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Contemporary Outcomes of Civilian Lower Extremity Arterial Trauma
808 Abstracts
JOURNAL OF VASCULAR SURGERY September 2015
in 16.5%. A total of 425 patients (16%) were readmitted #30 days of the index operation. Risk factors associated with readmission included return to operation room (odds ratio [OR], 9.2), wound infection (OR, 8.5), limb amputation (OR, 5.4), postoperative deep vein thrombosis (OR, 3.8), and major reintervention on bypass (OR, 3.4; P < .05; Fig). Conclusions: Readmission after lower extremity bypass surgery is a serious complication. Various factors put a patient at a high risk for readmission. Return to the operating room, wound infection, amputation, deep vein thrombosis, and major reintervention on bypass are independent risk factors for hospital readmission. Return to the operating room is associated with a ninefold increase in hospital readmission.
Fig. Prevalence of peripheral arterial disease (PAD) in females by age and bone mineral density score. and the prevalence of PAD in individuals who underwent vascular screening and BMD measurements. Methods: Patients underwent arterial Doppler studies; PAD was noted with an ankle-brachial index of #0.9. T scores were calculated using bone densitometry of the calcaneus. Normal was a T score of 1.0 or higher, osteopenia with a T score between 1.0 and 2.5, and osteoporosis with a T score of 2.5 or lower. Subject demographics, comorbidities, and history were self-reported. Univariate and multivariate statistics were used. Results: Of 766,172 men, osteopenia was noted in 23.4% and osteoporosis in 1.1%. Men with abnormal T scores did not have a different risk factor profile than normal men but had a higher rate of prior myocardial infarction (MI) and were older. The prevalence of PAD was higher in men with osteopenia (4.5%) and osteoporosis (10.9%) than in men with normal T scores (3%; P < .0001). Logistic regression controlling for age and risk factors revealed osteopenia (odds ratio [OR], 1.3) and osteoporosis (OR, 2.3) were independent risk factors for PAD in men. Of 1,256,909 women, osteopenia was noted in 30.3% and osteoporosis in 2.4%. Women with abnormal T scores were older and had a higher rate of prior MI but did not have a different risk factor profile than women with normal T scores. The prevalence of PAD was higher in women with osteopenia (4.8%) and osteoporosis (11.8%) than in normal women (3.3%; P < .001). Logistic regression again revealed osteopenia (OR, 1.15) and osteoporosis (OR, 1.8) were both independent risk factors for PAD in women. In a further examination of women stratifying by age, osteoporotic women had a significantly increased prevalence of PAD in all age groups (Fig). Conclusions: The current study reports a strong association of BMD analysis with the prevalence of PAD, which persists even when controlling for age and risk factors. The presence of osteoporosis should make clinicians aware of the possibility of occult PAD in appropriate patients. Author Disclosures: C. B. Rockman: None; T. Maldonado: None; J. Hiramoto: None; S. Honig: None; M. Conte: None; J. Berger: None. Return to Operating Room After Lower Extremity Arterial Bypass Is an Independent Predictor for Hospital Readmission Faisal Aziz, MD. Penn State University, Hershey, Pa Objectives: Hospital readmissions after surgical operations are considered as serious complications and affect health care associated costs. The Centers for Medicare and Medicaid services (CMS) strongly encourages identification and ramification of factors associated with hospital readmissions after operations. Despite advances in endovascular surgery, lower extremity arterial bypass remains the gold standard treatment for severe, symptomatic peripheral arterial disease (PAD). The purpose of this study was to retrospectively review the factors associated with hospital readmission after lower extremity bypass surgery. Methods: The 2013 lower extremity revascularization-targeted American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database and generalized 2013 general and vascular surgery ACS-NSQIP Participant Use File were used for this study. Patient, diagnosis, and procedure characteristics of patients undergoing lower extremity bypass surgery were assessed. Multivariate logistic regression analysis was used to determine independent risk factors for hospital readmission #30 days after surgery. Results: A total of 2646 patients (males, 35%; females, 65%) underwent lower extremity revascularization during 2013. Indications for operations included tissue loss (39%), rest pain (32%), and severe claudication (25%). Preoperative ankle-brachial indices were 0.4 to 0.9 in 32% and <.4
Fig. Factors associated with hospital readmission after lower extremity arterial bypass surgery. OR, Operating room.
Author Disclosures: F. Aziz: None. Gender Predicts Rupture of Pancreaticoduodenal Artery Aneurysms Kristine C. Orion, MD, Alireza Najafian, Bryan A. Ehlert, MD, Mahmoud B. Malas, MD, MHS, James H. Black III, MD, Christopher J. Abularrage, MD. The Johns Hopkins Hospital, Baltimore, Md Objectives: There remains no consensus on indication or technique for repair of pancreaticoduodenal artery aneurysms (PDAAs) because they are exceedingly rare. We sought to evaluate risk factors for rupture and to compare the outcomes of open and endovascular surgery. Methods: We performed a retrospective review of all PDAAs over a 15year period. The primary outcome was technical success, defined as complete cessation of flow within the aneurysm sac on follow-up imaging. Secondary outcomes included complications greater than Clavien-Dindo grade I. Results: A total of 21 PDAAs were identified (mean size, 20 [interquartile range, 8-32] mm). Eight patients (38%) were male, with an average age at diagnosis of 54.3 6 2.4 years. Aneurysm etiology included degenerative (90%), pancreatitis (14%), and connective tissue disorder (5%). Seven patients (33%) had additional aneurysms on imaging. Ten patients (48%) were asymptomatic, and five patients (24%) presented with rupture. Six patients (29%) had an open repair, including four aneurysm ligations and two emergency Whipple procedures. Eleven patients underwent an endovascular intervention, including 10 (48%) embolizations and one stent-assisted coiling (9%). Technical success was 100% for the open group and 91% in the endovascular group. Clavien-Dindo grade >1 complications occurred in 67% of open patients and in 0% of endovascular patients (P ¼ .01). Death occurred in two ruptured patients who underwent open repair. On univariate analysis, male gender was statistically associated with rupture (P ¼ .02); however, size of the aneurysm was not (P ¼ .77). There was a trend toward an increased rupture rate in those with celiac stenosis (P ¼ .10). Conclusions: In the largest series of PDAAs to date, only male gender was associated with rupture. Although technical success was greater in the open group, it was also associated with an increased incidence of clinically significant complications and death. Endovascular aneurysm embolization should be considered the treatment of choice. Author Disclosures: K. C. Orion: None; A. Najafian: None; B. A. Ehlert: None; M. B. Malas: None; J. H. Black: None; C. J. Abularrage: None.
Contemporary Outcomes of Civilian Lower Extremity Arterial Trauma Nathan L. Liang, MD, Louis H. Alarcon, MD, Geetha Jeyabalan, MD, Efthymios D. Avgerinos, MD, Michel S. Makaroun, MD, Rabih A. Chaer, MD, MSc. University of Pittsburgh Medical Center, Pittsburgh, Pa
JOURNAL OF VASCULAR SURGERY Volume 62, Number 3
Objectives: Lower extremity arterial injury may result in limb loss. The purpose of this study was to examine outcomes of civilian lower extremity arterial trauma and predictors of delayed amputation (DA). Methods: The records of patients presenting to a major level I trauma center from 2000 to 2014 with infrainguinal arterial injury were identified from a prospective institutional trauma registry and outcomes reviewed. Standard statistical methods were used for data analysis. Results: We identified 149 patients (86% male; mean age, 33 6 14 years). Of these, 46% presented with blunt trauma: 19 (13%) had common femoral (CFA), 26 (17%) had superficial femoral (SFA), 50 (33%) had popliteal, and 54 (36%) had tibial injury. Seven patients underwent primary amputation; of the remainder, 21 (15%) had ligation, 85 (59%) revascularization (80% bypass grafting, 20% primary repair), and the rest were observed. Twenty-four (17%) eventually required DA; 20 (83%) were due to irreversible ischemia or extensive musculoskeletal damage, despite having adequate perfusion. DA rates were 26% for popliteal, 20% for tibial, and 4.4% for CFA/SFA injury. The DA group had significantly more (P < .05) blunt trauma (79% vs 30%), popliteal injury (46% vs 27%), compound fracture/dislocation (75% vs 33%), bypass graft (63% vs 43%), fasciotomy (75% vs 43%), higher Mangled Extremity Severity Score (MESS; 6.1 6 1.8 vs 4.3 6 1.6), and longer ischemic time (5.8 6 3.9 vs 3.5 6 2.3 hours). Predictors of DA included younger age, higher injury severity score, popliteal or tibial injury, longer ischemic time, higher MESS score, blunt trauma, and pulseless examination on presentation. Subanalysis of those requiring revascularization showed blunt trauma and any fracture were predictors of DA. Conclusions: DA after civilian arterial trauma often occurs despite revascularization due to irreversible ischemia or extensive musculoskeletal damage. Individualized decision making based on age, mechanism, extent of musculoskeletal trauma and location of arterial injury should guide intensity of revascularization strategies. Author Disclosures: N. L. Liang: None; L. H. Alarcon: None; G. Jeyabalan: None; E. D. Avgerinos: None; M. S. Makaroun: None; R. A. Chaer: None.
Factors Contributing to Operating Room Cancellation Rates for Patients Undergoing Arteriovenous Access Procedures Chun K. Yang, MD, John Danks, MD, Selena Goss, MD, Sean Alcantara, MD, Michael Dudkiewicz, MD, Alan Benvenisty, MD, John Lantis II, MD. Mount Sinai St. Luke’s Hospital and Mount Sinai Roosevelt Hospital, New York, NY Objectives: Operating room cancellation rates, defined as cancellation #24 hours of planned surgery, have been reported to be as high as 14% to 17.4%. In the United Kingdom, this cancellation rate average is 8.1%. One large metropolitan hospital system in the United States has chosen 6% as a target mandatory cancellation rate. Procedures in the fields of vascular and transplant surgery fall well outside this benchmark, particularly ones involving arteriovenous access (AVA). Methods: PubMed was searched to determine the reported cancellation rates for patients undergoing AVA surgery. Interestingly, there were no clearly defined studies or published rates of AVA procedure cancellation in the English language literature. Using an operating room quality assurance database, we analyzed the 1-year cancellation rate of AVA procedures by Current Procedural Terminology (CPT) code. Analysis included the number of cases cancelled and the reasons stated for case cancellation. Results: Among 191 cases booked, encompassing CPT codes 36,819, 36,821, 36,830, and 36,831, 88 (46%) were cancelled #24 hours. Cancellations by surgical type were 36,819 (55%), 36,821 (46%), 36,830 (43%), and 36,830 (25%). The reasons for cancellation were as follows: 44% attributed to practice conditions, including scheduling issues, insurance verification, and attending schedule; 31% based on patient factors; and 25% listed as lack of medical clearance. Conclusions: A cancellation rate of 14% is generally reported, and accepted, for elective general surgery cases. This percentage is largely attributed to patient comorbidities and the disease process. However, the cancellation rate for patients undergoing AVA procedures is notably higher, at 46%. We believe that by minimizing practice-related and preoperative assessment variables, the AVA cancellation rate can be reduced to a percentage closer to the 14% for elective general surgery. Author Disclosures: C. K. Yang: None; J. Danks: None; S. Goss: None; S. Alcantara: None; M. Dudkiewicz: None; A. Benvenisty: None; J. Lantis: None.
Abstracts 809
Arteriovenous Fistulas as Endovascular Access Sites in the Pediatric Populations: A Multispecies Animal Model Chun K. Yang, John Danks, Selena G. Goss, Sean Alcantara, John C. Lantis This abstract has been published in the Abstracts of the 2015 Vascular Annual Meeting: The Society for Vascular Surgery. DOI: http://dx.doi. org/10.1016/j.jvs2015.04.157. Ruptured EVAR vs OSR: What Is the Cost per Day of Patient Survival Chetna Prasad1, Manish Mehta2, Philip S. K. Paty2, James Puleo1, Kamran Jafree3, Krishna Martinez-Singh3, Benjamin Chang4, Paul Feustel3. 1Center for Vascular Awareness, Albany, NY; 2Vascular Health Partners, CCP, Glens Falls, NY; 3Albany Medical College, Albany, NY; 4Institute for Vascular Health and Disease, Albany, NY Objectives: Using an amortized cost model, we evaluated the costs per day of patient survival after endovascular aneurysm repair a ruptured abdominal aortic aneurysm (r-EVAR) vs open surgical repair (r-OSR). Methods: Over the past 5 years, 149 patients presented with a ruptured abdominal aortic aneurysm; of whom 91 (61%) underwent rEVAR and 58 (39%) underwent rOSR. An amortized cost model that included survival data end points and all direct and indirect hospital costs of the initial and subsequent 30-day reinterventions was applied to a prospectively collected vascular database. For each patient, the total initial procedure costs and the number of patient days of survival were calculated for the first 30 days after rEVAR and rOSR. Statistical analysis was done via Student t-test and log-rank Kaplan-Meier analysis. Results: The rEVAR patients had significantly lower 30-day mortality than did rOSR patients (22% vs 36%; P < .005), and better cumulative 5year survival (37% vs 26%; P < .005). In all comers, the 91 rEVAR patients’ total cost was $6,485,584 for a cost of $72,062 per patient, and the 58 rOSR patients’ total cost was $2,934,487 for a cost of $50,595 per patient. Of the 30-day survivors, the median cost per day of patient survival was $2052 (interquartile range, $1471-$5336) in the rEVAR group and was $2415 (interquartile range, $1194-$5457) in the rOSR group. This difference was not statistically significant (P ¼ .54 by Mann-Whitney test). Conclusions: When compared with rOSR, rEVAR reduces the 30day mortality and improves long-term survival. This study provides, for the first time, evidence that amongst survivors, the total costs per day of the initial procedure and all 30-day secondary interventions are comparable for rEVAR and rOSR. It is likely with improved patient survival over the long-term that rEVAR cost per day of patient survival will be lower than that of rOSR. Further studies are needed. Author Disclosures: C. Prasad: None; M. Mehta: Honoraria, W. L. Gore, TriVascular Inc, Aptus Endosystems, Medtronic, and Endologix, speaking agreement; other financial benefit, W. L. Gore, Medtronic, TriVascular, Bolton Medical, Silkroad Medical, Terumo, Aptus Endosystems, and Boston Scientific, principal investigator clinical trial; P. S. K. Paty: Other financial benefit, W.L. Gore, Medtronic, TriVascular, Bolton Medical, Silkroad Medical, Terumo, Aptus Endosystems, and Boston Scientific, sub-investigator clinical trials; J. Puleo: None; K. Jafree: None; K. Martinez-Singh: None; B. Chang: None; P. Feustel: None. Open Repair of Ruptured Abdominal Aortic Aneurysm in Nonagenarians Is Associated With Substantially High Mortality Faisal Aziz, MD, Michael Sybert, Amy B. Reed, MD. Penn State University, Hershey, Pa Objectives: Open repair for ruptured abdominal aortic aneurysm (ROAR) has been the gold standard treatment. With the passage of time, more and more surgeons are performing endovascular repair (REVAR) for ruptured aortic aneurysms. Old age is associated with poor outcomes after ruptured aortic aneurysms. The purpose of this study was to review the outcomes of ruptured aortic aneurysm among an elderly population. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent surgical procedures from 2005 to 2010. They were divided into three groups based on their age: heptagenarians, octogenarians, and nonagenarians. Patients’ demographics and comorbidities (diabetes mellitus, hypertension, chronic obstructive pulmonary disease, congestive heart failure, myocardial infarction, dialysis dependency, and peripheral arterial disease) were collected. Operations performed by ROAR vs REVAR were identified. We also collected American Society of Anesthesiologists scores, operating times, hospital lengths of stay, postoperative complications, and mortality. Results: A total of 870 patients were identified: 492 heptagenarians, 341 octogenarians, and 37 nonagenarians. REVAR was performed in 31% of heptagenarians, 37% of octogenarians, and 33% of nonagenarians. ROAR was
JOURNAL OF VASCULAR SURGERY September 2015
in 16.5%. A total of 425 patients (16%) were readmitted #30 days of the index operation. Risk factors associated with readmission included return to operation room (odds ratio [OR], 9.2), wound infection (OR, 8.5), limb amputation (OR, 5.4), postoperative deep vein thrombosis (OR, 3.8), and major reintervention on bypass (OR, 3.4; P < .05; Fig). Conclusions: Readmission after lower extremity bypass surgery is a serious complication. Various factors put a patient at a high risk for readmission. Return to the operating room, wound infection, amputation, deep vein thrombosis, and major reintervention on bypass are independent risk factors for hospital readmission. Return to the operating room is associated with a ninefold increase in hospital readmission.
Fig. Prevalence of peripheral arterial disease (PAD) in females by age and bone mineral density score. and the prevalence of PAD in individuals who underwent vascular screening and BMD measurements. Methods: Patients underwent arterial Doppler studies; PAD was noted with an ankle-brachial index of #0.9. T scores were calculated using bone densitometry of the calcaneus. Normal was a T score of 1.0 or higher, osteopenia with a T score between 1.0 and 2.5, and osteoporosis with a T score of 2.5 or lower. Subject demographics, comorbidities, and history were self-reported. Univariate and multivariate statistics were used. Results: Of 766,172 men, osteopenia was noted in 23.4% and osteoporosis in 1.1%. Men with abnormal T scores did not have a different risk factor profile than normal men but had a higher rate of prior myocardial infarction (MI) and were older. The prevalence of PAD was higher in men with osteopenia (4.5%) and osteoporosis (10.9%) than in men with normal T scores (3%; P < .0001). Logistic regression controlling for age and risk factors revealed osteopenia (odds ratio [OR], 1.3) and osteoporosis (OR, 2.3) were independent risk factors for PAD in men. Of 1,256,909 women, osteopenia was noted in 30.3% and osteoporosis in 2.4%. Women with abnormal T scores were older and had a higher rate of prior MI but did not have a different risk factor profile than women with normal T scores. The prevalence of PAD was higher in women with osteopenia (4.8%) and osteoporosis (11.8%) than in normal women (3.3%; P < .001). Logistic regression again revealed osteopenia (OR, 1.15) and osteoporosis (OR, 1.8) were both independent risk factors for PAD in women. In a further examination of women stratifying by age, osteoporotic women had a significantly increased prevalence of PAD in all age groups (Fig). Conclusions: The current study reports a strong association of BMD analysis with the prevalence of PAD, which persists even when controlling for age and risk factors. The presence of osteoporosis should make clinicians aware of the possibility of occult PAD in appropriate patients. Author Disclosures: C. B. Rockman: None; T. Maldonado: None; J. Hiramoto: None; S. Honig: None; M. Conte: None; J. Berger: None. Return to Operating Room After Lower Extremity Arterial Bypass Is an Independent Predictor for Hospital Readmission Faisal Aziz, MD. Penn State University, Hershey, Pa Objectives: Hospital readmissions after surgical operations are considered as serious complications and affect health care associated costs. The Centers for Medicare and Medicaid services (CMS) strongly encourages identification and ramification of factors associated with hospital readmissions after operations. Despite advances in endovascular surgery, lower extremity arterial bypass remains the gold standard treatment for severe, symptomatic peripheral arterial disease (PAD). The purpose of this study was to retrospectively review the factors associated with hospital readmission after lower extremity bypass surgery. Methods: The 2013 lower extremity revascularization-targeted American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database and generalized 2013 general and vascular surgery ACS-NSQIP Participant Use File were used for this study. Patient, diagnosis, and procedure characteristics of patients undergoing lower extremity bypass surgery were assessed. Multivariate logistic regression analysis was used to determine independent risk factors for hospital readmission #30 days after surgery. Results: A total of 2646 patients (males, 35%; females, 65%) underwent lower extremity revascularization during 2013. Indications for operations included tissue loss (39%), rest pain (32%), and severe claudication (25%). Preoperative ankle-brachial indices were 0.4 to 0.9 in 32% and <.4
Fig. Factors associated with hospital readmission after lower extremity arterial bypass surgery. OR, Operating room.
Author Disclosures: F. Aziz: None. Gender Predicts Rupture of Pancreaticoduodenal Artery Aneurysms Kristine C. Orion, MD, Alireza Najafian, Bryan A. Ehlert, MD, Mahmoud B. Malas, MD, MHS, James H. Black III, MD, Christopher J. Abularrage, MD. The Johns Hopkins Hospital, Baltimore, Md Objectives: There remains no consensus on indication or technique for repair of pancreaticoduodenal artery aneurysms (PDAAs) because they are exceedingly rare. We sought to evaluate risk factors for rupture and to compare the outcomes of open and endovascular surgery. Methods: We performed a retrospective review of all PDAAs over a 15year period. The primary outcome was technical success, defined as complete cessation of flow within the aneurysm sac on follow-up imaging. Secondary outcomes included complications greater than Clavien-Dindo grade I. Results: A total of 21 PDAAs were identified (mean size, 20 [interquartile range, 8-32] mm). Eight patients (38%) were male, with an average age at diagnosis of 54.3 6 2.4 years. Aneurysm etiology included degenerative (90%), pancreatitis (14%), and connective tissue disorder (5%). Seven patients (33%) had additional aneurysms on imaging. Ten patients (48%) were asymptomatic, and five patients (24%) presented with rupture. Six patients (29%) had an open repair, including four aneurysm ligations and two emergency Whipple procedures. Eleven patients underwent an endovascular intervention, including 10 (48%) embolizations and one stent-assisted coiling (9%). Technical success was 100% for the open group and 91% in the endovascular group. Clavien-Dindo grade >1 complications occurred in 67% of open patients and in 0% of endovascular patients (P ¼ .01). Death occurred in two ruptured patients who underwent open repair. On univariate analysis, male gender was statistically associated with rupture (P ¼ .02); however, size of the aneurysm was not (P ¼ .77). There was a trend toward an increased rupture rate in those with celiac stenosis (P ¼ .10). Conclusions: In the largest series of PDAAs to date, only male gender was associated with rupture. Although technical success was greater in the open group, it was also associated with an increased incidence of clinically significant complications and death. Endovascular aneurysm embolization should be considered the treatment of choice. Author Disclosures: K. C. Orion: None; A. Najafian: None; B. A. Ehlert: None; M. B. Malas: None; J. H. Black: None; C. J. Abularrage: None.
Contemporary Outcomes of Civilian Lower Extremity Arterial Trauma Nathan L. Liang, MD, Louis H. Alarcon, MD, Geetha Jeyabalan, MD, Efthymios D. Avgerinos, MD, Michel S. Makaroun, MD, Rabih A. Chaer, MD, MSc. University of Pittsburgh Medical Center, Pittsburgh, Pa
JOURNAL OF VASCULAR SURGERY Volume 62, Number 3
Objectives: Lower extremity arterial injury may result in limb loss. The purpose of this study was to examine outcomes of civilian lower extremity arterial trauma and predictors of delayed amputation (DA). Methods: The records of patients presenting to a major level I trauma center from 2000 to 2014 with infrainguinal arterial injury were identified from a prospective institutional trauma registry and outcomes reviewed. Standard statistical methods were used for data analysis. Results: We identified 149 patients (86% male; mean age, 33 6 14 years). Of these, 46% presented with blunt trauma: 19 (13%) had common femoral (CFA), 26 (17%) had superficial femoral (SFA), 50 (33%) had popliteal, and 54 (36%) had tibial injury. Seven patients underwent primary amputation; of the remainder, 21 (15%) had ligation, 85 (59%) revascularization (80% bypass grafting, 20% primary repair), and the rest were observed. Twenty-four (17%) eventually required DA; 20 (83%) were due to irreversible ischemia or extensive musculoskeletal damage, despite having adequate perfusion. DA rates were 26% for popliteal, 20% for tibial, and 4.4% for CFA/SFA injury. The DA group had significantly more (P < .05) blunt trauma (79% vs 30%), popliteal injury (46% vs 27%), compound fracture/dislocation (75% vs 33%), bypass graft (63% vs 43%), fasciotomy (75% vs 43%), higher Mangled Extremity Severity Score (MESS; 6.1 6 1.8 vs 4.3 6 1.6), and longer ischemic time (5.8 6 3.9 vs 3.5 6 2.3 hours). Predictors of DA included younger age, higher injury severity score, popliteal or tibial injury, longer ischemic time, higher MESS score, blunt trauma, and pulseless examination on presentation. Subanalysis of those requiring revascularization showed blunt trauma and any fracture were predictors of DA. Conclusions: DA after civilian arterial trauma often occurs despite revascularization due to irreversible ischemia or extensive musculoskeletal damage. Individualized decision making based on age, mechanism, extent of musculoskeletal trauma and location of arterial injury should guide intensity of revascularization strategies. Author Disclosures: N. L. Liang: None; L. H. Alarcon: None; G. Jeyabalan: None; E. D. Avgerinos: None; M. S. Makaroun: None; R. A. Chaer: None.
Factors Contributing to Operating Room Cancellation Rates for Patients Undergoing Arteriovenous Access Procedures Chun K. Yang, MD, John Danks, MD, Selena Goss, MD, Sean Alcantara, MD, Michael Dudkiewicz, MD, Alan Benvenisty, MD, John Lantis II, MD. Mount Sinai St. Luke’s Hospital and Mount Sinai Roosevelt Hospital, New York, NY Objectives: Operating room cancellation rates, defined as cancellation #24 hours of planned surgery, have been reported to be as high as 14% to 17.4%. In the United Kingdom, this cancellation rate average is 8.1%. One large metropolitan hospital system in the United States has chosen 6% as a target mandatory cancellation rate. Procedures in the fields of vascular and transplant surgery fall well outside this benchmark, particularly ones involving arteriovenous access (AVA). Methods: PubMed was searched to determine the reported cancellation rates for patients undergoing AVA surgery. Interestingly, there were no clearly defined studies or published rates of AVA procedure cancellation in the English language literature. Using an operating room quality assurance database, we analyzed the 1-year cancellation rate of AVA procedures by Current Procedural Terminology (CPT) code. Analysis included the number of cases cancelled and the reasons stated for case cancellation. Results: Among 191 cases booked, encompassing CPT codes 36,819, 36,821, 36,830, and 36,831, 88 (46%) were cancelled #24 hours. Cancellations by surgical type were 36,819 (55%), 36,821 (46%), 36,830 (43%), and 36,830 (25%). The reasons for cancellation were as follows: 44% attributed to practice conditions, including scheduling issues, insurance verification, and attending schedule; 31% based on patient factors; and 25% listed as lack of medical clearance. Conclusions: A cancellation rate of 14% is generally reported, and accepted, for elective general surgery cases. This percentage is largely attributed to patient comorbidities and the disease process. However, the cancellation rate for patients undergoing AVA procedures is notably higher, at 46%. We believe that by minimizing practice-related and preoperative assessment variables, the AVA cancellation rate can be reduced to a percentage closer to the 14% for elective general surgery. Author Disclosures: C. K. Yang: None; J. Danks: None; S. Goss: None; S. Alcantara: None; M. Dudkiewicz: None; A. Benvenisty: None; J. Lantis: None.
Abstracts 809
Arteriovenous Fistulas as Endovascular Access Sites in the Pediatric Populations: A Multispecies Animal Model Chun K. Yang, John Danks, Selena G. Goss, Sean Alcantara, John C. Lantis This abstract has been published in the Abstracts of the 2015 Vascular Annual Meeting: The Society for Vascular Surgery. DOI: http://dx.doi. org/10.1016/j.jvs2015.04.157. Ruptured EVAR vs OSR: What Is the Cost per Day of Patient Survival Chetna Prasad1, Manish Mehta2, Philip S. K. Paty2, James Puleo1, Kamran Jafree3, Krishna Martinez-Singh3, Benjamin Chang4, Paul Feustel3. 1Center for Vascular Awareness, Albany, NY; 2Vascular Health Partners, CCP, Glens Falls, NY; 3Albany Medical College, Albany, NY; 4Institute for Vascular Health and Disease, Albany, NY Objectives: Using an amortized cost model, we evaluated the costs per day of patient survival after endovascular aneurysm repair a ruptured abdominal aortic aneurysm (r-EVAR) vs open surgical repair (r-OSR). Methods: Over the past 5 years, 149 patients presented with a ruptured abdominal aortic aneurysm; of whom 91 (61%) underwent rEVAR and 58 (39%) underwent rOSR. An amortized cost model that included survival data end points and all direct and indirect hospital costs of the initial and subsequent 30-day reinterventions was applied to a prospectively collected vascular database. For each patient, the total initial procedure costs and the number of patient days of survival were calculated for the first 30 days after rEVAR and rOSR. Statistical analysis was done via Student t-test and log-rank Kaplan-Meier analysis. Results: The rEVAR patients had significantly lower 30-day mortality than did rOSR patients (22% vs 36%; P < .005), and better cumulative 5year survival (37% vs 26%; P < .005). In all comers, the 91 rEVAR patients’ total cost was $6,485,584 for a cost of $72,062 per patient, and the 58 rOSR patients’ total cost was $2,934,487 for a cost of $50,595 per patient. Of the 30-day survivors, the median cost per day of patient survival was $2052 (interquartile range, $1471-$5336) in the rEVAR group and was $2415 (interquartile range, $1194-$5457) in the rOSR group. This difference was not statistically significant (P ¼ .54 by Mann-Whitney test). Conclusions: When compared with rOSR, rEVAR reduces the 30day mortality and improves long-term survival. This study provides, for the first time, evidence that amongst survivors, the total costs per day of the initial procedure and all 30-day secondary interventions are comparable for rEVAR and rOSR. It is likely with improved patient survival over the long-term that rEVAR cost per day of patient survival will be lower than that of rOSR. Further studies are needed. Author Disclosures: C. Prasad: None; M. Mehta: Honoraria, W. L. Gore, TriVascular Inc, Aptus Endosystems, Medtronic, and Endologix, speaking agreement; other financial benefit, W. L. Gore, Medtronic, TriVascular, Bolton Medical, Silkroad Medical, Terumo, Aptus Endosystems, and Boston Scientific, principal investigator clinical trial; P. S. K. Paty: Other financial benefit, W.L. Gore, Medtronic, TriVascular, Bolton Medical, Silkroad Medical, Terumo, Aptus Endosystems, and Boston Scientific, sub-investigator clinical trials; J. Puleo: None; K. Jafree: None; K. Martinez-Singh: None; B. Chang: None; P. Feustel: None. Open Repair of Ruptured Abdominal Aortic Aneurysm in Nonagenarians Is Associated With Substantially High Mortality Faisal Aziz, MD, Michael Sybert, Amy B. Reed, MD. Penn State University, Hershey, Pa Objectives: Open repair for ruptured abdominal aortic aneurysm (ROAR) has been the gold standard treatment. With the passage of time, more and more surgeons are performing endovascular repair (REVAR) for ruptured aortic aneurysms. Old age is associated with poor outcomes after ruptured aortic aneurysms. The purpose of this study was to review the outcomes of ruptured aortic aneurysm among an elderly population. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent surgical procedures from 2005 to 2010. They were divided into three groups based on their age: heptagenarians, octogenarians, and nonagenarians. Patients’ demographics and comorbidities (diabetes mellitus, hypertension, chronic obstructive pulmonary disease, congestive heart failure, myocardial infarction, dialysis dependency, and peripheral arterial disease) were collected. Operations performed by ROAR vs REVAR were identified. We also collected American Society of Anesthesiologists scores, operating times, hospital lengths of stay, postoperative complications, and mortality. Results: A total of 870 patients were identified: 492 heptagenarians, 341 octogenarians, and 37 nonagenarians. REVAR was performed in 31% of heptagenarians, 37% of octogenarians, and 33% of nonagenarians. ROAR was