Journal of Vascular Surgery
Abstracts
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Volume 64, Number 3 Table I. Overview of population of patients Variable Total No. of patients
136
White race
107 (81.1)
Male
80 (58.8) 70.2 6 11.9
Mean age, years
Fig. Type of intervention.
No.
%
Bleeding
1
0.38
Hematoma
5
1.9
Pseudoaneurysm
4
1.5
Arterial thrombosis
0
0
Nerve injury
0
0
Total
121 (89.0)
TEVAR indication aneurysm
56 (41.2)
TEVAR indication acute type B aortic dissection
25 (18.5)
TEVAR indication traumatic aortic injury
15 (11.0)
TEVAR indication chronic type B aortic dissection
12 (8.8)
TEVAR indication penetrating aortic ulcer
12 (8.8)
Other indications
16 (11.7)
TEVAR, Thoracic endovascular aortic repair. Categorical variables are presented as number (%).
Table. Complications Complication
History of hypertension
10
3.8
Required intervention or admission
5
1.9
Unable to reach lesion
6
2.7
Author Disclosures: R. Franz: None; C. F. Tanga: None; J. W. Herrmann: None.
Table II. Duplex outcomes Variable
Preoperatively
Postoperatively
Available duplex ultrasound studies
114
64
LVA flow antegrade
113 (99.1)
51 (79.7)
LVA flow retrograde
d
5 (7.8)
LVA flow abnormal LVA bidirectional
1 (0.9) d
P value
<.001 .063
5 (7.8)
.125
3 (4.7)
.250
Available duplex ultrasound studies
112
58
RVA flow antegrade
111 (99.1)
58 (100.0)
1.000
RVA flow abnormal
1 (0.9)
d
1.000
Impact of Left Subclavian Artery Revascularization Before Thoracic Endovascular Aortic Repair on Cerebrovascular Hemodynamics
PSV LVA, cm/s
56.5 6 23.6
34.4 6 25.1
<.001
PSV RVA, cm/s
53.7 6 21.7
64.0 6 24.2
.014
PSV left ICA, cm/s
101.8 6 33.9
101.6 6 41.9
.958
Arnoud V. Kamman, MD,1,2,3 Jonathan L. Eliason, MD,1 Foeke J. Nauta, MD,1,2,3 David M. Williams, MD,1 Bo Yang, MD,1 Frans L. Moll, MD,2 Santi Trimarchi, MD,3 Kim A. Eagle, MD,1 Himanshu J. Patel, MD1. 1 University of Michigan, Ann Arbor, Mich 2University of Utrecht, Utrecht, The Netherlands 3University of Milan, Milan, Italy
PSV right ICA, cm/s
98.1 6 50.4
104.8 6 44.4
.294
Objective: The impact of left subclavian artery (LSA) revascularization before thoracic endovascular aortic repair (TEVAR) on cerebrovascular flow is not well described. We studied bilateral vertebral and carotid artery flow characteristics before and after TEVAR to evaluate the hemodynamic effects of LSA revascularization. Methods: There were 136 patients with mixed causes (mean age, 70.2 6 11.9 years; Table I) who underwent LSA revascularization and TEVAR (2006-2016). Data from patient demographics, procedures, and preoperative and postoperative carotid duplex ultrasound studies were gathered. Revascularization was by left common carotid artery (LCCA) to LSA bypass (n ¼ 129 [94.9%]) or LSA to LCCA transposition (n ¼ 7 [5.1%]). Results: Duplex ultrasound confirmation of antegrade left vertebral artery (LVA) flow decreased significantly after TEVAR (99.1% vs 79.7%; P < .001). Incidence of retrograde LVA flow increased from 0.0% to 7.8% (P ¼ .063). Postoperatively, LVA bidirectional flow was observed in three patients. Flow direction in the right vertebral artery did not change significantly. Peak systolic velocity (PSV) in the LVA decreased significantly after TEVAR from 56.5 6 23.6 cm/s to 34.4 6 25.1 cm/s (P < .001). In contrast, PSV increased in the right vertebral artery from 53.7 6 21.7 cm/ s to 64.0 6 24.2 cm/s (P ¼ .014). PSV did not change significantly in the left and right internal carotid arteries (Table II). At mean follow-up of 35.8 6 29.8 months, primary bypass patency was 93.3%. The 30-day spinal cord ischemia rate was 2.9% (n ¼ 4), one permanent and three transient. Stroke rate was 6.7% (n ¼ 9; 88.9% embolic, 11.1% hemorrhagic), three permanent and six transient. Stroke circulation
ICA, Internal carotid artery; LVA, left vertebral artery; PSV, peak systolic velocity; RVA, right vertebral artery. Categorical variables are presented as number (%).
distribution was 55.6% posterior, 22.2% anterior, and 22.2% mixed. Location of stroke was left sided (n ¼ 5), right sided (n ¼ 3), or in both hemispheres (n ¼ 1). The 30-day all-cause mortality was 2.9% (n ¼ 4). Neurologic events during follow-up included one case of permanent spinal cord ischemia and three new strokes. All-cause mortality rate during follow-up was 19.1% (n ¼ 26). Conclusions: Adjunctive LSA revascularization in the setting of zone 2 TEVAR coverage is associated with hemodynamic vertebral artery changes. Future studies in larger sample sizes should evaluate whether these novel findings are an important determinant of postoperative neurologic events. Author Disclosures: A. V. Kamman: None; J. L. Eliason: None; F. J. Nauta: None; D. M. Williams: None; B. Yang: None; F. L. Moll: None; S. Trimarchi: None; K. A. Eagle: None; H. J. Patel: None.
Common Carotid Artery End-Diastolic Velocity and Acceleration Time Can Predict Degree of Internal Carotid Artery Stenosis David S. Strosberg, MD, Mounir J. Haurani, MD, Bhagwan Satiani, MD, Michael R. Go, MD. The Ohio State University Wexner Medical Center, Columbus, Ohio Objective: Whereas duplex ultrasound parameters for predicting internal carotid artery (ICA) stenosis are well defined, the use of common
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Abstracts
Journal of Vascular Surgery September 2016
carotid artery (CCA) Doppler characteristics to predict ICA stenosis when the ICA cannot be insonated directly because of anatomy or calcification has not been studied. The objective of this study was to identify CCA Doppler parameters that may predict ICA stenosis. Methods: We reviewed all patients who had carotid duplex ultrasound (CDU) examination from 2008 to 2015 at our institution who also had comparison catheter, computed tomography, or magnetic resonance angiography. We collected CCA and ICA peak systolic velocity (PSV), end-diastolic velocity (EDV), and acceleration time (AT) in addition to CDU and comparison imaging degree of stenosis. A multivariate model was used to identify predictors of ICA stenosis. Results: There were 99 CDU studies examined with corresponding comparison imaging. For every 10 cm/s increase in EDV in the CCA, the odds of a >50% ICA stenosis being present vs a #50% ICA stenosis decreased by 37% (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.41-0.97; P ¼ .034). For every 10 cm/s increase in EDV in the CCA, the odds of a 70% to 99% ICA stenosis being present vs a #50% ICA stenosis decreased by 48% (OR, 0.52; 95% CI, 0.28-0.94; P ¼ .031). A CCA EDV of 19 cm/s or below is associated with a 64% probability of a 70% to 99% ICA stenosis. For every 50-millisecond increase in AT in the CCA, the odds of a >50% stenosis being present vs a #50% ICA stenosis increased by 56% (OR, 1.56; 95% CI, 1.03-2.35; P ¼ .035). A CCA AT of 800 milliseconds or above is associated with a 69% probability of >50% ICA stenosis. There was no correlation between CCA PSV and ICA stenosis. Conclusions: CCA EDV and AT are independent predictors of ICA stenosis and may be used in the setting of patients whose ICA cannot be directly insonated or when standard duplex ultrasound parameters of ICA PSV, EDV, or ICA/CCA ratio conflict. Author Disclosures: D. S. Strosberg: None; M. J. Haurani: None; B. Satiani: None; M. R. Go: None.
Reporting of Claudication Does Not Differ by Race Samantha D. Minc, MD,1 Raj C. Shah, MD,2 David A. Bennett, MD,2 Lisa L. Barnes, PhD,2 Amy B. Reed, MD2. 1Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Ill 2Rush University Medical Center, Chicago, Ill Objective: In the United States, it is well established that black patients undergo amputations at rates two to four times higher than those of non-Hispanic white patients. Blacks are also more likely to present with more advanced peripheral arterial disease, which significantly increases the risk of amputation. Reasons for this health disparity are not fully understood. The objective of this study was to assess whether older, community-dwelling blacks reported claudication differently from whites when systematically queried about symptoms. Methods: Data were used from a combined cohort of older (>65 years), community-dwelling participants in two longitudinal, clinical-pathologic studies of common chronic conditions of aging: the Rush Memory and Aging Project (MAP, 1997 to present) and the Minority Aging Research Study (MARS, 2004 to present). Blacks in both studies were matched (1:2) by age, education, and sex to non-Hispanic whites. Claudication was self-reported annually using survey questions based on the Rose questionnaire for claudication (Fig). Using c2 tables, we evaluated the frequency of baseline and any report of claudication as a function of race.
Results: Claudication was self-reported using the survey at baseline and annually for 801 black participants who were matched with 1686 non-Hispanic white participants. Of the participants, 6.5% of blacks and 5.9% of non-Hispanic whites (P ¼ .545) reported claudication at baseline. At any point in the study, 19.5% of blacks and 19.6% of non-Hispanic whites reported claudication (P ¼ .954). Conclusions: In community-dwelling blacks and non-Hispanic whites observed in longitudinal studies of aging, no differences in claudication self-report rates were noted. Whether racial disparities in the severity of peripheral arterial disease at time of presentation are due to provider-patient communication, provider education and referral patterns, or overall access to care requires further study. Author Disclosures: S. D. Minc: None; R. C. Shah: None; D. A. Bennett: None; L. L. Barnes: None; A. B. Reed: None.
Treatment of Massive and Submassive Pulmonary Embolism With Catheter-Directed Thrombolysis Does Not Require Routine Follow-up Pulmonary Angiography Omar Al-Nouri, Krishna Mannava, Lisa Stevens. Vascular and Endovascular Surgery, Fairfield Medical Center, Lancaster, Ohio Objective: Catheter-directed thrombolysis (CDT) of massive and submassive pulmonary embolism (PE) has been shown to be a valuable treatment modality. A paucity of data exists, however, regarding length of treatment and guidelines for treatment. We believe that short-duration treatment without routine follow-up pulmonary angiography is safe and efficacious for massive and submassive PE. Methods: This was a retrospective review of prospectively collected data at a single institution treating massive and submassive PE with EKOS (EKOS Corporation, Bothell, Wash) CDT. Results: From 2011 to 2016, 66 patients were treated for massive and submassive PE with the EKOS CDT system. The majority of patients had evidence of right-sided heart strain on computed tomography angiography or echocardiography. Of the 66 patients, 35 had hemodynamic instability with either systolic blood pressure (SBP) <100 or tachycardia (heart rate >100). Mean right ventricle/left ventricle ratio before CDT was 1.21. After therapy, right ventricle/left ventricle ratio was reduced to 0.87 at 48 hours (P ¼ .0002). In addition, mean right ventricular systolic pressure before CDT treatment was 52.9. After treatment, right ventricular systolic pressure was reduced to 38.8 at 48 hours (P ¼ .000). The c2 analysis of hemodynamically altered patients (SBP <100) showed complete resolution of hypotension (SBP >100) within 24 hours (P ¼ .0001). Mean hospital length of stay was reduced throughout the study period from 8.3 days in 2011 to 3.5 days in 2015 (P ¼ .005). Conclusions: CDT treatment of massive and submassive PE is safe and highly efficacious at reducing right-sided heart strain in the short term. Significant hemodynamic improvement was shown in our cohort throughout the study period. Improvements in SBP and heart rate were seen within 24 hours of EKOS treatment. Routine pulmonary angiography is not necessary in performing CDT. Length of stay and tissue plasminogen activator dosage decreased significantly throughout the study period as a more restrictive approach to follow-up angiography was employed without adverse safety or patient outcomes. Author Disclosures: O. Al-Nouri: None; K. Mannava: Other financial benefit; My Role; Industry sponsored study SPEEK for PE treatment; L. Stevens: None.
Complication and Retrieval Rates of Inferior Vena Cava Filters, a Single-Center Retrospective Study Nathaniel A. Parker,1 Ankit Mohla,1 Scott W. Kujath, MD,2 Karl R. Stark, MD,2 Jonathon E. Wilson, DO,2 Rebecca J. Thomas, RN,2 Robert R. Carter, MD2. 1Kansas City University of Medicine and Biosciences, Kansas City, Mo 2Midwest Aortic and Vascular Institute (MAVI), Kansas City, Mo
Fig. Rose claudication survey questions.
Objective: Inferior vena cava (IVC) filters are used as prophylaxis against the sequelae of venous thromboembolisms (VTEs). These filters are classified as either permanent or retrievable, depending on whether they are designed to be removed at a later date or left in place lifelong. The choice of which type of filter to place is often dependent on whether the patient will need VTE protection long term. However, the risks associated with