Journal of Vascular and Endovascular Therapy

Description

Peripheral Arterial Disease (PAD) represents a spectrum from asymptomatic stenosis to limb-threatening ischemia. The last decade has seen a tremendous increase in the variety of endovascular devices and techniques to treat occlusive disease. As for many evolving technologies, the literature surrounding endovascular arterial therapy consists of mixed-quality manuscripts without clear standardization. Accordingly, critical evaluation of the reported results may be problematic. As such, providers and their patients make treatment decisions without the full benefit of a comparative effectiveness framework.

Percutaneous Revascularization

Although patients with diabetes frequently have concurrent risk factors, diabetes itself is a powerful independent risk factor for cardiovascular events. There are several pathophysiologic features of atherosclerosis in diabetic patients that contribute to their worse prognosis and unique response to coronary revascularization. Metabolic and hematologic abnormalities associated with type 2 diabetes include hyperglycemia, insulin resistance, dyslipidemia, inflammation, and thrombophilia. Platelets express more Gp IIb/IIIa receptors and are more prone to aggregation, particularly in the presence of hyperglycemia.Together these abnormalities contribute to development of hypertension, endothelial cell dysfunction, accelerated atherogenesis and, eventually, coronary thrombosis. Diabetic nephropathy, including reduced creatinine clearance and proteinuria, identifies patients with markedly decreased survival after coronary revascularization. The anatomical patterns of CAD in diabetic patients may influence their prognosis and response to revascularization. Autopsy and angiographic studies have demonstrated that persons with diabetes more frequently have left main coronary artery lesions, multivessel disease, and diffuse CAD. Diabetic patients have smaller luminal diameters in segments adjacent to obstructive coronary lesions and more completely occluded segments. Lower extremity peripheral arterial occlusive disease poses a unique challenge to traditional angioplasty-based endovascular therapies. The diffuse nature of lower extremity atherosclerotic disease, the presence of chronic total occlusions, poor distal runoff, and the presence of critical limb ischemia all have contributed to the disappointing results of balloon angioplasty for complex infrainguinal arterial disease. These challenges have spawned the development of a host of new technologies in an attempt to improve the safety and effectiveness of percutaneous revascularization for lower extremity peripheral arterial occlusive disease. This review summarizes the recent advances in available technologies, including novel angioplasty balloons; nitinol stents, stent grafts, and drug-eluting stents; excisional, laser, and rotational atherectomy devices; devices for crossing total occlusions; true-lumen reentry devices; thrombectomy catheters; and embolic protection devices. Health care quality metrics play an increasingly important role in hospital and physician public reporting, reimbursements, and determining the effectiveness of different clinical care paradigms. Clinicians, medical centers, public and private insurance carriers, and patients are all vested in ensuring optimal and efficient care, but identifying where the “best care” is provided can be difficult. Payers (governmental and private) and medical centers rely on various sources that report health care quality metrics; these metrics range from clinical outcomes and complications to length of stay (LOS) and total costs. Patients, on the other hand, rely on publicly available data, social media, and word of mouth to identify “best care.” Clinicians, on the frontlines of health care, walk a fine line delivering care in different environments where they must take into consideration the complex interplay of multiple, often competing, interests: cost effectiveness, patient satisfaction, standards of care, and clinical autonomy. Despite this strong push for the best care among all stakeholders, a transparent, validated, and consistent reporting methodology for health care quality metrics remains elusive. Health care quality metrics are publicly available, including to payers. CMS programs such as Value-Based Purchasing, Hospital-Acquired Conditions (HAC), and Hospital Readmission Reduction Program use these metrics either to reward or impose financial penalties. These penalties can result in a reduction of up to 6% for all CMS reimbursements. Therefore, it is critical that the health care quality metrics measured and reported are an accurate reflection of the actual care delivered. Vascular surgery is particularly challenging to accurately assess because of the wide variety of providers who perform what may be considered “vascular surgery” procedures. Thus, the objective of this study was to examine the accuracy and reliability of the health care quality metrics generated by the Vizient vascular surgery service line, with the hypothesis that a predetermined service line does not accurately reflect a vascular surgery division's quality metrics.

Etiopathogenic

Decision-making in vascular surgery has become more complex, given the range of treatment options from medical therapy to endovascular or open revascularization for carotid stenosis, Abdominal Aortic Aneurysm (AAA), and lower extremity occlusive disease. Ideally, the procedure with the greatest efficacy and the lowest risk would be offered to the patient. One critical component of patient and procedure selection in vascular surgery is a careful assessment of cardiac risk. Accurate risk assessment is also a key step in the process of informed patient consent. In addition to affecting procedure choice, the ability to identify patients at high risk for cardiac complications provides an opportunity for medical optimization before surgery. For these reasons, improved cardiac risk assessment is essential in the population of at-risk vascular surgery patients. Cardiac complications following vascular surgical procedures remain a primary cause of perioperative morbidity and mortality. Although regional variation in AMI admissions, management, and percutaneous coronary revascularization has been reported, relatively little information exists about regional differences in cardiac events after vascular surgery. Vascular anomalies are developmental defects of the vasculature and encompass a variety of disorders. The identification of genes mutated in the different malformations provides insight into the etiopathogenic mechanisms and the specific roles the associated proteins play in vascular development and maintenance. A few familial forms of vascular anomalies exist, but most cases occur sporadically. It is becoming evident that somatic mosaicism plays a major role in the formation of vascular lesions. The use of Next Generating Sequencing for high throughput and “deep” screening of both blood and lesional DNA and RNA has been instrumental in detecting such low frequency somatic changes. The number of novel causative mutations identified for many vascular anomalies has soared within a 10-year period. The discovery of such genes aided in unraveling a holistic overview of the pathogenic mechanisms, by which in vitro and in vivo models could be generated, and opening the doors to development of more effective treatments that do not address just symptoms. Moreover, as many mutations and the implicated signaling pathways are shared with cancers, current oncological therapies could potentially be repurposed for the treatment of vascular anomalies.