Quality review and education as method of improving guideline adherence for medication prescription and outcomes among vascular interventionalists performing non-cardiac vascular surgeries

Background: Medical management of patients undergoing non-cardiac vascular procedures often sub-optimally follow evidence based guidelines. We hypothesized that feedback to practitioners in regards to outcomes and medications prescribed would improve care. Methods: With conversion to new database in 2015 that allowed for more comprehensive tracking of vascular surgery outcomes, a decision was made to share these data with practitioners on regular basis as well as relay medications prescribed at discharge. Carotid and abdominal aortic surgeries were evaluated. The most frequent format for presentation of data was vascular morbidity and mortality conference. Medications included in presentations were antiplatelet and statin therapies. Comparisons were made between adherence to guideline based therapies 2 years before and 2 years after new database implementation. ACE inhibitor/aldosterone receptor blocker (ARB) therapy prescribing data were not included in these presentations. SAS Enterprise Guide 7.1 and R 3.6.1 software used for analysis. Results: 826 patients were evaluated. 400 patients were in pre new database implementation and 426 were included after implementation. No significant difference found with prescribing of ACE inhibitors/ARB, changing only from 47 to 48%. There was difference with univariate analysis of antiplatelet and statin prescribing. Antiplatelet prescribing improved from 89 to 93%, Odds Ratio (OR) = 1.7 (95% confidence interval, 1-2.8) and statin prescribing improved from 74 to 86%, OR= 2.1 (95% confidence interval, 1.5-3). Access site and bleeding complications also demonstrated improvement. See Figure. Conclusion: Regular feedback to vascular practitioners improves adherence to guideline based therapies and can improve surgical outcomes

Natural history of gutter-related type Ia endoleaks after snorkel/chimney endovascular aneurysm repair.

OBJECTIVE: Alternative endovascular strategies using parallel or snorkel/chimney (chimney endovascular aneurysm repair [ch-EVAR]) techniques have been developed to address the lack of widespread availability and manufacturing limitations with branched/fenestrated aortic devices for the treatment of complex abdominal aortic aneurysms. Despite high technical success and midterm patency of snorkel stent configurations, concerns remain regarding the perceived increased incidence of early gutter-related type Ia endoleaks. We aimed to evaluate the incidence and natural history of gutter-related type Ia endoleaks following ch-EVAR. METHODS: Review of medical records and available imaging studies, including completion angiography and serial computed tomographic angiography, was performed for all patients undergoing ch-EVAR at our institution between September 2009 and January 2015. Only procedures involving ≥1 renal artery with or without visceral snorkel stents were included. Primary outcomes of the study were presence and persistence or resolution of early gutter-related type Ia endoleak. Secondary outcomes included aneurysm sac shrinkage and need for secondary intervention related to the presence of type Ia gutter endoleak. RESULTS: Sixty patients (mean age, 75.8 ± 7.6 years; male, 70.0%) underwent ch-EVAR with a total of 111 snorkel stents (97 renal [33 bilateral renal], 12 superior mesenteric artery, 2 celiac). A mean of 1.9 ± 0.6 snorkel stents were placed per patient. Early gutter-related type Ia endoleaks were noted on 30.0% (n = 18) of initial postoperative imaging studies. Follow-up imaging revealed spontaneous resolution of these gutter endoleaks in 44.3%, 65.2%, and 88.4% of patients at 6, 12, and 18 months postprocedure, respectively. Long-term anticoagulation, degree of oversizing, stent type and diameter, and other clinical/anatomic variables were not significantly associated with presence of gutter endoleaks. Two patients (3.3%) required secondary intervention related to persistent gutter endoleak. At a mean radiologic follow-up of 20.9 months, no difference in mean aneurysm sac size change was observed between those with or without early type Ia gutter endoleak (-6.1 ± 10.0 mm vs -4.9 ± 11.5 mm; P = .23). CONCLUSIONS: Gutter-related type Ia endoleaks represent a relatively frequent early occurrence after ch-EVAR, but appears to resolve spontaneously in the majority of cases during early to midterm follow-up. Given that few ch-EVAR patients require reintervention related to gutter endoleaks and the presence of such endoleak did not correlate to increased risk for aneurysm sac growth, its natural history may be more benign than originally expected