103.20 Catheter-Associated Thrombosis in Pediatric Trauma Patients: Choose Your Access Wisely

Posted on January 31, 2019

C. M. McLaughlin1, E. Barin1, M. Fenlon1,2, C. Azen2,3, T. Deakers4, J. Stein1,2, D. Bliss1,2, J. Upperman1,2, A. Jensen1,2  1Children’s Hospital Los Angeles,Pediatric Surgery,Los Angeles, CA, USA 2University Of Southern California,Los Angeles, CA, USA 3Southern California Clinical and Translational Science Institute,Los Angeles, CALIFORNIA, USA 4Children’s Hospital Los Angeles,Anesthesia And Critical Care Medicine,Los Angeles, CA, USA

Introduction:  Traumatic injury and the presence of a central venous catheter are two of the strongest risk factors for venous thromboembolism in children. Central access is often necessary in pediatric trauma patients and the femoral vein is commonly used. The purpose of this study was to determine the incidence of symptomatic catheter-associated thrombosis in critically-injured children. We hypothesized that femoral venous catheters are associated with a higher rate of thrombotic complications when compared to all other central venous access points.    

Methods:  We reviewed a retrospective cohort (2006-2016) of injured children (≤18 years) admitted to a pediatric intensive care unit with central access placed ≤ 7 days from admission. Catheter type, insertion site, duration of use, use of thromboprophylaxis, and risk factors for thrombosis were recorded. Symptomatic catheter-associated thrombosis was determined by radiographic evidence. Confounding variables were compared with chi-square test of independence or Mann-Whitney U. Poisson regression was used to compare the incidence of catheter-associated thrombosis per 1000 catheter days between femoral and non-femoral catheters. All comparisons were two-tailed with alpha = 0.05.   

Results: This cohort included 209 pediatric trauma patients with central access (65% femoral, 19% subclavian, 11% arm vein, and 5% internal jugular). Femoral catheters were removed earlier when compared to all other catheters (median [IQR] 4 [2-7] vs 8 [3-12] days, p<0.001). Femoral catheters were more likely to have a larger diameter, despite there being no difference in age (Table). There were 13 (6%) symptomatic thrombosis events and 85% occurred in patients with femoral catheters. Incidence of catheter-associated thrombosis was significantly higher in femoral versus non-femoral catheters (18.4 vs 3.5 per 1000 catheter days, p=0.01). Catheter location was not significantly associated with mortality (18% vs 18%, p=1) or length of stay (13 [6-25] vs 16 [7-28], p=0.26). 

Conclusion: Femoral venous catheters are associated with higher incidence of symptomatic catheter-associated thrombosis in pediatric trauma patients. When central venous access is indicated for injured children, the femoral site should be avoided. If a femoral venous catheter is necessary, use of a smaller catheter should be considered. 

 

103.19 Evaluation of Cardiothoracic Surgery Residency and Fellowship Program Websites

Posted on January 31, 2019

V. M. Miller1, L. A. Padilla1,2, A. Schuh3, D. Mauchley1, D. Cleveland1, Z. Aburjania1, R. Dabal1  1University Of Alabama at Birmingham,Department Of Surgery,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,Department Of Epidemiology,Birmingham, Alabama, USA 3University Of Alabama at Birmingham,Birmingham, Alabama, USA

Introduction:  

The internet is a valuable resource for residency and fellowship candidates when deciding where to apply. Interviewing can affect medical debt, clinical scheduling, and institution finances, yet program websites have shown critical deficiencies in accessibility and content. Until now no analysis of cardiothoracic surgery program websites has been performed.

Methods:  

The Electronic Residency Application Service (ERAS), the Fellowship and Residency Electronic Interactive Database Access (FREIDA), the Accreditation Council for Graduate Medical Education (ACGME), the Thoracic Surgery Directors Association (TSDA) and Google® were used to identify integrated, 4+3, and traditional cardiothoracic surgery residency and fellowship programs. The accessibility of websites from each of these sources was assessed and the presence or absence of content deemed relevant to applicants was evaluated by two reviewers.

Results: 

Eighty nine active programs were identified and 86 had functional websites. Website content and accessibility were overall suboptimal in all 86 of these programs. Google® was the most reliable means of accessing a program’s website. Fifty percent of integrated program websites and 60% of traditional fellowship websites contained less than half of the content assessed. Information on 4+3 programs was extremely limited.

Conclusion:
Cardiothoracic surgery residency and fellowship websites remain difficult to access and are failing to provide important information. Improving website accessibility and content may have implications for attracting the most competitive applicants,limiting associated costs, and increasing match satisfaction for both the applicant and the institution.
 

103.18 Use of Thrombolysis in Acute Lower Extremity Ischemia with Known Distal Target Vessel for Revascularization

Posted on January 31, 2019

G. AlAwwa1, L. Flores1, P. Haser1, A. Tortolani1, F. J. Veith1, M. Khalil1, N. J. Gargiulo1  1The Brookdale Hospital and Medical Center,Vascular,New York, NY, USA

OBJECTIVES: Thrombolysis is an important therapeutic tool in localizing a distal arterial target vessel in patients presenting with acute lower extremity ischemia. In some patients, however, thrombolysis fails to identify a suitable target vessel for lower extremity bypass often resulting in amputation. Pre-existing knowledge of the distal target vessel may obviate the need for thrombolytic-mediated distal arterial recanalization. We report our five year experience in managing patients with acute lower extremity ischemia with a known distal arterial target vessel without thrombolytic therapy.

Methods: Over a five year period, 27 patients presented with varying degrees of lower extremity ischemia SVS I (7), SVS II (18), SVS III (2). All patients with emboli were excluded from this experience. Twenty three of 27 patients had acute graft occlusions and the remaining four patients had native arterial occlusions. In 14 of 27 patients, the distal peripheral arterial status was unknown and required thrombolytic therapy. In the other 13 patients, a known distal arterial target vessel was used for successful revascularization without the aid of thrombolysis.

Results: The 14 patients who failed to demonstrate a distal target vessel after thrombolysis ultimately required below-knee or above-knee amputation despite surgical intervention exploring distal arterial target vessels for revascularization. The other 13 patients with a known distal arterial target did not require thrombolysis and underwent successful revascularization. Despite this, 3 of these 13 patients ultimately required amputation between 3 and 6 months.
 

Conclusions: Pre-existing knowledge of the distal arterial target vessel obviates the need of thrombolytic therapy in those patients presenting with acute lower extremity ischemia. Additionally, amputation may be avoided in those patients who fail to manifest a distal arterial target after thrombolytic therapy in which the distal arterial target vessel is already known.

 

 

103.17 Bolton Aortic Endograft Demonstrates Significant Aneurysmal Sac Shrinkage.

Posted on January 31, 2019

M. D. Balceniuk1, P. Zhao1, L. Cybulski1, M. C. Stoner1  1University Of Rochester,Division Of Vascular Surgery,Rochester, NY, USA

Introduction:
Aneurysmal sac shrinkage is associated with successful aneurysm exclusion following endovascular aortic repair (EVR). There are a variety of approved aortic endografts, with recent data demonstrating device-specific sac shrinkage. The Bolton Treo endograft is a modular two-docking limb EVR device which has completed Phase II trial in the United States and is freely available in other markets. The objective of this study is to evaluate sac shrinkage of the Bolton Medical endograft.

Methods:
This is a retrospective analysis of EVRs at a single institution over a one-year period in which the Bolton graft was used. The change in sac size and rate of sac shrinkage (mm/month) was evaluated between Bolton and non-Bolton grafts. All Bolton grafts were included in the analysis. Non-Bolton grafts were matched a priori for Bolton IFU anatomic specifications. Only elective, intact aneurysm cases were selected. The primary outcome was sac shrinkage and secondary outcomes were composite complication profile within 30 days of operation.

Results:
Six Bolton grafts and 19 non-Bolton grafts were included for analysis (Table). The groups were similar in age, gender and race. The groups were also similar in aortic anatomy prior to EVR. The aneurysm sac shrinkage rate (mm/month) is significantly greater in the Bolton group compared to the non-Bolton group (0.504 ±0.109 vs 0.033 ±0.100, p=0.016). The total average size of sac shrinkage was also greater for the Bolton group (-0.571 ±2.422 vs 12.33 ±2.71, p<0.001). The composite complication profile of stroke, myocardial infarction, death and respiratory complications was not different between groups.

Conclusion:
The Bolton Treo is a pre-market modular endograft with several unique engineering properties. These data demonstrate a potential advantage the Bolton graft has with increased sac shrinkage while maintaining minimal complication rates, compared to other grafts. This study adds to the growing body of literature supporting Bolton graft use for EVR.
 

103.16 Efficacy and Safety of Interventional Approach for Pulmonary Embolism

Posted on January 31, 2019

A. A. Siddiq1, W. Qu1, H. Maldonado1, A. K. Baothman1, M. Osman1, F. Brunicardi1, M. Nazzal1  1University Of Toledo Medical Center,Department Of Surgery,Toledo, OH, USA

Introduction:

Pulmonary embolism (PE) is the third most common cause of cardiovascular-related death in the United States. Endovascular techniques have been suggested as an option to treat submissive and massive PE with lower hemorrhagic complications than systemic thrombolysis. We aim to evaluate the outcomes of different endovascular techniques of in the management of submissive and massive PE.

Methods:

This is a single center retrospective review. All adult (age≥18 years) patients with a diagnosis of acute massive or sub-massive PE during Jan 2012 and Jan 2017 were identified. Medical records were reviewed for demographics, medical history, and treatment modality of PE. The outcomes of PE including ICU stay, mortality, and postoperative complications were analyzed. Statistical analyses were performed using IBM SPSS Statistics, Version 24 (IBM Corp., Armonk, NY) as appropriate.  

Results:
 

There were 36 PE patients enrolled in our study. One third of patients (n=12 were had massive PE, the rest (n=24) were sub massive PE. In 32 (88.9%) patients, PE  involved both sides of the pulmonary artery.

The most common symptoms presented were dyspnea (58.3%, n=21), chest pain (25%, n=9), and syncope (16.7%, n=6). The average age was 54.8±12.6 years old. There were 28 Females (58.3%) and 15 males (41.7%). The majority of the patients were Caucasian (88.9%, n=32), 3 (8.3%) of the patients were African Americans. There were no significant differences in demographics between patients with massive PE and those with sub massive PE.  Four groups were identified on the basis of the therapy received: Catheter Directed Thrombolysis (CDT) only (n=9), CDT + EkoSonic Endovascular System (EKOS) (n=15), other( which includes; CDT with mechanical thrombectomy or maceration suction) (n=10). One patient had systemic thrombolysis while another one had open embolectomy. No significant differences were identified in outcomes (mortality, complications, and echocardiographic results) between those groups. Patients received EKOS have 30 days mortality rate 0% (P-value = 0.027) compared to those did not receive EKOS intervention (30%). Post-hoc pairwise comparison with Fisher exact test of 30 days mortality showed no significant difference between any pair of the endovascular intervention groups. There is no significantly difference in ICU or hospital length of stay between the different intervention (median 3 and 6 days respectively).

Conclusion:
 

Massive and sub massive PE can be safely treated with a variety of endovascular techniques. All endovascular techniques had comparable outcomes, although EKOS thrombolysis may have lower mortality.

103.14 Patients’ Experiences During Treatment for Critical Limb Threatening Ischemia: A Qualitative Study

Posted on January 31, 2019

O. Choy1, S. Monaro3,4, S. Aitken1,2  1The University of Sydney,Concord Clinical School,Sydney, NSW, Australia 2Concord Repatriation General Hospital,Institute Of Academic Surgery,Sydney, NSW, Australia 3Concord Repatriation General Hospital,Department Of Vascular Surgery,Sydney, NSW, Australia 4The University of Sydney,Susan Wakil School Of Nursing,Sydney, NSW, Australia

Introduction:

Critical Limb Threatening Ischemia (CLTI) is a debilitating vascular condition, often with patients requiring multiple operations associated with a high risk of adverse events and poor outcomes. Few studies examine patient experiences of treatment for CLTI, with most published outcome measures determined by researching clinicians. This study aims to describe patients’ concerns and values related to CLTI treatment, informing patient-centered care for CLTI patients.

Methods:
An exploratory qualitative study design was piloted to describe the experiences of CLTI patients undergoing elective vascular surgery. In-depth, semi-structured patient interviews were recorded preoperatively and three months post discharge. Transcribed interviews were analyzed by two independent researchers, using content analysis, to derive patient-centered themes. Findings were mapped to the patient-centered care framework described by Doyle et al (2013) with themes of relational care: supportive, participative, educative and trustworthy, and functional care: effective, holistic, situated, and integrated. The Consolidated Criteria for Reporting Qualitative research checklist (2007) informed qualitative rigor.

Results:
Six patients were recruited, comprising 12 interviews. Procedures included angioplasty, minor amputation and open surgical bypass. For patients with CLTI, the negative experience of multiple procedures (5, 83%), impaired mobility (5, 83%), pain (4, 67%) and ulceration (4, 67%) were frequently expressed concerns. Mobility and ulceration improved after surgery but pain and sleep disturbance varied. Only two (33%) patients had concerns about amputation, with current symptoms of greater concern for patients than possible future outcomes. Patient-centered values closely reflected the analysis framework, with patients valuing strong relationships with their surgeon, and holistic, effective care. Failure to integrate care or address other health issues was seen as a negative outcome. Contrary to other surgical patients, CLTI patients did not strongly desire shared decision-making.

Conclusion:

If confirmed in larger studies, these preliminary findings suggest for patients with CLTI, strong relationships with their treating surgeon, involving trust and support are of equal importance as functional symptom relief. CLTI patients want to be informed; however, often feel without a choice in treatment options, limiting their participation in decision making. Immediate functional and symptom related outcomes were prioritized over hypothetical future outcomes like amputation. This exploratory pilot study is feasible to assess patient-centered values.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open 2013;3:e001570.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ). International Journal for Quality in Health Care; 2007; 19(6): 349

103.15 The Effect of Social Determinants on In-patient Complications and Management of Diabetic Foot Ulcer.

Posted on January 31, 2019

A. R. ALDHAHERI1, M. F. Osman1, J. Ortiz1, F. C. Brunicardi1, W. Qu1, K. Bauer1, M. Shanidze1, M. Nazzal1  1University Of Toledo Medical Center,Vascular Surgery/ Department Of Surgery/ College Of Medicine,Toledo, OH, USA

Introduction:

Complications of diabetes (DM), such as diabetic foot ulcers (DFU), are common in hospital settings and are expected to increase in the future. Our goal is to analyze the prevalence, demographics, revascularization, and amputation associated with DFU.

Methods:

All diagnoses and procedures were identified with ICD-9-CM code from the National Inpatient Sample (NIS) database (2008-2014). All statistical analyses were done with IBM SPSS statistical software ver.24. Type I error level was set at 0.05.

Results:

The total number of DM and DFU in this study was (9567169 & 309496) respectively. Prevalence of DM was higher in the patients 65yr or older than younger patients, males (28.7% vs. 22.5%), Native Americans (NAA) and African Americans (AA) compared to Caucasians (CA, 31.1% and 30.6% vs. 23.3%), and patients in the 0-25thpercentile of the income scale (IT1) than those at 76th-100thpercentile (IT4, 28% vs 20.9%,all p<.001). DFU was most prevalent in those 45-64yr (IT3, 4.3%), males (4.4% vs. 2.2%), in NAA (4.1%) than AA (3.4%) and CA (3.2%) and higher in IT1 compared to the IT4 (3.4% vs 3.1%,all p<.001). Annual rates of minor amputation (MIA) increased from 13.7% to 16.4% over the study period (coeff=0.55%, P=.002) while major amputations (MAA) was relatively unchanged. The MAA rate in age group 18-24yr was 1.5% compared to 6.3% in age group >=65yr (p<.001). MIA was more common in age groups of 25-44yr (17.4%) and 45-64yr (17.3%). Both MIA and MAA were higher in males (6.1% and 16.9% vs 5.3% and 11.5%,both p<.001). MAA was higher in AA than CA (7.8% vs 5.2%, p<.001). Medicare patients had a higher rate of MAA than private insurance patients (6.3% vs 4.7%, p<.001). MAA and MIA were higher in IT1 group than the IT4 group (6.6% and 15.2% vs 4.8% and 14.2%, both p<.001).

Annual rate of revascularization (RV) decreased over time (11.2 to 10.5%, coeff = -0.16%, p=.011). RV for the DFU was higher in patients >=65yr (14.7%), females (11.3% vs 10.4%), Medicare patients than private insurance (12.8% vs 8.8%) and in IT4 than IT1 (11.5% vs 10.3%, all p<.001). Both open RV and endovascular interventions were higher in the IT4 group (8.3% and 3.7% respectively) compared to the IT1 group (7.8% and 3.1%, respectively, all p <.001).

Post-hospital discharge to nursing home was higher in females (33.4% vs 28.1%), higher in IT4 than IT1 (32.5% vs 28.5%, both p<.001), with no differences seen between AA and CA (31.5% vs 31.1%, P>.05).

Conclusion:

The prevalence of DM is higher in patients >=65yr, males, NAA, AA and low-income patients. DFU has a higher incidence in the IT3 group 45-64yr, males, NAA, AA and the low-income group. Amputation rate was high in the older age group, males, AA, and the low-income group. This study demonstrates variations in DM and DFU as well as amputations based on (ethnicity, income, age and gender), and also suggests that there are disparities of health in the prevalence and management of DFU.
 

103.13 Superior Cardiovascular Morbidity and Mortality in Patients Undergoing PTFE Tibial/Peroneal Bypass

Posted on January 31, 2019

M. Khalil2, F. J. Veith2, G. J. AlAwwa2, L. Flores2, P. Haser2, A. J. Tortolani2, N. J. Gargiulo2  2The Brookdale University Hospital and Medical Center,Surgery,New York, NY, USA

Background:  Polytetrafluoroethylene (PTFE) tibial and peroneal bypasses without vein cuffs, patches or arteriovenous fistulas have been advocated for critical limb ischemia.  We hypothesize superior short (30 day) and long-term (1/5 years) cardiovascular morbidity and mortality in those patients undergoing PTFE grafting as compared to those undergoing primary amputation.  This reviews our 40-year experience.

Methods: A retrospective analysis was performed on a cohort of 23,391 patients with critical limb ischemia requiring revascularization between July 1977 and January 2017.  In this cohort, 443 (1.89%) of the 23,391 patients underwent 443 PTFE bypasses to a tibial or peroneal artery without any adjunctive procedure.  In this same cohort, 103 (0.44%) patients had no distal target vessel for revascularization despite thrombolytic and/or anticoagulation/anti-platelet therapy and required primary amputation.  Cumulative life table primary and secondary patency and limb salvage rates were calculated for all PTFE tibial and peroneal artery bypass procedures.  Short (30 day) and long-term (1 year/5 year) cardiovascular morbidity and mortality were compared between the PTFE and primary amputation group.  In addition, ethnic background, TASC distribution, hemoglobin A1C levels, and inflammatory mediators (CRP, IL-6, and IL-10) were compared.  Multivariate logistic regression was used to calculate intergroup differences with significance determined as P<0.02.

Results: Five- and 10-year primary patency and five- and 10-year limb salvage for the PTFE cohort was 34.0%, 33%, 73.3%, and 33% respectively.   Short term (30 day) cardiovascular outcome in the PTFE (0.3%, 0.5%, 0%) cohort far exceeded that in the primary amputation (3%, 7%, 21%) group with regards to stroke, MI and death.    These short term cardiovascular benefits were also observed long term both at 1 and 5 years in the PTFE (0.7%, 1.1%, 9%) cohort as compared to the primary amputation (5%, 13%, 17%) cohort. 

Conclusions: PTFE bypasses without adjunctive procedures to infrapopliteal arteries is an acceptable alternative option for those patients without autologous vein facing imminent amputation.  Several important perioperative strategies may help improve PTFE graft patency and overall limb salvage.  We have observed a superior short (30 day) and long-term (1/5 years) cardiovascular morbidity and mortality in those patients undergoing PTFE grafting as compared to those undergoing primary amputation. 

103.12 Catheter Directed Lysis & Thrombectomy Equally Effective for Extensive Deep Vein Thrombosis

Posted on January 31, 2019

L. Loss1, S. Stefanopoulos1, A. Siddiq1, S. Markowiak1, W. Qu1, M. F. Osman1, J. Ortiz1, F. C. Brunicardi1, M. Nazzal1  1University Of Toledo Medical Center,Department Of Surgery,Toledo, OH, USA

Introduction:

The optimum treatment of deep vein thrombosis (DVT) remains elusive and practice guidelines continue to evolve.  For acute, extensive, proximal DVT, there is currently little consensus on the role of thrombectomy compared to catheter directed lysis (CDL).  We sought to determine whether any differences in outcomes exist between thrombectomy and CDL in terms of postoperative venous patency, recurrence rate, pulmonary embolism (PE), and bleeding/hematoma.

Methods:

An IRB approved, retrospective cohort study was performed at a single academic medical center for patients with radiographically confirmed lower extremity DVT during the period of 2012-2015.  The patients were divided into thrombectomy and CDL cohorts. The thrombectomy cohort included patients treated with Angiojet™, Pulse Spray Angiojet™, or Trellis Infusion Catheter™.  Demographic information, comorbidities and laboratory data, postoperative patency, postoperative bleeding, postoperative pulmonary embolism, popliteal hematoma, and recurrence of DVT were collected. X2 tests were used with p value set at 0.05.

Results:

35 patients were identified, 54.2% (n=19) received CDL (31.6% female (n=6), average age 58.6 years, median age 64 years) and 46% (n=16) underwent thrombectomy (37.5% female (n=6), average age 46 years).  Patient comorbidities and hypercoagulable states were not significantly different among the groups (Table 1). The two groups had the same indications for treatment as they did not differ significantly in terms of their presenting symptoms (Table 1). 

The two techniques did not have significantly different postoperative patency (p=0.871), bleeding (p=0.863), PE (p=0.930), popliteal hematoma (0.367), or recurrence of DVT (p=0.849, Table 1). 5.3% (n=1) of CDL patients had postoperative compartment syndrome while no thrombectomy patients had this complication. 6.7% (n=1) of thrombectomy patients had postoperative hematuria while no CDL patients had this complication. 63.2% (n=12) of CDL patients had no postoperative complications and 60% (n=9) of thrombectomy patients had no postoperative complications (p=0.927, Table 1).  This study was powered to detect a 33% difference in outcome based on a p-value of 0.05 and power of 0.80.

Conclusions:

In selecting optimum treatment for acute, extensive, proximal DVT our retrospective cohort study found no significant differences among treatment groups in safety, efficacy, recurrence, and progression to PE.  We conclude that modality of treatment should be decided upon based on hospital resources, surgeon experience and comfort with each technique, and the patient’s physiologic status.

103.11 Brachial Vessel Injuries: An Analysis of the National Trauma Data Bank

Posted on January 31, 2019

D. R. Rigg1, A. Person1, M. Dale1, G. Mendoza1, S. Brown1, D. Keleny1, J. Dabestani1, D. Agrawal1, J. Asensio1  1Creighton University Medical Center,Department Of Trauma Surgery And Surgical Critical Care,Omaha, NE, USA

Introduction:  Brachial vessel injuries remain uncommon, even in busy urban trauma centers, and therefore many trauma surgeons have limited experience with these types of injuries. Despite being a relatively uncommon injury, the brachial artery is the most frequently damaged artery in the upper extremity due to its vulnerability and close proximity to upper extremity bony structures. Therefore, trauma surgeons must be familiar with this injury and its associated outcomes. The objective of this study are: 1) review of the nationally reported experience with these injuries; 2) Identify predictors of outcome; 3) Compare predictors of outcome; 4) Report total charges incurred in the management of these injuries.

Methods:  The National Trauma Data Bank (NTDB) was queried for pre-hospital admission data for brachial vessel injuries. Data extracted included demographics, vital signs on admission, and mechanism of injury. Univariate and stepwise logistics regression statistical analysis was used

Results: There were 1,799 patients sustaining 1,900 brachial vessel injuries out of 1,466,887 patients registered in the NTDB from 2001 to 2005. Incidence was calculated to be 0.12%. Mean age at injury was 30 ± 14, mean RTS 7.23 ± 1.8, mean Glasgow Coma Scale 13.6 ± 3.5, mean ISS 11.5 ± 9.5. Mechanism of Injury: penetrating n=1,114 (61.9%), blunt n=699 (37.1%), and non-specific n=16 (1%). Mean initial SBP 119 ± 32.5; overall and adjusted survival rates: survivors 94.7%; non-survivors 5.3%. Patients underwent surgical repair n=671. Stratified as primary arteriorrhaphy 369 (55%), RSVG 165 (24.5%), resection of upper limb vessel with replacement 116 (17.3%), PTFE 21 (3.2%). Analysis revealed an increased ISS in the blunt injury group vs penetrating (10.65±8.82 vs 13.09±10.43; p<0.001). In survivors vs non-survivors, initial systolic blood pressure, glasgow coma scale, revised trauma score, and injury severity score were all statistically significant between the two groups (see table).

Conclusion: Brachial vessel injuries remain a low incidence injury as is shown in the NTDB. The injury severity score has a higher correlation with morbidity based on mechanism of injury. The overall cost of all brachial injuries was $22,954,998 in patient with extractable information (n=727).

 

103.10 Malnutrition in Vascular Surgery Patients: Looking Beyond Serologic Markers

Posted on January 31, 2019

J. Miranda1, H. Younes1, L. Le1, L. Probstfeld2, J. Braun1, N. Barshes1, P. Kougias1, H. S. Tran Cao1  1Baylor College Of Medicine,Surgery,Houston, TX, USA 2Michael E. DeBakey Veterans Affairs Medical Center,Nutrition,Houston, TX, USA

Introduction:   Malnutrition is a known risk factor for poor wound healing and surgical wound infections, especially important clinical outcomes for vascular surgery patients.  In 2012, leading dietetic organizations issued a consensus definition of clinical malnutrition based on 6 clinical parameters (AND/ASPEN criteria).  We sought to assess the incidence of malnutrition for vascular surgery patients using this definition compared to serologic markers commonly used as indicators.

Methods:   This is a retrospective cohort study of patients undergoing elective vascular surgical procedures at a single institution (2015-2017) who received malnutritional screening via a comprehensive nutritional program that included AND/ASPEN criteria.  These criteria include weight loss, decreased oral intake, muscle mass loss, loss of subcutaneous fat, fluid accumulation, and decreased hand grip strength.  Per AND/ASPEN guidelines, at least two deficits must be met to establish a diagnosis of malnutrition.  Correlation with serologic markers was measured.

Results:  Among 65 patients admitted for elective vascular procedures who received a comprehensive nutritional screening by a trained dietitian, 16 (24.6%) did not meet criteria for malnutrition, 21 (32.3%) were moderately malnourished, 11 (16.9%) were severely malnourished, and 17 (26.2%) were not fully assessed due to missing anthropometric data or key elements of the history and physical examination.  Although serum albumin was higher among non-malnourished patients than moderately and severely malnourished patients (3.12 ± 0.64 vs. 3.04 ± 0.51 vs. 2.71 ± 0.68, respectively, p=0.202), this difference failed to reach significance.  Moreover, 10/21 (47.6%) of moderately and 3/11 (27.3%) of severely malnourished patients had serum albumin > 3.0 g/dL, a cut-off often used to represent malnutrition.  Serum prealbumin was not routinely obtained, but was likewise non-discriminatory in detecting clinical malnutrition (e.g. exceeding 18 mg/dL in malnourished patients by AND/ASPEN criteria).  In turn, no surgical site infection was encountered in the clinically non-malnourished cohort, compared to 3 detected in clinically malnourished patients, including one without hypoalbuminemia.

Conclusion:  The prevalence of clinical malnutrition is significant among vascular surgery patients, and may not be fully appreciated with serologic markers alone.  As malnutrition may be a modifiable preoperative risk factor, efforts to comprehensively screen for this condition relying on a combination of clinical and serologic markers may be beneficial.
 

103.09 Examination of Race and Conduit Use for Lower Extremity Bypass in the SVS Vascular Quality Initiative

Posted on January 31, 2019

L. Stewart1, A. Beck1, E. Spangler1  1University Of Alabama at Birmingham,Department Of Surgery, Division Of Vascular Surgery And Endovascular Therapy,Birmingham, Alabama, USA

Introduction: Vein conduit for infrainguinal bypass (IB) has better patency than prosthetic conduits.  We explore if racial disparities exist in use of vein conduit for IB, and examine associations of patient factors and systems of care factors with racial disparities in conduit use. 

Methods: We analyzed a retrospective cohort of 23,959 IBs originating from the common femoral artery performed for occlusive disease with non-missing race/ethnicity in the SVS Vascular Quality Initiative (VQI) from 2003-17.  Demographics of patients receiving vein vs other conduit were compared by t test and X2 testing, while univariate and multivariate logistic regression analyses were performed to evaluate for predictors of vein conduit use, with the pseudo-R2 used as an assessment of the model. 

Results:Lower proportions were found in vein bypass patients of women, minorities, emergent cases, patients with ASA class>3, prior CABG, prior IB or ipsilateral IB, dialysis, or COPD.  A higher proportion of vein bypass patients had vein mapping, distal target below the knee, or diabetes. 

Unadjusted regression of vein use by race showed black patients were 88% as likely (p<.001), Hispanic patients 90% as likely (p=.08), and non-white/non-black/non-Hispanic patients 93% as likely (p=.37) to have a vein IB compared to white patients;  however race alone explains only 0.04% of variation in vein conduit use.  Adjusted models after backward stepwise regression demonstrated black patients were 76% as likely (p<.001), Hispanic patients 79% as likely (p=.003), and non-white/non-black/non-Hispanic patients 83% as likely (p=.09) to have a vein IB compared to white patients; however other factors had greater weight within the model.  Factors most correlating with vein use included vein mapping and more distal target.  Factors most strongly against vein use included higher age, ASA class 4, bedridden mobility status pre-op, any prior CABG, prior ipsilateral IB, or bypass performed before 2012; however the entire adjusted model still explained only 15% of variation in vein conduit use.  Due to the importance of vein mapping, we examined the racial breakdown of vein mapping by target level (Figure) and saw that while black patients were less likely to receive vein IB, they were vein mapped at similar or higher rates than other groups.

Conclusion: Racial disparities exist in conduit use for IB from the common femoral artery for occlusive disease, with blacks less likely to receive vein bypasses, however the contribution of race to conduit selection is small in adjusted and unadjusted models.  Overall, pre-operative variables captured in the VQI poorly predicted vein conduit use for IB.

 

103.08 Factors Contributing to Chronic Venous Disease and Venous Leg Ulcers

Posted on January 31, 2019

F. Alanazi1, A. Baothman1, W. Qu1, M. Osman1, K. Bauer1, J. Ortiz1, F. C. Brunicardi1, M. Nazzal1  1University Of Toledo Medical Center,Department Of Surgery,Toledo, OH, USA

Introduction:

Chronic venous disease (CVD) and venous leg ulcers (VLU) are common medical problems that cause loss of work hours and require lengthy medical treatment. In this study we analyzed the social determinants of health associated with factors that contribute to both CVD and VLU.

Methods:
National Inpatient Sample (NIS) database (2008-2014) of the Healthcare Cost and Utilization Project (HCUP) was used to select adult (≥18 years) CVD and VLU patients in the study. All diagnoses and procedures were identified with ICD-9-CM code. Statistical analyses were done with IBM SPSS statistical software ver. 24. Type I error level was set at 0.05.

Results:

Total number of patients with CVD and VLU in the study was 2,418,709 and 610,895, respectively. While the decrease in general hospital admission rate in the period from 2008 to 2014, the prevalence of CVD increased by 51.1% (from 0.87% to 1.32%, coeff=0.07, P<.001), and the prevalence of VLU increased by 57% (from 0.22% to 0.34%, coeff=0.02, P<.001). The prevalence of VLU in CVD patients increased by 3.9% in the same period (from 24.8% to 25.7%, coeff=0.135, p=.012).

Prevalence of CVD increased with age (from 0.3% in 18-24 years group to 1.7% in ≥65 years group, Cochran–Armitage test p<.001). Other risks for CVD included: male gender (1.37% vs 0.94%, P<.001 ), Caucasian (CA) vs. African American (AA) and Hispanics (HIS, 1.29% vs. 0.85% and 0.65%, both P<.001), patients in the 26th-50thpercentile (IT2) and 51st-75thpercentile of the income scale (IT3, 1.15 and 1.13%, respectively) compared to those in 0-25thpercentile (IT1, 1.08%) or76th-100thpercentile of the income scale (IT4, 1.11%)(all P<.001), and patients with BMI ≥ 40 compared to those with BMI<40 (5.5% vs. 0.90%,P<.001).

The prevalence of VLU in CVD patients was highest in patients of age 45-64 years (28.5%), gradually decreased to 25.8% (age 25-44 years), 23.8% (age ≥65 years), and 19.2% (age 18-24years, all P<.01). Other risk factors for VLU were: male gender (28.1% vs 22.7%, P<.001), AA and HIS compared to CA (36.2% and 27.4% vs. 23.7%, both P<.001), IT1 compared to IT2 -IT4 (27.6% vs. 24.8%, 24.6%, and 23.6%, all P<.001); patients with BMI ≥ 40 compared to those with BMI<40 (26.9% vs. 24.9%,P<.001).

Conclusion:

This paper reflects demographic and social status variations in patients with CVD and VLU. The prevalence of both CVD and VLU increased over the years of the study. Prevalence of CVD is higher in elders, in CA compared to HIS and AA, in patients in intermediate household incomes compared to higher and lower household income groups, and morbidly obese patients. The prevalence of VLU is higher in the middle age group, in men, in AA and HIS, in low income patients and morbidly obese patients. Analysis of the NIS data indicates an increasing burden of chronic venous disease and venous leg ulcers, particularly among populations at risk for poor social determinants of health.

103.07 Chronic Renal Failure is Not a Contraindication for Femoral Endarterectomy in Claudicants

Posted on January 31, 2019

L. A. Huntress1, J. Kalenik2, V. Dombrovskiy1, S. G. Huang1, R. Shafritz1, S. Rahimi1  1Rutgers RWJMS,Division Of Vascular Surgery,New Brunswick, NJ, USA 2University of Georgia,Athens, GA, USA

Introduction:  Femoral endarterectomy has proven to be a durable vascular reconstructive procedure for patients with critical limb ischemia (CLI). Our objective was to evaluate its applicability in patients with chronic renal failure that have severe claudication.

Methods:  Patients 18 years or older with severe claudication who underwent femoral endarterectomy were selected from the 2012-2015 National Inpatient Sample using the appropriate ICD-9 and ICD-10 diagnosis and procedure codes. Postoperative outcomes in those with and without renal failure were compared using the Chi square test, multivariable logistic regression analysis, and Wilcoxon rank sum test. Patients with acute renal failure were excluded from the analysis

Results: Among the 30,805 patients in the study population, 2,705 (8.8%) had chronic renal failure. The likelihood of this comorbid disease was greater in older patients (70 years or older) compared to younger counterparts (OR [odds ratio]=1.74; 95%CI [confidence interval] 1.61-1.88), greater in females as compared to males (OR=1.22; 95%CI 1.12-1.33), and greater in Blacks as compared to Whites (OR=1.96; 95%CI 1.73-2.22). In the multivariable logistic regression analysis with control for age, gender, race, and comorbidities, chronic renal failure did not affect the rates of cardiac and respiratory complications, postoperative stroke, sepsis, or embolism/thrombosis of lower extremity arteries. No patient with chronic renal failure who underwent femoral endarterectomy required a major amputation as a complication of the procedure. However, patients with renal failure were more likely to develop bleeding (OR=1.35; 95%CI 1.20-1.51), or require blood transfusions (OR=1.89; 95%CI 1.69-2.13). Multivariable analysis showed equivalence in all cause hospital mortality between two groups. However, patients with chronic renal failure had longer hospital length of stay (median= 3 days, IQR [interquartile range] 2-4 days vs median= 2 days, IQR 1-3 days; P<0.0001) and greater total hospital cost (median= $14,235; IQR $9,621-20.878 vs median= $12,810; IQR $8,824-18,953; P<0.0001) compared to patients with normal renal function.

Conclusion: Femoral endarterectomy is a safe procedure in severe claudicants with chronic renal failure, but is associated with greater hospital resource utilization. Because of greater hospital LOS and increased bleeding complications, femoral endarterectomy in patients with chronic renal failure and claudication should be offered with caution.

 

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.

 

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