Journal of vascular surgery
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We aimed to achieve accurate statistical modeling of a putative relationship between carotid endarterectomy (CEA) annual surgeon and hospital volume and in-hospital mortality. ⋯ We have demonstrated a technique for rigorous statistical analysis of volume-outcome data and have found a volume effect for death after CEA in this 10-year Maryland dataset. Higher volume surgeons had lower estimated odds of death, particularly those performing four to 15 CEAs per year. These data suggest that a patient undergoing CEA by a surgeon performing an average of 16 CEAs annually has a statistically equivalent risk of death compared with one undergoing CEA by a surgeon performing any number higher than this, when controlling for hospital volume, patient comorbidity, and patient age. Hospital volume was not seen to be as significant a predictor of postoperative death in this study, with only high volume hospitals (>/=130 CEAs per year) showing a statistically significant decrease in the odds ratio of death. As studies on volume-outcome relationships can have important implications for health policy and surgical training, such studies should consider non-linear effects in their modeling of procedural volume.
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Comparative Study
Colonic ischemia complicating open vs endovascular abdominal aortic aneurysm repair.
Colonic ischemia (CI) is a known complication of both open abdominal aortic aneurysm (AAA) repair and endovascular aneurysm repair (EVAR). Despite a relatively low incidence of 1% to 6%, the associated morbidity and mortality are high. We sought to analyze factors that affect the development of CI on the basis of type of repair as well as associated outcomes from a large nationwide database. ⋯ CI is significantly more common after open AAA repair and is associated with increased morbidity and a two- to fourfold increase in mortality.
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Stenosis of the cephalad internal carotid artery (ICA) can present a challenge, making it difficult to obtain a technically satisfying distal end point during endarterectomy. Surgical revision of distal defects can be difficult and yield unsatisfactory results. The purpose of this review is to evaluate the efficacy of intraoperative carotid stenting as an adjunct to endarterectomy to salvage technical defects identified at the cephalad ICA endarterectomy site. ⋯ Intraoperative salvage carotid stenting is an effective and safe adjunct to endarterectomy when unsatisfactory technical defects are identified at the cephalad ICA endarterectomy site.
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Randomized Controlled Trial Comparative Study
Endovenous laser ablation: does standard above-knee great saphenous vein ablation provide optimum results in patients with both above- and below-knee reflux? A randomized controlled trial.
Following above-knee (AK) great saphenous vein (GSV) endovenous laser ablation (EVLA) 40% to 50% patients have residual varicosities. This randomized controlled trial (RCT) assesses whether more extensive GSV ablation enhances their resolution and influences symptom improvement. ⋯ Extended EVLA is safe, increases spontaneous resolution of varicosities, and has a greater impact on symptom reduction. Similar benefits occurred after concomitant BK-GSV foam sclerotherapy.
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Reliability of the most commonly used duplex ultrasound (DUS) velocity thresholds for internal carotid artery (ICA) stenosis has been questioned since these thresholds were developed using less precise methods to grade stenosis severity based on angiography. In this study, maximum percent diameter carotid bulb ICA stenosis (European Carotid Surgery Trial [ECST] method) was objectively measured using high resolution B-mode DUS validated with computed tomography angiography (CTA) and used to determine optimum velocity thresholds for > or =50% and > or =80% bulb internal carotid artery stenosis (ICA). ⋯ Compared with established velocity thresholds commonly applied in practice, a substantially higher PSV (155 vs 125 cm/s) was more accurate for detecting > or =50% bulb/ICA stenosis. In combination, a PSV of > or =155 cm/s and an ICA/CCA ratio of > or =2 have excellent predictive value for this stenosis category. For > or =80% bulb ICA stenosis (NASCET 60% stenosis), an EDV of 140 cm/s, a PSV of > or =370 cm/s, and an ICA/CCA ratio of > or =6 are equally reliable and do not indicate any major change from the established criteria. Current DUS > or =50% bulb ICA stenosis criteria appear to overestimate carotid bifurcation disease and may predispose patients with asymptomatic carotid disease to untoward costly diagnostic imaging and intervention.