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

Socioeconomic Status and Clinical Stage of Patients Presenting for Treatment of Chronic Venous Disease

OBJECTIVES: The association between socioeconomic status (SES) and chronic venous insufficiency has not been rigorously studied. This study aimed to determine the influence of SES on the clinical stage of patients presenting for chronic venous disease therapy. METHODS: We performed a retrospective study of a prospectively collected data from the Vascular Quality Initiative Varicose Vein Registry at our tertiary referral center. Medical records of patients who underwent therapy for chronic venous disease between January 2015 and June 2019 were queried. SES was quantified using the neighborhood deprivation index (NDI), which summarizes 8 domains of socioeconomic deprivation and is based on census tract data derived from the patients\u27 addresses at the time of the treatment. High NDI scores correspond with lower SES. The association between SES and severity of vein disease at presentation was assessed with bivariate analysis of variance and linear regression analysis. RESULTS: A total of 449 patients with complete SES and clinical-etiology-anatomy-pathophysiology (CEAP) class data were included in the study. The mean age was 58 years, 67% were female, and 60% were White. CEAP classes were distributed as follows C2, 22%; C3, 50%; C4, 15%; C5, 5%; and C6, 8%. Patients with lower SES (higher NDI score) tended to have a higher CEAP class at presentation (P \u3c 0.05). SES was not associated with history of deep venous thrombosis, use of compression therapy, or venous clinical severity score. CONCLUSIONS: At our institution, patients with more advanced venous disease tended to belong to a lower SES group. This may reflect that patient with a lower SES have a longer time to presentation due to delay in seeking medical help for venous disease

Impact Of Preoperative Hemoglobina1c In Patients Undergoing Open Distal Vascular Procedures

Objective: The purpose of this study was to evaluate if preoperative hemoglobin (Hb) A1c levels was associated with worse outcomes in patients undergoing open lower extremity (LE) revascularization. Methods: A retrospective review of a statewide vascular surgery registry was queried for all patients who underwent open infrainguinal bypass or open LE thrombectomy procedures between January 2014 and June 2021. Patients were categorized into four groups depending on whether their plasma HbA1c was ≤6%, \u3e6% to ≤8%, \u3e8% to ≤10%, and \u3e10%. Regression models were used to evaluate the association between preoperative HbA1c and postoperative major adverse limb events (MALE), major adverse cardiac events (MACE), mortality, and length of stay (LOS). Results: A total of 5388 patients were included in the study. The average age was 66 years. Sixty-six percent of the cohort were male, and 78% were white. Demographics and comorbidities were associated with the HbA1c level. Mean LOS was 7 days for HbA1c \u3c6% and 10 days for HbA1c \u3e10% (P \u3c.001). No significant association was found when looking at perioperative MALE, MACE, 30-day mortality, or 1-year mortality. On multivariate analysis, only LOS remained significantly associated with the level of HbA1c (P \u3c.001) (Table). Conclusions: Suboptimal preoperative glycemic control in patients undergoing open LE vascular procedures for ischemia is associated with an increased risk of LOS. HbA1c level was not predictive of worse perioperative MACE, MALE, or mortality in this cohort. The increased in LOS could be explained by unmeasured complications, frailty, or increased hospitalization time needed to optimize glycemic control before discharge. [Formula presented

Outcomes of patients with acute type A aortic dissection and concomitant lower extremity malperfusion

OBJECTIVE: The occurrence of acute lower limb ischemia (ALLI) is a serious risk within the context of aortic dissection repair. The aim of the present study was to examine the outcomes of patients with acute type A aortic dissection (ATAD) and concomitant lower extremity malperfusion. METHODS: We performed a retrospective medical record review at our tertiary referral center of patients who underwent ATAD repair from January 2002 to June 2018. We used univariate and multivariate analyses to compare the outcomes of patients with and without lower extremity malperfusion. The primary outcomes were 30-day and 1-year mortality. RESULTS: A total of 378 patients underwent ATAD repair during the study period. Their mean age was 57 years, 68% were men, and 51% were White. A total of 62 patients (16%) presented with concomitant ALLI, including 35 (9%) who presented with isolated ALLI and 27 (7%) who presented with ALLI and concomitant malperfusion of at least one other organ. Of the 62 patients with ALLI, 46 underwent only proximal aortic repair. Of the 378 patients, 6 died within the first 24 hours, and their limb perfusion was not assessed. Among the 40 patients who underwent isolated proximal repair and survived \u3e24 hours, 34 (85%) had resolution of their ALLI. Of the 16 patients who underwent concomitant lower extremity peripheral vascular procedures, 10 had bypass procedures and 1 died within 24 hours due to refractory coagulopathy and hypotension. All six patients with adequate follow-up imaging studies had asymptomatic occlusion of the bypass graft with recanalization of the occluded native arteries. Patients who presented with any organ malperfusion had increased 30-day (odds ratio, 1.8; P = .04) and 1-year (odds ratio, 1.8; P = .04) mortality and decreased overall survival (P \u3c .01). For the patients with isolated ALLI, no significant differences were found in 30-day or 1-year mortality or overall survival (P = .57). CONCLUSIONS: Proximal repair of ATAD resolves most cases of associated ALLI, and isolated ALLI does not affect short- or long-term survival. All patients with follow-up in our study who underwent extra-anatomic bypass developed asymptomatic graft occlusion, which could be attributed to competitive flow from the remodeled native arterial system. We believe that rapid and aggressive restoration of flow to the lower extremity is the best method to treat ALLI malperfusion syndrome. Close monitoring for the development of compartment syndrome is recommended

Success Rate of Embolization for Type II Endoleaks at a Major Tertiary Referral Center

Objective: The rise of endovascular aneurysm repair (EVAR) as the preferred treatment for abdominal aortic aneurysm (AAA) has introduced endoleaks as a major complication following AAA repair. The objective of this study is to assess the outcomes associated with endovascular embolization of type II endoleaks after EVAR. Methods: The institutional Radiology database at our tertiary referral hospital was queried for type II endoleak during the period 2006-2018. A retrospective chart review was then carried out. Only patients who underwent intervention for isolated type 2 endoleaks were analyzed. The primary outcome was success of the endoleak repair as determined by cessation of growth (i.e., ≤5mm change in diameter over follow-up period) of the native aneurysm sac. Patient outcomes for each failure of the above criterion were also collected. Other data pertaining to the location of endoleak, type of occlusion performed, type of embolic agent used, type of endograft used for EVAR, and incidence of aneurysm rupture were collected as secondary outcomes.Results:During this period 41 patients were treated for type II endoleaks. Demographics are shown in table 1. Cessation of growth was achieved in 28/41 (68.3%) of the patients after one embolization procedure. In 13/41 (31.7%) of patients, growth of the native aneurysm sac continued. Of the patients whose aneurysms continued to grow, 61.5% (8/13) did not undergo a second embolization. The remaining 38.5% (5/13) underwent a second embolization.Patient outcomes for both of these groups are presented in table II. None of the patients were found to have ruptured their aneurysm sac during follow-up after embolization. None of gender, race, the embolization site, or method of embolization were associated with embolization failure. Conclusions: Embolization of type II endoleaks is associated with a cessation of growth in the majority of cases and seems to be protective regarding the risk of aneurysm sac rupture. Future studies and additional follow-up will be important to elucidate the most significant risk factors for expansion and/or rupture of the endovascularly repaired abdominal aneurysm.Table I: Demographics for patients with type II endoleaks who underwent endovascular embolizationVariableValue Age (years +/- sd)75.66 +/- yearsAverage follow-up (months)62.65 monthsSex (%)71.7% male28.3% femaleRace (%)77.7% white17.8% black4.4% otherInflow vessel (%)43.2% lumbar only36.4% IMA only20.5% mixEmbolization site (%)40.5% vessel only14.3% cavity only20.5% mixEmbolization type (%)66.7% coil9.5% glue23.8% mixTable II: Outcomes for patients with continued growth after embolizationThose that did no undergo further embolizationThose that underwent a second embolization 3 were found to have type III endoleak and were successfully repaired with lining of the graft.2 whose aneurysm sac ceased growing. 2 who declined further treatment. 2 whose aneurysm sac continued to grow with persistent evidence of endoleak.1 who died from non-vascular complications. 1 who was lost to follow-up. 1 who is scheduled future surgical repair. 1 who was lost to follow-up.https://scholarlycommons.henryford.com/merf2019clinres/1026/thumbnail.jp

Treading Water: Tools to Help US Coastal Communities Plan for Sea Level Rise Impacts

As communities grapple with rising seas and more frequent flooding events, they need improved projections of future rising and flooding over multiple time horizons, to assist in a multitude of planning efforts. There are currently a few different tools available that communities can use to plan, including the Sea Level Report Card and products generated by a United States. Federal interagency task force on sea level rise. These tools are a start, but it is recognized that they are not necessarily enough at present to provide communities with the type of information needed to support decisions that range from seasonal to decadal in nature, generally over relatively small geographic regions. The largest need seems to come from integrated models and tools. Agencies need to work with communities to develop tools that integrate several aspects (rainfall, tides, etc.) that affect their coastal flooding problems. They also need a formalized relationship with end users that allows agency products to be responsive to the various needs of managers and decision makers. Existing boundary organizations can be leveraged to meet this need. Focusing on addressing these needs will allow agencies to create robust solutions to flood risks, leading to truly resilient communities

Cultural experience tourist motives dimensionality : a cross-cultural study

This empirical research of tourists&rsquo; cultural experiences aims to advance theory by developing a measurement model of tourists&rsquo; motives towards attending cultural experiences for samples of Western and Asian tourists visiting Melbourne, Australia. Drawing upon Iso-Ahola&rsquo;s (1989) seeking/avoiding dichotomy theory for tourist motivation dimensions, the hypothesized dimensions primarily included escape and seeking-related dimensions, and some hedonic dimensions because of their relevance to aesthetic products (Hirschman &amp; Holbrook, 1982; Holbrook &amp; Hirschman, 1982), which are the context for this study. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used to crossvalidate the underlying dimensionality structure of cultural experience motives. A four-factor model was extracted from the EFA consistent with some theoretical formulations and was retained in the CFA. Specific cultural language group differences for the motive dimensions were also hypothesized between Western and Asian tourist samples, and within the Chinese- and Japanese-speaking Asian tourist samples, but not within the different cultural groups of English-speaking Western tourists. These cross-cultural hypotheses were tested for the motive dimension measurement model using invariance testing in CFA. The findings for the motive dimensions differing by cultural group were not as expected. Significant cultural differences between Western and Asian tourists were not found, but a new finding of this study was significant differences between English-speaking tourists in their motives for attending cultural experiences. Marketing implications of these findings are also presented.<br /