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Supplemental material, sj-docx-1-vmj-10.1177_1358863X221146207 for A biomechanical perspective on walking in patients with peripheral artery disease by Ganesh M Bapat, Ayisha Z Bashir, Philippe Malcolm, Jason M Johanning, Iraklis I Pipinos and Sara A Myers in Vascular Medicine

Supplemental material, sj-docx-1-vmj-10.1177_1358863X221146207 for A biomechanical perspective on walking in patients with peripheral artery disease by Ganesh M Bapat, Ayisha Z Bashir, Philippe Malcolm, Jason M Johanning, Iraklis I Pipinos and Sara A Myers in Vascular Medicine

INTRODUCTION: Frailty is a risk factor for adverse postoperative outcomes. We aimed to test the performance of a prospectively-validated frailty measure, the Risk Analysis Index (RAI) in vascular surgery patients and delineate the additive impact of procedure complexity on surgical outcomes. METHODS: We queried the 2007–2013 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify six major elective vascular procedure categories (carotid revascularization, abdominal aortic aneurysm [AAA] repair, suprainguinal revascularization, infrainguinal revascularization, thoracic aortic aneurysm [TAA] repair, and thoracoabdominal aortic aneurysm [TAAA] repair). We trained and tested logistic regression models for 30-day mortality, major complications and prolonged length of stay (LOS). The first model, “RAI”, used the RAI alone; “RAI-Procedure (RAI-P)” included procedure category (e.g., AAA repair) and procedure approach (e.g., endovascular); “RAI-Procedure Complexity (RAI-PC)” added outpatient versus inpatient surgery, general anesthesia use, work relative value units (RVUs), and operative time. RESULTS: The RAI model was a good predictor of mortality for vascular procedures overall (C-statistic 0.72). The C-statistic increased with the RAI-P (0.78), which further improved minimally, with the RAI-PC (0.79). When stratified by procedure category, the RAI predicted mortality well for infrainguinal (0.79) and suprainguinal (0.74) procedures, moderately well for AAA repairs (0.69) and carotid revascularizations (0.70), and poorly for TAAs (0.62) and TAAAs (0.54). For carotid, infrainguinal, and suprainguinal procedures, procedure complexity (RAI-PC) had little impact on model discrimination for mortality, did improve discrimination for AAAs (0.84), TAAs (0.73), and TAAAs (0.80). While the RAI model was not a good predictor for major complications or LOS, discrimination improved for both with the RAI-PC model. CONCLUSIONS: Frailty as measured by the RAI was a good predictor of mortality overall after vascular surgery procedures. While the RAI was not a strong predictor of major complications or prolonged LOS, the models improved with the addition of procedure characteristics like procedure category and approach.

ImportanceNational guidelines do not agree on the role of carotid screening in asymptomatic patients (ie, patients who have not had a stroke or transient ischemic attack). Recently, several physician organizations participating in the Choosing Wisely campaign have identified carotid imaging in selected asymptomatic populations as being of low value. However, the majority of patients who are evaluated for carotid stenosis and subsequently revascularized are asymptomatic.ObjectiveTo better understand why asymptomatic patients who undergo revascularization receive initial carotid imaging.Design, setting, and participantsRetrospective cohort study of 4127 Veterans Health Administration patients 65 years and older undergoing carotid revascularization for asymptomatic carotid stenosis between 2005 and 2009.Main outcomes and measuresIndications for carotid ultrasounds were extracted using trained abstractors. Frequency of indications and appropriateness of initial carotid ultrasound imaging for patients within each rating category after the intervention were reported.ResultsThe mean (SD) age of this cohort of 4127 patients was 73.6 (5.9) years; 4014 (98.8%) were male. Overall, there were 5226 indications for 4063 carotid ultrasounds. The most common indications listed were carotid bruit (1578 [30.2% of indications]) and follow-up for carotid disease (stenosis/history of carotid disease) in patients who had previously documented carotid stenosis (1087 [20.8% of indications]). Multiple vascular risk factors were the next most common indication listed. Rates of appropriate, uncertain, and inappropriate imaging were 5.4% (227 indications), 83.4% (3387 indications), and 11.3% (458 indications), respectively. Among the most common inappropriate indications were dizziness/vertigo and syncope. Among the 4063 patients, 3373 (83.0%) received a carotid endarterectomy. Overall, 663 procedures were performed in patients 80 years and older.Conclusions and relevanceCarotid bruit and follow-up for carotid disease accounted for approximately half of all indications provided by physicians for carotid testing. Strong consideration should be given to improving the evidence base around carotid testing, especially around monitoring stenosis over long periods and evaluating carotid bruits. Targeting carotid ultrasound ordering with decision support tools may also be an important step in reducing use of low-value imaging.

Key points: Intraabdominal infections may be confined, localized, or diffuse. Compared with younger patients, elderly patients with intraabdominal infection tend to present in delayed or atypical fashion and have a narrow therapeutic window, both of which are associated with significantly increased morbidity and mortality. Treatment of intraabdominal infections is based on source control and judicious use of antibiotics. In elderly patients, this requires a balanced approach, taking into consideration the invasiveness and inherent risk of a procedure as well as its efficacy for producing the desired outcomes. Multimodal and aggressive preventative management of geriatric syndromes and collateral damage of diagnostic and therapeutic interventions decreases the risk of adverse outcomes in geriatric acute-surgery patients.

Accumulating evidence suggests revascularization of peripheral arterial disease (PAD) limbs results in limited improvement in functional gait parameters, suggesting underlying locomotor system pathology. Spatial and temporal (ST) gait parameters are well studied in patients with PAD at baseline and are abnormal when compared to controls. The purpose of this study was to systematically review and critically analyze the available data on ST gait parameters before and after interventions. A full review of literature was conducted and articles were included which examined ST gait parameters before and after intervention (revascularization and exercise). Thirty-three intervention articles were identified based on 154 articles that evaluated ST gait parameters in PAD. Four articles fully assessed ST gait parameters before and after intervention and were included in our analysis. The systematic review of the literature revealed a limited number of studies assessing ST gait parameters. Of those found, results demonstrated the absence of improvement in gait parameters due to either exercise or surgical intervention. Our study demonstrates significant lack of research examining the effectiveness of treatments on ST gait parameters in patients with PAD. Based on the four published articles, ST gait parameters failed to significantly improve in patients with PAD following intervention.

Discusses a system for use in classifying the reasons for conversion from a laparoscopic to an open approach., Background and Objectives: To examine and classify the reasons for conversion and the points at which laparoscopic cholecystectomies are converted to open procedures and whether these change over time. Methods: This is a retrospective study of all patients undergoing cholecystectomy from June 1, 1990 to June 30, 1995. Reasons for conversion were classified using the “AEIOU:ABC” system developed for this study and conversion points were assigned chronologically. Results: The “AEIOU:ABC” classification system was utilized. The most common reasons for conversion were: acute inflammation N=61 (26.1%); adhesions N=51 (21.8%); and organ system pathology N=39 (16.7%). The most common conversion points were; after visualization of the peritoneal cavity but prior to dissection of the cystic structures N=103 (44.0%); dissection of the cystic structures N=58 (24.8%); initial laparoscopy N=36 (15.4%). When the reasons for conversion were evaluated for changes over time there was no statistically significant change for the total group or any individual surgeon. Conversion points did not change with increasing operative experience. Conclusion: The “AEIOU:ABC” classification system is a simple, effective and easy to use system for classifying the myriad of reasons for conversion. The system needs to be validated prospectively not only for laparoscopic cholecystectomy but for possible application to other laparoscopic procedures.

Previous reports in selected patient populations have noted an increase in the number of cholecystectomies since the introduction of laparoscopic cholecystectomy. To assess the impact of laparoscopic cholecystectomy in a more general population, 6473 consecutive cholecystectomies from 7/1/86 to 6/30/95 were reviewed to assess changes in rate of cholecystectomy, diagnosis leading to cholecystectomy, and general patient demographics. During the 9-year period, the number of cholecystectomies increased from 618 to 800 per year (29%; P < 0.002). Even more striking was the redistribution of cholecystectomies performed for acalculous disease (P < 0.0001), with the rate of increase more than doubling for each individual diagnosis (biliary dyskinesia, 348%; acute acalculous cholecystitis, 139%; chronic acalculous cholecystitis, 138%). When comparing patient characteristics, there was a significant increase in the number of cholecystectomies performed on females when compared with males. When compared with other races, whites underwent cholecystectomy for chronic acalculous cholecystitis at a higher rate (120%; P < 0.0003). The introduction of laparoscopic cholecystectomy was followed by a dramatic increase in cholecystectomies performed for acalculous disease and less so for cholelithiasis. Accompanying the increase were significant alterations in patient demographics. The study provides indirect evidence for lowering thresholds and changing indications with reasons for the increases yet to be determined.