103.06 Opioid Prescribing and Filling Practices Following Trivex Phlebectomy and Carotid Endarterectomy

Posted on January 31, 2019

A. Berezovsky2, P. Castaneda2, B. Cleary2, N. Osborne1, D. Coleman1  1University Of Michigan,Vascular Surgery,Ann Arbor, MI, USA 2University Of Michigan,Medical School,Ann Arbor, MI, USA

Introduction:  The opioid epidemic has gained increasing visibility especially within surgery. Several surgical specialties have been analyzed for their postoperative opioid prescription patterns; however, vascular surgery prescribing practices have yet to be widely studied. Initial survey data from vascular surgery providers at an academic center reveal variable opioid prescribing patterns. This study examines vascular surgery prescribing patterns following Trivex Powered Phlebectomy (TPP) and Carotid Endarterectomy (CEA) procedures and compares these patterns with patient-reported opioid need. 

Methods:  A retrospective chart review examining CEA (May 2016-Jun 2017) and TPP (Jan 2016-Jun 2017) procedures was performed. Patient characteristics, chronic pain risk factors, comorbidities, and case complexity (only analyzed for TPP) were collected. Postoperative opioid prescriptions were recorded. A tri-state database of narcotic prescriptions was used to collect filling data. Phone surveys were conducted for patients who underwent CEA or TPP in this timeframe, assessing postoperative pain medication need and opioid use. Bivariate statistics were used to examine factors associated with opioid prescription filling and STATA was used to determine if risk factors, comorbidities, and case complexity were associated with prescription filling.

Results: 70 patients (61.4% male; mean age 68.3 (9.4)) underwent a total of 72 CEAs. 47 patients (67.1%) carried a diagnosis of at least one predisposing factor to pain. Postoperative opioids were prescribed after 54 procedures (75.0%). Of these prescriptions, 35 (64.8%) were filled. Mean prescribed oral morphine equivalent (OME) for filled prescriptions was 200.6mg (140.1) (median = 150mg); notably 100 OME is equivalent to 20 tablets Hydrocodone-acetaminophen 5-325. 56 patients completed phone survey on postoperative opioid need (response rate 80.0%). Of these patients, 38 (67.9) reported taking half or less than half the number of pills prescribed or no pills at all.

212 patients (34.4% male, mean age 52.2 (12.7)) underwent a total of 222 TPPs. 121 patients (57.1%) had a prior diagnosis of a predisposing factor to pain. Postoperative opioids were prescribed after 198 procedures (89.2%). Of these prescriptions, 169 (85.4%) were filled. Mean OME for filled prescriptions was 121mg (139.8) (median= 100mg). 88 TPP patients (response rate 41.5%) completed phone survey. 46 (52.3%) reported taking half or less than half the number of pills prescribed or no pills.

Conclusion: This preliminary data is a step towards understanding opioid prescribing patterns and patient filling habits following common vascular procedures. In these populations, not all patients filled their prescriptions; and those who did frequently did not require as many pills as provided. Further research is needed to identify factors predictive for opioid needs and use, and guide ‘best-prescription practices’ following vascular surgery procedures.
 

103.05 Impact of Temporal Artery Biopsy on Clinical Management of Suspected Giant Cell Arteritis

Posted on January 31, 2019

C. Deyholos1, M. Systek1, S. Smith1, J. Cardella1, K. C. Orion1  1Yale University School Of Medicine,Section Of Vascular Surgery, Department Of Surgery,New Haven, CT, USA

Introduction: Temporal arteritis (TA) or giant cell arteritis (GCA) is a systemic inflammatory vasculitis of unclear etiology that affects medium sized vessels. The gold standard for diagnosis has traditionally been histological by TA biopsy.  Due to the risk of permanent vision loss if the disease is left untreated, standard of care is to begin steroid therapy prior to confirming the diagnosis.  In up to one third of GCA patients, the temporal arteries are not involved and there has been reported facial nerve injury during TA biopsy. Improved imaging modalities such as color duplex, PET CT or MRI have been increasingly used to aid diagnosis and are  recommended in the newest 2018 European (EULAR) Guidelines.  We hypothesize that a negative TA biopsy result does not change management in patients for whom temporal arteritis is strongly suspected and that duplex ultrasound can be successfully used as a screening tool.

Methods: A retrospective review of patients undergoing TA biopsy between May 1, 2012 and December 31, 2015. We reviewed patient's age, gender, co-morbidities, symptoms, histology, and whether patients were prescribed steroids prior to or following biopsy. We also began small prospective series of 3 patients where ultrasound of the bilateral temporal arteries was performed prior to biopsy, using a high frequency linear transducer to evaluate for wall thickening. Radiology report and pathology report were then reviewed.

Results: Within period of study, 171 temporal artery biopsies were performed. 7.6% positive (n=13) 92.4% negative (n=158) for acute GCA.  Patients with positive biopsy result had mean age 80± 6 (Range 69-88). Patients with negative biopsy had mean age of 72± 11 (Range 17-95). We also performed subgroup analysis on patients with negative biopsies (n=158). Cases in which there was no documentation of steroids prior to or after biopsy were excluded (n=15). 20% of patients who had negative biopsies were not on steroids prior to the procedure (n=28). 31% of patients with negative biopsies continued on steroids despite the negative result (n=45).  In series of 3 ultrasounds, all 3 correlated with subsequent biopsy histology. 1 was positive, and 2 were negative.

Conclusion:  Our results suggest that the yield of temporal artery biopsy is low, and a negative biopsy alone often does not lead to termination of steroid therapy. Ultrasound may present a viable diagnostic tool to reduce number of unnecessary temporal artery biopsies performed.

103.04 Surviving Ruptured Abdominal Aortic Aneurysm: Is There a Golden Hour To Operative Intervention?

Posted on January 31, 2019

G. Metzger1, T. Yoo1, D. Chou1, M. J. Haurani1, J. Starr1  1Ohio State University,Vascular Diseases And Surgery,Columbus, OH, USA

Introduction: ~~: Ruptured abdominal aortic aneurysm (rAAA) is the 13th leading cause of death in the United States, responsible for approximately 15,000 deaths per year. The prognosis of untreated rAAA is dismal, with an overall mortality of 90%, with immediate diagnosis and surgical intervention as the only modality for survival. We hypothesize that the time to intervention is a significant factor in determining survival.

Methods: ~~We retrospectively reviewed all patients in a single institution from 2012-2017 with diagnosis of ruptured abdominal or type IV thoraco-abdominal aortic aneurysm presenting to the Emergency Department (ED) that underwent emergent attempted open or endovascular repair. Patients that did not travel straight from the ED to the OR were excluded. Records were retrospectively reviewed to determine hemodynamic status on initial presentation, the need for imaging, time from ED (arrival or initial evaluation??)to incision, and type of repair. The primary outcome was 30-day mortality.

Results:~~101 patients with aortic emergency were reviewed of which 32 met criteria. 30-day mortality was 28.1% (n=9). Time from arrival to incision ranged from 36 to 269 minutes (median=94 min, STD±65.7 min). There was no difference in mortality between open (n=19) and endovascular intervention (n=13). There was increased mortality in patients with hemodynamic instability before intervention (46.2% vs. 16.7%, p=0.10). In patients who underwent intervention within 60 minutes of arrival, there were no deaths, even in those with hemodynamic instability. Increasing time-to-intervention increased risk of death, especially in unstable patients (Figure 1, 0% mortality within 60 minutes, 57% within 61-120 min, and 100% mortality over 120+ min).

Conclusion:~~Similar to trauma reports, time-to-operation appears to be a significant factor predicting survival, especially in unstable patients. We have identified intervention within one hour as a possible metric for quality improvement, with the aim of streamlining an expedited, team-based, multi-disciplinary approach to improve survival.

 

103.03 Prevalence Of Carotid Artery Dissections After Trauma: A Five Year Review Of the TQIP

Posted on January 31, 2019

M. Hamidi1, M. Zeeshan1, N. Kulvatunyou1, T. O’Keeffe1, A. Northcutt1, A. Tang1, E. Zakaria1, L. Gries1, B. Joseph1  1University Of Arizona,Trauma And Acute Care Surgery,Tucson, AZ, USA

Introduction:
Traumatic carotid artery dissection (CAD) is a rare and potentially disastrous injury. Because of the infrequent occurrence of this injury, the incidence data have not been available. The aim of our study was to analyze the trends of CAD and survival in the past 5 years.

Methods:
Five-year (2010-2014) analysis of all trauma patients diagnosed with CAD in the TQIP. Outcome measures were prevalence and mortality after CAD in past 5 years. Regression analysis was performed to control for demographics, vital and injury parameters.

Results:
808194 trauma patients were analyzed. 51 patients were diagnosed with CAD. Mean age 43±17 years, 76.4% (39/51) were males, and 68.6% (37/51) whites. Mechanism of Injury (MOI) was blunt in 98%(50/51). Overall mortality rate was 13.7% (7/51). Head injuries (73%, n=26/51) was most commonly associated with CAD followed by face (57%, n=29/51) and cervical spine injuries (43%, n=20/51). 19.6% (10/51) of the patients had a cerebrovascular accident. All of the patients were admitted to ICU and received mechanical ventilation. Prevalence of CAD decreased during the 5-years study period while mortality rate increased (Fig1). On regression analysis presence of combined head, C-spine and facial injuries were an independent predictor of CAD (OR 1.3, [1.05-4.53], p=0.04).

Conclusion:
Carotid artery dissection following trauma is a rare injury, detected in about 6.3/100,000 trauma patients. Combination of cervical, head and face injuries increases the risk of carotid artery dissection. Patients with combined head, facial and cervical injuries should undergo CTA for early detection of carotid artery dissection and may help to improve outcomes.
 

103.02 Usefulness of Frailty Indices for Predicting Outcomes in Carotid Endarterectomy

Posted on January 31, 2019

M. Aizpuru2, K. X. Farley2, M. V. Poirier2, L. P. Brewster1, E. R. Wagner3, R. S. Crawford1  1Emory University School Of Medicine,Department Of Surgery, Division Of Vascular Surgery,Atlanta, GA, USA 2Emory University School Of Medicine,Atlanta, GA, USA 3Emory University School Of Medicine,Department Of Orthopaedics,Atlanta, GA, USA

Introduction: Frailty has been used as a predictor of adverse outcomes in vascular surgery, yet there are few studies comparing the available frailty indices head-to-head. The National Inpatient Sample has the unique capability to allow calculation of three major frailty measures used in vascular surgery. The aim of our study is to compare frailty indices for predicting in-patient mortality and prolonged length of stay following carotid endarterectomy (CEA).

Methods:  315,354 patients underwent carotid endarterectomy between 2002-2015 Q3 in the National Inpatient Sample (NIS). Comorbidities were identified using previously published ICD-9 coding methods. Charlson Comorbidity Index (CCI, 0-26), the Modified Frailty Index (mFl, 0-1), and the Elixhauser Comorbidity Measure (Elixhauser, 0-31) were calculated. Prolonged length of stay (LOS) was defined as a hospital stay of 2 days or greater. The predictive value of CCl, mFl, and Elixhauser were compared using receiver-operating curves for both in-patient mortality and prolonged length of stay.

Results: The mean age was 71.0 ± 9.5 years. 244,208 (77%) patients had a history of hypertension, 44,506 (14%) had a history of stroke, and 34,896 (11%) had a history of MI. The mean mFI was 0.17 (range=0.00-0.82), the mean CCI was 1.3 (range=0-17) and the mean ECM was 2.2 (range=0-12). Median LOS was 1 day (range=0-283 days). There were 1,635 (0.05%) in-hospital deaths. mFI (AUC= 0.524, CI [0.509-0.538]) was inferior to CCI (AUC=0.636, CI [0.624-0.653]) and ECM (AUC=0.648, CI [0.634-0.663]), which were equivalent for predicting mortality. Elixhauser comorbidity measure (AUC=0.606, CI [0.604-0.608]) was superior to mFI (AUC=0.551, CI [0.549, 0.553]) and CCI (AUC=0.572, CI [0.570-0.574]) for predicting prolonged LOS (≥2 days).

Conclusion: Frailty indices were not strong predictors of in-hospital mortality or prolonged LOS in patients undergoing CEA in the National Inpatient Sample. Despite receiving the most attention in the vascular literature, the modified frailty index (mFI) was the least effective. These results call into question the usefulness of frailty in predicting outcomes without some consideration of the extent of the procedure.

 

103.01 Open versus Endovascular repair of Type-IV Thoracoabdominal Aortic Aneurysms.

Posted on January 31, 2019

A. S. Shaaban1, S. S. Locham1,2, H. Dakour-Aridi1,2, M. Malas1,2  1The Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA 2University Of California – San Diego,Surgery,San Diego, CA, USA

Introduction: Type-IV Thoraco-abdominal aortic aneurysms (TAAA IV) are commonly managed via open surgical repair (OSR). The development of endovascular option with snorkel, branched and fenestrated endografts (EVAR) has provided a minimally invasive alternative to OSR. Very few studies are available in the literature specifically on TAAA IV and are limited to either case series or single institution. Thus, the aim of this study is to use a large national surgical database to evaluate adverse outcomes after OSR vs EVAR of TAAA IV.

Methods:  All patients undergoing repair of TAAA IV were included using the National Surgical Quality Initiative Program (NSQIP) – vascular targeted database (2011-2016).  Categorical and continuous variables were analyzed using chi-square, fishers exact and student’s t-test as appropriate. Logistic regression analyses were performed to evaluate primary (mortality) and secondary (acute renal injury, cardiopulmonary failure) outcomes.

Results: A total of 158 patients with Type-IV TAAA were identified. Of which majority of them underwent OSR (62%). Patients’ demographics and comorbidities were similar between the two groups. Except for preoperative renal failure/dialysis which was more common in patients undergoing endovascular repair (12% vs. 3%, P=0.04). Patients in the OSR group required transfusions more frequently (71% vs. 35% P<0.001) and had longer hospital stay (Median [IQR]: 10[7-19] vs. 5[2-10] days; P=0.005). In univariate analysis, no significant difference was seen in 30-day mortality (19% vs. 13%, P=0.39). However, acute renal and cardiopulmonary failures were higher among patients undergoing OSR (figure). After adjusting for potential confounders, 30-day mortality remained not different between the two groups (OR [95%CI]: 1.56[0.64-3.83], P=0.33). Additionally, OSR was associated with almost 6 and 3 folds increase in the odds of renal (OR [95%CI]: 5.60[1.47-21.31], P=0.01) and cardiopulmonary failure (OR [95%CI]: 2.98[1.23-7.23], P=0.02), respectively. 

Conclusion: Using a large nationally representative vascular dataset, our study found no difference in operative mortality between OSR and EVAR of TAAA IV. However, patients undergoing OSR required more transfusion and had significantly higher cardiopulmonary and renal failure and longer length of stay compared to EVAR. Larger prospective studies are needed to compare the durability and cost-effectiveness of the newer endovascular techniques.

 

08.20 Racial Disparities Among Patients Undergoing Lower Extremity Amputation

Posted on January 31, 2019

S. Jhajj1, V. Pandit1, K. Goshima1, C. Weinkauf1, W. Zhou1, G. Doros2, D. Rybin2, T. Tan1  1University Of Arizona,Department Of Surgery,Tucson, AZ, USA 2Boston University,Boston, MA, USA

Introduction:
Recent studies have suggested racial and ethnic disparities in lower extremity amputation. The goal of our study was to determine whether race impact the perioperative outcomes following above knee amputation (AKA) and below knee amputation (BKA).

Methods:
The ACS-National Surgical Quality Initiative Program (2012 to 2016) was queried to identify patients who underwent major amputation (AKA and BKA) using CPT-codes. Outcomes evaluated include perioperative mortality and morbidity, hospital length of stay (LOS) and readmission. Multivariable regression analyses were performed to assess the association between race/ethnicity and outcomes.   

Results:
There were 19,293 major amputations (7,528 AKAs) in the study cohort, including 11,564 Whites, 5,380 African Americans (AAs), 1,767 Hispanics, 310 Asians, and 272 Native Americans (NAs). Overall, the average age was 64.2 years, 65.7% male and 64% had diabetes. The perioperative mortality was 7.3% and average LOS was 11.5 days. In risk-adjusted analyses, AAs had significantly lower mortality (OR 0.81, 95% CI 0.7,0.9, p=.002) and surgical site infection (OR 0.74, 95% CI 0.6,0.8, p<.001) when comparison was made with Whites. The hospital LOS was significantly longer (all p<.001) for AAs (OR 1.06, 95% CI 1.03,1.09), Hispanics (OR 1.06, 95% CI 1.02,1.10), Asians (OR 1.47, 95% CI 1.35,1.60) and NAs (OR 1.32, 95% CI 1.2, 1.44), compared to White counterparts.  

Conclusion:
Although race is not a significant factor impacting perioperative mortality and morbidity following major amputations, the hospital length of stay is significantly longer for AAs and other racial groups than their White counterparts. Further study is required to understand the impact of the racial and ethnic group on hospital stay and other resource utilization following lower extremity amputation.
 

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