Socioeconomic Disparities Do Not Affect Outcomes in Acute Limb Ischemia

Objective: The association between socioeconomic status (SES) and outcome after acute limb ischemia (ALI) is largely unknown. We aimed to determine whether SES is associated with worse presentations and outcomes for patients with ALI. Methods: We performed a retrospective review of a prospectively collected database containing all patients who had presented with ALI between April 2016 and October 2020 to a tertiary care center. SES was quantified using individual variables (median household income, level of education, employment) and a composite endpoint, the neighborhood deprivation index (NDI). The NDI is a standardized and reproducible index that uses census tract data, with a higher number indicating lower SES status. The NDI summarizes eight domains of socioeconomic deprivation. ALI severity was categorized using the Rutherford classification. The associations between SES and the severity of ALI at presentation and between SES and the outcomes were analyzed using bivariate analysis of variance, an independent t test, and multivariate logistic regression, as appropriate. Results: During the study period, 278 patients were treated for ALI, of whom 211 had complete SES data available. Their mean age was 64 years; 55% were men and 57% were white. The Rutherford classification of disease severity was grade 1, 2a, 2b, and 3 for 6%, 54%, 32%, and 8%, respectively. Patients with a low SES status using the NDI were more likely to have a history of peripheral arterial disease and chronic kidney disease at presentation (Table). The etiology (thrombotic vs embolic) was not associated with SES. No significant differences were seen between SES and the severity of ALI at presentation ( P = .96) or the treatment modality ( P = .80). We found no association between SES and either 30-day or 1-year limb loss or mortality (Table). Lower SES (higher NDI) was associated with increased 30-day readmissions ( P = .021). This association persisted on multivariate analysis ( P = .023). Conclusions: SES was not associated with the severity of ALI at presentation. Although SES was associated with the presence of peripheral arterial disease and chronic kidney disease at presentation and higher readmission rates for patients with ALI, SES was not a predictor of short-term or 1-year limb loss or mortality. In the present study, ALI presentation and treatment outcome were independent of SES

Re-vascularization Of Left Subclavian Artery May Not Influence The Incidence Of Spinal Cord Injury After Endovascular Repair Of Acute Type B Aortic Dissection

Objective: The objective of this study was to analyze whether left subclavian artery (LSA) revascularization in patients undergoing thoracic endovascular aortic repair (TEVAR) for acute type B aortic dissection (TBAD) is associated with decreased spinal cord ischemia (SCI). Methods: The national Vascular Quality Initiative TEVAR module was queried for all procedures performed between 2014 and 2021. Patients presenting with aortic aneurysms or aortic ruptures were excluded from the analysis. Patients with therapeutic spinal drains were excluded as well. Patients were divided into two groups according to whether their left subclavian artery (LSA) was revascularized (prior to or during TEVAR) or not. A propensity score matching approach was used to account for possible confounders and evaluate the effect of LSA revascularization on the primary outcome of SCI. Results: Among patients who had TEVAR for acute TBAD, 852 patients had the LSA covered. The LSA was revascularized prior to or concomitant with TEVAR in 44% of these patients (n = 378). The incidence of LSA revascularization significantly increased over the study period (Fig) (P \u3c.001). A total of 650 patients were split equally and matched between the two groups. Average age was 57 years, and 71% (n = 458) were male (Table). Spinal cord ischemia developed in 26 patients (4%), and cerebral stroke in 46 patients (7%). On univariate analysis, patients who had their LSA revascularized were significantly less likely to develop cerebral stroke (5% vs 9%; P =.03). However, this association dropped after accounting for preoperative and intraoperative variables (P =.14). No significant difference was seen when comparing SCI, 30-day mortality, or 1-year mortality between patients who had LSA revascularization and those who did not (Table). The average follow-up was 24 months (range, 0-99 months). Long-term survival did not differ between the two groups on Kaplan-Meier analysis. Conclusions: In patients with acute TBAD undergoing TEVAR requiring LSA coverage, an increasing percentage of patients underwent preoperative or concomitant LSA revascularization over the course of the study: 51% in 2021. In this study, LSA revascularization did not affect the incidence of postoperative SCI, cerebral stroke, or short or long-term mortality. LSA revascularization may carry its own morbidity in TEVAR requiring LSA coverage

Left Subclavian Artery Revascularization May Not Influence the Incidence of Spinal Cord Ischemia in Elective Thoracic Endovascular Aortic Aneurysm Repair

Objectives: To analyze whether left subclavian artery (LSA) revascularization in patients undergoing elective thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysm (TAA) is associated with decreased spinal cord ischemia (SCI). Methods: The national Vascular Quality Initiative TEVAR module was queried for all procedures performed between 2014 and 2021. Patients presenting with acute aortic dissections or aortic ruptures were excluded from the analysis. Only patients undergoing elective TEVAR for TAA and had their LSA covered during the procedure were included. Patients were divided into two groups according to their LSA revascularization (before or during TEVAR). A descriptive analysis was done to evaluate the change in frequency of LSA revascularization over the study interval. Univariate analysis was done to compare preoperative and intraoperative variables, and primary outcomes of SCI and cerebral stroke between the two groups. Results: Among patients who had elective TEVAR for TAA, 669 patients had the LSA covered. The LSA was revascularized in 67% of these patients (n = 446). The incidence of LSA revascularization increased over the study period (Fig 1) (P \u3c .001). Average age was 69 years, and 65% (n = 433) were male. Demographics and past medical history are summarized in Table I. Spinal cord ischemia developed in 20 patients (3%), and cerebral stroke in 29 patients (4%). No significant difference was seen when comparing postoperative SCI, cerebral stroke, 30-day or 1-year mortality between patients who had LSA revascularization and those who did not (Table II). Long-term survival did not differ between the two groups on Kaplan-Meier analysis (Fig 2). Conclusions: In patients with TAA undergoing elective TEVAR with LSA coverage, an increasing percentage of patients underwent preoperative or concomitant LSA revascularization over the course of the study—81% in 2021. In this study, LSA revascularization, however, did not aff5ct the incidence of postoperative SCI, cerebral stroke, or short or long-term mortality. In conclusion, LSA revascularization did not protect against SCI and may carry its own morbidity in elective TAAs requiring LSA coverage. More detailed studies are needed to help define the role of LSA revascularization in this setting

Socioeconomic status is not associated with unfavorable outcomes in patients with acute limb ischemia

OBJECTIVE: Whether socioeconomic status (SES) is associated with health outcomes in patients with acute limb ischemia (ALI) is largely unknown. We aimed to determine whether SES is associated with worse presentations and outcomes for patients with ALI. METHODS: We performed a retrospective medical record review of patients who presented with ALI between April 2016 and October 2020 at a single tertiary care center. SES was quantified using individual variables (median household income, level of education, and employment) and a composite endpoint, the neighborhood deprivation index (NDI). The NDI is a standardized and reproducible index that uses census tract data (higher number indicates lower SES status). The NDI summarizes 8 domains of socioeconomic deprivation. ALI severity was categorized using the Rutherford classification. The association between SES and the severity of ALI at presentation and between SES and other health outcomes were analyzed using bivariate analysis of variance, independent t test, and multivariate logistic regression. RESULTS: During the study period, 278 patients were treated for ALI, of whom 211 had complete SES data available. The mean age was 64 years, 55% were men, and 57% were White. The Rutherford classification of disease severity was grade 1, 2a, 2b, and 3 for 6%, 54%, 32%, and 8% of patients, respectively. Patients with a low SES status per the NDI were more likely to have a history of peripheral arterial disease and chronic kidney disease at presentation. The ALI etiology (thrombotic vs embolic) was not associated with SES. No significant differences were seen between SES and the severity of ALI at presentation (p = 0.96) or the treatment modality (p = 0.80). No associations between SES and 30-day or 1-year mortality were observed (mean NDI, 0.15 vs 0.26, p = 0.58, and 0.20 vs 0.26, p = 0.71, respectively) or between SES and 30-day or 1-year limb loss (mean NDI, 0.06 vs 0.30, p = 0.18, and 0.1 vs 0.32, p = 0.17, respectively). Lower SES (higher NDI) was associated with increased 30-day readmission (mean NDI, 0.49 vs 0.15, p = 0.021). However, this association was not significant on multivariate analysis (odds ratio 1.4, 95% CI 0.9-2.1, p = 0.06). CONCLUSIONS: SES was not associated with the severity of ALI at patient presentation. Although SES was associated with the presence of peripheral arterial disease and chronic kidney disease at presentation, SES was not a predictor of short-term or 1-year limb loss and mortality. Overall, ALI presentation and treatment outcomes were independent of SES

Comprehensive multicenter graduate surgical education initiative incorporating entrustable professional activities, continuous quality improvement cycles, and a web-based platform to enhance teaching and learning

BACKGROUND: It is increasingly important for faculty to teach deliberately and provide timely, detailed, and formative feedback on surgical trainee performance. We initiated a multicenter study to improve resident evaluative processes and enhance teaching and learning behaviors while engaging residents in their education. STUDY DESIGN: Faculty from 7 US postgraduate training programs rated resident operative performances using the perioperative briefing, intraoperative teaching, debriefing model, and rated patient visits/academic performances using the entrustable professional activities model via a web-based platform. Data were centrally analyzed and iterative changes made based on participant feedback, individual preferences, and database refinements, with trends addressed using the Plan, Do, Check, Act improvement methodology. RESULTS: Participants (92 surgeons, 150 residents) submitted 3,880 assessments during July 2014 through September 2017. Evidence of preoperative briefings improved from 33.9% ± 2.5% to 95.5% ± 1.5% between April and September 2014 compared with April and September 2017 (p \u3c 0.001). Postoperative debriefings improved from 10.6% ± 2.7% to 90.2% ± 2.5% (p \u3c 0.001) for the same period. Meaningful self-reflection by residents improved from 28.6% to 67.4% (p \u3c 0.001). The number of assessments received per resident during a 6-month period increased from 6.4 ± 6.2 to 13.4 ± 10.1 (p \u3c 0.003). Surgeon-entered assessments increased from 364 initially to 685 in the final period, and the number of resident assessments increased from 308 to 445. We showed a 4-fold increase in resident observed activities being rated. CONCLUSIONS: By adopting recognized educational models with repeated Plan, Do, Check, Act cycles, we increased the quality of preoperative learning objectives, showed more frequent, detailed, and timely assessments of resident performance, and demonstrated more effective self-reflection by residents. We monitored trends, identified opportunities for improvement and successfully sustained those improvements over time, applying a team-based approach