Incidence and prognosis of vascular complications after percutaneous placement of left ventricular assist device

OBJECTIVE: Mechanical assist devices have found an increasingly important role in high-risk interventional cardiac procedures. The Impella (Abiomed Inc, Danvers, Mass) is a percutaneous left ventricular assist device inserted through the femoral artery under fluoroscopic guidance and positioned in the left ventricular cavity. This study was undertaken to assess the incidence of vascular complications and associated morbidity and mortality that can occur with Impella placement. METHODS: We used a prospective database to review patients who underwent placement of an Impella left ventricular assist device in our tertiary referral center from July 2010 to December 2013. Patient demographics, comorbidities, interventional complications, and 30-day mortality were recorded. RESULTS: The study included 90 patients (60% male). Mean age was 66 years (range, 17-97 years). Hypertension was found in 69% of the patients, 37% were diabetic, 57% had a history of tobacco abuse, and 65% had chronic renal insufficiency. The median preprocedure cardiac ejection fraction was 30%. Most (87%) had undergone coronary artery intervention. Cardiogenic shock was documented in 67 patients (74%). The Impella was placed for an average of 1 day (range, 0-5 days). At least one vascular complication occurred in 15 patients (17%). Acute limb ischemia occurred in 12 patients; of whom four required an amputation and six required open or endovascular surgery. Other complications included groin hematomas and one pseudoaneurysm. All-patient 30-day mortality was 50%, which was not significantly associated with vascular complications. Female sex and cardiogenic shock at the time of insertion were associated with vascular complications (P = .043 and P = .018, respectfully). CONCLUSIONS: Vascular complications are common with placement of the Impella percutaneous left ventricular assist device (17%) and are related to emergency procedures. Vascular complications in this high-risk patient population frequently lead to withdrawal of care. These data provide quality improvement targets for left ventricular assist device programs

Evolution of Health Insurance in India Over a Decapod

Health insurance has seen a rapid growth in the Indian market over the last decade. The number of health insurance companies operating in India has increased from around 20 in 2014 to over 50 in 2023. Covid-19 pandemic has led to the integration of telemedicine into health insurance policies. Digitalization has played a major role in the evolution of the industry. On the one hand, it led to an increase in demand for health insurance products and higher premiums. On the other hand, it also led to an increase in claims and a greater emphasis on preventive care and mental health coverage. Profitability of the industry increased during the pandemic, as the higher premiums outweighed the increased claims. In addition, the pandemic led to several positive changes in the industry, such as an increased focus on telemedicine and preventive care. As healthcare and insurance industries further intertwine with technological advancements, the future holds the promise of even greater accessibility, customization, and affordability in health insurance coverage, ensuring that more Indians can access quality healthcare when they need it most

Thlaspi montanum L. (BR0000010535691)

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Epithelioid Hemangioendothelioma Presenting as Inferior Vena Cava Obstruction Diagnosed Using an Endovascular Thrombectomy Device.

Epithelioid hemangioendothelioma is a rare vascular sarcoma that arises from the lining (intima) of blood vessels. We report a case of a 43-year-old male patient, who presented with inferior vena cava (IVC) obstruction and acute bilateral lower extremity deep vein thrombosis. Mechanical thrombectomy was performed with an endovascular thrombectomy device, followed by stent placement in the IVC. The initial pathology on the retrieved specimen obtained from the thrombectomy device revealed an undifferentiated neoplasm, and definitive surgical resection of the retroperitoneal soft tissue tumor of the IVC documented a rare case of epithelioid hemangioendothelioma

Post-anastomotic venous stenosis after Optiflow deployment: An unexpected outcome

Arteriovenous fistula failure represents a major cause of hospitalization and a significant economic burden for end-stage renal disease patients on hemodialysis. The Optiflow (Bioconnect Systems Inc., Ambler, PA) is a new device developed to improve arteriovenous fistula outcomes and decrease failure rates by reducing the risk of stenosis and improving maturation rates. This case report describes a 50-year-old male with hypertensive nephropathy on dialysis who had multiple arteriovenous fistula failures in the past. He was scheduled to undergo brachiocephalic fistula construction using the Optiflow device. After 8 months of use, the new fistula developed a peri-anastomotic venous stenosis, just distal to the Optiflow device. To our knowledge, this is the first time such a complication has been reported

Survival after AAA repair is affected by socioeconomic status

Objectives The association between socioeconomic status (SES) and outcome after abdominal aortic aneurysm (AAA) repair is largely unknown. This study aimed to determine the influence of SES on postoperative survival after either open or endovascular AAA repair. Methods All patients undergoing surgical treatment for their AAA at a tertiary referral center between January 1993 and July 2013 were retrospectively included and analyzed. Thirty-day postoperative mortality and long-term survival were documented through medical record review and the Michigan Social Security Death Index. SES was quantified using the Messer neighborhood deprivation index, which is a standardized and reproducible index used in research that summarizes eight domains of socioeconomic deprivation. The association between SES and survival was studied using univariate and multivariate Cox regression analysis. Results A total of 767 patients were included. Patients were a mean age of 73 years, 80% were male, 78% were Caucasian, and 20% were African American. There was no difference in SES between patients who underwent open vs endovascular repair of their AAA ( P = .489). Univariate Cox regression analysis showed the Messer index was not associated with increased 30-day mortality ( P = .561; hazard ratio [HR], 1.39 [0.45, 4.27]) but was associated with decreased long-term survival ( P \u3c.001; HR, 1.35 [1.18, 1.54]). After adjusting for other medical comorbidities, the association between the Messer index and long-term survival was still significant ( P = .003; HR, 1.28 [1.09, 1.50]). Conclusions Long-term mortality but not short-term mortality after AAA repair is influenced by SES. Further studies are required to assess what risk factors (behavioral or psychosocial) are responsible for this decreased survival in low SES patients after AAA repair

Long-term decline in renal function is more significant after endovascular repair of infrarenal abdominal aortic aneurysms

OBJECTIVE: It is not clear whether endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) results in an increase in renal insufficiency during the long term compared with open repair (OR). We reviewed our experience with AAA repair to determine whether there was a significant difference in postoperative and long-term renal outcomes between OR and EVAR. METHODS: A retrospective cohort study was conducted of all patients who underwent AAA repair between January 1993 and July 2013 at a tertiary referral hospital. Demographics, comorbidities, preoperative and postoperative laboratory values, morbidity, and mortality were collected. Patients with ruptured AAAs, preoperative hemodialysis, juxtarenal or suprarenal aneurysm origin, and no follow-up laboratory values were excluded. Preoperative, postoperative, 6-month, and yearly serum creatinine values were collected. Glomerular filtration rate (GFR) was calculated on the basis of the Chronic Kidney Disease Epidemiology Collaboration equation. Acute kidney injury (AKI) was classified using the Kidney Disease: Improving Global Outcomes guidelines. Change in GFR was defined as preoperative GFR minus the GFR at each follow-up interval. Comparison was made between EVAR and OR groups using multivariate logistics for categorical data and linear regression for continuous variables. RESULTS: During the study period, 763 infrarenal AAA repairs were performed at our institution; 675 repairs fit the inclusion criteria (317 ORs and 358 EVARs). Mean age was 73.9 years. Seventy-nine percent were male, 78% were hypertensive, 18% were diabetic, and 31% had preoperative renal dysfunction defined as GFR below 60 mL/min. Using a multivariate logistic model to control for all variables, OR was found to have a 1.6 times greater chance for development of immediate postoperative AKI compared with EVAR (P = .038). Hypertension and aneurysm size were independent risk factors for development of AKI (P = .012 and .022, respectively). Using a linear regression model to look at GFR decline during several years, there was a greater decline in GFR in the EVAR group. This became significant starting at postoperative year 4. AKI and preoperative renal dysfunction were independent risk factors for long-term decline in renal function. CONCLUSIONS: Although AKI is less likely to occur after EVAR, patients undergoing EVAR experience a significant but delayed decline in GFR over time compared with OR. This became apparent after postoperative year 4. Studies comparing EVAR and OR may need longer follow-up to detect clinically significant differences in renal function

Long-term decline in renal function is more significant after endovascular repair of infrarenal abdominal aortic aneurysms

OBJECTIVE: It is not clear whether endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) results in an increase in renal insufficiency during the long term compared with open repair (OR). We reviewed our experience with AAA repair to determine whether there was a significant difference in postoperative and long-term renal outcomes between OR and EVAR. METHODS: A retrospective cohort study was conducted of all patients who underwent AAA repair between January 1993 and July 2013 at a tertiary referral hospital. Demographics, comorbidities, preoperative and postoperative laboratory values, morbidity, and mortality were collected. Patients with ruptured AAAs, preoperative hemodialysis, juxtarenal or suprarenal aneurysm origin, and no follow-up laboratory values were excluded. Preoperative, postoperative, 6-month, and yearly serum creatinine values were collected. Glomerular filtration rate (GFR) was calculated on the basis of the Chronic Kidney Disease Epidemiology Collaboration equation. Acute kidney injury (AKI) was classified using the Kidney Disease: Improving Global Outcomes guidelines. Change in GFR was defined as preoperative GFR minus the GFR at each follow-up interval. Comparison was made between EVAR and OR groups using multivariate logistics for categorical data and linear regression for continuous variables. RESULTS: During the study period, 763 infrarenal AAA repairs were performed at our institution; 675 repairs fit the inclusion criteria (317 ORs and 358 EVARs). Mean age was 73.9 years. Seventy-nine percent were male, 78% were hypertensive, 18% were diabetic, and 31% had preoperative renal dysfunction defined as GFR below 60 mL/min. Using a multivariate logistic model to control for all variables, OR was found to have a 1.6 times greater chance for development of immediate postoperative AKI compared with EVAR (P = .038). Hypertension and aneurysm size were independent risk factors for development of AKI (P = .012 and .022, respectively). Using a linear regression model to look at GFR decline during several years, there was a greater decline in GFR in the EVAR group. This became significant starting at postoperative year 4. AKI and preoperative renal dysfunction were independent risk factors for long-term decline in renal function. CONCLUSIONS: Although AKI is less likely to occur after EVAR, patients undergoing EVAR experience a significant but delayed decline in GFR over time compared with OR. This became apparent after postoperative year 4. Studies comparing EVAR and OR may need longer follow-up to detect clinically significant differences in renal function