Publications by authors named "Eric B Rosero"

51 Publications

Outcomes of Sleep Apnea Surgery in Outpatient and Inpatient Settings.

Anesth Analg 2021 05;132(5):1215-1222

From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas.

Background: Upper airway surgery is an alternative treatment for patients with severe obstructive sleep apnea (OSA). However, there is controversy regarding selection criteria for outpatient versus inpatient settings for these surgical procedures. The aim of this retrospective study was to compare postoperative outcomes of patients undergoing airway surgery in outpatient and inpatient settings based on length of stay at the facility.

Methods: The 2011-2017 American College of Surgeons National Surgical Quality Improvement databases were used to select adult patients with a diagnosis of OSA undergoing elective airway surgery procedures. Single-level (eg, uvulopalatopharyngoplasty [UPPP]) or multilevel surgery (eg, concomitant procedures on base of tongue, maxilla, palate, nose/turbinate, or tracheotomy) was identified using appropriate current procedural terminology (CPT) codes. Surgery setting was classified as outpatient (length of hospital stay = 0 days) or inpatient (length of stay ≥1 day). Propensity scores derived from logistic regression models were used to match inpatient to outpatient cases at a ratio of 1:1. Primary outcome was a composite of 30-day readmissions, reoperations, and/or postoperative complications. Outcomes between the matched groups were compared with McNemar's tests and generalized mixed linear regression analyses.

Results: A total of 3208 cases were identified (1049 [32.7%] outpatient and 2159 [67.3%] inpatient). Inpatients were older, had more comorbidities, larger body mass index, and more multilevel procedures. UPPP was performed in about 96% of both inpatients and outpatients. The overall rate of composite of readmission, reoperations, and/or complications in the whole unmatched sample was 6.4% (6.8% and 5.5% in inpatients and outpatients, respectively). The propensity-matching algorithm produced a sample of 987 patients per surgical setting well balanced on available baseline characteristics. The incidence of the composite primary outcome was not significantly different between the groups (6.2% and 5.9% in inpatients and outpatients, respectively; odds ratio [OR] [95% confidence interval {CI}], 1.06 [0.73-1.53]; P = .77).

Conclusions: This retrospective study found that the complications and 30-day readmission rates after airway surgery for OSA are low. There were no significant differences in the composite outcome of 30-day readmissions, reoperations, or complications between inpatient and outpatient settings. Adequately designed prospective studies are necessary to confirm the retrospective observations of this study.
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http://dx.doi.org/10.1213/ANE.0000000000005394DOI Listing
May 2021

Intraoperative Airway Management Considerations for Adult Patients Presenting With Tracheostomy: A Narrative Review.

Anesth Analg 2021 04;132(4):1003-1011

Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas.

Tracheotomy is a surgical procedure through which a tracheostomy, an opening into the trachea, is created. Indications for tracheostomy include facilitation of airway management during prolonged mechanical ventilation, treatment of acute upper airway obstruction when tracheal intubation is unfeasible, management of chronic upper airway obstructive conditions, and planned airway management for major head and neck surgery. Patients who have a recent or long-term tracheostomy may present for a variety of surgical or diagnostic procedures performed under general anesthesia or sedation/analgesia. Airway management of these patients can be challenging and should be planned ahead of time. Anesthesia personnel should be familiar with the different components of cuffed and uncuffed tracheostomy devices and their connectivity to the anesthesia circuits. An appropriate airway management plan should take into account the indication of the tracheostomy, the maturity status of the stoma, the type and size of tracheostomy tube, the expected patient positioning, and presence of patient's concurrent health conditions. Management of the patient with a T-tube is highlighted. Importantly, there is a need for multidisciplinary care involving anesthesiologists, surgical specialists, and perioperative nurses. The aim of this narrative review is to discuss the anesthesia care of patients with a tracheostomy. Key aspects on relevant tracheal anatomy, tracheostomy tubes/devices, alternatives of airway management, and possible complications related to tracheostomy are summarized with a recommendation for an algorithm to manage intraoperative tracheostomy tube dislodgement.
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http://dx.doi.org/10.1213/ANE.0000000000005330DOI Listing
April 2021

Finding the body mass index cutoff for hospital readmission after ambulatory hernia surgery.

Acta Anaesthesiol Scand 2020 10 16;64(9):1270-1277. Epub 2020 Jul 16.

Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA.

Background: The suitability of ambulatory surgery in obese patients remains controversial. This study aimed to investigate the "cutoff" value of body mass index (BMI) associated with increased likelihood of hospital readmissions within the first 24 hours of surgery in patients undergoing ambulatory hernia repair.

Materials And Methods: The study used data from the 2012-2016 American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP). Cochran Armitage trend tests were conducted to assess progression in rates hospital readmissions across categories of patient BMI. The minimum p-value method, Kolmogorov-Smirnov goodness of fit tests, logistic regression, and receiver-operating characteristic (ROC) curve analyses were used to investigate the cutoff of patient BMI indicative of increased likelihood of readmissions.

Results: A total of 214,125 ambulatory hernia repair cases were identified. Of those, 908 patients (0.42%) had an unexpected hospital admission within the first 24 hours after surgery. The readmission rates did not significantly increase across the categories of BMI. However, some of the reasons for readmission significantly differed by BMI category. Logistic regression analysis revealed no statistically significant association between BMI and hospital readmissions (odds ratio [95% Cl], 0.96 [0.91-1.02] P = .179). An optimal BMI threshold predictive of an increased likelihood of hospital readmissions was not identifiable by any of the statistical methods used.

Conclusions: Although reasons for readmission differed by BMI category, there is no clear cutoff value of BMI associated with increased hospital readmission within the first 24 hours after surgery.
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http://dx.doi.org/10.1111/aas.13660DOI Listing
October 2020

Readmission Rate After 2-level Lumbar Decompression: A Propensity-matched Cohort Study Comparing Inpatient and Outpatient Settings.

Clin Spine Surg 2021 Feb;34(1):E1-E6

Departments of Anesthesiology and Pain Management.

Study Design: Retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database years 2012-2015.

Objective: Compare the 30-day readmission and postoperative major complications rates of 2-level lumbar decompression performed in the ambulatory and the inpatient settings.

Summary Of Background Data: In recent years, there is an increasing trend toward ambulatory spine surgery. However, there remains a concern regarding risks of readmission and postoperative morbidity after discharge.

Methods: The ACS-NSQIP database from 2012 to 2015 was queried for adult patients who underwent elective 2-level lumbar decompression (CPT code 63047 accompanied with code 63048). A cohort of ambulatory lumbar decompression cases was matched 1:1 with an inpatient cohort after controlling for patient demographics, comorbidities, and complexity of the procedure. The primary outcome was the 30-day readmission rate. Secondary outcomes included a composite of 30-day postoperative major complications and hospital length of stay for hospitalized patients.

Results: A total of 7505 patients met our study criteria. The ambulatory 2-level lumbar decompression surgery rate increased significantly over the study period from 28% in 2012 to 49% in 2015 (P<0.001). In the matched sample, there was no statistically significant difference in the 30-day readmission rate (odds ratio, 0.82; 95% confidence interval, 0.64-1.04; P=0.097) between the two cohorts; however, the ambulatory cohort had a lower 30-day postoperative major complication rate (odds ratio, 0.55; 95% confidence interval, 0.38-0.79; P=0.002).

Conclusions: After 2-level lumbar decompression performed on inpatient versus outpatient basis, the 30-day readmission rate is similar. However, the 30-day postoperative complication rate is significantly lower in the ambulatory setting. The reasons for these differences need further exploration.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BSD.0000000000000990DOI Listing
February 2021

Failure to rescue after major abdominal surgery: The role of hospital safety net burden.

Am J Surg 2020 10 12;220(4):1023-1030. Epub 2020 Mar 12.

Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA.

Background: We aimed to examine whether safety-net burden is a significant predictor of failure-to-rescue (FTR) after major abdominal surgery controlling for patient and hospital characteristics, including surgical volume.

Methods: Data were extracted from the 2007-2011 Nationwide Inpatient Sample. FTR was defined as mortality among patients experiencing major postoperative complications. Differences in rates of complications, mortality, and FTR across quartiles of safety-net burden were assessed with univariate analyses. Multilevel regression models were constructed to estimate the association between FTR and safety-net burden.

Results: Among 238,645 patients, the incidence of perioperative complications, in-hospital mortality, and FTR were 33.7%, 4.4%, and 11.8%, respectively. All the outcomes significantly increased across the quartiles of safety-net burden. In the multilevel regression analyses, safety-net burden was a significant predictor of FTR after adjustment for patient and hospital characteristics, including hospital volume.

Conclusion: Increasing hospital safety-net burden is associated with higher odds of FTR for major abdominal surgery.
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http://dx.doi.org/10.1016/j.amjsurg.2020.03.014DOI Listing
October 2020

Defining the threshold surgeon volume associated with improved patient outcomes for carotid endarterectomy.

J Vasc Surg 2020 07 19;72(1):209-218.e1. Epub 2020 Feb 19.

Department of Anesthesiology and Pain Management, University Of Texas Southwestern Medical Center, Dallas, Tex.

Objective: The outcomes for common vascular operations, such as carotid endarterectomy (CEA), are associated with surgeon volume. However, the number of operations associated with an improved stroke or death rate for CEA is not known. The objective of the current study was to define the annual surgeon volume of CEAs that is associated with a lower risk of stroke or death rate.

Methods: The Nationwide Inpatient Sample was analyzed to identify patients undergoing CEA between 2003 and 2009. Annual surgeon volume was correlated with a composite end point of in-hospital stroke or death. Mixed linear regression analyses were conducted to determine if annual surgeon volume of CEAs is independent predictor of the composite outcome. Receiver operating characteristic curves were constructed from the regression models and used to calculate the Youden Index, which defined the optimal cutoff point of annual surgeon volume of CEAs in predicting in-hospital stroke and death. This cutoff point was further assessed using Chi square analyses to determine whether incremental increases in the annual volume of CEAs were associated with a lower in-hospital stroke or death rate.

Results: A total of 104,918 CEA cases with surgeon identifiers were included in the analysis. The crude in-hospital stroke or death rate for CEA was 1.26 %. As expected, the stroke or death rate after CEA was higher for symptomatic patients, compared to asymptomatic patients (6.46 % vs 0.72%; P < .0001). For symptomatic patients, the relationship between surgeon volume and the composite end point was not significant (P = .435). In contrast, there was a strong relationship between surgeon volume and outcomes for asymptomatic patients undergoing CEA with a stroke/death rate of 1.66%, 0.91%, and 0.65% for low-, moderate-, and high-volume surgeons (P < .0001). Multivariate analysis identified age, African-American race, Charlson Comorbidity Index, and surgeon volume as independent predictors of stroke/death after CEA for asymptomatic carotid stenosis. For asymptomatic patients, the optimal cutoff number of CEAs to predict stroke/death rate was 19.4 CEAs per year (sensitivity = 74.9%, specificity = 72.6%, Youden index = 0.475). Analyses of outcomes at different cutoff points of surgeon volume revealed that the rate of crude complications and the adjusted probability of stroke or death was higher with case numbers less than 20 CEAs per year and lower with case numbers of 20 CEA or higher per year. Cutoff points above 20 cases were year did not yield a stroke/death rate that was significantly lower than the stroke/death rate at 20 CEAs per year, which confirmed the cutoff point of 20 CEAs per year. Only 16% of surgeons in the database achieved the threshold of 20 CEAs per year.

Conclusions: Higher surgeon volume is associated with improved outcomes for CEAs performed in patients with asymptomatic carotid disease, but not for symptomatic carotid disease. For asymptomatic carotid disease, the probability of stroke or death was no longer reduced significantly at cutoff points of 20 or more CEAs per year. There are a number of other variables that may impact the clinical outcomes for CEA, so it is premature at this time to restrict privileges based on surgeon volume criteria.
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http://dx.doi.org/10.1016/j.jvs.2019.10.057DOI Listing
July 2020

A Randomized Controlled Trial Comparing Learners' Decision-making, Anxiety, and Task Load During a Simulated Airway Crisis Using Two Difficult Airway Aids.

Simul Healthc 2019 Apr;14(2):96-103

From the Department of Anesthesiology and Pain Management (A.P.A., E.B.R., R.B., J.G., D.W.M.), University of Texas Southwestern Medical Center, Dallas; US Anesthesia Partners-Texas Central (B.A.R.), Austin; Department of Clinical Sciences (A.T.M.), University of Texas Southwestern Medical Center; Department of Surgery Center for Minimally Invasive Surgery (M.S.K.), University of Texas Southwestern Medical Center, Dallas, TX; and Department of Anesthesiology (O.T.G.), Thomas Jefferson University Medical Center, Philadelphia, PA.

Introduction: The American Society of Anesthesiologists (ASA) difficult airway algorithm and the Vortex approach are difficult airway aids. Our objective was to demonstrate that a simpler cognitive model would facilitate improved decision-making during a process such as difficult airway management. We hypothesized the simpler Vortex approach would be associated with less anxiety and task load.

Methods: Medical students were randomized to the ASA algorithm (n = 33) or Vortex approach (n = 34). All learned basic airway techniques on day 1 of their rotation. Next, they watched a video of their respective aid then managed a simulated airway crisis. We assessed decision-making using a seven-point airway management score and a completeness score. Completeness was at least one attempt at each of four techniques (mask ventilation, supraglottic airway, intubation, and cricothyrotomy). Two validated tools, the State-Trait Anxiety Inventory Form Y and the National Aeronautics and Space Administration Task Load Index, were used to assess anxiety and task load.

Results: Students in the Vortex group had higher airway management scores [4.0 (interquartile range = 4.0 to 5.0) vs. 4.0 (3.0 to 4.0), P = 0.0003] and completeness (94.1% vs. 63.6%, P = 0.003). In the ASA group, the means (SD) of National Aeronautics and Space Administration Task Load Index scores of 55 or higher were observed in mental [61.4 (14.4)], temporal [62.3 (22.9)], and effort [57.1 (15.6)] domains. In the Vortex group, only the temporal load domain was 55 or higher [mean (SD) = 57.8 (25.4)]. There was no difference in anxiety.

Conclusions: Medical students perform better in a simulated airway crisis after training in the simpler Vortex approach to guide decision-making. Students in the ASA group had task load scores indicative of high cognitive load.
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http://dx.doi.org/10.1097/SIH.0000000000000362DOI Listing
April 2019

Effects of Increasing Airway Pressures on the Pressure of the Endotracheal Tube Cuff During Pelvic Laparoscopic Surgery.

Anesth Analg 2018 07;127(1):120-125

From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas.

Background: Tracheal tube cuff pressures exceeding the perfusion pressures of the tracheal mucosa have been associated with complications such as sore throat, tracheal mucosa ulcers, tracheal rupture, and subglottic stenosis. Despite appropriate inflation, many factors can increase the tracheal cuff pressure during mechanical ventilation. This prospective observational cohort study was designed to test the hypothesis that during a clinical model of decreasing respiratory compliance, the pressure within the endotracheal tube cuff will rise in direct relationship to increases in the airway pressures.

Methods: Twenty-eight adult obese patients (BMI ≥30 kg/m) scheduled for elective laparoscopic gynecologic procedures were enrolled. All patients received general anesthesia utilizing endotracheal tubes with low-pressure high-volume cuffs. After baseline adjustment of the cuff pressure to 25 cm H2O, the airway pressures and endotracheal cuff pressures were continuously measured using pressure transducers connected to the anesthesia circuit and cuff pilot, respectively. Data on cuff and airway pressures, mechanical ventilation parameters, intraabdominal pressures, and degree of surgical table inclination were collected throughout the anesthetic procedure. General linear regression models with fixed and random effects were fit to assess the effect of increases in airway pressures on cuff pressure, after adjusting for covariates and the clustered structure of the data.

Results: The mean (standard deviation) age and body mass index were 42.2 (8.8) years and 37.7 (5.1) kg/m, respectively. After tracheal intubation, the cuffs were overinflated (ie, intracuff pressures >30 cm H2O) in 89% of patients. The cuff pressures significantly changed after concomitant variations in the airway pressures from a mean (standard error) value of 29.6 (1.30) cm H2O before peritoneal insufflations, to 35.6 (0.68) cm H2O after peritoneal insufflation, and to 27.8 (0.79) cm H2O after peritoneal deflation (P < .0001). The multilevel mixed regression models revealed that after controlling for clustering of the data (at the patient and study phase levels) and covariates, increased peak airway pressures were significantly associated with increased pressures within the endotracheal cuff (coefficient [95% confidence interval], 0.25 [0.14-0.36]; P < .0001). Other variables associated with increasing endotracheal cuff pressure included degree of surgical table inclination (0.08 [0.04-0.12]; P = .0003) and I:E ratio of 1:1 (4.47 [2.10-6.83]; P = .0002).

Conclusions: This clinical model of decreased respiratory compliance in mechanically ventilated patients reveals that the pressure within the endotracheal cuff significantly changes in direct relation to changes in the airway pressures. This finding may have clinical relevance in patients requiring prolonged use of high airway pressures.
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http://dx.doi.org/10.1213/ANE.0000000000002657DOI Listing
July 2018

Hospital readmission after ambulatory laparoscopic cholecystectomy: incidence and predictors.

J Surg Res 2017 11 28;219:108-115. Epub 2017 Jun 28.

Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas.

Background: The aim of the study was to assess the rate of 30-d hospital readmissions after ambulatory laparoscopic cholecystectomy.

Materials And Methods: The 2009 to 2011 State Ambulatory Surgery and Services and State Inpatient Databases from California, Florida, and New York were analyzed to evaluate the incidence of 30-d readmissions after laparoscopic cholecystectomy performed in outpatient settings. Hospital transfers and the principal diagnoses of hospital readmission were analyzed as secondary outcomes. Multilevel generalized mixed linear regression analyses with fixed and random effects were used to evaluate variables associated with increased likelihood of readmissions.

Results: A total of 230,745 encounters for ambulatory laparoscopic cholecystectomies performed in 890 ambulatory facilities between 2009 and 2011 in the three states were analyzed. The rate of 30-d readmission was 20.2 per 1000 discharges. The rate of direct transfers from the ambulatory surgery center to an acute care hospital was 0.6 per 1000 discharges. The most common diagnoses of readmission were surgical complications, postoperative pain, infection, and nausea or vomiting. After adjusting for comorbidities, increasing age, male sex, non-Hispanic white race/ethnicity, any nonprivate insurance type, diagnosis of acute cholecystitis, use of intraoperative cholangiography, and having the procedure performed on a weekend were significantly associated with increased odds of 30-d readmissions.

Conclusions: This large-state data analysis reveals that the unplanned admission and readmission rates after laparoscopic cholecystectomy are very low. Some causes of readmission (e.g., pain, nausea, and vomiting) are modifiable by the intervention of surgeons and anesthesia providers.
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http://dx.doi.org/10.1016/j.jss.2017.05.071DOI Listing
November 2017

Reducing sedation time for thyroplasty with arytenoid adduction with sequential anesthetic technique.

Laryngoscope 2017 12 8;127(12):2813-2817. Epub 2017 Jul 8.

Clinical Center for Voice Care, Department of Otolaryngology-Head and Neck Surgery.

Objective: To determine the extent to which a sequential anesthetic technique 1) shortens time under sedation for thyroplasty with arytenoid adduction (TP-AA), 2) affects the total operative time, and 3) changes the voice outcome compared to TP-AA performed entirely under sedation/analgesia.

Study Design: Case-control study.

Methods: A new sequential anesthetic technique of performing most of the TP-AA surgery under general anesthesia (GA), followed by transition to sedation/analgesia (SA) for voice assessment, was developed to achieve smooth emergence from GA. Twenty-five TP-AA cases performed with the sequential GA-SA technique were compared with 25 TP-AA controls performed completely under sedation/analgesia. The primary outcome measure was the time under sedation. Voice improvement, as assessed by Consensus Auditory-Perceptual Evaluation of Voice, and total operative time were secondary outcome measures.

Results: With the conventional all-SA anesthetic, the duration of SA was 209 ± 26.3 minutes. With the sequential GA-SA technique, the duration of SA was 79.0 ± 18.9 minutes, a 62.3% reduction (P < 0.0001). There was no significant difference in the total operative time (209.5 vs. 200.9 minutes; P = 0.42) or in voice outcome. This sequential anesthetic technique has been easily adopted by multiple anesthesiologists and nurse anesthetists at our institution.

Conclusion: TP-AA is effectively performed under sequential GA-SA technique with a significant reduction in the duration of time under sedation. This allows the surgeon to perform the technically more challenging part of the surgery under GA, without having to contend with variability in patient tolerance for laryngeal manipulation under sedation.

Level Of Evidence: 3b. Laryngoscope, 127:2813-2817, 2017.
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http://dx.doi.org/10.1002/lary.26743DOI Listing
December 2017

The Surgeon Volume-outcome Relationship: Not Yet Ready for Policy.

Ann Surg 2018 05;267(5):863-867

Department of Anesthesiology and Pain Management, University Of Texas Southwestern Medical Center, Dallas, TX.

Objective: Increasing surgeon volume may improve outcomes for index operations. We hypothesized that there may be surrogate operative experiences that yield similar outcomes for surgeons with a low-volume experience with a specific index operation, such as esophagectomy.

Background: The relationship between surgeon volume and outcomes has potential implications for credentialing of surgeons. Restrictions of privileges based on surgeon volume are only reasonable if there is no substitute for direct experience with the index operation. This study was aimed at determining whether there are valid surrogates for direct experience with a sample index operation-open esophagectomy.

Methods: The Nationwide Inpatient Sample (2003-2009) was utilized. Surgeons were stratified into low and high-volume groups based on annual volume of esophagectomy. Surrogate volume was defined as the aggregate annual volume per surgeon of upper gastrointestinal operations including excision of esophageal diverticulum, gastrectomy, gastroduodenectomy, and repair of diaphragmatic hernia.

Results: In all, 26,795 esophagectomies were performed nationwide (2003-2009), with a crude inhospital mortality rate of 5.2%. Inhospital mortality decreased with increasing volume of esophagectomies performed annually: 7.7% and 3.8% for low and high-volume surgeons, respectively (P < 0.0001). Among surgeons with a low-volume esophagectomy experience, increasing volume of surrogate operations improved the outcomes observed for esophagectomy: 9.7%, 7.1%, and 4.3% for low, medium, and high-surrogate-volume surgeons, respectively (P = 0.016).

Conclusions: Both operation-specific volume and surrogate volume are significant predictors of inhospital mortality for esophagectomy. Based on these observations, it would be premature to limit hospital privileges based solely on operation-specific surgeon volume criteria.
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http://dx.doi.org/10.1097/SLA.0000000000002334DOI Listing
May 2018

Renal Salvage with Renal Artery Stenting Improves Long-term Survival.

Ann Vasc Surg 2017 Nov 7;45:106-111. Epub 2017 Jun 7.

Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX.

Background: The Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) Trial cast doubt on the benefits of renal artery stenting (RAS). However, the outcomes for patients with chronic kidney disease (CKD) were not analyzed separately in the CORAL Trial. We hypothesized that patients who experienced a significant improvement in renal function after RAS would have improved long-term survival, compared with patients whose renal function was not improved by stenting.

Methods: This single-center retrospective study included 60 patients with stage 3 or worse CKD and renal artery occlusive disease who were treated with RAS for renal salvage. Patients were categorized as "responders" or "nonresponders" based on postoperative changes in estimated glomerular filtration rate (eGFR) after RAS. "Responders" were those patients with an improvement of at least 20% in eGFR over baseline; all others were categorized as "nonresponders." Survival was analyzed using the Kaplan-Meier method. Cox proportional hazards regression was used to identify predictors of long-term survival.

Results: The median age of the cohort was 66 years (interquartile range [IQR], 60-73). Median preoperative eGFR was 34 mL/min/1.73 m (IQR, 24-45). At late follow-up (median 35 months, IQR, 22-97 months), 16 of 60 patients (26.7%) were categorized as "responders" with a median increase in postoperative eGFR of 40% (IQR, 21-67). Long-term survival was superior for responders, compared with nonresponders (P = 0.046 by log-rank test). Cox proportional hazards regression identified improved renal function after RAS as the only significant predictor of increased long-term survival (hazard ratio = 0.235, 95% confidence interval = 0.075-0.733; P = 0.0126 for improved versus worsened renal function after RAS).

Conclusions: Successful salvage of renal function by RAS is associated with improved long-term survival. These data provide an important counter argument to the prior negative clinical trials that found no benefit to RAS.
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http://dx.doi.org/10.1016/j.avsg.2017.05.033DOI Listing
November 2017

Effects of hospital safety-net burden and hospital volume on failure to rescue after open abdominal aortic surgery.

J Vasc Surg 2017 08 19;66(2):404-412. Epub 2017 Apr 19.

Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Tex.

Objective: Failure to rescue (FTR) is defined as the inability to rescue a patient from major perioperative complications, resulting in operative mortality. FTR is a known contributor to operative mortality after open abdominal aortic surgery. Understanding the causes of FTR is essential to designing interventions to improve perioperative outcomes. The objective of this study was to determine the relative contributions of hospital volume and safety-net burden (the proportion of uninsured and Medicaid-insured patients) to FTR.

Methods: The Nationwide Inpatient Sample (2001-2011) was analyzed to investigate variables associated with FTR after elective open abdominal aortic operations in the United States. FTR was defined as in-hospital death following postoperative complications. Mixed multivariate regression models were used to assess independent predictors of FTR, taking into account the clustered structure of the data (patients nested into hospitals).

Results: A total of 47,233 elective open abdominal aortic operations were performed in 1777 hospitals during the study period. The overall incidences of postoperative complications, in-hospital mortality, and FTR in the whole cohort were 32.7%, 3.2%, and 8.6%, respectively. After adjusting for demographics, comorbidities, and hospital characteristics, safety-net burden was significantly associated with increased likelihood of FTR (highest vs lowest quartile of safety-net burden, odds ratio, 1.59; 95% confidence interval, 1.32-1.91; P < .0001). In contrast, after adjusting for safety-net burden, procedure-specific hospital volume was not significantly associated with FTR (P = .897).

Conclusions: After adjusting for patient- and hospital-level variables, including hospital volume, safety-net burden was an independent predictor of FTR after open aortic surgery. Future investigations should be aimed at better understanding the relationship between safety-net hospital burden and FTR to design interventions to improve outcomes after open abdominal aortic surgery.
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http://dx.doi.org/10.1016/j.jvs.2016.12.146DOI Listing
August 2017

A sequential anesthesia technique for surgical repair of unilateral vocal fold paralysis.

J Anesth 2016 12 13;30(6):1078-1081. Epub 2016 Aug 13.

Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA.

Thyroplasty with arytenoid adduction, a combined procedure for treatment of unilateral vocal fold paralysis, is typically performed under local anesthesia with sedation to allow for intraoperative voice assessment. However, the need for patient immobility and suppression of laryngeal responses to surgical manipulation can make sedation-analgesia challenging. We describe our first 26 consecutive cases undergoing thyroplasty and arytenoid adduction with a standardized technique consisting of a combination of general anesthesia with tracheal intubation followed by sedation-analgesia. Most patients (69 %) were women, with age of 53 ± 15 years (mean ± SD). Neck surgery was the cause of vocal fold paralysis in 50 % of patients. Initially, general anesthesia was maintained with desflurane and remifentanil with dexmedetomidine added just before tracheal extubation. During the sedation-analgesia phase, patients received infusions of remifentanil and dexmedetomidine. Duration of general anesthesia and sedation-analgesia phases was 162 ± 68.2 and 79 ± 18.3 min, respectively. Mean (SD) wake-up time was 8.0 ± 4.0 min after desflurane discontinuation. Extubation occurred without coughing, bucking, or agitation in 96 % of patients. All the patients were able to phonate appropriately and remained comfortable after emergence. This technique allowed improved surgical conditions with reduced patient discomfort and may be advantageous for other laryngeal and neck surgeries in which intraoperative patient feedback is required.
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http://dx.doi.org/10.1007/s00540-016-2231-0DOI Listing
December 2016

Epidural analgesia does not increase the rate of inpatient falls after major upper abdominal and thoracic surgery: a retrospective case-control study.

Can J Anaesth 2016 May 2;63(5):544-51. Epub 2016 Feb 2.

Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9068, USA.

Purpose: Postoperative epidural analgesia for major upper abdominal and thoracic surgery can provide significant benefits, including superior analgesia and reduced pulmonary dysfunction. Nevertheless, epidural analgesia may also be associated with decreased muscle strength, sympathetic tone, and proprioception that could possibly contribute to falls. The purpose of this retrospective case-control study was to search a large national database in order to investigate the possible relationship between postoperative epidural analgesia and the rate of inpatient falls.

Methods: Data from the nationwide inpatient sample for 2007-2011 were queried for adult patients who underwent elective major upper abdominal and thoracic surgery. Multiple International Classification of Diseases, Ninth Revision, Clinical Modification codes for inpatient falls and accidents were combined into one binary variable. Univariate analyses were used for initial statistical analysis. Logistic regression analyses and McNemar's tests were subsequently used to investigate the association of epidural analgesia with inpatient falls in a 1:1 case-control propensity-matched sample after adjustment of patients' demographics, comorbidities, and hospital characteristics.

Results: Forty-two thousand six hundred fifty-eight thoracic and 54,974 upper abdominal surgical procedures were identified. The overall incidence of inpatient falls in the thoracic surgery group was 6.54% with an increasing trend over the study period from 4.95% in 2007 to 8.11% in 2011 (P < 0.001). Similarly, the overall incidence of inpatient falls in the upper abdominal surgery group was 5.30% with an increasing trend from 4.55% in 2007 to 6.07% in 2011 (P < 0.001). Postoperative epidural analgesia was not associated with an increased risk for postoperative inpatient falls in the thoracic surgery group (relative risk [RR], 1.18; 95% confidence interval [CI], 0.95 to 1.47; P = 0.144) and in the upper abdominal surgery group (RR, 0.84; 95% CI 0.64 to 1.09; P = 0.220). Inpatient falls compared with non-falls were associated with a longer median (interquartile range) length of hospital stay in both the thoracic surgery group (11 [7-17] days vs 9 [6-16] days, respectively; P < 0.001) and the upper abdominal surgery group (12 [7-20] days vs 10 [6-17] days, respectively; P < 0.001).

Conclusion: Our study suggests that postoperative epidural analgesia for patients undergoing major upper abdominal and thoracic surgery is not associated with an increased risk of inpatient falls.
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http://dx.doi.org/10.1007/s12630-016-0602-5DOI Listing
May 2016

Evaluation of epidural analgesia for open major liver resection surgery from a US inpatient sample.

Proc (Bayl Univ Med Cent) 2014 Oct;27(4):305-12

Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, Texas.

The aim of this study was to assess the nationwide use of epidural analgesia (EA) and the incidence of postoperative complications in patients undergoing major liver resections (MLR) with and without EA in the United States. The 2001 to 2010 Nationwide Inpatient Sample was queried to identify adult patients undergoing MLR. A 1:1 matched cohort of patients having MLR with and without EA was assembled using propensity-score matching techniques. Differences in the rate of postoperative complications were compared between the matched groups. We identified 68,028 MLR. Overall, 5.9% of patients in the database had procedural codes for postoperative EA. A matched cohort of 802 patients per group was derived from the propensity-matching algorithm. Although use of EA was associated with more blood transfusions (relative risk, 1.36; 95% confidence interval, 1.12-1.65; P = 0.001) and longer hospital stay (median [interquartile range], 6 [5-8] vs 6 [4-8] days), the use of coagulation factors and the incidence of postoperative hemorrhage/hematomas or other postoperative complications were not higher in patients receiving EA. In conclusion, the use of EA for MLR is low, and EA does not seem to influence the incidence of postoperative complications. EA, however, was associated with an increased use of blood transfusions and a longer hospital stay.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4255849PMC
http://dx.doi.org/10.1080/08998280.2014.11929141DOI Listing
October 2014

Preemptive, preventive, multimodal analgesia: what do they really mean?

Plast Reconstr Surg 2014 Oct;134(4 Suppl 2):85S-93S

Dallas, Tex. From the Department of Anesthesiology and Pain Medicine, University of Texas Southwestern Medical Center.

Summary: To improve postoperative pain management, several concepts have been developed, including preemptive analgesia, preventive analgesia, and multimodal analgesia. This article will discuss the role of these concepts in improving perioperative pain management. Preemptive analgesia refers to the administration of an analgesic treatment before the surgical insult or tissue injury. Several randomized clinical trials have, however, provided equivocal evidence regarding the benefits of preincisional compared with postincisional analgesic administration. Current general consensus, therefore, indicates that use of preemptive analgesia does not translate into consistent clinical benefits after surgery. Preventive analgesia is a wider concept where the timing of analgesic administration in relation to the surgical incision is not critical. The aim of preventive analgesia is to minimize sensitization induced by noxious stimuli arising throughout the perioperative period. Multimodal analgesia consists of the administration of 2 or more drugs that act by different mechanisms for providing analgesia. These drugs may be administered via the same route or by different routes. Thus, the aim of multimodal analgesia is to improve pain relief while reducing opioid requirements and opioid-related adverse effects. Analgesic modalities currently available for postoperative pain control include opioids, local anesthetic techniques [local anesthetic infiltration, peripheral nerve blocks, and neuraxial blocks (epidural and paravertebral)], acetaminophen, nonsteroidal anti-inflammatory drugs, and cyclooxygenase-2-specific inhibitors as well as analgesic adjuncts such as steroids, ketamine, α-2 agonists, and anticonvulsants.
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http://dx.doi.org/10.1097/PRS.0000000000000671DOI Listing
October 2014

Nationwide use and outcomes of ambulatory surgery in morbidly obese patients in the United States.

J Clin Anesth 2014 May 5;26(3):191-8. Epub 2014 May 5.

Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX 75390-9068, USA.

Study Objective: To compare the overall characteristics and perioperative outcomes in morbidly obese and nonobese patients undergoing ambulatory surgery in the United States.

Design: Retrospective, propensity-matched cohort study.

Setting: Academic medical center.

Measurements: The association between duration of surgical procedures, postoperative complications, and unplanned hospital admission was assessed in a propensity-matched cohort of morbidly obese and nonobese patients derived from the 2006 National Survey of Ambulatory Surgery.

Main Results: Only 0.32% of the ambulatory procedures were performed on morbidly obese patients. The morbidly obese were significantly younger but had a higher burden of comorbidities, were more likely to undergo the procedure in hospital-based outpatient departments (HOPD; 80.1% vs 56.5%; P = 0.004), and had significantly shorter procedures than the nonobese (median [interquartile range], 28 [21-38] vs 42 [22-65] min; P < 0.0001). The incidences of postoperative hypertension, hypotension, hypoxia, cancellation of surgery, and unplanned hospital admissions did not differ significantly between groups. Similarly, adjusted rates of delayed discharge were similar in morbidly obese and nonobese patients (odds ratio [OR], 0.46; 95% confidence interval [CI], 0.18 - 1.15; P = 0.09). In contrast, morbid obesity was associated with decreased odds of postoperative nausea and vomiting (OR, 0.27; CI, 0.09 - 0.84; P = 0.01).

Conclusions: In 2006 in the U.S., the prevalence of ambulatory surgery in the morbidly obese was low, with most of the procedures being performed in the HOPD facilities, suggesting a conservative patient selection. The incidence of adverse postoperative outcomes and delayed discharge, as well as unplanned hospital admission after ambulatory surgery in the morbidly obese, was similar to that reported in the nonobese.
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http://dx.doi.org/10.1016/j.jclinane.2013.10.009DOI Listing
May 2014

In reply.

Obstet Gynecol 2014 Apr;123(4):885-6

University of Texas Southwestern Medical Center, Department of Obstetrics & Gynecology, Dallas, Texas.

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http://dx.doi.org/10.1097/AOG.0000000000000191DOI Listing
April 2014

Low rates of complications for carotid artery stenting are associated with a high clinician volume of carotid artery stenting and aortic endografting but not with a high volume of percutaneous coronary interventions.

J Vasc Surg 2014 Jul 20;60(1):70-6. Epub 2014 Mar 20.

Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Tex.

Objective: Prior studies have demonstrated improved clinical outcomes for surgeons with a high-volume experience with certain open vascular operations. A high-volume experience with carotid artery stenting (CAS) improves clinical outcomes. Moreover, it is not known whether experience with other endovascular procedures, including percutaneous coronary interventions (PCIs), is an adequate substitute for experience with CAS. The goal of this study was to quantify the effect of increasing clinician volume of CAS, endovascular aneurysm repair (EVAR), and thoracic endovascular aortic aneurysm repair (TEVAR), and PCI on the outcomes for CAS.

Methods: The Nationwide Inpatient Sample was analyzed to identify patients undergoing CAS for the years 2005 to 2009. Clinicians were stratified into tertiles of low-volume, medium-volume, and high-volume groups by annual volume of CAS, EVAR/TEVAR, and PCI. Multiple logistic regression analyses were used to examine the relationship between clinician volume and a composite outcome of the in-hospital stroke and death rate after CAS.

Results: Between 2005 and 2009, 56,374 elective CAS procedures were performed nationwide, with a crude in-hospital stroke and death rate of 3.22%. A median of nine CAS procedures (interquartile range, 3-20) were performed annually per clinician. As expected, stroke and death rates for CAS decreased with increasing volume of CAS performed by a clinician (low-volume vs medium-volume vs high-volume: 4.43% vs 2.89% vs 2.27%; P = .0001). Similar patterns were noted between clinicians' volume of EVAR/TEVAR (low-volume vs medium-volume vs high-volume: 4.58% vs 3.18% vs 2.16%; P = .0023). In contrast, increasing PCI volume was not associated with decreased stroke and death rates after CAS (low-volume vs medium-volume vs high-volume: 2.99% vs 3.18% vs 3.55%; P = .35). After adjusting for patient and hospital characteristics, clinician volume of CAS (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.74-0.94; P = .003) and EVAR/TEVAR (OR, 0.85; 95% CI, 0.75-0.97; P = .020) remained significant predictors of stroke and death after CAS, whereas increasing clinician volume of PCI was associated with significantly increasing likelihood of stroke or death after CAS (OR, 1.025; 95% CI, 1.004-1.047; P = .019).

Conclusions: The stroke and death rate for CAS to treat carotid stenosis is inversely affected by the number of CAS and EVAR/TEVAR procedures performed by a clinician. In contrast, a high-volume experience with PCI is not associated with improved outcomes after CAS.
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http://dx.doi.org/10.1016/j.jvs.2014.01.044DOI Listing
July 2014

Comparison of robotic and laparoscopic hysterectomy for benign gynecologic disease.

Obstet Gynecol 2013 Oct;122(4):778-786

Departments of Anesthesiology and Pain Management and Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas.

Objective: Use of robotically assisted hysterectomy for benign gynecologic conditions is increasing. Using the most recent, available nationwide data, we examined clinical outcomes, safety, and cost of robotic compared with laparoscopic hysterectomy.

Methods: Women undergoing robotic or laparoscopic hysterectomy for benign disease were identified from the United States 2009 and 2010 Nationwide Inpatient Sample. Propensity scores derived from a logistic regression model were used to assemble matched cohorts of patients undergoing robotic and laparoscopic hysterectomy. Differences in in-hospital complications, hospital length of stay, and hospital charges were assessed between the matched groups.

Results: Of the 804,551 hysterectomies for benign conditions performed in 2009 and 2010, 20.6% were laparoscopic and 5.1% robotically assisted. Among minimally invasive hysterectomies, the use of robotic hysterectomy increased from 9.5% to 13.6% (P=.002). In a propensity-matched analysis, the overall complication rates were similar between robotic and laparoscopic hysterectomy (8.80% compared with 8.85%, relative risk 0.99, 95% confidence interval [CI] 0.89-1.09, P=.910). There was a lower incidence of blood transfusions in robotic cases (2.1% compared with 3.1%; P<.001), but patients undergoing robotic hysterectomy were more likely to experience postoperative pneumonia (relative risk 2.2, 95% CI 1.24-3.78, P=.005). The median cost of hospital care was $9,788 (interquartile range $7,105-12,780) for robotic hysterectomy and $7,299 (interquartile range $5,650-9,583) for laparoscopic hysterectomy (P<.001). Hospital costs were on average $2,489 (95% CI $2,313-2,664) higher for patients undergoing robotic hysterectomy.

Conclusion: The use of robotic hysterectomy has increased. Perioperative outcomes are similar between laparoscopic and robotic hysterectomy, but robotic cases cost substantially more.

Level Of Evidence: : II.
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http://dx.doi.org/10.1097/AOG.0b013e3182a4ee4dDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4361072PMC
October 2013

Ultrasound-guided transversus abdominal plane block with multimodal analgesia for pain management after total abdominal hysterectomy.

Arch Gynecol Obstet 2013 Jul 6;288(1):105-11. Epub 2013 Jan 6.

Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9068, USA.

Background: Transversus abdominis plane (TAP) block has been shown to provide pain relief after abdominal procedures. However, TAP block combined with multimodal analgesia technique have not been assessed in a randomized controlled trial. This randomized, controlled, observer-blinded study was designed to evaluate the analgesic efficacy of bilateral ultrasound-guided TAP blocks with or without acetaminophen and non-steroidal anti-inflammatory drug (NSAID) combination.

Methods: Patients undergoing total abdominal hysterectomy were randomized to one of three groups. Group 1 (n = 25) received a TAP block and ketorolac 30 mg, IV at the end of surgery and then ketorolac plus paracetamol 650 mg, orally, every 6 h for 24 h. Group 2 (n = 24) received only TAP block at the end of surgery. Group 3 (n = 25) received ketorolac 30 mg, IV at the end of surgery and then ketorolac plus paracetamol 650 mg, orally, every 6 h for 24 h. All patients received IV-PCA morphine for 24-h, postoperatively. All patients received a standardized general anaesthetic technique and dexamethasone 4 mg and ondansetron 4 mg, IV for antiemetic prophylaxis.

Results: There were no statistically significant differences in pain at rest between the groups. However, the pain on coughing (dynamic pain) in Group 1 was significantly less variable, compared with the other two groups (P = 0.012). Opioid consumption and occurrences of nausea, vomiting, and rescue antiemetic were similar in three the groups.

Conclusions: The combination of TAP block and acetaminophen and NSAID provided less variability in dynamic pain compared with either treatment alone.
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http://dx.doi.org/10.1007/s00404-012-2698-3DOI Listing
July 2013

Cerebral embolization in asymptomatic versus symptomatic patients after carotid stenting.

J Vasc Surg 2012 Dec 3;56(6):1579-84; discussion 1584. Epub 2012 Oct 3.

Division of Vascular and Endovascular Surgery, Department of Surgery, the University of Texas Southwestern Medical Center, Dallas, TX 75390-9157, USA.

Background: Previous studies have investigated the development of new ischemic brain lesions on diffusion-weighted magnetic resonance imaging (DW-MRI) after carotid artery stenting (CAS). The rate of ischemic brain injury after CAS for asymptomatic stenosis has not been extensively studied but is presumed to be less likely than in symptomatic patients. This study assessed the occurrence of cerebral embolization after CAS for asymptomatic vs symptomatic carotid stenosis.

Methods: During an 18-month period, 40 patients undergoing CAS under filter embolic protection were prospectively evaluated. Transcranial Doppler (TCD) during CAS and preprocedural and 24-hour postprocedural DW-MRI were used to assess cerebral embolization. Univariate and nonparametric analyses were used to compare differences in cerebral embolization after CAS in asymptomatic and symptomatic patients.

Results: CAS was performed for 23 asymptomatic (58%) and 17 symptomatic (42%) carotid stenoses. The median microembolic counts detected by TCD were 285 (interquartile range [IQR], 182-376) for asymptomatic and 313 (IQR, 170-426) for symptomatic carotid stenosis (P=.6). DW-MRI was available for assessment in 20 asymptomatic and 14 symptomatic patients. New acute cerebral emboli detected with DW-MRI occurred in 10 asymptomatic (50%) and 7 symptomatic patients (50%) undergoing CAS (P=.9). The ipsilateral and total median number of DW-MRI lesions between groups were not statistically significantly different at, respectively, 1 (IQR, 0-2.5) and 1.5 (IQR, 0-3) for asymptomatic vs 0.5 (IQR, 0-2) and 0.5 (IQR, 0-3) for symptomatic carotid stenosis (P>.5). One asymptomatic patient sustained a minor stroke after CAS. No new neurologic events occurred in symptomatic patients. The 30-day stroke-death rate was 2.5% in this series.

Conclusions: Cerebral embolization, as detected by TCD and DW-MRI, occurs with a similar frequency after CAS for asymptomatic and symptomatic carotid stenosis. Because postprocedural ischemic brain injury occurs in approximately half of asymptomatic patients, the safety of CAS under filter embolic protection for asymptomatic carotid stenosis is uncertain and warrants further study.
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http://dx.doi.org/10.1016/j.jvs.2012.06.074DOI Listing
December 2012

Longitudinal changes in kidney parenchymal volume associated with renal artery stenting.

J Vasc Surg 2012 Mar 21;55(3):774-80; discussion 780. Epub 2012 Jan 21.

Dallas Veterans Affairs Medical Center, Dallas, TX, USA.

Objective: This study assessed the longitudinal changes in renal volume after renal artery stenting (RAS) to determine if renal mass is preserved by stenting.

Methods: The study cohort consisted of 38 patients with longitudinal imaging available for renal volume quantification before and after RAS. Renal volume was estimated as (kidney length) × (width) × (depth/2) based on preoperative renal imaging. For each patient, the clinical response of blood pressure (BP) and renal function to RAS was categorized according to modified American Heart Association guidelines. Changes in renal volume were assessed using paired nonparametric analyses.

Results: The cohort was a median age of 69 years (interquartile range [IQR], 60-74 years). A favorable BP response was observed in 11 of 38 patients (28.9%). At a median interval between imaging studies of 21 months (IQR, 13-32 months), ipsilateral renal volume was significantly increased from baseline (146.8 vs 133.8 cm(3);P = .02). This represents a 6.9% relative increase in ipsilateral kidney volume from baseline. A significant negative correlation between preoperative renal volume and the relative change in renal volume postoperatively (r = -0.42; P = .0055) suggests that smaller kidneys experienced the greatest gains in renal volume after stenting. It is noteworthy that the 25 patients with no change in BP or renal function-clinical failures using traditional definitions-experienced a 12% relative increase in ipsilateral renal volume after RAS. Multivariate analysis determined that stable or improved renal volume after stenting was an independent predictor of stable or improved long-term renal function (odds ratio, 0.008; 95% confidence interval, 0.000-0.206; P = .004).

Conclusions: These data lend credence to the belief that RAS preserves renal mass in some patients. This benefit of RAS even extends to those patients who would be considered treatment failures by traditional definitions. Patients with stable or increased renal volume after RAS had more stable renal function during long-term follow-up, whereas patients with renal volume loss after stenting were prone to deterioration of renal function.
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http://dx.doi.org/10.1016/j.jvs.2011.10.026DOI Listing
March 2012

Assessing outcomes to determine whether symptoms related to hypertension justify renal artery stenting.

J Vasc Surg 2012 Feb 1;55(2):413-9; discussion 419-20. Epub 2011 Dec 1.

Dallas Veterans Affairs Medical Center, University of Texas Southwestern Medical School, Dallas, TX, USA.

Objective: The goal of the study was to determine the blood pressure (BP) response to renal artery stenting (RAS) for patients with hypertension urgency, hypertension emergency, and angina with congestive heart failure (angina/congestive heart failure [CHF]).

Methods: Patients who underwent RAS for hypertension emergencies (n = 13), hypertension urgencies (n = 25), and angina/CHF (n = 14) were included in the analysis. By convention, hypertension urgency was defined by a sustained systolic BP ≥ 180 mm Hg or diastolic BP ≥ 120 mm Hg, while the definition of hypertension emergency required the same BP parameters plus hypertension-related symptoms prompting hospitalization. Patient-specific response to RAS was defined according to modified American Heart Association reporting guidelines.

Results: The study cohort of 52 patients had a median age of 66 years (interquartile range 58-72). The BP response to RAS varied significantly according to the indication for RAS. Hypertension emergency provided the highest BP response rate (85%), while the response rate was significantly lower for hypertension urgency (52%) and angina/CHF (7%; P = .03). Only 1 of 14 patients with angina/CHF was a BP responder. Multivariate analysis showed that hypertension urgency or emergency were not independent predictors of BP response to RAS. Instead, the only independent predictor of a favorable BP response was the number of preoperative antihypertensive medications (odds ratio 7.5; 95% confidence interval 2.5-22.9; P = .0004), which is another indicator of the severity of hypertension. Angina/CHF was an independent predictor of failure to respond to RAS (odds ratio 118.6; 95% confidence interval 2.8-999.9; P = .013).

Conclusions: Hypertension urgency and emergency are clinical manifestations of severe hypertension, but the number of preoperative antihypertensive medications proved to be a better predictor of a favorable BP response to RAS. In contrast, angina/CHF was a predictor of failure to respond to stenting, providing further evidence against the practice of incidental stenting during coronary interventions.
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http://dx.doi.org/10.1016/j.jvs.2011.08.056DOI Listing
February 2012

Defining the type of surgeon volume that influences the outcomes for open abdominal aortic aneurysm repair.

J Vasc Surg 2011 Dec 1;54(6):1599-604. Epub 2011 Oct 1.

Dallas Veterans Affairs Medical Center, Dallas, Tex., USA.

Objective: Prior studies have reported improved clinical outcomes with higher surgeon volume, which is assumed to be a product of the surgeon's experience with the index operation. We hypothesized that composite surgeon volume is an important determinant of outcome. We tested this hypothesis by comparing the impact of operation-specific surgeon volume versus composite surgeon volume on surgical outcomes, using open abdominal aortic aneurysm (AAA) repair as the index operation.

Methods: The Nationwide Inpatient Sample was analyzed to identify patients undergoing open AAA repairs for 2000 to 2008. Surgeons were stratified into deciles based on annual volume of open AAA repairs ("operation-specific volume") and overall volume of open vascular operations ("composite volume"). Composite volume was defined by the sum of several open vascular operations: carotid endarterectomy, aortobifemoral bypass, femoral-popliteal bypass, and femoral-tibial bypass. Multiple logistic regression analyses were used to examine the relationship between surgeon volume and in-hospital mortality for open AAA repair, adjusting for both patient and hospital characteristics.

Results: Between 2000 and 2008, an estimated 111,533 (95% confidence interval [CI], 102,296-121,232) elective open AAA repairs were performed nationwide by 6,857 surgeons. The crude in-hospital mortality rate over the study period was 6.1% (95% CI, 5.6%-6.5%). The mean number of open AAA repairs performed annually was 2.4 operations per surgeon. The mean composite volume was 5.3 operations annually. As expected, in-hospital mortality for open AAA repair decreased with increasing volume of open AAA repairs performed by a surgeon. Mortality rates for the lowest and highest deciles of surgeon volume were 10.2% and 4.5%, respectively (P < .0001). A similar pattern was observed for composite surgeon volume, as the mortality rates for the lowest and highest deciles of composite volume were 9.8% and 4.8%, respectively (P < .0001). After adjusting for patient and hospital characteristics, increasing composite surgeon volume remained a significant predictor of lower in-hospital mortality for open AAA repair (odds ratio, 0.994; 95% CI, .992-.996; P < .0001), whereas increasing volume of AAA repairs per surgeon did not predict in-hospital deaths.

Conclusions: The current study suggests that composite surgeon volume-not operation-specific volume-is a key determinant of in-hospital mortality for open AAA repair. This finding needs to be considered for future credentialing of surgeons.
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http://dx.doi.org/10.1016/j.jvs.2011.05.103DOI Listing
December 2011

Predictors of outcome for renal artery stenting performed for salvage of renal function.

J Vasc Surg 2011 Nov 31;54(5):1414-1421.e1; discussion 1420-1. Epub 2011 Jul 31.

Dallas Veterans Affairs Medical Center, Dallas, TX, USA.

Objective: To identify preoperative clinical features that predict a durable improvement in renal function with renal artery stenting (RAS).

Methods: Sixty-one patients with renal insufficiency (serum creatinine ≥ 1.5 mg/dL) underwent RAS for renal salvage. Patients were categorized as "responders" if estimated glomerular filtration rate (eGFR) at last follow-up was improved 20% or more over baseline. Patients with stable or worse renal function after RAS were labeled "non-responders." For the purpose of calculating changes in eGFR, patients on dialysis were represented by an eGFR of 10 ml/min/1.73 m(2). Renal volume was estimated as kidney length × width × depth/2.

Results: The median age of the cohort was 66 years (interquartile range [IQR], 60-73 years). Median preoperative serum creatinine was 1.8 mg/dL (IQR, 1.6-2.3), and median estimated glomerular filtration rate (eGFR) was 34 mL/min/1.73 m(2) (IQR, 24-45). With stenting, 17 of 61 patients (27.9%) derived a durable improvement in renal function at a median follow-up of 24 months (IQR, 16-33 months). The largest proportion of stented patients (44.3%) had no improvement in renal function after stenting, while a subset (27.9%) experienced a decline in renal function. Responders enjoyed a 47% improvement in renal function from baseline, while non-responders had a 13% decrement in renal function (P < .0001). Responders had a higher baseline serum creatinine, lower eGFR, and a steeper decline in renal function prior to RAS, compared with non-responders. Kidney length, width, depth, and volume were not significantly different between responders and non-responders. Logistic regression analysis identified the rate of decline of renal function prior to stenting as the only independent preoperative predictor of improved renal function after RAS (odds ratio, 3.4; 95% confidence interval, 1.6 to 7.5; P = .0019). The rate of decline in eGFR per week was more than 20-fold greater for responders than non-responders (2.1% vs 0% decline in eGFR per week; P < .0001). No predictors of renal function deterioration after stenting were identified.

Conclusions: The current study found that a steep decline in preoperative renal function portends a higher likelihood of renal salvage from RAS among patients with renal insufficiency. Incorporating this finding into patient selection may improve outcomes for RAS.
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http://dx.doi.org/10.1016/j.jvs.2011.04.042DOI Listing
November 2011

Randomized clinical trial of open-cell vs closed-cell stents for carotid stenting and effects of stent design on cerebral embolization.

J Vasc Surg 2011 Nov 1;54(5):1310-1316.e1; discussion 1316. Epub 2011 Jul 1.

Division of Vascular and Endovascular Surgery, Department of Surgery, Veterans Affairs North Texas Health Care System, Dallas, TX, USA.

Objective: The effect of stent design on cerebral embolization has not been established. The purpose of this trial was to contrast the incidence of subclinical cerebral embolization in high-risk patients undergoing carotid artery stenting (CAS) with open-cell vs closed-cell stents.

Methods: During an 18-month period, 40 patients were randomized (1:1) to undergo CAS with open-cell (Acculink, n = 20) or closed-cell stents (Xact, n = 20). A single filter device for embolic protection (Accunet filter) was used. Transcranial Doppler (TCD)-detected microembolic signals (MES) during CAS and preprocedural and 24-hour postprocedural diffusion-weighted magnetic resonance imaging (DW-MRI) were used to determine cerebral embolization. Univariate and nonparametric analyses were used to assess associations between stent design and cerebral embolization.

Results: CAS was performed in 17 symptomatic patients (43%) and 23 asymptomatic patients (57%) with a similar number of open-cell and closed-cell stents (9/8 and 11/12, respectively). The total and poststenting median ipsilateral MES counts detected by TCD were 264 (interquartile range [IQR], 222-343) and 48 (IQR, 41-66) for open-cell stents and 339 (IQR, 163-408) and 53 (IQR, 23-88) for closed-cell stents, respectively (P > .56). New acute cerebral emboli detected with DW-MRI occurred in 53% and 47% of patients undergoing CAS with open-cell and closed-cell stents, respectively (P = 1.0). The total and ipsilateral median numbers of DW-MRI lesions between groups were not statistically significantly different (ie, 2 [IQR, 0-4] and 1 [IQR, 0-3] for open-cell stents and 1 [IQR, 0-3] and 1 [IQR, 0-2] for closed cell-stents, respectively; P > .4). One asymptomatic patient undergoing CAS with an open-cell stent sustained a minor stroke; the 30-day stroke-death rate in this series was 2.5%.

Conclusion: Cerebral embolization, as detected by TCD and DW-MRI, occurs with similar frequency after CAS with open-cell and closed-cell stents. This randomized trial does not support the superiority of any stent design with respect to cerebral embolization.
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http://dx.doi.org/10.1016/j.jvs.2011.05.013DOI Listing
November 2011

Clinical and kidney morphologic predictors of outcome for renal artery stenting: data to inform patient selection.

J Vasc Surg 2011 May 12;53(5):1282-89; discussion 1289-90. Epub 2011 Feb 12.

Dallas Veterans Affairs Medical Center, University of Texas Southwestern Medical Center, Dallas, TX 75390-9157, USA.

Background: The purpose of the current study was to identify clinical and kidney morphologic features that predict a favorable blood pressure (BP) response to renal artery stenting (RAS).

Methods: The study cohort consisted of 149 patients who underwent primary RAS over 9 years. Patients were categorized as "responders" based on modified American Heart Association guidelines: BP <160/90 mm Hg on fewer antihypertensive medications or diastolic BP <90 mm Hg on the same medications. All other patients were deemed "nonresponders." Renal volume was estimated as kidney length × width × depth/2 based on preoperative computed tomography or magnetic resonance scans. Median follow-up was 19 months (interquartile range [IQR] 10.0-29.5 months).

Results: The median age of the cohort was 68 years (IQR, 60-74 years). A favorable BP response was observed in 50 of 149 patients (34%). Multivariate analysis identified three independent predictors of a positive BP response: (1) requirement for four or more medications (odds ratio, 29.9; P = .0001), (2) preoperative diastolic BP >90 mm Hg (OR, 31.4; P = .0011), and (3) preoperative clonidine use (OR, 7.3; P = .029). The BP response rate varied significantly based on the number of predictors present per patient (P < .0001). Among patients with three-drug hypertension, a larger ipsilateral kidney (volume ≥150 cm(3)) increased the BP response rate more than threefold compared with patients with smaller kidneys (63% vs 18% BP response rate; P = .018).

Conclusions: The current study demonstrated that three clinical predictors (≥4 antihypertensive medications, diastolic BP ≥90 mm Hg, and clonidine use) are preoperative predictors of BP response to RAS. Kidney volume may help in discriminating responders from nonresponders among those patients with three-drug hypertension. These parameters may assist clinicians in patient selection and provide more concrete data with which to counsel patients on the likely outcomes for RAS.
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http://dx.doi.org/10.1016/j.jvs.2010.11.103DOI Listing
May 2011

Sex, race, and age distributions of mean aortic wall thickness in a multiethnic population-based sample.

J Vasc Surg 2011 Apr 6;53(4):950-7. Epub 2011 Jan 6.

Division of Vascular and Endovascular Surgery, Department of Surgery, Donald W. Reynolds Cardiovascular Clinical Research Center, University Of Texas Southwestern Medical School, Dallas, TX 75390-9157, USA.

Background: Reference values and age-related changes of the wall thickness of the abdominal aorta have not been described in the general population. We characterized age-, race-, and gender-specific distributions, and yearly rates of change of mean aortic wall thickness (MAWT), and associations between MAWT and cardiovascular risk factors in a multi-ethnic population-based probability sample.

Methods: Magnetic resonance imaging measurements of MAWT were performed on 2466 free-living white, black, and Hispanic adult subjects. MAWT race/ethnicity- and gender-specific percentile values across age were estimated using regression analyses.

Results: MAWT was greater in men than in women and increased linearly with age in all the groups and across all the percentiles. Hispanic women had the thinnest and black men the thickest aortas. Black men had the highest and white women the lowest age-related MAWT increase. Age, gender, ethnicity, smoking status, systolic blood pressure, low-density lipoprotein-cholesterol levels, high-density lipoprotein-cholesterol levels, and fasting glucose levels were independent predictors of MAWT.

Conclusions: Age, gender, and racial/ethnic differences in MAWT distributions exist in the general population. Such differences should be considered in future investigations assessing aortic atherosclerosis and the effects of anti-atherosclerotic therapies.
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http://dx.doi.org/10.1016/j.jvs.2010.10.073DOI Listing
April 2011