4 results
2528 Variable utilization of cross-sectional imaging prior to percutaneous peripheral vascular interventions
- Nathan K. Itoga, Kenneth Tran, Vivian Ho, Venita Chandra, Ronald L. Dalman, Edmund J. Harris, Jason T. Lee, Matthew W. Mell
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- Journal:
- Journal of Clinical and Translational Science / Volume 2 / Issue S1 / June 2018
- Published online by Cambridge University Press:
- 21 November 2018, p. 90
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- Article
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OBJECTIVES/SPECIFIC AIMS: Reducing radiologic exams has been a focus of cost reduction in healthcare systems. The utility and justification of obtaining cross-sectional imaging (PPCSI) before surgical intervention continues to be evaluated. For peripheral artery disease (PAD) consensus guidelines regarding PPCSI do not exist and may be influenced by patient complexity, variation of disease presentation, and physician preference. The objective of this study was to determine the utility of PPCSI before percutaneous PAD intervention. METHODS/STUDY POPULATION: Patients receiving first-time endovascular revascularization procedure for PAD from 2013 to 2015 were evaluated for PPCSI done within 180 days prior to revascularization. Patient and physician demographics, perioperative characteristics, and disease distribution/severity were evaluated. The primary outcome was technical success defined as improving inflow and/or revascularization of the target outflow vessels to <50% stenosis. RESULTS/ANTICIPATED RESULTS: Of the 348 patients who underwent an attempted revascularization procedure 159 (45.7%) patients underwent PPCSI, including 151 CTA and 8 MRA. Of these, 48% were ordered by the referring provider (84% at an outside institution), and 52% were ordered by the treating physician. PPCSI was performed a median of 26 days (IQR 9-53) prior to procedure. Individual vascular surgeon practice identified PPCSI rates ranging from 31% to 70%. On multivariate analysis chronic kidney disease (OR=0.35; CI 0.17–0.73) had the strongest effect against of PPCSI, and Inpatient/ED evaluation (OR=3.20; CI 1.58–6.50), aorto-iliac (OR=2.78; CI 1.46–5.29) and femoral-popliteal occlusions (OR=2.51; CI 1.38–4.55) most strongly predicted PPCSI. After excluding 31 diagnostic procedures, technical success did not differ between endovascular procedures with PPSCI (91.3%) or without PPCSI (85.6%), p=0.11. When analyzing 89 femoral-popliteal occlusions, technical success was higher with PPCSI (88%) compared to procedures without PPSCI (69%), p=0.026. DISCUSSION/SIGNIFICANCE OF IMPACT: PPCSI use is influenced by inpatient status, chronic kidney disease, and anatomic consideration. PPCSI was not associated with overall technical success although it appeared beneficial for femoral-popliteal occlusions. Routine practices of ordering of PPCSI may not be warranted when considering technical success but may be important in treatment planning. Further studies are warranted to determine if radiation, cost, and contrast load justify PPCSI.
Contributors
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- By Deborah Abeles, Adrian Alvarez, Euler Ázaro, Paulo Batista, Donald P. Bernstein, Jay B. Brodsky, Kathleen Carey, Venita Chandra, Jenny Choi, Maria L. Collazo-Clavell, Jeremy Collins, Eric J. DeMaria, Galina Dimirova, Sanjeev Dutta, João Ettinger, Ronald Harter, Matthew M. Hutter, Jerry Ingrande, Daniel B. Jones, Stephanie B. Jones, Helen Karakelides, Fawzi S. Khayat, Hendrikus J. M. Lemmens, Yigal Leykin, Amy Lightner, Masha Livhits, Melinda A. Maggard, Tracy Martinez, John M. Morton, Patrick J. Neligan, Ninh T. Nguyen, Alfons Pomp, Silvia E. Perez-Protto, Steve E. Raper, Roman Schumann, Scott A. Shikora, Ashish Sinha, Brian R. Smith, Juraj Sprung, Pedro P. Tanaka, Brandon Tari, David O. Warner, Toby N. Weingarten, Joseph G. Werner, Gavitt A. Woodard, Basil M. Yurcisin, David Zvara
- Edited by Adrian Alvarez, Jay B. Brodsky, Stanford University School of Medicine, California, Hendrikus J. M. Lemmens, Stanford University School of Medicine, California, John M. Morton, Stanford University School of Medicine, California
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- Book:
- Morbid Obesity
- Published online:
- 04 May 2010
- Print publication:
- 11 March 2010, pp -
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24 - Bariatric surgery in adolescents
- from Section 5 - Special topics
- Edited by Adrian Alvarez, Jay B. Brodsky, Stanford University School of Medicine, California, Hendrikus J. M. Lemmens, Stanford University School of Medicine, California, John M. Morton, Stanford University School of Medicine, California
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- Book:
- Morbid Obesity
- Published online:
- 04 May 2010
- Print publication:
- 11 March 2010, pp -
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Summary
This chapter discusses respiratory system mechanics and gas exchange during anesthesia of morbidly obese (MO) patients. It describes ventilatory strategies that can improve oxygenation while protecting the lungs from ventilator-induced mechanical stress. After induction of anesthesia, deterioration of partial pressure of arterial oxygen (PaO2) occurs in MO patients. For normal weight and obese patients, prolonged mechanical ventilation with high pressure can induce mechanical stress and acute ventilator-associated lung injury (VALI). PaCO2 is correlated with effective ventilation, and an acute decrease in PaCO2 after recruitment indicates improvement (decrease) of physiologic dead space. The chapter summarizes various peri-operative strategies that provide open-lung ventilation and protect against ventilator-induced lung injury. High tidal volume (VT) without positive end-expiratory pressure (PEEP) during mechanical ventilation may cause subclinical lung injury. For MO patients, a protective ventilatory strategy incorporates prevention of atelectasis and lung overexpansion while using lower end-inspiratory pressure (PEI).
18 - MINIMAL ACCESS PEDIATRIC SURGERY
- Camran Nezhat, Stanford University School of Medicine, California, Farr Nezhat, Mount Sinai School of Medicine, New York, Ceana Nezhat
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- Book:
- Nezhat's Operative Gynecologic Laparoscopy and Hysteroscopy
- Published online:
- 23 December 2009
- Print publication:
- 07 July 2008, pp 509-515
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Summary
The rapid co-evolution of instrumentation and surgical technique has allowed for an ever-growing number of pediatric procedures to be performed using minimal access surgery (MAS). Presently, patients of any size or age (i.e., from fetus to adolescent) can benefit from MAS. This chapter discusses current applications of MAS in infants and children and explores new developments and future directions in the field. Throughout this chapter, the term MAS is defined as procedures that are performed with tiny (≤12-mm) incisions, those performed percutaneously, or those performed endoluminally. It encompasses the field of robotic surgery and image-guided therapy. Common synonyms are laparoscopic surgery (abdominal MAS), thoracoscopic surgery (thoracic MAS), videoscopic surgery, and endosurgery.
WHY MINIMAL ACCESS PEDIATRIC SURGERY?
To date, there is only one randomized controlled trial of MAS in the pediatric population; however, many large retrospective studies in adults have demonstrated decreased postoperative pain, earlier return to feeds, shorter hospital stays, and improved cosmetic results when compared with open surgery. Despite these advantages, a number of concerns limited early widespread adoption of minimal access techniques in children. Appropriately sized instruments were slow to develop as the manufacturers focused on the adult population. The cost of these instruments was believed to be too high and the length of setup too long. Further, perioperative pain and stress have historically been underappreciated in children, and the benefit of smaller incisions was not seen to be substantial as many pediatric surgeons believed they had already made “small incisions.”