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• W4236549568 abstract "Upon considering vascular surgery as a profession, a mentor once told me that the best thing about vascular surgery was that, if you present a case to a room of 20 vascular surgeons, you would get 20 opinions on how to treat the patient. The treatment of infrainguinal vascular disease is no different. It is treated by a multitude of specialists (vascular surgeons, interventionalists, cardiologists, etc) with a wide variation in patient selection and choice of therapy. With such variability, it is imperative to identify baseline targets to improve patient outcomes. In 2009, the Society for Vascular Surgery (SVS) developed suggested objective performance goals (OPGs) for the treatment of critical limb ischemia.1Conte M.S. Geraghty P.J. Bradbury A.W. Hevelone N.D. Lipsitz S.R. Moneta G.L. et al.Suggested objective performance goals and clinical trial design for evaluating catheter-based treatment of critical limb ischemia.J Vasc Surg. 2009; 50: 1462-1473Abstract Full Text Full Text PDF PubMed Scopus (329) Google Scholar These were based on the outcomes of three randomized, controlled trials focusing on the outcomes for open bypass with autogenous vein. The outcomes included both safety measures at 30 days and efficacy measures at 1 year in a risk-stratified patient population. The current study compares 30-day adverse events in the National Surgical Quality Improvement Program (NSQIP) database for both open lower extremity bypass (LEB) and infrainguinal endovascular intervention (IEI) to the SVS OPG. They found, among other things, that the major adverse limb events (MALE) and rates of 30-day amputation exceeded the OPG for both their entire cohort and those with high anatomic risk, that is, infrapopliteal disease. These findings should give us pause, because the NSQIP dataset represents a real-world view of how patients with infrainguinal vascular disease are being treated and what the outcomes are. A recent study by Goodney et al2Goodney P.P. Schanzer A. Demartino R.R. Nolan B.W. Hevelone N.D. Conte M.S. et al.Vascular Study Group of New EnglandValidation of the Society for Vascular Surgery's objective performance goals for critical limb ischemia in everyday vascular surgery practice.J Vasc Surg. 2011; 54: 100-108Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar similarly examined the SVS OPG in patients undergoing LEB in the Vascular Study Group of New England (VSGNE) and found that MALE was lower in the VSGNE compared with the SVS OPG, as was the primary OPG endpoint of 1 year MALE or postoperative death.2Goodney P.P. Schanzer A. Demartino R.R. Nolan B.W. Hevelone N.D. Conte M.S. et al.Vascular Study Group of New EnglandValidation of the Society for Vascular Surgery's objective performance goals for critical limb ischemia in everyday vascular surgery practice.J Vasc Surg. 2011; 54: 100-108Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar In all other safety and efficacy OPGs, the VSGNE met or exceeded the SVS OPG benchmarks. Is it that the VSGNE is better than the rest of the country? Possibly. More likely, however, is that a lack of risk adjustment in the current study makes the groups noncomparable. As the original SVS OPG paper pointed out, “CLI [critical limb ischemia] encompasses a spectrum of disease severity and comorbidities and these factors greatly impact procedural risk, limb related outcomes and patient survival.” A brief review of Table I shows how different patient populations with critical limb ischemia can be, with multiple, statistically significant differences between the NSQIP LEB and IEI groups compared with the SVS OPG group. Without appropriate risk adjustment, the only conclusion that can be made is that univariable event rates in the NSQIP dataset do not meet the SVS OPG safety thresholds. Furthermore, a lack of 1-year outcomes within the dataset limit any comment on outcome efficacy. Anyone who works with national datasets understands that there are limitations to the datasets themselves that cannot be circumvented. That, however, does not mean that we cannot glean any information from such datasets. The current study is the first to compare outcomes for infrainguinal endovascular therapies with the SVS OPG. Although the rates were unadjusted, perhaps most striking about the data presented was that MALE and amputation were worse in the IEI group than the LEB group, far exceeding the defined safety thresholds. Although the SVS wound, ischemia, and foot infection (WIfI) classification is not used in the NSQIP, it is possible that we are performing IEI for a long-shot limb salvage situation, which may be an inappropriate use of resources. The current study is a step in the right direction, because it critically evaluates performance measures in an effort to improve national outcomes. As reimbursement models transition from a fee-for-service model to a quality of care model, similar evaluations will likely become commonplace on the regional, local, and institutional levels. We, as vascular surgeons, should champion this effort to standardize and, thus, improve patient care. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Lower extremity bypass and endovascular intervention for critical limb ischemia fail to meet Society for Vascular Surgery's objective performance goals for limb-related outcomes in a contemporary national cohortJournal of Vascular SurgeryVol. 68Issue 5PreviewIn 2009, the Society for Vascular Surgery (SVS) developed objective performance goals (OPGs) to define the therapeutic benchmarks in critical limb ischemia (CLI) based on outcomes from randomized trials of lower extremity bypass (LEB). Current performance relative to these benchmarks in both LEB and infrainguinal endovascular intervention (IEI) remains unknown. The objective of this study was to determine whether LEB and IEI performed for CLI in a contemporary national cohort met OPG 30-day safety thresholds. Full-Text PDF Open Archive" @default.
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• W4236549568 date "2018-11-01" @default.
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• W4236549568 title "Invited commentary" @default.
• W4236549568 doi "https://doi.org/10.1016/j.jvs.2018.03.415" @default.
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