复合血管与倒置大隐静脉旁路移植治疗严重慢性下肢缺血的对比研究

目的比较复合血管序贯式下肢动脉旁路术和倒置自体大隐静脉旁路术治疗严重慢性下肢缺血的效果。方法回顾性分析采用复合式血管(25例)及倒置自体大隐静脉(16例)旁路移植术治疗的41例严重慢性下肢缺血患者的临床资料。复合血管用聚四氟乙烯(PTFE)人工血管及自体静脉组合而成。人工血管近心端与股总动脉吻合,远端与孤立腘动脉吻合;自体静脉从PTFE血管远端发出并与小腿的胫或腓动脉吻合。倒置自体大隐静脉旁路术采用同侧大隐静脉作为血管桥。比较两者血管桥的累积通畅率和保肢率。结果平均随访18.7个月。男29例,女12例。平均年龄(67±10.4)岁。FontaineⅢ级23例,FontaineⅣ级18例。复合血管组中自体静脉远端吻合口止于胫前动脉5例,胫后动脉14例,腓动脉6例;倒置大隐静脉移植组中10例吻合口止于胫后动脉,3例腓动脉,3例胫前动脉。复合血管组踝肱指数术前为0.24±0.14,术后为0.68±0.22(P=0.000)。倒置大隐静脉组平均踝肱指数术前为0.24±0.14,术后为0.68±0.22(P=0.000)。复合血管术后1,2,3年首次通畅率分别为78%,72%,61%;二期通畅率分别为83%,76%,6...     

小腿动脉为流出道的股-小腿动脉或股-腘-小腿动脉旁路术随访分析

.9%.保肢患者中重症下肢缺血占13.0%,随访时踝肱指数足背动脉0.66±0.26,胫后动脉0.64±0.25,与术前和术后相比差异均有统计学意义.自体静脉和复合血管、股-小腿动脉直接旁路和股-腘-小腿动脉序贯旁路在保肢率和旁路血管通畅率上差异无统计学意义.结论 以小腿动脉为流出道的旁路术对于腔内治疗失败或长段、多节段动脉闭塞濒临截肢者是有效的治疗方法 .加强术后随访和早期干预有助于提高二期通畅率和保肢率.     

糖尿病下肢缺血膝下动脉重建临床效果的初步评价

目的 评价糖尿病下肢缺血患者膝下动脉旁路移植术的中远期通畅率.方法 回顾性分析2001年11月至2006年12月因糖尿病下肢缺血行膝下动脉旁路移植的患者51例共56条肢体.其中男性35例,女性16例,平均年龄68岁,平均缺血时间26个月,平均糖尿病史11年.静息痛26例,足部溃疡坏疽25例.所有患者均行至小腿(胫前、胫后或腓)动脉的旁路移植手术.应用Kaplan-meier生存分析法评价中远期通畅情况,并按照手术方式和流出道血管的不同,进一步采用Log-rank检验比较其对通畅率的影响.结果 平均随访23个月,失访率15%.随访患者总体1年和5年的一期通畅率为68%和54%,二期通畅率为70%和60%,保肢率为69%和65%,存活率为82%和60%.股-腘动脉人工血管-小腿动脉自体静脉旁路移植、股/腘-小腿动脉人工血管旁路移植和股/腘-小腿动脉自体静脉旁路移植的1年(3年)的通畅率分别为70%(50%)、33%(33%)和70%(70%);以胫后、胫前和腓动脉作为流出道的1年(4年)通畅率分别为65%(60%)、80%(53%)和77%(66%);经Log-rank检验,以上各组间差异均无统计学意义(P>0.05).结论 糖尿病下肢缺血旁路移植手术的血管桥应首选自体静脉无论采用胫前、胫后还是腓动脉作为流出道,其中远期通畅率均是可以接受的.     

胫腓动脉血管成形术治疗下肢严重缺血35例

目的 评价胫腓动脉经皮血管腔内成形术(percutaneous transluminal angioplasty,PTA)治疗下肢严重缺血的可行性、安全性和有效性.方法 对2004年6月至2007年5月收治的35例胫腓动脉闭塞的下肢严重缺血(critical limb ischemia,CLI)患者应用PTA治疗.评价的主要参数为:胫腓动脉PTA技术成功率、通畅率、救肢率和并发症.结果 胫腓动脉PTA的技术成功率为83%,平均随访11.5个月,通畅率为57%,救肢率82%.胫腓动脉平均扩张长度9.5 cm(4.5～14 cm),19例患者同时行髂或股胭动脉PTA或支架术.有3例并发症发生,其中1例动脉痉挛和血栓形成,经溶柃、解痉等治疗缓解;2例动脉穿孔,未有严重后果.结论 PTA治疗CLI合并胫腓动脉闭塞具有较高技术成功率和救肢率,较少发生严重并发症,是一种安全、有效可供选择的治疗方法.     

非体外循环冠状动脉旁路移植术后大隐静脉序贯桥与单支桥中期通畅率的比较

目的比较非体外循环冠状动脉旁路移植术（OPCAB）后大隐静脉序贯桥与单支桥的中期通畅率,评价序贯吻合技术在OPCAB的应用效果。方法回顾性分析2005年6月至2009年3月中国人民解放军总医院398例冠心病患者分别采用大隐静脉序贯桥和单支桥行OPCAB的临床资料,其中男301例,女97例;年龄53～82岁（63.6±10.3岁）。患者于术后3个月～5年（19.8±23.6个月）行64层螺旋CT血管造影（64-MSCTA）检查,共有448支大隐静脉桥上的714个远端吻合口接受评估,分别比较血管桥血流、血管桥及吻合口的通畅率,并分析不同位置对吻合口通畅率的影响。结果大隐静脉双支序贯桥（37.11±16.70ml/min vs.25.15±14.24ml/min,P=0.042）和3支序贯桥（37.56±19.58ml/min vs.25.15±14.24ml/min,P=0.048）的近段血流速度均显著高于单支桥。序贯桥总吻合口通畅率高于单支桥（95.1%vs.90.1%,P=0.013）。序贯桥中间吻合口通畅率分别高于序贯桥远端吻合口（97.0%vs.93.1%,P=0.002）和单支桥远端吻合口（97.0%vs.90.1%,P=0.041）。序贯桥远端吻合口通畅率与单支桥比较差异无统计学意义（P=0.253）;不同吻合方式下各冠状动脉系统（左前降支系统、右冠状动脉系统和回旋支系统）间差异无统计学意义,序贯桥吻合口在右冠状动脉系统的通畅率高于单支桥吻合口（P=0.008）。结论 OPCAB术后大隐静脉序贯桥的中期通畅率较单支桥更满意,序贯吻合时应尽量选择条件较好的靶血管作为序贯桥的最远端血管,条件较差的血管放在序贯桥的中间     

肝素涂层人工血管在腔内治疗失败的严重下肢缺血血运重建中的应用

目的:评价肝素涂层人工血管在腔内治疗失败的严重下肢缺血(CLI)患者行下肢动脉旁路移植术中的疗效。方法:回顾性分析2017年10月至2019年4月北京医院血管外科收治的腔内治疗失败的CLI患者行下肢动脉旁路移植术治疗的临床资料,根据患者临床症状、病变特点,选择个性化治疗方案,包括支架取出术、动脉内膜剥脱和成形术、人工血管或人工血管复合自体静脉旁路移植术等多种手术方式完成下肢动脉血运重建。分析围术期并发症、症状缓解和溃疡伤口愈合情况、桥血管通畅率及保肢率。结果:入组患者共27例,其中16例静息痛患者术后疼痛均有效缓解,11例有足部溃疡和组织坏死者中,9例完全愈合,2例术后半年溃疡面缩小。术后并发症6例,术后30 d无死亡病例。所有患者获得随访,随访时间为(13.0±8.9)个月(范围:2~35个月)。通过Kaplan-Meier曲线计算,术后6、12及24个月一期通畅率分别为83.3%、73.7%及49.1%;二期通畅率分别为91.8%、82.1%及70.8%;保肢率分别为91.8%、86.9%及76.6%。其中15例股-腘动脉旁路移植术术后1、2年一期通畅率分别为86.7%、49.5%;二期通畅率分别为93.3%、81.7%;保肢率分别为93.3%、81.7%。8例股-小腿动脉旁路移植术术后1、2年一期通畅率分别为45.0%、45.0%;二期通畅率分别为58.3%、58.3%;保肢率分别为58.3%、58.3%。结论:肝素涂层人工血管动脉旁路移植术为腔内治疗失败的下肢动脉复杂病变提供了一种安全有效的治疗方式,能够有效缓解症状及提高保肢率。     

联合动静脉瘘对流出道不良患者动脉旁路术通畅率的影响

目的通过对流出道不良患者行动脉旁路术联合动静脉瘘通畅率的分析,强调对流出道不良患者积极手术抢救患肢的重要性,并探讨合理的手术方式。方法回顾性分析行动脉旁路术(ePTFE)联合动静脉瘘手术治疗的26例下肢流出道严重不良患者的临床资料。结果26例(28条肢体)患者中,有14例行浅组(膝部大隐静脉)动静脉瘘,有12例联合行深组(腘、胫腓干、胫后静脉)动静脉瘘。24例获随访,平均随访8个月,近期通畅率两组均为78·6%,远期通畅率深组为78·6%,浅组为57·1%。结论动脉旁路术联合动静脉瘘可提高流出道不良的下肢缺血患者术后通畅率。     

PTFE血管加自体静脉段减轻动脉内膜增生的实验研究

目的:探讨PTFE人造血管加自体静脉段吻合对动脉内膜增生的缓和作用。方法:12只健康杂种犬的24条犬腿随机分成对照组及实验组。对照组股动脉阻断后,以PTFE人造血管直接行旁路转流术,实验组以自体颈外静脉段间置于PTFE与远端股动脉之间,术后第八周动脉造影后,收集标本行病理组织学观察及计算机图象分析测算增生内膜、中膜的厚度,增生内膜的截面面积、血管腔截面面积及两者的比值和静脉“动脉化”后中膜的厚度,同时,行间置静脉扫描电镜观察。结果:血管造影示两组通畅率分别为16.7％和66.7％(P<0.05);内膜厚度分别是483.5μm±67.3μm和147.1μm±38.6μm(P<0.1);中膜厚度组间差异不明显;增生内膜面积分别是5217±1123(pixel)和3117±890(pixel),分别占血管腔截面的80.9％±17.2％和47.7±13.7％(P<0.01);间置静脉呈动脉化表现。结论:间置自体静脉段能明显减轻PTFE管旁路手术后的动脉内膜增生,有效地提高血管手术后的通畅率。     

56例腘动脉以下肢体动脉缺血的血管重建术分析

目的总结腘动脉水平动脉闭塞血运重建术治疗的临床疗效。方法对2001年7月至2005年8月56例累及腘动脉及腘动脉以下三分支病变重建肢体血运进行回顾性分析。根据病变阻塞平面不同,采用不同的血管架桥,对多平面、多节段动脉闭塞采用聚四氟乙烯人工血管和自体静脉桥复合序贯架桥血运重建。结果术后平均随访17个月,移植血管一期通畅率67．3％,二期通畅率78．8％。结论复合序贯搭桥术治疗累及股浅-腘动脉水平以下多节段（平面）动脉闭塞症是一种较实用的方法,可有效解决自体血管不足和单纯使用人工血管腘动脉以下血管重建通畅率差的问题。     

动脉旁路手术治疗慢性下肢缺血的中远期结果

目的 探讨慢性下肢缺血的动脉旁路治疗的中远期效果.方法 回顾性分析2002年1月至2007年4月212例经动脉旁路治疗的慢性下肢缺血患者的临床资料.治疗方式包括股.膝上腘动脉旁路111例,股-膝下胭动脉旁路59例,主-髂动脉旁路25例,股股转流17例.结果 术后186例(87.7%)获随访6～68个月(中位随访期18个月),股-膝上胭动脉旁路术与股-膝下胭动脉旁路术1年初次通畅率分别为69.7%、53.5%,二次累计通畅率为81.6%、60.5%,两者差异无统计学意义(P＞0.05);其3年通畅率分别为56.3%和23.8%,两者差异有统计学意义(P＜0.05);腹主-髂股旁路与股一膝上胭动脉旁路及股股转流术近远期通畅率差异均无统计学意义(P＞0.05).随访期内52例患者行二次手术,23例行膝上或膝下截肢,保肢率为89.2%.围手术期死亡10例(4.7%),随访死亡20例,多数死于心脑血管原发疾病;人工血管感染6例.结论 根据患者病情选用适当的旁路手术方式,可取得满意的效果.股-膝上腘动脉旁路中、远期通畅率高于股-膝下胭动脉旁路,两者近期通畅率无差异.     

Composite sequential grafts for femorocrural bypass reconstruction: experience with a modified technique

BACKGROUND: To evaluate the efficacy of a modification of the composite sequential femorocrural bypass graft that we adopted in 1985, a retrospective case-note study was undertaken. The grafts combined a prosthetic femoropopliteal section with a popliteal to crural section with autologous vein, linked via a common intermediate anastomosis sited on the above-knee popliteal artery. PATIENTS AND METHODS: Between 1985 and 2000, 68 grafts of this type were constructed in 65 patients with critical ischemia of the lower limb and insufficient autologous vein for construction of an all venous bypass. Reasons for insufficient long saphenous vein included previous lower limb bypass in 33 cases, phlebitis in 16 cases, venous hypoplasia in eight cases, and previous varicose vein surgery in seven cases. Distal anastomoses were carried out to the peroneal artery in 26 cases, the anterior tibial artery in 17 cases, the posterior tibial artery in 17 cases, and the pedal arteries in eight cases. Sources of vein included the long saphenous vein in 26 cases, the arm vein in 38 cases, and the short saphenous vein in two cases. In 22 limbs (32%), angiography had shown an occluded segment of above-knee popliteal artery, and in these cases, local popliteal disobliteration was performed to receive the composite anastomosis and to provide additional outflow. RESULTS: The 2-year cumulative primary patency, secondary patency, and limb salvage rates were 68%, 73%, and 75%, respectively. Localized popliteal disobliteration did not compromise graft patency (P =.07, with log-rank test). CONCLUSION: In the absence of sufficient autologous vein, patients needing bypass to crural arteries can be offered reconstruction with composite sequential grafting with satisfactory results. Furthermore, an occluded above-knee popliteal segment is not a contraindication for composite sequential bypass reconstruction.     

Composite sequential arterial reconstruction for limb salvage

OBJECTIVE: Autogenous vein is the conduit of choice in patients presenting for infrainguinal arterial reconstruction. Venous conduit may be limited because of inadequacy or prior utilization. Our group and others use prosthetics to maximize limb salvage with moderate results. However, in cases where patients present with an isolated popliteal segment that may extend below the knee, we have performed prosthetic bypasses to this above-knee segment and then used a venous reconstruction from the native arterial circulation to a more distal outflow tract. In this report, we will analyze our results using this type of reconstruction in patients who present for limb salvage with no all-autogenous option. METHOD: From 1992 to 2000, 27 patients presented for limb salvage with an isolated popliteal artery and inadequate vein for continuous bypass. There were 106 patients in this period without an isolated popliteal segment or adequate vein who underwent prosthetic bypass with distal vein cuff or arteriovenous fistula. The vascular registry and patient charts were reviewed for indication, demographics, and type of composite reconstruction. Outcomes were calculated with use of life table methods and compared by log rank analysis. RESULTS: Demographics revealed 16 (59%) men, 16 (59%) patients with diabetes, and 4 (15%) smokers with a mean age of 71 years (range, 51-87 years). The venous reconstructions had the inflow taken from the distal native popliteal artery in 26 (above knee in 8 and below knee in 18) and the peroneal artery in one. The outflow involved the below-knee popliteal in one (4%), a tibial in 23 (85%), and the dorsalis pedis artery in 3 (11%). Morbidity included bleeding (4%), wound infection (4%), and limb loss (4%). Mortality occurred in one patient (4%), and no revisions were required in follow-up. Six late failures were identified, one of which resulted in amputation. Primary patency and limb salvage were 80% and 88% at 1 year, respectively. For comparison, our results using prosthetic with vein cuff had a 1-year primary patency of 52% and limb salvage of 92% (P = NS), whereas prosthetic with an arteriovenous fistula was 73% and 84%, respectively (P = NS). CONCLUSIONS: Composite sequential reconstruction using an isolated popliteal segment as inflow for the distal reconstruction is an acceptable option in patients presenting for limb salvage reconstruction with limited venous conduit. This type of reconstruction, when available, may be a better option than pure prosthetic with or without a vein cuff or arteriovenous fistula.     

Long-term evaluation of composite sequential bypass for limb-threatening ischemia.

When sufficient vein for a completely autogenous femorotibial artery bypass is not available, composite sequential grafting by using vein combined with polytetrafluoroethylene material is a surgical option. This study reviews what is currently the largest collection of these grafts and focuses on technical aspects and long-term patency characteristics. During a 7-year period 67 composite sequential bypasses were used to manage rest pain (38), ulcer (18), or gangrene (11) in 62 patients (mean age, 66 years). Fifty-two percent were men, and 51% had diabetes. This method was used as a primary reconstruction in 30, a second bypass in 16, and in 21 it was used after multiple other failed bypasses. Femoral to above-knee popliteal (44) and below-knee popliteal (23) 6 mm polytetrafluoroethylene grafts were placed. Then extensions of greater saphenous (57) or lesser saphenous (10) vein were anastomosed to the anterior tibial (19), posterior tibial (26), or peroneal (22) arteries. Fifty-three percent were maintained on long-term warfarin (Coumadin) anticoagulation, and 33% were maintained on aspirin. No deaths occurred in the perioperative period. Bypass patency was ascertained by a Doppler pressure and waveform analysis, with mean follow-up of patency or to the time of graft failure of 33 months (1 to 91 months). Three-year patient survival was 72%. Cumulative life-table primary patency of 72% (1-year), 64% (2-year), and 48% (3-year) was calculated. Two grafts are functioning 7 years after placement. Limb salvage was 84% at 2 years and 70% at 4 years. At the time of failure, five grafts retained a patent venous bypass segment, which allowed prompt reconstruction of the proximal portion. In a comparison of grafts with early failure and those with long-term patency, the SVS/ISCVS runoff score, vein diameter, tibial artery diameter, and coagulation status were similar. However, patients with the popliteal anastomosis above the knee had 2-year patency of 72% compared with 46% for those with below-knee anastomoses. This technique, when possible, appears preferable to an all prosthetic tibial bypass.     

Late results with Dardik-biograft in peripheral arterial surgery

A total of 117 vascular reconstructions below the inguinal ligament were performed using Dardik's human umbilical vein. The indication for surgery was limb salvage in 91.5%. In 61.5% a previous reconstruction had failed. The distal anastomosis was done with the popliteal artery above the knee in 9 cases, below the knee in 41, and with a tibial or the peroneal artery in 60 cases. The umbilical vein was combined with a prosthesis or the autologous saphenous vein in 20 cases. The cumulative patency rates of all reconstructions were 59.6% after 3, and 46.7% after 6 years. Crural reconstructions had a cumulative patency rate of 52% 3 years after surgery. The main factors influencing patency were the preoperative grade of ischemia, the site of the distal anastomosis and the angiographic run-off. It is concluded that the human umbilical vein is the graft material of choice in long length revascularization whenever the saphenous vein is not available.     

Distal Venous Patch improves results in PFTE bypasses to Tibial arteries

In recent years, the management of limb-threatening ischemia has involved the use of distal bypasses to vessels beyond the popliteal trifurcation. Excellent patency rates and limb salvage data are achieved through the use of autologous long saphenous vein. However, an increasing number of patients in need of tibial bypass do not have adequate saphenous vein due to previous procedures, thrombophlebitis, or inadequate vein. In such cases alternative conduits have been proposed including lesser saphenous vein, arm vein, composite veins, composite vein with poly-tetrafluoroethylene (PTFE), and PTFE with or without a distal arteriovenous fistula. Unfortunately these alternative conduits have not resulted in equivalent results when used for distal bypass to tibial arteries. Several authors have reported upon the use of venous tissue at the distal anastomosis in the form of cuffs, collars, and boots to improve the results of prosthetic grafts in this challenging patient population. These techniques have been proposed as an option for revascu-larization in patients without adequate saphenous vein in an attempt to obtain limb salvage. The purpose of this review is to examine some of those techniques and focus on distal vein patch configuration with its perceived advantages and drawbacks.     

Distal venous patch improves results in PFTE bypasses to tibial arteries

In recent years, the management of limb-threatening ischemia has involved the use of distal bypasses to vessels beyond the popliteal trifurcation. Excellent patency rates and limb salvage data are achieved through the use of autologous long saphenous vein. However, an increasing number of patients in need of tibial bypass do not have adequate saphenous vein due to previous procedures, thrombophlebitis, or inadequate vein. In such cases alternative conduits have been proposed including lesser saphenous vein, arm vein, composite veins, composite vein with polytetrafluoroethylene (PTFE), and PTFE with or without a distal arteriovenous fistula. Unfortunately these alternative conduits have not resulted in equivalent results when used for distal bypass to tibial arteries. Several authors have reported upon the use of venous tissue at the distal anastomosis in the form of cuffs, collars, and boots to improve the results of prosthetic grafts in this challenging patient population. These techniques have been proposed as an option for revascularization in patients without adequate saphenous vein in an attempt to obtain limb salvage. The purpose of this review is to examine some of those techniques and focus on distal vein patch configuration with its perceived advantages and drawbacks.     

Linton patch angioplasty. An adjunct to distal bypass with polytetrafluoroethylene grafts

Expanded polytetrafluoroethylene (PTFE) grafts have shown promise in bypasses to the popliteal and tibial arteries, but a significant incidence of immediate and late graft failure has limited general acceptance. Compliance differences between the PTFE graft and artery may present technical difficulties in small vessel anastomosis, as well as being implicated in late development of intimal hyperplasia. A retrospective study of 68 patients who had bypass to the distal popliteal and tibial arteries using PTFE grafts with adjunctive distal patch angioplasty was undertaken. Operation was done for limb salvage in 85%. Runoff was marginal in 69%. A venous patch was sutured to the distal artery and the PTFE graft was then sutured into an opening in the proximal portion of the patch. There was one early graft occlusion. Cumulative patency was 97% at 1 month, 92% at 3 months, 87% at 6 months, 74% at 12 months, and 65% at 24, 36, and 48 months. A distal autogenous vein patch permits precise suturing of the distal anastomosis and minimizes technical difficulties leading to early graft failure. Improvement of the compliance mismatch of the PTFE graft and artery may impede the unwelcome development of intimal hyperplasia at the distal anastomotic site. The adjunctive use of a distal patch has resulted in excellent immediate graft patency, despite a high incidence of poor run-off and limb salvage situations.     

Bypass graft to the midpopliteal artery with a combined anterior and posterior approach

PURPOSE: The medial supragenicular and infragenicular approaches to the popliteal artery were introduced almost 50 years ago and replaced the posterior approach to the popliteal artery for distal graft implantation. We review a contemporary series of bypass grafts to the midpopliteal artery by use of a combined anterior and posterior approach to evaluate its potential clinical benefits. TECHNIQUE: After the proximal graft anastomosis is constructed, an incision is made in the popliteal fossa to access the midpopliteal artery, the graft is passed into that incision, and all but the popliteal incision is closed. The patient is turned, the midpopliteal artery dissection is completed, and the graft is anastomosed distally. METHODS: Fifty-seven bypass grafts, implanted distally on the midpopliteal artery by this technique over a 13-year period, chosen in preference to an infragenicular bypass graft in selected patients when a supragenicular bypass was not feasible, were assessed in terms of indications for surgery, conduit type, complications, length of postoperative hospitalization, and graft patency. RESULTS: Bypass grafting originated from the axillary artery in two cases, the common iliac artery in one case, and the femoral artery in 54 cases. The procedure was performed in five patients with a popliteal trifurcation anomaly, nine patients with a blind popliteal segment, 20 patients with limited length of autologous vein, and five patients with an above-knee graft infection requiring an alternate path for revascularization. Autologous vein was used in 35 and polytetrafluoroethylene (PTFE) in 19 bypass grafts. Three other patients had a composite sequential femoral-popliteal-tibial bypass graft, with PTFE and autologous vein. Postoperative (30 day) complications include one death (composite sequential), one stroke (PTFE), and one graft thrombosis (saphenous vein). The mean postoperative hospitalization for the last 31 patients was 4.2 +/- 3.7 days. In the autologous vein group, the 1-year primary patency rate was 87%, and the primary assisted patency rate was 94%. In the PTFE group, the 1-year primary patency rate was 72%. Two composite sequential grafts remained patent at 1 year. CONCLUSIONS: Bypass grafting to the midpopliteal artery with a combined anterior and posterior approach offers a safe and effective option to below-knee bypass grafting when an above-knee bypass grafting is not feasible. Compared with the medial infragenicular incision, the posterior incision results in reduced morbidity rates, rapid mobilization, and early hospital discharge.