2.9% in SS (P > .99). The overall perioperative complication rates were 8.3% in RS (2 TIA, 3 hemorrhage, 1 myocardial infarction [MI], and 1 asymptomatic carotid thrombosis) vs 7.8% in SS (2 strokes, 1 TIA, 3 hemorrhage, 1 MI, and 1 congestive heart failure; P = .917). CONCLUSIONS RS and SS were associated with a low stroke rate. Both methods are acceptable, and surgeons should select the method with which they are more comfortable.

Percutaneous Nephrolithotomy Versus Extracorporeal Shock Wave Lithotripsy for Moderate Sized Kidney Stones

OBJECTIVE To compare the outcomes of percutaneous nephrolithotomy (PNL) and extracorporeal shock wave lithotripsy (ESWL) for moderate sized (1-2 cm) upper and middle pole renal calculi in regards to stone clearance rate, morbidity, and quality of life. METHODS All patients diagnosed with moderate sized upper and middle pole kidney stones by computed tomography (CT) were offered enrollment. They were randomized to receive either ESWL or PNL. The SF-8 quality of life survey was administered preoperatively and at 1 week and 3 months postoperatively. Abdominal radiograph at 1 week and CT scan at 3 months were used to determine stone-free status. All complications and outcomes were recorded. RESULTS PNL established a stone-free status of 95% and 85% at 1 week and 3 months, respectively, whereas ESWL established a stone-free status of 17% and 33% at 1 week and 3 months, respectively. Retreatment in ESWL was required in 67% of cases, with 0% retreatment in PNL. Stone location, stone density, and skin-to-stone distance had no impact on stone-free rates at both visits, irrespective of procedure. Patient-reported outcomes, including overall physical and mental health status, favored a better quality of life for patients who had PNL performed. CONCLUSION PNL more often establishes stone-free status, has a more similar complication profile, and has similar reported quality of life at 3 months when compared with ESWL for moderate-sized kidney stones. PNL should be offered as a treatment option to all patients with moderate-sized kidney stones in centers with experienced endourologists.

Primary carotid artery stenting versus carotid artery stenting for postcarotid endarterectomy stenosis

BACKGROUND Carotid artery stenting (CAS) has been advocated as an alternative to carotid endarterectomy (CEA) in high-risk surgical patients, including stenosis after CEA. This study compared early and midterm clinical outcomes for primary CAS vs CAS for post-CEA stenosis. METHODS This study analyzed 180 high-risk surgical patients: 68 had primary CAS (group A), and 112 had CAS for post-CEA stenosis (group B). Patients were followed-up prospectively and had duplex ultrasound imaging at 1 month and every 6 months thereafter. All patients had cerebral protection devices. Kaplan-Meier life-table analysis was used to estimate rates of freedom from stroke, stroke-free survival, > or =50% in-stent stenosis, > or =80% in-stent stenosis, and target vessel reintervention (TVR). RESULTS Patients had comparable demographic and clinical characteristics. Carotid stent locations were similar. Indications for CAS were transient ischemic attacks (TIA) or stroke in 50% for group A and 45% for group B. The mean follow-up was comparable, at 21 (range, 1-73) vs 25 (range, 1-78) months, respectively. The technical success rate was 100%. The perioperative stroke rates and combined stroke/death/myocardial infarction (MI) rates were 7.4% for group A vs 0.9% for group B (P = .0294). No perioperative MIs occurred in either group. One death was secondary to stroke. The combined early and late stroke rates were 10.8% for group A and 1.8% for group B (P = .0275). The stroke-free rates at 1, 2, 3, and 4 years for groups A and B were 89%, 89%, 89%, and 89%; and 98%, 98%, 98%, and 98%, respectively (P = .0105). The rates of freedom from > or =50% carotid in-stent stenosis were 94%, 83%, 83%, and 66% for group A vs 96%, 91%, 83%, and 72% for group B (P = .4705). Two patients (3%) in group A and seven patients (6.3%) in group B had > or =80% in-stent stenosis (all were asymptomatic except one). The freedom from > or =80% in-stent stenosis at 1, 2, 3, and 4 years for groups A and B were 100%, 98%, 98%, and 78% vs 99%, 96%, 92%, and 87%, respectively (P = .7005). Freedom from TVR rates at 1, 2, 3, and 4 years for groups A and B were 100%, 100%, 100%, and 100% vs 99%, 97%, 97%, and 92%, respectively (P = .261). CONCLUSIONS CAS for post-CEA stenosis carried a lower risk of early postprocedural neurologic events than primary CAS, with a trend toward a higher restenosis rate during follow-up.

Improving the Care of Dual Eligible Patients in Rural Federally Qualified Health Centers The Impact of Care Coordinators and Clinical Pharmacists

Background: Dual eligible persons are those covered by both Medicare and Medicaid. There were 9.6 million dual eligible persons in the United States and 82 000 in West Virginia in 2010. Dual eligibles are poorer, sicker, and more burdened with serious mental health conditions than Medicare or Medicaid patients as a whole. Their health care costs are significantly higher and they are more likely to receive fragmented ineffective care. Purpose: To improve the care experience and health care outcomes of dual eligible patients by the expanded use of care coordinators and clinical pharmacists. Methods: During 2012, 3 rural federally qualified community health centers in West Virginia identified 200 dual eligible patients each. Those with hospitalizations received more frequent care coordinator contacts. Those on more than 15 chronic medications had drug utilization reviews with recommendations to primary care providers. Baseline measures included demographics, chronic diseases, total medications and Beers list medications, hospitalization, and emergency room (ER) use in the previous year. Postintervention measures included hospitalization, ER use, total medications, and Beers list medications. Results: Out of 556 identified patients, 502 were contacted and enrolled. Sixty-five percent were female. The median age was 69 years, with a range of 29 to 93 years. Nineteen percent (19%) of patients were on 15 or more medications, 56% on psychotropic medication, and 33% on chronic opiates. One site showed reductions of 34% in hospitalizations and 25% in ER visits during the intervention year. For all sites combined, there was a 5.5% reduction in total medications and a 14.8% reduction in Beers list medications. Conclusions: A modest investment in care coordination and clinical pharmacy review can produce significant reductions in hospitalization and harmful polypharmacy for community dwelling dual eligible patients.

Coal Mine Dust Desquamative Chronic Interstitial Pneumonia: A Precursor of Dust-Related Diffuse Fibrosis and of Emphysema

Background: Diseases associated with coal mine dust continue to affect coal miners. Elucidation of initial pathological changes as a precursor of coal dust-related diffuse fibrosis and emphysema, may have a role in treatment and prevention. Objective: To identify the precursor of dust-related diffuse fibrosis and emphysema. Methods: Birefringent silica/silicate particles were counted by standard microscope under polarized light in the alveolar macrophages and fibrous tissue in 25 consecutive autopsy cases of complicated coal workers pneumoconiosis and in 21 patients with tobacco-related respiratory bronchiolitis. Results: Coal miners had 331 birefringent particles/high power field while smokers had 4 (p<0.001). Every coal miner had intra-alveolar macrophages with silica/silicate particles and interstitial fibrosis ranging from minimal to extreme. All coal miners, including those who never smoked, had emphysema. Fibrotic septa of centrilobular emphysema contained numerous silica/silicate particles while only a few were present in adjacent normal lung tissue. In coal miners who smoked, tobacco-associated interstitial fibrosis was replaced by fibrosis caused by silica/silicate particles. Conclusion: The presence of silica/silicate particles and anthracotic pigment-laden macrophages inside the alveoli with various degrees of interstitial fibrosis indicated a new disease: coal mine dust desquamative chronic interstitial pneumonia, a precursor of both dust-related diffuse fibrosis and emphysema. In studied coal miners, fibrosis caused by smoking is insignificant in comparison with fibrosis caused by silica/silicate particles. Counting birefringent particles in the macrophages from bronchioalveolar lavage may help detect coal mine dust desquamative chronic interstitial pneumonia, and may initiate early therapy and preventive measures.