Shipra Arya, MD SM FACS is an Associate Professor of Surgery at the Stanford University School of Medicine and section chief of vascular surgery at VA Palo Alto Healthcare System. She has a Master’s degree in epidemiology from the Harvard School of Public Health with focus on research methodology and cardiovascular epidemiology. She completed her General Surgery Residency at Creighton University Medical Center followed by a Vascular Surgery Fellowship at University of Michigan. She recently completed an American Heart Association (AHA) grant on risk prediction of cardiovascular outcomes and limb loss in Peripheral Arterial Disease (PAD) patients. She is currently funded by the NIH/NIA GEMSSTAR grant studying the impact of frailty on quality of surgical care in PAD and aortic aneurysm patients. The accumulated evidence from her research all points to the fact that frailty is a versatile tool that can be utilized to guide surgical decision making, inform patient consent and design quality improvement initiatives at the patient and hospital level. The field of frailty research in surgical population is still relatively nascent and her current work focuses on streamlining frailty evaluation, and implementation of patient and system level interventions to improve surgical outcomes and enhance patient centered care.
- Vascular Surgery
- Peripheral Arterial Disease
- Aortic Aneurysms
- Carotid artery disease
Associate Professor - Med Center Line, Surgery - Vascular Surgery
Section Chief- Vascular Surgery, VA Palo Alto Healthcare System (2018 - Present)
Board Certification: Vascular Surgery, American Board of Surgery (2014)
Fellowship:University of Michigan GME Training Verifications (2013) MI
Board Certification: General Surgery, American Board of Surgery (2012)
Residency:Creighton University General Surgery Residency (2011) NE
Medical Education:All India Institute of Medical Sciences (2005) India
Poor glycemic control is a strong predictor of postoperative morbidity and mortality in patients undergoing vascular surgery.
Journal of vascular surgery
OBJECTIVE: Hyperglycemia is a common occurrence in patients undergoing cardiovascular surgery. It has been identified in several surgical cohorts that improved perioperative glycemic control reduced postoperative morbidity and mortality. A significant portion of the population with peripheral arterial disease suffers from the sequelae of diabetes or metabolic syndrome. A paucity of data exists regarding the relationship between perioperative glycemic control and postoperative outcomes in vascular surgery patients. The objective of this study was to better understand this relationship and to determine which negative perioperative outcomes could be abated with improved glycemic control.METHODS: This is a retrospective review of a vascular patient database at a large academic center from 2009 to 2013. Eligible procedures included carotid endarterectomy and stenting, endovascular and open aortic aneurysm repair, and all open bypass revascularization procedures. Data collected included standard demographics, outcome parameters, and glucose levels in the perioperative period. Perioperative hyperglycemia was defined as at least one glucose value>180mg/dL within 72hours of surgery. The primary outcome was 30-day mortality, with secondary outcomes of complications, need to return to the operating room, and readmission.RESULTS: Of the total 1051 patients reviewed, 366 (34.8%) were found to have perioperative hyperglycemia. Hyperglycemic patients had a higher 30-day mortality (5.7% vs 0.7%; P< .01) and increased rates of acute renal failure (4.9% vs 0.9%; P<.01), postoperative stroke (3.0% vs 0.7%; P< .01), and surgical site infections (5.7% vs 2.6%; P= .01). In addition, these patients were also more likely to undergo readmission (12.3% vs 7.9%; P= .02) and reoperation (6.3% vs 1.8%; P< .01). Furthermore, multivariable logistic regression demonstrated that perioperative hyperglycemia had a strong association with increased 30-day mortality and multiple negative postoperative outcomes, including myocardial infarction, stroke, renal failure, and wound complications.CONCLUSIONS: This study demonstrates a strong association between perioperative glucose control and 30-day mortality in addition to multiple other postoperative outcomes after vascular surgery.
View details for PubMedID 30459015
- Interaction of Frailty and Postoperative Complications on Unplanned Readmission after Elective Outpatient Surgery ELSEVIER SCIENCE INC. 2018: E25
Evaluation of Peripheral Calcium Score as a Measure of Peripheral Artery Disease Severity
MOSBY-ELSEVIER. 2018: E137
View details for Web of Science ID 000433036700169
Association of Statin Dose With Amputation and Survival in Patients With Peripheral Artery Disease.
2018; 137 (14): 1435–46
BACKGROUND: Statin dose guidelines for patients with peripheral artery disease (PAD) are largely based on coronary artery disease and stroke data. The aim of this study is to determine the effect of statin intensity on PAD outcomes of amputation and mortality.METHODS: Using an observational cohort study design and a validated algorithm, we identified patients with incident PAD (2003-2014) in the national Veterans Affairs data. Highest statin intensity exposure (high-intensity versus low-to-moderate-intensity versus antiplatelet therapy but no statin use) was determined within 1 year of diagnosis of PAD. Outcomes of interest were lower extremity amputations and death. The association of statin intensity with incident amputation and mortality was assessed with Kaplan-Meier plots, Cox proportional hazards modeling, propensity score-matched analysis, and sensitivity and subgroup analyses, as well, to reduce confounding.RESULTS: In 155647 patients with incident PAD, more than a quarter (28%) were not on statins. Use of high-intensity statins was lowest in patients with PAD only (6.4%) in comparison with comorbid coronary/carotid disease (18.4%). Incident amputation and mortality risk declined significantly with any statin use in comparison with the antiplatelet therapy-only group. In adjusted Cox models, the high-intensity statin users were associated with lower amputation risk and mortality in comparison with antiplatelet therapy-only users (hazard ratio, 0.67; 95% confidence interval, 0.61-0.74 and hazard ratio, 0.74; 95% confidence interval, 0.70-0.77, respectively). Low-to-moderate-intensity statins also had significant reductions in the risk of amputation and mortality (hazard ratio amputation, 0.81; 95% confidence interval, 0.75- 0.86; hazard ratio death, 0.83; 95% confidence interval, 0.81-0.86) in comparison with no statins (antiplatelet therapy only), but effect size was significantly weaker than the high-intensity statins (P<0.001). The association of high-intensity statins with lower amputation and death risk remained significant and robust in propensity score-matched, sensitivity, and subgroup analyses.CONCLUSIONS: Statins, especially high-intensity formulations, are underused in patients with PAD. This is the first population-based study to show that high-intensity statin use at the time of PAD diagnosis is associated with a significant reduction in limb loss and mortality in comparison with low-to-moderate-intensity statin users, and patients treated only with antiplatelet medications but not with statins, as well.
View details for DOI 10.1161/CIRCULATIONAHA.117.032361
View details for PubMedID 29330214
The association of comorbid depression with mortality and amputation in veterans with peripheral artery disease.
Journal of vascular surgery
OBJECTIVE: Peripheral artery disease (PAD) is an increasing health concern with rising incidence globally. Previous studies have shown an association between PAD incidence and depression. The objective of the study was to determine the association of comorbid depression with PAD outcomes (amputation and all-cause mortality rates) in veterans.METHODS: An observational retrospective cohort of 155,647 patients with incident PAD (2003-2014) from nationwide U.S. Veterans Health Administration hospitals was conducted using the national Veterans Affairs Corporate Data Warehouse. Depression was measured using concurrent International Classification of Diseases, Ninth Revision diagnosis codes 6months before or after PAD diagnosis. The main outcomes were incident major amputation and all-cause mortality. Crude associations were assessed with Kaplan-Meier plots. The effects of depression adjusted for covariates were analyzed using Cox proportional hazards models.RESULTS: Depression was present in 16% of the cohort, with the occurrence of 9517 amputations and 63,287 deaths (median follow-up, 5.9years). Unadjusted hazard ratios (HRs) of comorbid depression for amputations and all-cause mortality were 1.32 (95% confidence interval [CI], 1.25-1.39) and 1.02 (95% CI, 0.99-1.04), respectively. After adjustment for covariates in Cox regression models, a diagnosis of comorbid depression at the time of PAD diagnosis was associated with a 13% higher amputation (HR, 1.13; 95% CI, 1.07-1.19) and 17% higher mortality (HR, 1.17; 95% CI, 1.14-1.20) risk compared with patients with no depression. On stratification by use of antidepressants, depressed patients not taking antidepressants had a 42% higher risk of amputation (HR, 1.42; 95% CI, 1.27-1.58) compared with those without depression. Patients taking antidepressants for depression still had increased risk of amputation but only 10% higher compared with those without depression (HR, 1.10; 95% CI, 1.03-1.17). Interestingly, patients taking antidepressants for other indications also had a higher risk of amputation compared with those not having depression or not taking antidepressants (HR, 1.08; 95% CI, 1.03-1.14). Having any diagnosis of depression or the need for antidepressants increased the mortality risk by 18% to 25% in the PAD cohort compared with those without depression and not taking antidepressants for any other indication.CONCLUSIONS: PAD patients with comorbid depression have a significantly higher risk of amputation and mortality than PAD patients without depression. Furthermore, untreated depression was associated with an increased amputation risk in the PAD population, more so than depression or other mental illness being treated by antidepressants. The underlying mechanisms for causality, if any, remain to be determined. The association of antidepressant treatment use with amputation risk should prompt further investigations into possible mechanistic links between untreated depression and vascular dysfunction.
View details for PubMedID 29588133
Race and Socioeconomic Status Independently Affect Risk of Major Amputation in Peripheral Artery Disease.
Journal of the American Heart Association
2018; 7 (2)
BACKGROUND: Black race has been shown to be a risk factor for amputation in peripheral artery disease (PAD); however, race has been argued to be a marker for socioeconomic status (SES) rather than true disparity. The aim of this study is to study the impact of race and SES on amputation risk in PAD patients.METHODS AND RESULTS: Patients with incident PAD in the national Veterans Affairs Corporate Data Warehouse were identified from 2003 to 2014 (N=155647). The exposures were race and SES (measured by median income in residential ZIP codes). The outcome was incident major amputation. Black veterans were significantly more likely to live in low-SES neighborhoods and to present with advanced PAD. Black patients had a higher amputation risk in each SES stratum compared with white patients. In Cox models (adjusting for covariates), black race was associated with a 37% higher amputation risk compared with white race (hazard ratio: 1.37; 95% confidence interval, 1.30-1.45), whereas low SES was independently predictive of increased risk of amputation (hazard ratio: 1.12; 95% confidence interval, 1.06-1.17) and showed no evidence of interaction with race. In predicted amputation risk analysis, black race and low SES continued to be significant risk factors for amputation regardless of PAD presentation.CONCLUSIONS: Black race significantly increases the risk of amputation within the same SES stratum compared with white race and has an independent effect on limb loss after controlling for comorbidities, severity of PAD at presentation, and use of medications.
View details for PubMedID 29330260