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Excellent outcomes following surgical intervention in 542 patients with thoracic outlet syndrome over a decade
Vol. 219, No. 4S, October 2014
on how to resolve conflict should issues arise during the pilot. Patients identified as ASA 3 or higher and an expected LOS>1 day were co-managed by their attending surgeon, surgical residents, and attending hospitalist. RESULTS: There have been a total of 250 admissions to the service. The patients in the pilot consisted of 53% males with an average age of 63 years. The average length of stay (ALOS) for this group of patients is 8 days. There has been a reduction of 1.25 days since before this pilot began. From a financial perspective the ACMI of this service has increased .19. This might be due to the better medical record documentation by the hospitalist. CONCLUSIONS: Using outcome measures including the American College of Surgeons National Surgical Quality Improvement Program, surgical co-management appears to have a positive impact on hospitalized surgical patients. The survival benefit of kidney transplantation in ESRD patients with peripheral arterial disease James Cassuto, Sateesh C Babu, MD, Igor A Laskowski, MD, PhD Westchester Medical Center, Valhalla, NY INTRODUCTION: Previously, we asked if concomitant peripheral arterial disease (PAD) and ESRD were associated with an increased risk of mortality in patients on the kidney transplant waitlist. Given the general decreased survival of patients with both PAD and chronic kidney disease, we specifically sought to determine if a survival benefit of renal transplantation in PAD patients exists. METHODS: Multivariable COX regression and Kaplan-Meier survival models were fit using UNOS data to assess waitlist and posttransplant 5-year survival. Logistic regression was used to model waitlist survival at varying time points to determine if the risk of death with combined PAD and dialysis (Dial) is time dependent. RESULTS: As previously shown, compared to PAD-Dial- (no PAD or dialysis) waitlist survival, PAD+Dial- was associated with a 36%, PAD-Dial+ a 95%, and PAD+Dial+ a 190% increased risk of death. The combined effects of PAD and Dial on the risk of mortality increased with time. Herein, we demonstrate that the risk of waitlist death in PAD+ can indeed be modified by transplantation (p<0.001, HR¼0.440) and that survival is significantly greater post transplant (5-year survival without transplant¼34.5%, with transplant¼68.1%, p<0.001). Additionally, the survival benefit in PAD+Dial- (p<0.001, HR¼0.265) is greater than in PAD+Dial+ (p<0.001, HR¼0.469). Compared to cadaveric donation, living donor kidneys have greater post-transplant survival in PAD+. CONCLUSIONS: Given the synergistic risk of death and poor waitlist survival in patients with concomitant PAD and dialysis, pre-emptive transplantation with emphasis on living donations prior to dialysis should be advocated to improve outcomes in this high risk patient population.
Scientific Poster Presentations: 2014 Clinical Congress
e201
Calcification predicts in-stent restenosis after carotid artery stenting (CAS) in high-risk patients Kirstyn Brownson, MD, Roland Assi, MD, Penny Vasilas, RN, Bart Muhs, MD, PhD, Alan Dardik, MD, PhD, FACS, Michael R Hall, MD Yale New Haven Hospital, New Haven, CT INTRODUCTION: Carotid artery stenting is an alternative treatment for high-risk carotid disease; studies report stroke protection and reduced MI compared to endarterectomy. Criteria defining and predicting restenosis remain controversial. METHODS: Records of patients who underwent CAS at our institution (January 2006-December 2012) were reviewed and preoperative, operative, and postoperative data were analyzed with JMP. RESULTS: 34 patients underwent 38 CAS placements (19 ICA, 1 CCA, 18 ICA/CCA). Patients were male with a mean age of 707 years; 21 had prior ipsilateral neck surgery, 9 prior neck radiation, and 8 ipsilateral stroke/TIA within 6 months before CAS. Angiographic success of CAS was 100%; perioperative mortality and cerebrovascular complications were 0% and 3%. Mean follow-up time was 37.424.2 months during which 6 patients underwent angioplasty with or without stenting for in-stent restenosis. Restenosis was defined using ICA peak systolic velocity (PSV) values (>250, >300, >350 cm/sec); intervention for restenosis was correlated with all 3 criteria, with 8 (p¼0.005), 7 (p¼0.0017), and 5 (p¼0.001) developing restenosis respectively. Restenosis was also defined using ICA/CCA PSV ratios (>3.75, >4.0, >4.25); intervention for restenosis was correlated with all 3 criteria with 8 (p¼0.005), 7 (p¼0.0017), and 6 (p¼0.0004) developing restenosis. Presence of calcification, ulceration, stent type, and preoperative PSV predictited restenosis using univariable analysis. Calcification was predictive of restenosis defined by PSV >250 using multivariable analysis. CONCLUSIONS: CAS is performed in selected, high-risk populations with excellent results. Development of in-stent restenosis depends on the criteria used to define it. Because calcification predicts restenosis, patients may benefit from intense post-CAS surveillance. Excellent outcomes following surgical intervention in 542 patients with thoracic outlet syndrome over a decade Megan Orlando, Kendall Likes, BS, Ying Wei Lum, MD, FACS, Thomas Reifsnyder, MD, FACS, Julie A Freischlag, MD Johns Hopkins University Medical Institutions, Baltimore, MD INTRODUCTION: The purpose of this study was to evaluate the clinical presentation and outcomes of patients who underwent first rib resection and scalenectomy (FRRS) for thoracic outlet syndrome (TOS) over a ten-year period. METHODS: Patients treated with FRRS from 2003 to 2013 were retrospectively reviewed using a prospectively maintained database. RESULTS: 542 patients underwent 598 FRRS for indications of neurogenic (312, 52%), venous (261, 44%), and arterial (25, 4%)
e202
Scientific Poster Presentations: 2014 Clinical Congress
TOS. 56 (10%) patients had bilateral FRRS. 52 (10%) patients had cervical ribs. 402 (67%) FRRS were performed on female patients with an average age of 33 years (range 10-71). 341 (57%) were right-sided procedures. 75 children (age 18 years) underwent FRRS; 25 during the first five years and 50 during the second five years. In the second five-year period, more patients had venous TOS (47% vs 37%, p < .02), fewer patients had neurogenic TOS (49% vs 58%, p < .05), and positive outcomes (markedly improved or fully resolved symptoms) increased from 93% to 96%.
J Am Coll Surg
Complications included 2 vein injuries, 2 hemothoraces, 4 hematomas, 138 pneumothoraces (23%), and 8 (1.3%) wound infections. Length of stay averaged one day. CONCLUSIONS: Excellent results were seen in this largest surgical series of neurogenic, venous, and arterial TOS due to appropriate selection of neurogenic patients, utilization of a standard protocol for venous patients, and expedient intervention in arterial patients. There is an increasing role for surgical intervention in children.
on how to resolve conflict should issues arise during the pilot. Patients identified as ASA 3 or higher and an expected LOS>1 day were co-managed by their attending surgeon, surgical residents, and attending hospitalist. RESULTS: There have been a total of 250 admissions to the service. The patients in the pilot consisted of 53% males with an average age of 63 years. The average length of stay (ALOS) for this group of patients is 8 days. There has been a reduction of 1.25 days since before this pilot began. From a financial perspective the ACMI of this service has increased .19. This might be due to the better medical record documentation by the hospitalist. CONCLUSIONS: Using outcome measures including the American College of Surgeons National Surgical Quality Improvement Program, surgical co-management appears to have a positive impact on hospitalized surgical patients. The survival benefit of kidney transplantation in ESRD patients with peripheral arterial disease James Cassuto, Sateesh C Babu, MD, Igor A Laskowski, MD, PhD Westchester Medical Center, Valhalla, NY INTRODUCTION: Previously, we asked if concomitant peripheral arterial disease (PAD) and ESRD were associated with an increased risk of mortality in patients on the kidney transplant waitlist. Given the general decreased survival of patients with both PAD and chronic kidney disease, we specifically sought to determine if a survival benefit of renal transplantation in PAD patients exists. METHODS: Multivariable COX regression and Kaplan-Meier survival models were fit using UNOS data to assess waitlist and posttransplant 5-year survival. Logistic regression was used to model waitlist survival at varying time points to determine if the risk of death with combined PAD and dialysis (Dial) is time dependent. RESULTS: As previously shown, compared to PAD-Dial- (no PAD or dialysis) waitlist survival, PAD+Dial- was associated with a 36%, PAD-Dial+ a 95%, and PAD+Dial+ a 190% increased risk of death. The combined effects of PAD and Dial on the risk of mortality increased with time. Herein, we demonstrate that the risk of waitlist death in PAD+ can indeed be modified by transplantation (p<0.001, HR¼0.440) and that survival is significantly greater post transplant (5-year survival without transplant¼34.5%, with transplant¼68.1%, p<0.001). Additionally, the survival benefit in PAD+Dial- (p<0.001, HR¼0.265) is greater than in PAD+Dial+ (p<0.001, HR¼0.469). Compared to cadaveric donation, living donor kidneys have greater post-transplant survival in PAD+. CONCLUSIONS: Given the synergistic risk of death and poor waitlist survival in patients with concomitant PAD and dialysis, pre-emptive transplantation with emphasis on living donations prior to dialysis should be advocated to improve outcomes in this high risk patient population.
Scientific Poster Presentations: 2014 Clinical Congress
e201
Calcification predicts in-stent restenosis after carotid artery stenting (CAS) in high-risk patients Kirstyn Brownson, MD, Roland Assi, MD, Penny Vasilas, RN, Bart Muhs, MD, PhD, Alan Dardik, MD, PhD, FACS, Michael R Hall, MD Yale New Haven Hospital, New Haven, CT INTRODUCTION: Carotid artery stenting is an alternative treatment for high-risk carotid disease; studies report stroke protection and reduced MI compared to endarterectomy. Criteria defining and predicting restenosis remain controversial. METHODS: Records of patients who underwent CAS at our institution (January 2006-December 2012) were reviewed and preoperative, operative, and postoperative data were analyzed with JMP. RESULTS: 34 patients underwent 38 CAS placements (19 ICA, 1 CCA, 18 ICA/CCA). Patients were male with a mean age of 707 years; 21 had prior ipsilateral neck surgery, 9 prior neck radiation, and 8 ipsilateral stroke/TIA within 6 months before CAS. Angiographic success of CAS was 100%; perioperative mortality and cerebrovascular complications were 0% and 3%. Mean follow-up time was 37.424.2 months during which 6 patients underwent angioplasty with or without stenting for in-stent restenosis. Restenosis was defined using ICA peak systolic velocity (PSV) values (>250, >300, >350 cm/sec); intervention for restenosis was correlated with all 3 criteria, with 8 (p¼0.005), 7 (p¼0.0017), and 5 (p¼0.001) developing restenosis respectively. Restenosis was also defined using ICA/CCA PSV ratios (>3.75, >4.0, >4.25); intervention for restenosis was correlated with all 3 criteria with 8 (p¼0.005), 7 (p¼0.0017), and 6 (p¼0.0004) developing restenosis. Presence of calcification, ulceration, stent type, and preoperative PSV predictited restenosis using univariable analysis. Calcification was predictive of restenosis defined by PSV >250 using multivariable analysis. CONCLUSIONS: CAS is performed in selected, high-risk populations with excellent results. Development of in-stent restenosis depends on the criteria used to define it. Because calcification predicts restenosis, patients may benefit from intense post-CAS surveillance. Excellent outcomes following surgical intervention in 542 patients with thoracic outlet syndrome over a decade Megan Orlando, Kendall Likes, BS, Ying Wei Lum, MD, FACS, Thomas Reifsnyder, MD, FACS, Julie A Freischlag, MD Johns Hopkins University Medical Institutions, Baltimore, MD INTRODUCTION: The purpose of this study was to evaluate the clinical presentation and outcomes of patients who underwent first rib resection and scalenectomy (FRRS) for thoracic outlet syndrome (TOS) over a ten-year period. METHODS: Patients treated with FRRS from 2003 to 2013 were retrospectively reviewed using a prospectively maintained database. RESULTS: 542 patients underwent 598 FRRS for indications of neurogenic (312, 52%), venous (261, 44%), and arterial (25, 4%)
e202
Scientific Poster Presentations: 2014 Clinical Congress
TOS. 56 (10%) patients had bilateral FRRS. 52 (10%) patients had cervical ribs. 402 (67%) FRRS were performed on female patients with an average age of 33 years (range 10-71). 341 (57%) were right-sided procedures. 75 children (age 18 years) underwent FRRS; 25 during the first five years and 50 during the second five years. In the second five-year period, more patients had venous TOS (47% vs 37%, p < .02), fewer patients had neurogenic TOS (49% vs 58%, p < .05), and positive outcomes (markedly improved or fully resolved symptoms) increased from 93% to 96%.
J Am Coll Surg
Complications included 2 vein injuries, 2 hemothoraces, 4 hematomas, 138 pneumothoraces (23%), and 8 (1.3%) wound infections. Length of stay averaged one day. CONCLUSIONS: Excellent results were seen in this largest surgical series of neurogenic, venous, and arterial TOS due to appropriate selection of neurogenic patients, utilization of a standard protocol for venous patients, and expedient intervention in arterial patients. There is an increasing role for surgical intervention in children.