89.01 Where You Live Matters: Regional Differences in Outcomes After Percutaneous Cholecystostomy

Posted on January 26, 2017

A. E. Hozain1,2, P. J. Chung1,2, M. C. Smith1,2, V. Roudnitsky2, A. E. Alfonso1, G. Sugiyama1  1State University Of New York Downstate Medical Center,Department Of Surgery,Brooklyn, NY, USA 2Kings County Hospital Center,Department Of Surgery,Brooklyn, NY, USA

Introduction:
With over 200,000 cases per year, acute cholecystitis is one of the most frequent causes for admission to hospitals and management by general surgeons. Percutaneous cholecystostomy is an increasingly used treatment for patients diagnosed with acute cholecystitis, who are otherwise too ill to undergo cholecystectomy. Given these patients’ significant comorbidities, a retrospective analysis to determine predictors of mortality was performed using the Nationwide Inpatient Sample (NIS).

Methods:
The Nationwide Inpatient Sample (NIS) from 2005 – 2012 was sampled. Inclusion criteria included patients with a diagnosis of acute cholecystitis by ICD 9 code (574.0, 574.00, 574.01, 575.0, 575.12) who underwent percutaneous cholecystostomy (51.01). We excluded patients with a diagnosis of acalculous cholecystitis (575.10), patients age < 18 years, and cases where gender, race, weekend admission, and month of admission data were missing. For each case, we computed the Elixhauser-Van Walraven score for comorbidity status. Multiple imputation was performed for missing data. We then performed multivariable logistic regression analysis with inpatient mortality as the primary outcome variable. Age, gender, race, insurance status, income status, hospital size, hospital type, geographical region, weekend admission, month of admission, and Elixhauser-Van Walraven score were used as risk variables.?

Results:
8,299 patients were included in this study. 785 (9.46%) patients died during the hospital admission. After adjusting for the risk variables, predictors for inpatient mortality included age (OR 1.16 [1.00 – 1.34 95% CI], p = 0.0492), receiving care in an urban non-teaching hospital (OR 1.27 [1.08 – 1.50 95% CI], p = 0.0169), female gender (OR 1.30 [1.12 – 1.52 95% CI], p = 0.0006), and the Elixhauser-Van Walraven score (OR 2.13 [1.93 – 2.36 95% CI], p < 0.0001). There was a decreased risk of death for patients receiving care in the Midwest (OR 0.74 [0.59 – 0.94 95% CI], p = 0.0357) and West (0.78 [0.63 – 0.98 95% CI], p = 0.0357) compared to the Northeast.

Conclusion:

Adjusting for multiple variables, receiving treatment within the Midwest and Western regions of the United States was independently associated with a decreased risk of mortality in patients undergoing percutaneous cholecystostomy. Risk factors associated with increased mortality include age, female gender, Elixhauser-Van Walraven comorbidity score and urban, non-teaching hospitals. To improve outcomes nationally, models looking at practice differences between regions may further elucidate significant differences in quality or process of care.  

88.20 Depression Increases Amputation and Mortality Risk in Patients with Peripheral Arterial Disease

Posted on January 26, 2017

S. Lee1, A. Khakharia1, Z. O. Binney1, G. Zahner2, M. S. Grenon2, S. Arya1,3  1Emory University School Of Medicine,Vascular Surgery,Atlanta, GA, USA 2University Of California – San Francisco,Vascular Surgery,San Francisco, CA, USA 3Atlanta VA Medical Center,Surgery Service,Decatur, GA, USA

Introduction: As a multi-system illness, peripheral arterial disease (PAD) affects many areas of patients’ lives, including their mental health. Recent studies have associated depression with increased risk of PAD. The link between PAD outcomes and depression has however yet to be fully defined. In this study, we examined the effects of comorbid depression on amputation rate and mortality in the Veteran Affairs (VA) population.

Methods: Patients with PAD in the VA database were identified (2003-2014) using a validated algorithm. The diagnosis of depression was defined using 2 outpatient diagnosis codes for depression within 14 months or one inpatient primary diagnosis code of depression (ICD-9 codes 296.2, 296.3, 300.4 and 311). Outcomes were amputation risk and overall mortality at 1, 3, and 5 years. Kaplan-Meier analysis was used to assess time to amputation. A Cox proportional hazards model was used to assess the effect of depression on amputation and mortality adjust for covariates, including age, gender, race, social economic status, comorbidities, cholesterol levels, creatinine, and medications.

Results: In 208,194 patients with PAD, depression was present in 15.2% of the cohort, with occurrence of 14,981 major amputations and 99,870 deaths [Median follow up 5.2 yrs]. Bivariate comparisons showed increased risk of amputation at 1, 3 and 5 years for patients with depression (4.6% vs 3%, 7.3% vs 5.1% and 10.3% vs 7.3% respectively; p<0.0001 for each group). Mortality was also similarly higher in patients with depression at each time point (7.2% vs 6.2%, 22.4% vs 20.0% and 38.3% vs 33.5% respectively; p<0.0001 for each group). On Kaplan-Meier analysis, patients with depression had more amputations earlier in the disease course than patients without depression [Figure 1] but did not have an increased risk of mortality after accounting for censoring [Figure 2]. In the Cox model, depression was associated with a 16% higher amputation risk as compared to patients with no underlying depression [HR 1.16; 95% CI (1.11, 1.22)].  Depression was also associated with increase in overall mortality of 17% [HR 1.17; 95% CI (1.14, 1.19).

Conclusion:PAD patients with depression have a significantly higher risk of amputation and mortality than patients without depression. These results suggest that concomitant depression in PAD contributes to morbidity and mortality of these patients and could possibly be a target for intervention.

 

88.19 Feasibility of an Image-Based Mobile Health Protocol for Postoperative Wound Monitoring

Posted on January 26, 2017

R. Gunter1, S. Fernandes-Taylor1, S. Rahman1, L. Awoyinka1, K. Bennett1, C. Greenberg1, K. C. Kent2  1University Of Wisconsin,Wisconsin Institute Of Surgical Outcomes Research,Madison, WI, USA 2University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction:
Surgical site infection is the most common nosocomial infection and a leading cause of unplanned hospital readmission among surgical patients. Many of these infections develop in the critical interval between hospital discharge and routine follow-up. If diagnosed at an early stage, SSI can often be treated in the outpatient setting. However, patients rarely recognize early stage wound infections causing them to present with an advanced infection requiring rehospitalization or operative reintervention. An intervention to prevent these catastrophic consequences would represent a substantial improvement in patient care. To address this, we developed and pilot tested a mobile health application (app) and protocol of remote wound monitoring using smartphones for vascular surgery patients at a large tertiary care academic institution.

Methods:
We are currently recruiting 40 patients following vascular surgery. Eligible patients are 18 years of age or older with an incision at least 3 cm in length. Patients participate in a training session to learn to use the iPhone and the wound monitoring app. Following hospital discharge, patients send digital images of their wound and responses to a short survey daily for two weeks. Experienced healthcare providers on the vascular surgery service review these submissions daily and contact patients for any concerning findings. We will present final results, if accepted.

Results:
Since June 2016, 89 patients have been screened, 41 of whom were eligible for participation. Twenty-eight have consented to participate and been enrolled (68% consent rate). Fifty-four percent of participants were novice smartphone users. Participants completed training in an average 16.5 minutes, with an average system usability score of 85.2 (scale 0-100). Fifty-five percent of participants submitted data every day, with an average of 1 day missed per participant. A provider reviewed submissions an average of 9.4 (range 0.1-51.6) hours after submission. Review took an average 2.3 (range 1-33) minutes per patient, with an average total 7.9 (range 1-39) minutes per day. Three participants were readmitted, two of whom fell on amputation stumps. Two early wound infections were detected using submitted images and treated on an outpatient basis; no wound infections developed undetected in monitored sites. Patient satisfaction has been universally high upon completion.

Conclusion:
Vascular surgery patients and their caregivers are willing to participate in a mobile health program aimed at remote monitoring of postoperative recovery, and they are able to complete the program with a high level of fidelity and satisfaction. Such a program is easily integrated into existing service lines and does not add a significant clinical burden. Preliminary results indicate the ability to detect and intervene on wound complications at earlier stages and prevent hospital readmission and potentially catastrophic wound complications.

88.17 Examining the Impact of Hospital Transfer in Patients with Isolated Lower Extremity Vascular Trauma

Posted on January 26, 2017

C. McDaniel1, N. Samra1, B. Hu2, W. Zhang1, T. Tan1  1Louisiana State University Health Sciences Center, Shreveport,Vascular And Endovascular Surgery,Shreveport, LA, USA 2Cleveland Clinic,Cleveland, OHIO, USA

Introduction:
Care of patients with vascular trauma often poses complex challenges that prompt transfer to higher-level trauma centers. We seek to investigate the impact of hospital transfer on the outcomes of patients with isolated lower extremity vascular injuries.

Methods:
A retrospective review of the National Trauma Data Bank (2007-2014) was performed to identify patients with isolated lower extremity vascular injury. Bivariate analysis was used to compare patient characteristics and outcomes between those transferred into level I centers and patients treated at non-level I trauma centers. Multivariable logistic regression was used to examine association between hospital transfer and outcomes, as well as factors associated with fasciotomy.

Results:
Among 2,698 with lower extremity vascular trauma included in the study, 35% (956) were transfer to level I trauma centers and 65% (1,742) were treated in non-level I centers. Overall amputation rate was 12% and fasciotomy rate was 35%, and were similar between two cohorts (Table 1). Although there were no significant impact on mortality or amputation rates, hospital transfer was associated with increased risk of fasciotomy (OR 1.3, 95% CI 1.1-1.6, p=.002) in patients with lower extremity vascular injuries. Other factors associated with fasciotomy were open surgery (OR 1.8, 95% CI 1.4-2.2,p<.001), venous (OR 1.5, 95% CI 1.1-2.0,P=.02) and nerve injury (OR 2.7, 95% CI 2.2-3.2,p<.001).

Conclusions:
Hospital transfer was associated with increased risk of fasciotomy that might be secondary to potential delay in care in patients with lower extremity vascular injuries.

 

88.16 Brachial Vein Arteriovenous Graft: Approach From Small Outflow Vein To A Large Diameter Vein

Posted on January 26, 2017

P. Sanchez1, J. C. Duque1, g. klimovich2, H. Labove4, L. Martinez2, R. Vazquez-padron2, L. Salman3, M. Tabbara2  1University Of Miami,Medicine,Miami, FL, USA 2University Of Miami,Surgery,Miami, FL, USA 3University Of Miami,Interventional Nephrology,Miami, FL, USA 4University Of Miami,Miller School Of Medicine,Miami, FL, USA

Introduction:

Arteriovenous Grafts are created in the arm when there are no adequate veins for a fistula. The outflow vein is usually the axillary vein in order to match the outflow to a 6-8mm graft. Our technique involves using a 3.5-4 mm brachial vein and create a preliminary mid arm brachial artery to brachial vein arteriovenous fistula. This is followed with a graft extension involving ligation of the fistula and using the dilated, mature vein as the outflow in an end-to-end anastomosis.  

Methods:
The study included 92 patients who underwent a Brachial- Brachial Arteriovenous Graft creation at the University of Miami or Jackson Memorial Hospital from 2008 to 2015. The effects of primary graft survival were determined using multivariate logistic regressions and Cox proportional hazard models adjusted for clinical and demographic covariates (age, gender, ethnicity, hypertension, diabetes, antiplatelet agents, statins, prior catheter use, history of previous AVF and graft size). 

Results:

Neither primary nor secondary graft survival was significantly correlated with clinical and demographic covariates.  Primary failure at one year (365 days) was 55.4% (51 patients) with a mean survival of 283 (±128) days. The most common intravascular intervention in primary graft survival was balloon angioplasty in 32 (64.0%), followed by thrombectomy 11 (22.0%) and finally surgical revision 7 (14.0%).     

Conclusion:

Our results suggest that the technique of a brachial vein fistula, followed by graft extension can result in a durable access and preserves the axillary vein for future grafts.

 

88.15 Assessment of Ventricular Mass Changes after Arteriovenous Fistula Banding in Hemodialysis Patients

Posted on January 26, 2017

J. C. Duque1, C. Cortesi1, A. Dejman3, L. martinez2, r. vazquez-padron2, L. salman4, m. tabbara2  1University Of Miami,Medicine,Miami, FL, USA 2University Of Miami,surgery,Miami, FL, USA 3University Of Miami,Nephrology,Miami, FL, USA 4University Of Miami,Interventional Nephrology,Miami, FL, USA

Introduction:

Cardiac remodeling and left ventricular hypertrophy are relatively common complications seen in patients with advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD) ranging from 32 to 75% and 27 to 58%, respectively. Arteriovenous fistula (AVF) for hemodialysis has been traditionally implicated as one of the main factors related to cardiovascular stress and subsequent remodeling. 

Methods:

We retrospectively reviewed AVF banding procedures performed at University of Miami Hospital /Jackson Memorial Health System between Jan 1st 2009 and Dec 31st 2014. Demographic data, patient´s comorbidities, AVF type and 2D-Echocardiogram done before and after banding with a minimum interval of 6 months from the procedure were analyzed. 

Results:
From at total of 74 patients who underwent AVF banding, 24 had 2D-Echocardiogram performed before and after the banding; 33 patients had a 2D-Echocardiogram done before and 38 had it after the procedure. The interval time between the 2 sonograms was 1108.9 (±628) days, 651.8 (±484) days before and 457.0 (±365) days after the surgical banding. The mean age at the time of the procedure was 55 (±12); hypertension was present in 95.8% of the patients, coronary artery disease 41.6% and diabetes mellitus 62.5%. Brachio-basilic AVF was the most common vascular access in 62.55% of the patients, followed by brachio-cephalic in 29.1% and radio-cephalic in 8.3% of the patients. Left ventricular mass calculated by (LVmass(ASE): 0.8 (1.04 ([LVIDD + PWTD + IVSTD] 3 – [LVIDD] 3 ))+ 0,6 g) was 202.8 (±78) before the surgical banding and 216.8 (±82) after the banding with a p value: 0.5591. (Normal LV mass 90 – 117).

Conclusion:

We found statistical significance supporting that patients with ESRD who underwent AVF surgical banding have minimal changes or left ventricular mass restitution after the procedure and likely the hypertrophic changes are related to non-surgical factors.

88.13 Human Immunodeficiency Virus effect on Hemodialysis Arteriovenous Fistulas Remodeling Outcomes

Posted on January 26, 2017

A. Dejman1, J. C. Duque2, L. Martinez3, L. Salman4, R. Vazquez-Padron3, M. Tabbara3  1University Of Miami,Nephrology,Miami, FL, USA 2University Of Miami,Medicine,Miami, FL, USA 3University Of Miami,Suergery,Miami, FL, USA 4University Of Miami,Interventional Nephrology,Miami, FL, USA

Introduction:
Arteriovenous fistulas (AVF) for hemodialysis in ESRD patients is the preferred vascular access type and it currently remains to be one of the areas under profound research given the high rates of failure, complications and cost burden for the health system. Multiple advances in vascular diseases in HIV patients independent to hemodialysis accesses have been reported. One remarkable connotation is the role of the HIV virus and the direct effect in the vessel wall, in which some authors have shown that these patients have a higher incidence of cardiovascular illnesses with elevated morbidity and mortality and poor vascular outcomes. Unfortunately, the impact of the Human Immunodeficiency Virus (HIV) in the AVF remodeling and outcomes is not well known.

Methods:
This retrospective study assessed the impact of HIV infection on one-stage and two-stage hemodialysis AVF outcomes. The study included 494 patients but only 42 patients were HIV positive. All of them underwent an AVF creation at the University of Miami/Jackson Memorial Hospital from 2008 to 2014. The effects of HIV on primary failure were determined using multivariate logistic regressions and Cox proportional hazard models adjusted for 10 clinical and demographic covariates.

Results:

Primary failure was not correlated with clinical including medications and demographic covariates, but population was relatively younger than controls. Patients with diagnosis of HIV had a positive correlation with AVF primary failure (p=0.004) no mater the anastomosis type. Patients with HIV and history of previous AVF had association with primary failure (p=0.002). Moreover different access such as Tunneled dialysis catheters showed correlation with primary failure (p=0.012)  A T-cell subset including  (CD3, CD4, or CD8)  did not show any association with primary failure. 

Conclusion:

Our results suggest that HIV immunosuppression may play a role in AVF outcomes specially primary failure. HIV infection relates to increased rate of AVF primary failure, but this is not explained by the T-cell subset counts and  there should be a different immunological relationship between AVF failure and vascular remodeling.

 

88.12 The Role of Inferior Vena Cava (IVC) Filters in Robotic Gastric Bypass Procedures

Posted on January 26, 2017

N. J. Gargiulo1, N. Cayne2, E. Lipsitz3, G. Landis4, F. J. Veith2  1Cinch Valley Medical Center,Vasclar Surgery,Richlands, VIRGINIA, USA 2New York University School Of Medicine,New York, NY, USA 3Albert Einstein College Of Medicine,Bronx, NY, USA 4North Shore University And Long Island Jewish Medical Center,Manhasset, NY, USA

Introduction:  It has been previously suggested that inferior vena cava (IVC) filter placement at the time of open gastric bypass in patients with a body mass index (BMI) > 55 kg/m2 reduces both the pulmonary embolism rate and perioperative mortality.  This has not been observed in patients undergoing laparoscopic gastric bypass.  Little is known regarding the necessity of IVC filter placement in patients undergoing robotic gastric bypass surgery.

Methods:  Over a 3 year period, 51 morbid obese patients have undergone robotic gastric bypass procedures, and 37 (72.5%) had a BMI > 55 kg/m2.  All 51 patients had routine preoperative subcutaneous lovenox injections and systemic compression devices prior to the administration of general anesthesia.  Robotic gastric bypass was completed utilizing the da Vinci system.
 

Results: Fifty of 51 (98%) patients remained free of thrombo-embolic phenomena over the 3 year period (range 6 months-3 years) following successful robotic gastric bypass with the da Vinci system.  One patient (2%) with a BMI > 55 kg/m2 developed a pulmonary embolism (PE) 1 month post procedure.  She was treated  successfully with intravenous heparin and had complete resolution of the PE.  She was incidentally diagnosed with a Factor V Leiden deficiency and placed on long-term oral anticoagulation.
 

Conclusion: It appears that IVC filter placement at the time of robotic gastric bypass is not required even in patients with a BMI > 55 kg/m2.  A note of caution should be exerted in those obese patients who have a hypercoagulable disorder.  An aggressive posture should be advocated in this small sub-group of morbid obese patients which may consist of immediate anticoagulation (when it is deemed safe) following their procedures.  

 

88.11 Analysis of Short-term Outcomes After Endovascular and Open Infrapopliteal Revascularization

Posted on January 26, 2017

H. J. Leraas1, S. S. Adkar1, Z. Sun1, B. F. Gilmore1, U. P. Nag1, C. A. Long1, W. S. Jones1, C. K. Shortell1, R. S. Turley1  1Duke University Medical Center,Durham, NC, USA

Introduction:  Consensus guidelines regarding optimal treatment of infrapopliteal arterial disease for critical limb ischemia (CLI) lack specificity with respect to surgical and endovascular interventions. Evidence that endovascular approaches to infrapopliteal disease are associated with lower 30-day morbidity than open surgical bypass consists predominantly of small case series without matched surgical comparisons. The objective of this study is to compare the 30-day outcomes of patients treated with endovascular or open interventions for infrapopliteal disease.

Methods: The 2011-2013 NSQIP Vascular database was queried for CLI patients undergoing femoral distal bypass, popliteal distal bypass, or tibial angioplasty. Surgical patients were propensity matched 2:1 to tibial angioplasty using the nearest neighbor method. Variables for matching were age, race, BMI, elective vs. emergency surgery, ASA class, rest pain vs. ischemic tissue loss, diabetes, renal failure, dialysis, wound classification, and smoking. Primary endpoints were 30-day major adverse events (death, stroke, MI), or major amputation. Secondary endpoints were post-operative wound complications, length of stay, and readmission.

Results: 317 endovascular patients were matched to 634 surgery patients. Types of surgery were femoral distal bypass with prosthetic (28%), femoral distal bypass with saphenous vein (48%), and popliteal distal bypass with saphenous vein (24%). All endovascular patients underwent tibial angioplasty/stenting. Median age (95% CI) was 54 (45-63) and 53 (44-62) years and median BMI (95% CI) was 27 (24-31) and 27 (24-31) for surgery and endovascular, respectively. Tissure loss was present in 77% of surgery patients and 80% of endovascular patients, with all remaining having rest pain. The need for emergency intervention (3.9% vs. 3.8%) was similar in both groups. While there were no significant differences in major amputation or 30-day mortality between the treatment groups, surgery had a higher incidence of combined stroke/MI (4.6% vs. 1.3%, p=0.009), post-operative wound infection (12.8% vs 7.3%, p =.01), and longer median hospital stay (8 days vs 3 days, p <.001). Surgery patients were also more likely to be discharged to a skilled care facility (25.9% vs 12.6%, p<.001) or be readmitted (4.4% vs 3.2%, p=.024). (Table 1) 

Conclusion: Endovascular treatment of infrapopliteal disease with CLI has similar 30-day major amputation and mortality with fewer stroke/MIs, wound infections, hospital days and readmissions compared to surgery. Long term comparisons are needed to provide objective data on which to form consensus guidelines for the optimal treatment for critical limb ischemia due to infrapopliteal arterial disease.

 

88.10 Open & Endovascular Ruptured AAA Repair Have Equivalent Outcome When Performed Weekdays vs Weekends

Posted on January 26, 2017

G. Gilot1, E. Abotsi1, G. Ortega1, C. Zogg2, D. Taghipour1, D. Tran1, E. Cornwell1, K. Hughes1  1Howard University College Of Medicine,Department Of Surgery,Washington, DC, USA 2Yale University School Of Medicine,New Haven, CT, USA

Introduction:

Studies have demonstrated that there may be an increased risk of postoperative complications for certain surgical procedures when performed during weekends.  This “weekend effect”, however, has not been studied for vascular surgical procedures such as repair of an abdominal aortic aneurysm (AAA). We undertook this study to determine if repair of ruptured AAA (rAAA) performed on weekends differed in outcomes as compared to rAAA operations performed on weekdays.    

Methods:

We conducted a retrospective review of the Nationwide Inpatient Sample (NIS) database to identify all patients who underwent an open or endovascular rAAA repair from 2007 to 2012. Data analyzed included patient characteristics including demographics and comorbidities, as well as postoperative morbidity and mortality. Operations were dichotomized into Weekday (Mon-Fri) and Weekend (Sat and Sun); and open versus endovascular. Multivariate analysis was performed adjusting for patient characteristics and comorbidities to evaluate postoperative outcomes by groups. 

Results:

A total of 15,418 patients had a rAAA repair. The majority were non-Hispanic White (87%), males (72%), with a mean age of 75 (SD±10) years. Overall mortality was 47.8%.  Postoperative complications occurred in 30.5% of patients.

 

In those undergoing open repair, (n=6,623), the mean age was 73 (SD±9) years with an overall mortality of 39.5% and overall complication rate of 43.1%. Most open rAAA repairs were performed on a weekday (72.4%). Comparing weekday versus weekend, open rAAA repair, there were similar rates of mortality (40.6% weekday vs. 39.1% weekend; p=0.264) and morbidity (43.5% weekday vs. 42.9% weekend; P=0.693).

 

In those undergoing endovascular repair, (n=2,170), the mean age was 74 (SD±10) years with an overall mortality of 26.5% and morbidity of 31.6%.  The mortality rate was 26.5%. The in-hospital complication rate was 31.6%. A majority of operations were performed on a weekday (75.2%). Comparing weekday versus weekend endovascular rAAA repair, there were similar rates of mortality (24.5% weekday vs. 32.7% weekend; OR [95%CI]: 1.30 [0.87-1.96]) and morbidity (31.9% weekday vs. 31.5% weekend; p=0.843).

Conclusion:

rAAA repair is associated with equivalent outcomes when performed on the weekend vs weekday.  Endovascular repair of rAAA is associated with superior outcomes. 

 

88.09 Race, Socioeconomic Factors and Leg Amputations among Patients with P.A.D. in Texas

Posted on January 26, 2017

N. R. Barshes1, K. D. Smith3, H. Serag3, B. J. Carter2, S. O. Rogers2  1Baylor College Of Medicine,Division Of Vascular And Endovascular Surgery, DeBakey Department Of Surgery,Houston, TX, USA 2University Of Texas Medical Branch,Galveston, TX, USA 3University Of Texas Medical Branch,Center To Eliminate Health Disparities,Galveston, TX, USA

Introduction:  Previous analyses of national data have suggested racial disparities in leg amputation rates. We sought to determine whether race- or insurance-based disparities in leg amputations occur among people in Texas with peripheral artery disease (PAD).

Methods:  Deidentified hospital admission data from the Texas Inpatient Public Use Data File was used to identify admissions associated with the diagnosis of PAD as well as either revascularization (endovascular or surgical procedures) or leg (i.e. above-ankle) amputation from 2004 to 2010. Multivariate regression models were used to identify factors independently associated with ER admission and leg amputation. All analyses were performed using Intercooled State v8.0 (College Station, TX), with p<0.05 considered significant. 

Results: 29,128 revascularization procedures and 6,482 leg amputations were performed in Texas from 2004-2009 for PAD-related diagnoses. The unadjusted incidence rates of leg amputation were 5.0 per 100,000 total population per year (per 100K/yr) for non-Hispanic white persons versus 7.2 for black persons, 3.1 for Hispanic persons, and 0.7 for Asian persons. Leg amputation rates also ranged from 2.7 per 100K/yr in zip codes in lowest quartile of poverty prevalence to 5.0 per 100K/yr in the middle two quartiles and 6.8 per 100K/yr in the highest quartile of poverty prevalence. Hospital admission through the emergency room was much more common among those without insurance (odds ratio [OR] 2.2, p<0.001) or only Medicaid coverage (OR 1.1, p=0.002) and was much less common among those with Medicare, HMO/PPO, or private insurance coverage (odds ratio [OR] 0.68-0.76, all p<0.0001). After adjustment for clinical factors (incl. foot infection, comorbidities), demographic features (incl. age, gender), and geography (viz. Texas public health region), leg amputations without antecedent revascularization attempts occurred much more frequently in patients that were categorized as black (odds ratio [OR] 2.1, p<0.001) or Hispanic (OR 1.6, p<0.001), those with Medicaid coverage (OR 2.1, p<0.001), and those that were uninsured (OR 2.0, p<0.001; Table 1). Overall model R2 was 0.16. Race/ethnicity, Medicaid coverage, or uninsured status was not associated with an increased rate of leg amputation in patients that had undergone revascularization.

Conclusion: Leg amputations among people with PAD in Texas vary widely, with higher risk-adjusted rates occuring in people who are uninsured, insured only by Medicaid, or are categorized as black or Hispanic. State-wide efforts should focus on addressing these existing health disparities. 

88.07 Mortality following Endovascular versus Open Repair of Abdominal Aortic Aneurysm in the Elderly.

Posted on January 26, 2017

S. Locham1, R. Lee1, B. Nejim1, H. Aridi1, M. Faateh1, H. Alshaikh1, M. Rizwan1, J. Dhaliwal1, M. Malas1  1Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA

Introduction:
Prior RCTs have reported better perioperative outcomes following endovascular aneurysm repair (EVAR) as compared to open aneurysm repair (OAR). EVAR-1 and DREAM trial reported significantly higher mortality for OAR as compared to EVAR. However most of these studies excluded the elderly.  Age is a well-known risk factor for postoperative death and the efficacy of these approaches remains controversial in the elderly population. The aim of the study is to provide recent real world outcomes using the NSQIP database (2010-2014) exclusively looking at the predictors of mortality in a large cohort of elderly population in the United States. 

Methods:

Using the NSQIP targeted vascular database (2010-2014), we identified all patients over 70 years of age who underwent OAR and EVAR for non-ruptured AAA. Explanatory analyses using Pearson’s Chi-square and Student’s t-tests were performed. Univariate and multivariable logistic regression analyses were implemented to examine postoperative morbidities and mortality adjusting patient demographics and characteristics.

Results:
A total of 5,332 non-ruptured AAA repairs were performed [OAR: 809 (15%) vs. EVAR: 4,523 (85%)]. The majority of patients were male (77%) and white (81%) with mean age of 78 ± 6 years. Diabetes mellitus and obesity were more prevalent in the EVAR group (15% vs. 12%, p=0.01) and (30% vs. 25%, p=0.002), respectively. Whereas, history of chronic obstructive pulmonary disease (COPD) (22% vs. 19%, p=0.02) and smoking status (35% vs 23%, p<0.001) were more likely to be seen in patients undergoing an OAR. On average the operative time in minutes (250 vs. 151) and mean length of stay in days (11 vs. 3) was also longer for patients undergoing OAR versus EVAR (p<0.001). The mortality was higher following OAR versus EVAR (8% vs 3%, p<0.001). Compared to EVAR, OAR was associated with higher rates of cardiac (7% vs. 2%), renal (7% vs. 1%), pulmonary (20% vs. 3%) and any wound complications (4% vs. 2%) (all p<0.05). After adjusting for patients’ characteristics and comorbidities, OAR was associated with 3 times higher mortality than EVAR [OR(95%CI): 3.04(2.01-4.57), p<0.001]. The predictors of mortality in our elderly cohort were age, female gender, smoking status, functional dependency, history of COPD, steroid use, bleeding disorders, progressive renal failure, transfusion, aneurysm diameter and Type IV TAAA. 

Conclusion:

Our study reflects contemporary real world outcomes following repair of non-ruptured AAA in the elderly. Endovascular approach was associated with significant reduction in the risk of postoperative cardiac, pulmonary and renal complications the elderly. Open repair was associated with 3 fold increase in mortality compared to EVAR and should be avoided in the elderly. Further prospective studies involving geriatric population is required to better understand the predictors of mortality following AAA repair. 

88.05 Lower Extremity Bypass: Are We Meeting Guidelines?

Posted on January 26, 2017

S. S. Adkar1, R. S. Turley1, L. Youngwirth1, E. Benrashid1, C. K. Shortell1, L. Mureebe1  1Duke University Medical Center,Department Of Surgery,Durham, NC, USA

Introduction:

The American Heart Association recommends use of an anti-platelet agent (APA) and a statin in patients with symptomatic peripheral arterial disease. The extent of guideline adherence by clinicians and patients is unknown. Given the inherent morbidity of lower extremity bypass (LEB), including limb loss, loss of patency, cardiac risk and bleeding complications, we sought to assess current usage of APA and statins and their effects on LEB outcomes.

Methods:
Data were obtained from the 2011-2013 ACS-NSQIP participant user files with LEB targeted data. Patients with LEB performed for aneurysmal disease and trauma were excluded from this analysis.  Patient, procedural characteristics, and 30-day postoperative outcomes were compared using Pearson Χ2 tests for categorical variables and Wilcoxon rank-sum tests for continuous variables. The primary outcome measures were graft patency rates, perioperative bleeding, and mean hospital length of stay.

Results:
During the study period, 5500 total LEB were identified. Demographics and major complications are displayed in Table 1. We stratified patients treated with both statin and APA (59.4%), statin only (9.3%), APA only (20.3%), and those receiving neither medication (11%). Smoking was more prevalent in the group receiving neither medication and diabetics were more often treated with either an APA or statin (p<.01). Graft patency rates were higher in patients receiving APA compared to other groups (51.3% vs 44.4%, p < .001). The incidence of bleeding requiring transfusion or a second procedure was higher in patients receiving a statin but not APA alone (13.2% vs 19%, p<.01). Mean hospital length of stay was significantly lower in patients receiving APA alone (8 days vs 9 days, p<.001). No significant difference in post-operative myocardial infarction or stroke was observed between treatment groups (p=.762). No differences in wound infection or mortality was observed between groups.

Conclusion:

Both the American Heart Association and the Society for Vascular Surgery have given their strongest recommendations that patients with atherosclerotic lower extremity arterial disease be treated with APA and statins (literature grade: Level 1A). We fail to accomplish this in 4 out of every 10 patients undergoing LEB nationally. Furthermore, APA, and not statin, treatment is associated with a shorter post-operative length of stay, but statin use (not APA) is associated with an increased risk of bleeding after surgery. This dichotomy between guidelines and our observed data suggests an ambiguous interplay between statins and APA that will require concentrated exploration.

88.04 Experience with Tibial/Peroneal Polytetrafluoroethylene Bypasses for Critical Limb Ischemia (CLI)?

Posted on January 26, 2017

N. J. Gargiulo4, E. C. Lipsitz2, N. Cayne1, G. Landis3, F. J. Veith1  1New York University School Of Medicine,New York, NY, USA 2Albert Einstein College Of Medicine,Bronx, NY, USA 3North Shore University And Long Island Jewish Medical Center,Manhasset, NY, USA 4Clinch Valley Medical Center,Vascular Surgery,Richlands, VIRGINIA, USA

Introduction:  Polytetrafluoroethylene (PTFE) tibial and peroneal bypasses without vein cuffs, patches or arteriovenous fistulas have been advocated for critical limb ischemia in circumstances when autologous saphenous vein is not available. This reviews a 30-year experience.

Methods:  A retrospective analysis was performed on a group of 377 patients with critical limb ischemia requiring revascularization between July 1977 and June 2011. These 377 patients underwent 411 PTFE bypasses to a tibial or peroneal artery without any adjunctive procedure.  Cumulative life table primary and secondary patency and limb salvage rates were calculated for those bypasses performed between July 1977 through June 1987 (Group I). These were compared to those performed between July 1987 through June 1997 (Group II) and July 1997 through June 2011 (Group III).  Ethnic background, TASC distribution, hemoglobin A1C levels, and inflammatory mediators (CRP, IL-6, and IL-10) were measured in a subset of Group III patients.  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 Group I patients was 28.6%, 9.0%, 55.0%, and 27% respectively, for Group II patients was 27.3%, 9.9%, 50.0%, and 26%,  respectively, and for Group III  patients was 34.0%, 11%, 73.3%, and 33% respectively.  Patency and limb salvage for Group III patients exceeded that observed in Group I and II patients which correlated with the implementation of several perioperative strategies.  Group III patients manifested a statistically better outcome compared to Group I and II patients.  Interestingly, Group III patients manifested a greater distribution of TASC II D atherosclerotic disease and a greater percentage of Latino patients compared to Group I and II patients, and in this subset of patients had a trend towards a statistically worse five- and 10-year primary patency and five- and 10-year limb salvage rate (P=0.12).  There was no direct correlation between hemoglobin A1C level, PTFE patency or successful limb salvage rates in any of the Groups (P>0.02).  There was a trend towards a statistical correlation to PTFE graft patency and inflammatory mediators (CRP, IL-6 and IL-10, P=0.17).

Conclusion:  PTFE bypasses without adjunctive procedures to infrapopliteal arteries is an acceptable alternative option for those patients without autologous vein facing imminent amputation in this small cohort of patients.  

88.03 Natural History of Dialysis Interventions Based Upon Initial Dialysis Access Type

Posted on January 26, 2017

E. S. Lee1,2, K. C. Chun1, T. Yenumula1, A. S. Schmidt1, K. M. Samadzadeh1, A. Rona1, A. Gonzalves1, M. D. Wilson3, R. E. Noll1,2, E. S. Lee1,2  1VA Northern California Health Care System,Surgery,Mather, CA, USA 2University Of California, Davis,Surgery,Sacramento, CA, USA 3University Of California, Davis,Department Of Public Health Sciences, Division Of Biostatistics,Sacramento, CA, USA

Introduction: End-stage renal disease (ESRD) patients face an unknown number of dialysis access interventions (DAI) that could occur throughout their lifetime on dialysis. The purpose of this study is to determine the frequency of DAI per year while on dialysis to better inform prospective dialysis patients.

Methods: A retrospective chart review of ESRD patients on dialysis for a minimum of 1 year was conducted at a large regional medical center. The frequency of DAI per year was the primary outcome measure. An intervention is defined as any procedure (fistulogram, catheter placement, or new access) done to regain dialysis access for the patient. Average days between interventions is determined by time between first dialysis access until date of death or end of study analysis (Dec. 31, 2015), divided by total number of interventions. The primary outcome was then evaluated with other patient factors such as initial access type (catheter, fistula, or graft), time between DAI, time on dialysis, age, hypertension, diabetes, smoking, cholesterol, triglycerides, statin use, blood thinner use, body mass index, coronary artery disease, peripheral vascular disease, chronic obstructive pulmonary disease, and stroke. A general linear model (GLM) was fit to test for associations between the measured variables and average days between interventions. The Tukey correction for multiple comparisons was used to compare across groups in variables significant from GLM.

Results: A total of 166 patients (mean ± standard deviation; 67.2 ± 10.3 years) were analyzed from 1991 to 2015 in this study. The patients are comprised of 54.2% (n=90) white, 37.4% (n=62) African American, and 8.4% other. Patients averaged 1.4 ± 1.4 DAI per year (7.2 ± 8.5 DAI total, range: 1 to 37 DAI) within an average follow up length of 5.6 ± 3.8 years while on dialysis. The average days between interventions based upon initial access type were: catheter (n=86) 475 ± 359.8 days, graft (n=16) 516.1 ± 448.5 days, and fistula (n=64) 546.8 ± 595.5 days (Table).

Conclusion: ESRD patients can expect 1 to 2 interventions per year to maintain dialysis access, regardless of initial dialysis access type. Although not statistically different, longer days between interventions can be expected with the fistula versus other access types and that the average life expectancy after starting dialysis is 5 to 6 years.

 

88.02 Bundling Of Reimbursement For Inferior Vena Cava Filter Placement Decreased Procedural Utilization

Posted on January 26, 2017

M. J. TerBush1, E. L. Hill1, J. Guido1, A. Doyle1, J. Ellis1, G. R. Morrow1, M. Stoner1, K. Raman1, R. J. Glocker1  1University Of Rochester,Surgery,Rochester, NY, USA

Introduction: On January 1, 2012, reimbursement for inferior vena cava filters (IVCF) became bundled by the Centers for Medicare and Medicaid Services (CMS). This resulted in a 70% decrease in RVUs associated with ICVF placement from 15.6 RVUs to 4.71 RVUs.  Our hypothesis was that procedural utilization would decrease following this change. We previously performed an analysis which revealed no significant changes in utilization. As new data have become available, we have revised our analysis in an effort to identify practice pattern changes.
 

Methods: We analyzed data from 2010-2014 using 5% inpatient, outpatient, and carrier files of Medicare limited data sets, analyzing IVCF utilization, controlling for total diagnosis of deep vein thrombosis (DVT) and pulmonary embolism (PE) (ICD – 9 codes 453.xx and 415.xx, respectively).

 

Results: In 2010 and 2011, the rates per 10,000 DVT/PE diagnoses were 918 and 1052, respectively (average 985). In 2012, 2013, and 2014, rates were 987, 877, and 605, respectively (average 823). The included figure demonstrates these trends graphically across different specialties. Comparing each year individually, there is a significant difference (p<0.0001) with 2012, 2013, and 2014 having lower rates of ICVF utilization. Comparing averages between the 2010-2011 and 2012-2014 groups, there is also a significant decrease in utilization after bundling (p<0.0001).

Conclusion: These data demonstrate that adjusted IVCF deployment rates dropped after the introduction of a bundled code with a reduced RVU and professional fee reimbursement value. This correlation may be evidence of a supply-sensitive medical service, and a successful realignment based on procedural valuation. More data from 2015 to present will be needed to show if this decrease in utilization continues to persist today.

 

88.01 Human Adiponectin Correlates with Severe Carotid Plaque Calcification

Posted on January 26, 2017

V. T. Hurst1,2, S. E. Deery1, G. Sharma2, M. D. Coll1,2, M. Tao2, K. Trocha2, A. Longchamp2, C. K. Ozaki2, R. J. Guzman1  1Beth Israel Deaconess Medical Center,Vascular And Endovascular Surgery,Boston, MA, USA 2Brigham And Women’s Hospital,Vascular And Endovascular Surgery,Boston, MA, USA

Introduction:  The mechanisms underlying calcification of atherosclerotic plaques remain obscure. Since carotid plaque calcification is associated with stability, and the adipose associated hormone adiponectin underlies multiple vasculo-protective pathways, we hypothesized that human adiponectin would positively correlate with severe carotid plaque calcification in a compartment specific (e.g. perivascular adipose) manner.

Methods:  Fifty-five patients who received either a carotid endarterectomy (n=38) or open lower extremity revascularization (n=17) and who had a carotid duplex ultrasound were studied. After informed consent, blood, perivascular and subcutaneous adipose samples, and medical history were obtained. Carotid bulb plaque was assessed via duplex ultrasonography, and patients were stratified into two groups: none/mild or severe calcification. Potentially relevant biomarkers were measured by multiplex bead immunoassay after tissue protein isolation, and data were normalized to initial adipose tissue mass. Wilcoxon Rank Sum testing was used to compare adiponectin levels in none/mild versus severe calcification patients. Categorical variables were presented as counts (percentages); continuous variables were presented as mean (standard deviation) or median (interquartile range), based on the normality of distribution. Differences between those with none/mild calcification and those with severe calcification were assessed using the Fisher’s exact test for categorical variables and either the Student T test or the Mann Whitney U test for continuous variables, where appropriate. All tests were 2-sided, and a P-value of less than 0.05 was considered significant. Statistical analysis was conducted using STATA 14.1.

Results: Of the clinical/biologic factors evaluated, carotid plaque calcification most strongly associated with adiponectin. In all compartments assayed, adiponectin levels positively linked to severe carotid plaque calcification (note log scale).

Conclusion: Human plasma, subcutaneous, and perivascular adiponectin levels positively correlate with carotid plaque calcification. These findings suggest relationships between adipose associated biomediators and vascular calcification. Furthermore, adiponectin based interventions may serve as novel strategies toward vascular plaque stabilization.

 

87.19 Social Indices as Potential Measures of Patient’s Health-Related Quality of Life

Posted on January 26, 2017

S. Yi1,3, S. Mukhopadhyay2,3  1George Washington University,Washington, DC, USA 2University Of Connecticut,General Surgery,Storrs, CT, USA 3Harvard School Of Medicine,Program In Global Surgery And Social Change,Brookline, MA, USA

Introduction:  Traditional surgical outcomes have been measured in clinical terms such as mortality, margin of resection, or infection rates. More holistic measures such as health-related quality of life (HRQoL) have become increasingly important to capture less tangible outcomes of quality health care.

At a broader level, social indices attempt to evaluate quality of life across multiple domains. These comprehensive summary measures may better reflect effects of health outcomes (e.g. economic productivity or increased happiness). Despite the importance of these indices in social analyses, their use is poorly understood in health system prioritization. We examine these indices and assess their feasibility of use to evaluate growing surgical health systems.

 

Methods:  We compiled leading indices from the Social Progress Imperative (Social Progress Index, SPI), UN Sustainable Development Solutions Network (World Happiness Index, WHI), UN Development Programme (Human Development Index, HDI), Organisation for Economic Co-operation and Development (Better Life Index, BLI), World Economic Forum (Global Competitiveness Index, GCI), Oxford Poverty & Human Development Initiative (Multidimensional Poverty Index, MPI), Legatum Institute (Prosperity Index, PI), and The Economist Intelligence Unit (Where-to-be-born Index, WBI). Indicators only directly related to health and medical care were extracted (Table 1). Other related indicators such as access to clean water or sanitation were not included.

 

Results: All eight indices included at least one measure of health. All indices but the MPI used life expectancy as a key health indicator, but differed in when it was measured (SPI at 60 years of age, the BLI at 80, 65, 60, 40, and at birth; all others measured at birth only). Three (WHI, HDI, WBI) used life expectancy at birth as the only health indicator. Five indices used infant mortality rates, while only two used maternal mortality rates, as well. Three cited undernourishment as a health indicator.

 

Conclusions: All examined social indices include an indicator for measuring health. Life expectancy is the most common indicator, with only the MPI excluding it. The MPI instead uses child mortality rate and undernourishment. The index with the most numerous health indicators is the PI. Interestingly, other common measures of quality health systems, such as access to timely care, workforce density, or complication rates, have not been included in these social indices. As surgery becomes a more integral component of developing health systems, it is important to utilize effective health indicators that reflect the quality of care and health that individuals experience.

87.18 Upper Gastrointestinal Endoscopy: Indications and Findings in Kumasi, Ghana

Posted on January 26, 2017

C. Dally1, J. Valenzuela2, A. Merchant2, O. Gunter3  1Komfo Anokye Teaching Hospital,Surgery,Kumasi, ASHANTI, Ghana 2University Of Cincinnati,Surgery,Cincinnati, OHIO, USA 3Vanderbilt University Medical Center,Surgery,Nashville, TN, USA

Introduction:
Abdominal pain remains a large proportion of presenting complaints when seeking medical assistance. Comprehensive patient information is scarce in Africa to follow these patients and characterize epidemiology, pathology, and treatment. Endoscopy remains vital to the diagnosis and treatment of upper gastrointestinal diseases including peptic ulcer disease (PUD), gastrointestinal reflux disease (GERD), gastrointestinal tumors and causes of bleeding. Direct visualization along with photography and biopsy can lead to definitive diagnosis and collaborative efforts for treatment. This study looks at presenting complaints of patients who underwent endoscopy in Kumasi, Ghana and correlates them with endoscopic findings, CLO test, and need for biopsy.

Methods:
Between 2012 and 2015, 1077 endoscopies were performed by a single-operator at three institutions in Kumasi, Ghana.  No image-capturing ability was available. A retrospective review was completed that evaluated age, sex, presenting complaint, endoscopic findings, CLO test for H. Pylori, and pathology reports when available. 

Results:
The average patient age for endoscopy was 44.5 years.  Sixty percent of endoscopies were performed on woman and 40% on men.  Forty percent of the clinical complaints leading to endoscopy were abdominal/epigastric pain.  Another 37% of patients were thought to have gastritis, peptic ulcer disease, or gastrointestinal reflux disease.  Eighty-nine percent of patients underwent CLO test; 56% of those patients had a positive CLO test indicating H. Pylori infection.  The remaining 11% could not undergo CLO testing due to lack of testing strips. Thirty-eight percent of endoscopic findings included gastritis.  Of 1065 patient records, 12.4% had lesions or ulcers biopsied. 

Conclusion:
The overwhelming findings show gastritis from endoscopy. The incidence of H. Pylori remains high.  Current patient data does not indicate whether patients received a proton-pump inhibitor trial prior to endoscopy and complete biopsy results are not available, sometimes due to affordability. Improved documentation and a database can further characterize epidemiology of abdominal pain in developing countries. One major limitation in endoscopy reports is the lack of pictures to accompany the descriptive report.  Image-capturing ability can confirm endoscopic findings, assist the referring physician with treatment plan and patient education, as well as lead to multi-disciplinary efforts in treatment.
 

87.17 Neonatal Surgical Outcomes In A Tertiary Care Center In India

Posted on January 26, 2017

A. Ranjit2, R. Shrestha1, A. Prasad3, K. P. Devkota1, R. Kulshrestha3  1Nepal Medical College And Teaching Hospital,Surgery,Kathmandu, BAGMATI, Nepal 2Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 3Sir Ganga Ram Hospital,Pediatric Surgery,Delhi, NEW DELHI, India

Introduction:

Low and Middle-Income countries (LMIC) bear the majority of the global pediatric surgical burden. Despite increasing volumes of pediatric surgery being performed in LMIC, outcomes of these surgeries in LMIC remains unknown due to lack of robust data. To that end, the objective of our study was to collect data on and evaluate neonatal surgical outcomes at a tertiary level center in India.

Methods:

The surgical outcomes data of all neonates undergoing major surgical procedure between February 1, 2015 and December 31, 2015, at Sir Ganga Ram Hospital, a tertiary level center in New Delhi, India was collected prospectively. Patient demographics, preoperative clinical characteristics and postoperative outcomes including surgical site infection (SSI), sepsis, length of stay (LOS), number of ventilator days and in-hospital mortality were recorded. Descriptive statistics were used to determine the rates of various postoperative outcomes.

Results:
A total of 37 neonatal surgeries were performed during the study period. The mean age of the neonates on the day of surgery was 7 days (range: 1-30 days). Most of the neonates (72.9%, n=27) were males. About 40% (n=15) of the neonates were preterm and 15 (40.5%) of them were small for gestational age. The average LOS was 22 days (range: 2-80 days). In our study,10 neonates (28.6%) needed ventilation for 48 hours or less after surgery and 5 neonates (13.5%) were kept postoperative Nil per Oral (NPO) for more than 10 days. Out of 37 neonates, 4 (10.80%) developed a surgical site infection and 8 neonates (21.6%) had postoperative sepsis. The in-hospital mortality rate among neonates undergoing a surgical procedure during the study period was 8.1 deaths per 100 neonates.

Conclusion:

Our study demonstrates the feasibility of data collection to study neonatal surgical outcomes in low and middle-income countries and might help encourage other centers in LMIC to conduct pediatric surgical outcome research.

 

 

« Previous Page
Next Page »