Evidence-Based Strategies and Recommendations for Preservation of Central Venous Access in Children

Journal Journal of Parenteral and Enteral Nutrition
Baskin KM, Mermel LA, Saad TF, Journeycake JM, Schaefer CM, Modi BP, Vrazas JI, Gore B, Drews BB, Doellman D, Kocoshis SA, Abu-Elmagd KM, Towbin RB; Venous Access: National Guideline and Registry Development (VANGUARD) Initiative Affected Persons Advisory Panel.
Year Published 2019
Link to publication

Abstract

Children with chronic illness often require prolonged or repeated venous access. They remain at high risk for venous catheter-related complications (high-risk patients), which largely derive from elective decisions during catheter insertion and continuing care. These complications result in progressive loss of the venous capital (patent and compliant venous pathways) necessary for delivery of life-preserving therapies. A nonstandardized, episodic, isolated approach to venous care in these high-need, high-cost patients is too often the norm, imposing a disproportionate burden on affected persons and escalating costs. This state-of-the-art review identifies known failure points in the current systems of venous care, details the elements of an individualized plan of care, and emphasizes a patient-centered, multidisciplinary, collaborative, and evidence-based approach to care in these vulnerable populations. These guidelines are intended to enable every practitioner in every practice to deliver better care and better outcomes to these patients through awareness of critical issues, anticipatory attention to meaningful components of care, and appropriate consultation or referral when necessary.

Dual antiplatelet therapy reduces stroke but increases bleeding at the time of carotid endarterectomy

Journal Journal of Vascular Surgery
Jones DW, Goodney PP, Conrad MF, Nolan BW, Rzucidlo EM, Powell RJ, Cronenwett JL, Stone DH
Year Published 2016
Link to publication

Abstract

OBJECTIVE:

Controversy persists regarding the perioperative management of clopidogrel among patients undergoing carotid endarterectomy (CEA). This study examined the effect of preoperative dual antiplatelet therapy (aspirin and clopidogrel) on in-hospital CEA outcomes.

METHODS:

Patients undergoing CEA in the Vascular Quality Initiative were analyzed (2003-2014). Patients on clopidogrel and aspirin (dual therapy) were compared with patients taking aspirin alone preoperatively. Study outcomes included reoperation for bleeding and thrombotic complications defined as transient ischemic attack (TIA), stroke, or myocardial infarction. Secondary outcomes were in-hospital death and composite stroke/death. Univariate and multivariable analyses assessed differences in demographics and operative factors. Propensity score-matched cohorts were derived to control for subgroup heterogeneity.

RESULTS:

Of 28,683 CEAs, 21,624 patients (75%) were on aspirin and 7059 (25%) were on dual therapy. Patients on dual therapy were more likely to have multiple comorbidities, including coronary artery disease (P < .001), congestive heart failure (P < .001), and diabetes (P < .001). Patients on dual therapy were also more likely to have a drain placed (P < .001) and receive protamine during CEA (P < .001). Multivariable analysis showed that dual therapy was independently associated with increased reoperation for bleeding (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.20-2.42; P = .003) but was protective against TIA or stroke (OR, 0.61; 95% CI, 0.43-0.87; P = .007), stroke (OR, 0.63; 95% CI, 0.41-0.97; P = .03), and stroke/death (OR, 0.66; 95% CI, 0.44-0.98; P = .04). Propensity score matching yielded two groups of 4548 patients and showed that patients on dual therapy were more likely to require reoperation for bleeding (1.3% vs 0.7%; P = .004) but less likely to suffer TIA or stroke (0.9% vs 1.6%; P = .002), stroke (0.6% vs 1.0%; P = .04), or stroke/death (0.7% vs 1.2%; P = .03). Within the propensity score-matched groups, patients on dual therapy had increased rates of reoperation for bleeding regardless of carotid symptom status. However, asymptomatic patients on dual therapy demonstrated reduced rates of TIA or stroke (0.6% vs 1.5%; P < .001), stroke (0.4% vs 0.9%; P = .01), and composite stroke/death (0.5% vs 1.0%; P = .02). Among propensity score-matched patients with symptomatic carotid disease, these differences were not statistically significant.

CONCLUSIONS:

Preoperative dual antiplatelet therapy was associated with a 40% risk reduction for neurologic events but also incurred a significant increased risk of reoperation for bleeding after CEA. Given its observed overall neurologic protective effect, continued dual antiplatelet therapy throughout the perioperative period is justified. Initiating dual therapy in all patients undergoing CEA may lead to decreased neurologic complication rates.

Sex-Based Assessment of Patient Presentation, Lesion Characteristics, and Treatment Modalities in Patients Undergoing Peripheral Vascular Intervention

Journal Circulation: Cardiovascular Interventions
Ramkumar N, Suckow BD, Brown JR, Sedrakyan A, Cronenwett JL, Goodney PP
Year Published 2018
Link to publication

Abstract

BACKGROUND:

Limited evidence suggests that women and men might be treated differently for peripheral arterial disease.
This analysis evaluated sex-based differences in disease presentation and its effect on treatment modality among patients
who underwent endovascular treatment for peripheral arterial disease.

METHODS AND RESULTS:

Using national registry data from the Vascular Quality Initiative between 2010 and 2013, we
examined patient, limb, and artery characteristics by sex through descriptive statistics. We studied 26750 procedures
performed in 23820 patients to treat 30545 limbs and 44804 arteries. Women presented at an older age (69 versus 67
years; P<0.001) and were less often current or former smokers (72% versus 85%; P<0.001). Transatlantic Inter-Society
Consensus classification was similar among men and women (Transatlantic Inter-Society Consensus C or D: 37% in men
versus 37% in women; P=0.81), as was mean occlusion length (4.5 cm in men versus 4.6 cm in women; P=0.04), even
after accounting for lesion location. Women more frequently underwent treatment for rest pain (11% in men versus 16%
in women; P<0.001) versus claudication (59% in men versus 53% in women; P<0.001) or tissue loss (28% in men versus
27% in women; P=0.75). Treatment modality did not differ by sex but was associated with disease severity (P for trend
<0.001) and lesion location (P for trend <0.001).

CONCLUSIONS:

Women undergo peripheral endovascular intervention for peripheral arterial disease at an older age with
critical limb ischemia. Treatment modalities do not vary by sex but are determined by disease severity and site. Although
there exist sex differences in presentation, these differences do not lead to differential treatment for women with peripheral
arterial disease.

Vascular Quality Initiative. Relationships between 2-Year Survival, Costs, and Outcomes following Carotid Endarterectomy in Asymptomatic Patients in the Vascular Quality Initiative

Journal Annals of Vascular Surgery
Wallaert JB, Newhall KA, Suckow BD, Brooke BS, Zhang M, Farber AE, Likosky D, Goodney PP
Year Published 2016
Link to publication

Abstract

BACKGROUND:

Carotid endarterectomy (CEA) for asymptomatic patients with limited life expectancy may not be beneficial or cost-effective. The purpose of this study was to examine relationships among survival, outcomes, and costs within 2 years following CEA among asymptomatic patients.

METHODS:

Prospectively collected data from 3097 patients undergoing CEA for asymptomatic disease from Vascular Quality Initiative VQI registry were linked to Medicare. Models were used to identify predictors of 2-year mortality following CEA. Patients were classified as low, medium, or high risk of death based on this model. Next, we examined costs related to cerebrovascular care, occurrence of stroke, rehospitalization, and reintervention within 2 years following CEA across risk strata.

RESULTS:

Overall, 2-year mortality was 6.7%. Age, diabetes, smoking, congestive heart failure (CHF), chronic obstructive pulmonary disease, renal insufficiency, absence of statin use, and contralateral internal carotid artery (ICA) stenosis were independently associated with a higher risk of death following CEA. In-hospital costs averaged $7500 among patients defined as low risk for death, and exceeded $10,800 among high risk patients. Although long-term costs related to cerebrovascular disease were 2 times higher in patients deemed high risk for death compared with low risk patents ($17,800 vs. $8800, P = 0.001), high risk of death was not independently associated with a high probability of high cost. Predictors of high cost at 2 years were severe contralateral ICA stenosis, dialysis dependence, and American Society for Anesthesia Class 4. Both statin use and CHF were protective of high cost.

CONCLUSIONS:

Greater than 90% of patients undergoing CEA live long enough to realize the benefits of their procedure. Moreover, the long-term costs are supported by the effectiveness of this procedure at all levels of patient risk.

Renal dysfunction and the associated decrease in survival after elective endovascular aneurysm repair

Journal Journal of Vascular Surgery
Zarkowsky DS, Hicks CW, Bostock IC, Stone DH, Eslami M, Goodney PP
Year Published 2016
Link to publication

Abstract

OBJECTIVE:

The reported frequency of renal dysfunction after elective endovascular aneurysm repair (EVAR) varies widely in current surgical literature. Published research establishes pre-existing end-stage renal disease as a poor prognostic indicator. We intend to quantify the mortality effect associated with renal morbidity developed postoperatively and to identify modifiable risk factors.

METHODS:

All elective EVAR patients with preoperative and postoperative renal function data captured by the Vascular Quality Initiative between January 2003 and December 2014 were examined. The primary study end point was long-term mortality. Preoperative, intraoperative, and postoperative parameters were analyzed to estimate mortality stratified by renal outcome and to describe independent risk factors associated with post-EVAR renal dysfunction.

RESULTS:

This study included 14,475 elective EVAR patients, of whom 96.8% developed no post-EVAR renal dysfunction, 2.9% developed acute kidney injury, and 0.4% developed a new hemodialysis requirement. Estimated 5-year survival was significantly different between groups, 77.5% vs 53.5%, respectively, for the no dysfunction and acute kidney injury groups, whereas the new hemodialysis group demonstrated 22.8% 3-year estimated survival (P < .05). New-onset postoperative congestive heart failure (odds ratio [OR], 3.50; 95% confidence interval [CI], 1.18-10.38), return to the operating room (OR, 3.26; 95% CI, 1.49-7.13), and postoperative vasopressor requirement (OR, 2.68; 95% CI, 1.40-5.12) predicted post-EVAR renal dysfunction, whereas a preoperative estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2 was protective (OR, 0.33; 95% CI, 0.21-0.53). Volume of contrast material administered during elective EVAR varies 10-fold among surgeons in the Vascular Quality Initiative database, but the average volume administered to patients is statistically similar, regardless of preoperative eGFR. Multivariable logistic regression demonstrated nonsignificant correlation between contrast material volume and postoperative renal dysfunction.

CONCLUSIONS:

Any renal dysfunction developing after elective EVAR is associated with decreased estimated long-term survival. Protecting renal function with a rational dosing metric for contrast material linked to preoperative eGFR may better guide treatment.