Impact of metabolic syndrome on the outcomes of superficial femoral artery interventions

BackgroundMetabolic syndrome (MetSyn) is an epidemic in the United States and is associated with early onset of atherosclerosis, increased thrombotic events, and increased complications after cardiovascular intervention. MetSyn is found in ∼50% of patients with peripheral vascular disease. However, its impact on peripheral interventions is unknown. The aim of this study is to determine the outcomes of superficial femoral artery (SFA) interventions in patients with and without MetSyn.MethodsA database of patients undergoing endovascular treatment of SFA disease between 1999 and 2009 was retrospectively queried. MetSyn was defined as the presence of ≥3 of the following criteria: blood pressure ≥130 mm Hg/≥85 mm Hg; triglycerides ≥150 mg/dL; high-density lipoprotein ≤50 mg/dL for women and ≤40 mg/dL for men; fasting blood glucose ≥110 mg/dL; or body mass index ≥30 kg/m2. Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. Factor analyses were performed using a Cox proportional hazard model for time-dependent variables.ResultsA total of 1018 limbs in 738 patients (64% male, average age 67 years) underwent endovascular treatment for symptomatic SFA disease with 45% of patients meeting the criteria for MetSyn. MetSyn patients were more likely to be female (P = .001), to present with critical ischemia (rest pain/tissue loss: 55% MetSyn vs 45% non-MetSyn; P = .001), have poorer ambulatory status (P = .001), and have more advanced SFA lesions (TransAtlantic Inter-Society Consensus II C/D: 51% vs 11%; P = .001) and worse tibial runoff (P = .001). MetSyn patients required more complex interventions (P = .0001). There was no difference in mortality and major adverse cardiac events, but systemic complications (4% vs 1%; P = .001) and major adverse limb events (12% vs 7%; P = .0009) were significantly higher in the MetSyn group. Immediate postprocedural hemodynamic improvement, resolved or improved symptoms, and restoration of impaired ambulation were equivalent in both groups. Early failure (<6 months) was more common in those with MetSyn. At 5 years, primary, assisted primary, and secondary patencies were not affected by the presence of MetSyn. The presence of MetSyn was associated with a decrease in clinical efficacy, decreased freedom from recurrent symptoms, and decreased freedom from major amputation at 5 years.ConclusionsMetSyn is present in nearly half of the patients presenting with SFA disease. These patients present with more advanced disease and have poorer symptomatic and functional outcomes compared with those patients without MetSyn

Building an immune-mediated coagulopathy consensus: early recognition and evaluation to enhance post-surgical patient safety

Topical hemostats, fibrin sealants, and surgical adhesives are regularly used in a variety of surgical procedures involving multiple disciplines. Generally, these adjuncts to surgical hemostasis are valuable means for improving wound visualization, reducing blood loss or adding tissue adherence; however, some of these agents are responsible for under-recognized adverse reactions and outcomes. Bovine thrombin, for example, is a topical hemostat with a long history of clinical application that is widely used alone or in combination with other hemostatic agents. Hematologists and coagulation experts are aware that these agents can lead to development of an immune-mediated coagulopathy (IMC). A paucity of data on the incidence of IMC contributes to under-recognition and leaves many surgeons unaware that this clinical entity, originating from normal immune responses to foreign antigen exposure, requires enhanced post-operative vigilance and judicious clinical judgment to achieve best outcomes

Incorporating simulation in vascular surgery education

The traditional apprenticeship model introduced by Halsted of “learning by doing” may just not be valid in the modern practice of vascular surgery. The model is often criticized for being somewhat unstructured because a resident's experience is based on what comes through the “door.” In an attempt to promote uniformity of training, multiple national organizations are currently delineating standard curricula for each trainee to govern the knowledge and cases required in a vascular residency. However, the outcomes are anything but uniform. This means that we graduate vascular specialists with a surprisingly wide spectrum of abilities. Use of simulation may benefit trainees in attaining a level of technical expertise that will benefit themselves and their patients. Furthermore, there is likely a need to establish a simulation-based certification process for graduating trainees to further ascertain minimum technical abilities

Weight loss does not decrease risk of breast cancer-related arm lymphedema.

BackgroundThe goal of this study was to determine the relationship between postoperative weight change and breast cancer-related lymphedema (BCRL).MethodsIn this cohort study, 1161 women underwent unilateral breast surgery for breast cancer from 2005 to 2020 and were prospectively screened for BCRL. Arm volume measurements were obtained via an optoelectronic perometer preoperatively, postoperatively, and in the follow-up setting every 6 to 12 months. Mean follow-up from preoperative baseline was 49.1 months. The main outcome was BCRL, defined as a relative volume change of the ipsilateral arm of ≥10% at least 3 months after surgery.ResultsA total of 92 patients (7.9%) developed BCRL. Net weight loss versus net weight gain from baseline to last follow-up was not protective against developing BCRL (hazard ratio, 1.38; 95% confidence interval, 0.89-2.13; P = .152).ConclusionsAlthough weight loss may be recommended as part of an individualized lifestyle management program for overall health, weight loss alone may not decrease the risk of developing BCRL