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A shifting paradigm for the treatment of acute mesenteric ischemia
VASCULAR SURGERY II A shifting paradigm for the treatment of acute mesenteric ischemia Robert J Beaulieu, MD, James H Black, III, MD, FACS Johns Hopkins Hospital, Baltimore, MD INTRODUCTION: Acute mesenteric ischemia (AMI) is a commonly fatal result of inadequate bowel perfusion. Prompt diagnosis through identification of at-risk patients and treatment with appropriate endovascular or open revascularization has the potential to significantly alter outcomes. METHODS: Using the NIS database, admissions from 2005-2009 were identified according to ICD-9-CM codes correlating to both AMI (557.0) and subsequent vascular intervention (39.26, 38.16, 38.06, 39.9, 99.10) or bowel resection (45.6, 45.71-9, 45.8). Patient-level data, interventional procedures and mortality outcomes were examined. RESULTS: Of 23,744 patients presenting with AMI, 4,665 underwent interventional treatment from 2005-2009. For patients with the diagnosis of AMI, 66.5% were female and mean age was 67.6 years. The proportion of treated patients undergoing vascular intervention increased from 11.4% in 2005 to 19.0% in 2009 (p⬍ 0.001). Among patients treated with vascular intervention, 514 (75.7%) underwent open surgery and 165 (24.3% ) underwent endovascular treatment. Between 2005 and 2009, the proportion of vascular patients treated with endovascular intervention trended upward from 23.7% to 30.0% (p⫽0.259). Across all 5 years, mortality was lower among endovascular patients (21.8% vs 33.3%, p⫽0.005). In multivariable logistic regression, among patients undergoing vascular intervention, endovascular treatment was associated with 39% reduced odds of mortality (O.R. 0.61, 95%CI 0.390.95), controlling for year of admission, age, gender, insurance status, and comorbid illness. CONCLUSIONS: Among AMI patients undergoing revascularization, endovascular treatment was associated with 39% reduced odds of mortality versus open intervention. Further research is warranted to determine whether increased use of endovascular intervention could benefit patients presenting with AMI.
RESULTS: Of the 139 patients in this study, 40 were noted as deceased with a mean follow-up of 30.1 months. Protein content varied from 20.7 to 187.5 mg protein/gm wet weight and CS activity varied from 8,112.1 to 32,377.0 nmol/min/gm wet weight. Mortality rate was lowest for patients in the upper (3rd) tertile of protein content (1st vs 3rd tertile: p⫽0.071 for the Log-Rank test; p⫽0.025 for the LR test) and middle (2nd) tertile of CS activity (1st vs 2nd tertile: p⫽0.036 for the Log-Rank test; p⫽0.049 for the Wilcoxon test; Table). 5-Year mortality 1st tertile 2nd tertile 3rd tertile
p Value
Protein/muscle weight 55.2%*
45.4%
20.0%* *0.025 (Likelihood ratio)
CS/muscle weight
36.2%**
47.7%
56.2%**
**0.036 (Log-rank), 0.049 (Wilcoxon)
CONCLUSIONS: Survival analysis of a contemporaneous population of PAD patients identifies protein and mitochondrial content of the gastrocnemius as predictors of mortality rate.
National survey of the management of calf vein thrombosis T Calloway Robertson, BA, Michael J Anstadt, MD, Pegge M Halandras, MD, Ross Milner, MD, FACS Loyola University Health System, Maywood, IL, University of Chicago, Chicago, IL INTRODUCTION: Calf vein thrombosis (CVT) remains a therapeutic enigma. CVT poses a potential risk for propagation as well carries a risk of post-phlebitic syndrome. Multiple studies have differing conclusions on the use of anticoagulation for CVT. METHODS: Members of the Society of Vascular Surgeons received a survey via Survey MonkeyTM with 10 multiple choice questions about CVT. The questions addressed whether anti-coagulation was used; choices of anti-coagulation; use of follow-up ultrasound; time period before follow-up ultrasound; use of conservative management; duration of anti-coagulation therapy; and IVC filter use.
Protein and mitochondrial content in the gastrocnemius predicts mortality rates in patients with peripheral arterial disease Jonathan Robert Thompson, MD, Stanley A Swanson, BA, Gleb Haynatzki, PhD, George P Casale, PhD, Jason M Johanning, MD, FACS, Eva Papoutsi, BA, Panagiotis Koutakis, MS, Dimitrios Miserlis, MD, Zhen Zhu, MD, Iraklis I Pipinos, MD, PhD, FACS The University of Nebraska Medical Center, Omaha, NE INTRODUCTION: Patients with peripheral arterial disease (PAD) experience advancing myopathy with mitochondrial dysfunction in their ischemic legs, and increased mortality rates. We hypothesize that protein concentration and mitochondrial content in gastrocnemius biopsies from PAD patients predict mortality rate. METHODS: Protein concentration and citrate synthase activity (CS; standard measure of cellular, mitochondrial content) in the
© 2012 by the American College of Surgeons Published by Elsevier Inc.
gastrocnemius of PAD patients were quantified and normalized to muscle wet weight. Patient (N⫽139) data, collected over time, were analyzed and the date of last known contact or death was noted. Protein and CS data were grouped into tertiles and survival in each tertile was determined with Kaplan-Meier plots and compared by the Log-Rank, Wilcoxon, and exponential-based likelihood ratio (LR) tests.
RESULTS: A total of 410 physicians responded. 281 (69.2%) stated that they anti-coagulate patients with unprovoked CVTs and 125 (30.8%) do not anti-coagulate. Of the 281 physicians that anticoagulate, 72.1% use LMW heparin. Anti-platelet agents were used by 9% and IV heparin by 6%. Of the 125 physicians who do not anti-coagulate, 68.4% reassessed for clot propagation with an ultrasound. 25.3% obtain follow-up scans at 1 week, 13.1% at 2 weeks, 26% at 1 month, and 35.6% at greater than 1 month. The proposed length of anti-coagulation was 3 months for 69.3%. IVC filters were used by 53% when there was a contraindication to anti-coagulation or when propagation was noted by follow-up scan.
S155
ISSN 1072-7515/12/$36.00 http://dx.doi.org/10.1016/j.jamcollsurg.2012.06.399
RESULTS: Of the 139 patients in this study, 40 were noted as deceased with a mean follow-up of 30.1 months. Protein content varied from 20.7 to 187.5 mg protein/gm wet weight and CS activity varied from 8,112.1 to 32,377.0 nmol/min/gm wet weight. Mortality rate was lowest for patients in the upper (3rd) tertile of protein content (1st vs 3rd tertile: p⫽0.071 for the Log-Rank test; p⫽0.025 for the LR test) and middle (2nd) tertile of CS activity (1st vs 2nd tertile: p⫽0.036 for the Log-Rank test; p⫽0.049 for the Wilcoxon test; Table). 5-Year mortality 1st tertile 2nd tertile 3rd tertile
p Value
Protein/muscle weight 55.2%*
45.4%
20.0%* *0.025 (Likelihood ratio)
CS/muscle weight
36.2%**
47.7%
56.2%**
**0.036 (Log-rank), 0.049 (Wilcoxon)
CONCLUSIONS: Survival analysis of a contemporaneous population of PAD patients identifies protein and mitochondrial content of the gastrocnemius as predictors of mortality rate.
National survey of the management of calf vein thrombosis T Calloway Robertson, BA, Michael J Anstadt, MD, Pegge M Halandras, MD, Ross Milner, MD, FACS Loyola University Health System, Maywood, IL, University of Chicago, Chicago, IL INTRODUCTION: Calf vein thrombosis (CVT) remains a therapeutic enigma. CVT poses a potential risk for propagation as well carries a risk of post-phlebitic syndrome. Multiple studies have differing conclusions on the use of anticoagulation for CVT. METHODS: Members of the Society of Vascular Surgeons received a survey via Survey MonkeyTM with 10 multiple choice questions about CVT. The questions addressed whether anti-coagulation was used; choices of anti-coagulation; use of follow-up ultrasound; time period before follow-up ultrasound; use of conservative management; duration of anti-coagulation therapy; and IVC filter use.
Protein and mitochondrial content in the gastrocnemius predicts mortality rates in patients with peripheral arterial disease Jonathan Robert Thompson, MD, Stanley A Swanson, BA, Gleb Haynatzki, PhD, George P Casale, PhD, Jason M Johanning, MD, FACS, Eva Papoutsi, BA, Panagiotis Koutakis, MS, Dimitrios Miserlis, MD, Zhen Zhu, MD, Iraklis I Pipinos, MD, PhD, FACS The University of Nebraska Medical Center, Omaha, NE INTRODUCTION: Patients with peripheral arterial disease (PAD) experience advancing myopathy with mitochondrial dysfunction in their ischemic legs, and increased mortality rates. We hypothesize that protein concentration and mitochondrial content in gastrocnemius biopsies from PAD patients predict mortality rate. METHODS: Protein concentration and citrate synthase activity (CS; standard measure of cellular, mitochondrial content) in the
© 2012 by the American College of Surgeons Published by Elsevier Inc.
gastrocnemius of PAD patients were quantified and normalized to muscle wet weight. Patient (N⫽139) data, collected over time, were analyzed and the date of last known contact or death was noted. Protein and CS data were grouped into tertiles and survival in each tertile was determined with Kaplan-Meier plots and compared by the Log-Rank, Wilcoxon, and exponential-based likelihood ratio (LR) tests.
RESULTS: A total of 410 physicians responded. 281 (69.2%) stated that they anti-coagulate patients with unprovoked CVTs and 125 (30.8%) do not anti-coagulate. Of the 281 physicians that anticoagulate, 72.1% use LMW heparin. Anti-platelet agents were used by 9% and IV heparin by 6%. Of the 125 physicians who do not anti-coagulate, 68.4% reassessed for clot propagation with an ultrasound. 25.3% obtain follow-up scans at 1 week, 13.1% at 2 weeks, 26% at 1 month, and 35.6% at greater than 1 month. The proposed length of anti-coagulation was 3 months for 69.3%. IVC filters were used by 53% when there was a contraindication to anti-coagulation or when propagation was noted by follow-up scan.
S155
ISSN 1072-7515/12/$36.00 http://dx.doi.org/10.1016/j.jamcollsurg.2012.06.399