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Faster Surgery for Stroke and TIA Requires More Expedient Referral to the Vascular Service
JOURNAL OF VASCULAR SURGERY August 2015
536 Abstracts
Objective: Access-related hand ischemia (ARHI) is a potentially limbthreatening complication of arteriovenous access for dialysis. The distal revascularization-interval ligation (DRIL) and revision using distal inflow (RUDI) procedures both allow treatment of ischemic symptoms while maintaining fistula patency. Although outcomes with the DRIL are well established, experience with the RUDI for ARHI remains preliminary. We compared outcomes in these procedures with respect to cumulative patency, resolution of symptoms, and patient survival. Methods: A large, prospectively maintained database was used to identify all patients after autogenous arteriovenous fistula construction at two hospitals between 2005 and 2015. Patients with severe (Society for Vascular Surgeons grade 3) ARHI were included for analysis. Results: A total of 2035 autogenous accesses were created during the study period, and 58 (2.8%) developed grade 3 ARHI. Of this cohort, 20 patients underwent RUDI and 21 had a DRIL. The indication for intervention was tissue loss (61%) or ischemic rest pain (39%). Mean age was 57.5 years, and 53.7% of patients were female. Most patients had diabetes (85.3%) and symptomatic peripheral arterial disease (63.4%). The mean digital-brachial index was 0.25 6 0.12. There were no preoperative differences in patient comorbidities between the RUDI and DRIL cohorts. Twelvemonth primary patency (60% vs 67.7%; P ¼ .658) and secondary patency (85% vs 90.5%; P ¼ .592) were similar between groups. Three-year primary patency (55% vs 52.4%; P ¼ .867) and secondary patency (80% vs 90.5%; P ¼ .343) also showed no significant difference. Resolution of ischemic symptoms, including resolution or improvement in pain or healing of ischemic ulcers or amputations, occurred in 90% with RUDI and in 81% with DRIL (P ¼ .131). Survival for the RUDI and DRIL groups at 1 and 3 years was 85% vs 85.7% (P ¼ .948) and 57.9% vs 49.2% (P ¼ .278). Conclusions: Compared with DRIL, RUDI demonstrated equivalent patency, symptom resolution, and survival for the treatment of severe ARHI. Given the poor long-term survival, preoperative risk assessment is critical to procedural decision making. Author Disclosures: J. D. Misskey: None; C. Yang: None; S. MacDonald: None; Y. Hsiang: None.
VA001 Faster Surgery for Stroke and TIA Requires More Expedient Referral to the Vascular Service Hong-Yau Tan, Phillip Puckridge, Conor Marron, James Ian Spark. Flinders Medical Centre, Bedford Park, SA, Australia Objective: Risk of recurrent transient ischemic attack (TIA) or stroke is highest #48 hours of the index event. Carotid endarterectomy (CEA) remains the gold standard for prevention of stroke for patients with a significant ipsilateral stenosis. Evolving evidence has led to pressure to perform CEA #48 hours of the index event. This study aimed to assess and identify rate-limiting steps to performing CEA. Methods: A retrospective review of patients undergoing CEA for symptomatic stenosis during a 40-month period was performed. Patients were identified from the Australasian Vascular Audit and cross-referenced with a prospectively collected audit database. Data were collected on the dates of index symptoms, referral to the vascular service, and to surgery. The day of referral was recorded with separation into referrals received on days with elective theater list availability immediately after the referral (Sunday to Wednesday) and days with only emergency theater list capacity (Thursday to Saturday). Results: The study included 93 patients. CEA was performed in 55% #48 hours of referral to vascular surgery, and in 92% #7 days of referral. Surgery was performed in 20% of patients #48 hours of symptom onset and in 62% #7 days of symptom onset. Surgery in 45% of patients referred Sunday to Wednesday occurred #48 hours and in 90% #7 days. Surgery was performed #48 hours in 66% of patients referred Thursday to Saturday and #7 days in 92%. For patients in 2014, the median time from referral to surgery was 2 days and was 3.5 days from symptom onset to surgery. Conclusions: CEA can be performed #48 hours of appropriate referral. The major challenge of expediently managing symptomatic carotid stenosis is not the timing of surgery after referral but the time from the index symptom to referral to the vascular service. Ongoing education for other disciplines involved in the management of transient ischemic attack and stroke is required regarding the expedient role of CEA in stroke prevention.
VA003 Technical Skills Assessment of Vascular Trainees: Analysis of Performance in a Binational Cohort Over 6 Years Mark Jackson, Nicholas Boyne, Peter Charalabidis, Thodor Vasudevan, Tim Wagner. Griffith University, Brisbane, QLD, Australia
Objective: This study was conducted to validate and introduce a standardized, technical skills assessment task in addition to current assessment methods. Currently, the fellowship examinations are the final arbiter of competence, but increasing reliance is placed on formative (competencybased) assessments. Mentor and direct observation assessments are validated but lack standardization and reproducibility. Methods: A “low-stakes” technical skills simulation was used from 2008 to 2014, observing the progress of a binational cohort through their training. Overall, 123 vascular trainees were assessed on a standardized task (simulated end-to-side artificial anastomosis). Generic and procedure-specific assessment tools were used live (by mentor assessors), and end-product evaluations were also carried out. Year cohorts and individual scores and progress during the 7-year period were analyzed. Correlation of ranked performance vs current assessment methods (mentor assessment scores, log book case volumes, progression through training, and examination success) was sought. Results: Blinded assessment methods were more discriminatory. Using end-product evaluations, there was a stepwise trend between SET levels (Kruskal-Wallis test: P ¼ .01). No correlation was demonstrated between technical skill assessments and in-training “mentor” assessments (P ¼ .12). There was some correlation between performance and individual trainee’s case volume of “infrainguinal” procedures (P ¼ .008). Conclusions: Serial assessment of this large cohort demonstrates validity of this standard vascular technical skill task throughout training. Because the skill assessment scores are poorly correlated with the currently accepted methods of assessing “competence,” an additional component of formative assessment can be recommended for all vascular trainees.
VA004 Improving Care and Outcomes for Older Vascular Surgical Patients Alison Mudge, Prue Mcrae, Michael Reade, Peter Donovan, Jason Jenkins, Melanie Foster, Philip Walker. Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia Objective: Geriatric syndromes are common in older vascular surgery inpatients and associated with poorer outcomes. Multidisciplinary geriatric interventions can reduce geriatric syndromes in other inpatient groups. This pilot study examined the effect of a multidisciplinary improvement intervention for older vascular surgery patients. Methods: This was a prospective study of vascular surgical inpatients aged $65 years admitted to a tertiary hospital vascular surgery service. Cohorts were enrolled before and after implementation of “Eat Walk Engage” program and proactive medical consultation. “Eat Walk Engage” facilitates clinical, environmental, and workforce interventions to improve nutritional care, mobility, and cognitive engagement. Implementation was supported by improved multidisciplinary communication, clinical champions, audit and feedback, and an additional health assistant. The medical service included a senior medical fellow on the ward and twice-weekly joint medical/surgical consultant rounds. Major outcomes were length of stay (vascular ward and total hospital stay) and geriatric syndromes, including delirium (confusion assessment method), functional decline (increase in assistance with activities of daily living between admission and discharge), hospital-acquired pressure injury, and falls. Results: The study enrolled 113 preimplementation and 124 postimplementation participants (mean age, 75 years), of which 46% were elective and 54% were urgent/interhospital transfers. The postimplementation group had a shorter vascular ward (10.0 vs 12.5 days; P ¼ .047) and total (12.6 vs 16.7 days; P ¼ .065) length of stay. They were less likely to develop a geriatric syndrome (24.2% vs 36.0%; P ¼ .048), including less functional decline (14.5% vs 24.3%; P ¼ .056), delirium (14.5% vs 21.4%; P ¼ .16) and hospital acquired pressure injury (4.0% vs 11.6%, P ¼ .03). Conclusions: A multidisciplinary, multicomponent intervention significantly reduced length of stay and geriatric syndromes in older vascular patients.
VA006 Procedural Benefits of Three-Dimensional Image Fusion Angiography During EVAR Are Associated With Improved Postoperative Outcomes Lina Hua, Koah Doan, Nicholas Bajic, Robert Fitridge, Joseph Dawson. University of Adelaide Discipline of Surgery, Adelaide, SA, Australia Objective: Three-dimensional image fusion (3D-IF) angiography during endovascular aneurysm repair (EVAR) allows the amalgamation of preoperative computerized tomography images with live fluoroscopy, resulting in a three-dimensional (3D) volume-rendered angiogram that can be used as a virtual roadmap during EVAR. We previously demonstrated
536 Abstracts
Objective: Access-related hand ischemia (ARHI) is a potentially limbthreatening complication of arteriovenous access for dialysis. The distal revascularization-interval ligation (DRIL) and revision using distal inflow (RUDI) procedures both allow treatment of ischemic symptoms while maintaining fistula patency. Although outcomes with the DRIL are well established, experience with the RUDI for ARHI remains preliminary. We compared outcomes in these procedures with respect to cumulative patency, resolution of symptoms, and patient survival. Methods: A large, prospectively maintained database was used to identify all patients after autogenous arteriovenous fistula construction at two hospitals between 2005 and 2015. Patients with severe (Society for Vascular Surgeons grade 3) ARHI were included for analysis. Results: A total of 2035 autogenous accesses were created during the study period, and 58 (2.8%) developed grade 3 ARHI. Of this cohort, 20 patients underwent RUDI and 21 had a DRIL. The indication for intervention was tissue loss (61%) or ischemic rest pain (39%). Mean age was 57.5 years, and 53.7% of patients were female. Most patients had diabetes (85.3%) and symptomatic peripheral arterial disease (63.4%). The mean digital-brachial index was 0.25 6 0.12. There were no preoperative differences in patient comorbidities between the RUDI and DRIL cohorts. Twelvemonth primary patency (60% vs 67.7%; P ¼ .658) and secondary patency (85% vs 90.5%; P ¼ .592) were similar between groups. Three-year primary patency (55% vs 52.4%; P ¼ .867) and secondary patency (80% vs 90.5%; P ¼ .343) also showed no significant difference. Resolution of ischemic symptoms, including resolution or improvement in pain or healing of ischemic ulcers or amputations, occurred in 90% with RUDI and in 81% with DRIL (P ¼ .131). Survival for the RUDI and DRIL groups at 1 and 3 years was 85% vs 85.7% (P ¼ .948) and 57.9% vs 49.2% (P ¼ .278). Conclusions: Compared with DRIL, RUDI demonstrated equivalent patency, symptom resolution, and survival for the treatment of severe ARHI. Given the poor long-term survival, preoperative risk assessment is critical to procedural decision making. Author Disclosures: J. D. Misskey: None; C. Yang: None; S. MacDonald: None; Y. Hsiang: None.
VA001 Faster Surgery for Stroke and TIA Requires More Expedient Referral to the Vascular Service Hong-Yau Tan, Phillip Puckridge, Conor Marron, James Ian Spark. Flinders Medical Centre, Bedford Park, SA, Australia Objective: Risk of recurrent transient ischemic attack (TIA) or stroke is highest #48 hours of the index event. Carotid endarterectomy (CEA) remains the gold standard for prevention of stroke for patients with a significant ipsilateral stenosis. Evolving evidence has led to pressure to perform CEA #48 hours of the index event. This study aimed to assess and identify rate-limiting steps to performing CEA. Methods: A retrospective review of patients undergoing CEA for symptomatic stenosis during a 40-month period was performed. Patients were identified from the Australasian Vascular Audit and cross-referenced with a prospectively collected audit database. Data were collected on the dates of index symptoms, referral to the vascular service, and to surgery. The day of referral was recorded with separation into referrals received on days with elective theater list availability immediately after the referral (Sunday to Wednesday) and days with only emergency theater list capacity (Thursday to Saturday). Results: The study included 93 patients. CEA was performed in 55% #48 hours of referral to vascular surgery, and in 92% #7 days of referral. Surgery was performed in 20% of patients #48 hours of symptom onset and in 62% #7 days of symptom onset. Surgery in 45% of patients referred Sunday to Wednesday occurred #48 hours and in 90% #7 days. Surgery was performed #48 hours in 66% of patients referred Thursday to Saturday and #7 days in 92%. For patients in 2014, the median time from referral to surgery was 2 days and was 3.5 days from symptom onset to surgery. Conclusions: CEA can be performed #48 hours of appropriate referral. The major challenge of expediently managing symptomatic carotid stenosis is not the timing of surgery after referral but the time from the index symptom to referral to the vascular service. Ongoing education for other disciplines involved in the management of transient ischemic attack and stroke is required regarding the expedient role of CEA in stroke prevention.
VA003 Technical Skills Assessment of Vascular Trainees: Analysis of Performance in a Binational Cohort Over 6 Years Mark Jackson, Nicholas Boyne, Peter Charalabidis, Thodor Vasudevan, Tim Wagner. Griffith University, Brisbane, QLD, Australia
Objective: This study was conducted to validate and introduce a standardized, technical skills assessment task in addition to current assessment methods. Currently, the fellowship examinations are the final arbiter of competence, but increasing reliance is placed on formative (competencybased) assessments. Mentor and direct observation assessments are validated but lack standardization and reproducibility. Methods: A “low-stakes” technical skills simulation was used from 2008 to 2014, observing the progress of a binational cohort through their training. Overall, 123 vascular trainees were assessed on a standardized task (simulated end-to-side artificial anastomosis). Generic and procedure-specific assessment tools were used live (by mentor assessors), and end-product evaluations were also carried out. Year cohorts and individual scores and progress during the 7-year period were analyzed. Correlation of ranked performance vs current assessment methods (mentor assessment scores, log book case volumes, progression through training, and examination success) was sought. Results: Blinded assessment methods were more discriminatory. Using end-product evaluations, there was a stepwise trend between SET levels (Kruskal-Wallis test: P ¼ .01). No correlation was demonstrated between technical skill assessments and in-training “mentor” assessments (P ¼ .12). There was some correlation between performance and individual trainee’s case volume of “infrainguinal” procedures (P ¼ .008). Conclusions: Serial assessment of this large cohort demonstrates validity of this standard vascular technical skill task throughout training. Because the skill assessment scores are poorly correlated with the currently accepted methods of assessing “competence,” an additional component of formative assessment can be recommended for all vascular trainees.
VA004 Improving Care and Outcomes for Older Vascular Surgical Patients Alison Mudge, Prue Mcrae, Michael Reade, Peter Donovan, Jason Jenkins, Melanie Foster, Philip Walker. Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia Objective: Geriatric syndromes are common in older vascular surgery inpatients and associated with poorer outcomes. Multidisciplinary geriatric interventions can reduce geriatric syndromes in other inpatient groups. This pilot study examined the effect of a multidisciplinary improvement intervention for older vascular surgery patients. Methods: This was a prospective study of vascular surgical inpatients aged $65 years admitted to a tertiary hospital vascular surgery service. Cohorts were enrolled before and after implementation of “Eat Walk Engage” program and proactive medical consultation. “Eat Walk Engage” facilitates clinical, environmental, and workforce interventions to improve nutritional care, mobility, and cognitive engagement. Implementation was supported by improved multidisciplinary communication, clinical champions, audit and feedback, and an additional health assistant. The medical service included a senior medical fellow on the ward and twice-weekly joint medical/surgical consultant rounds. Major outcomes were length of stay (vascular ward and total hospital stay) and geriatric syndromes, including delirium (confusion assessment method), functional decline (increase in assistance with activities of daily living between admission and discharge), hospital-acquired pressure injury, and falls. Results: The study enrolled 113 preimplementation and 124 postimplementation participants (mean age, 75 years), of which 46% were elective and 54% were urgent/interhospital transfers. The postimplementation group had a shorter vascular ward (10.0 vs 12.5 days; P ¼ .047) and total (12.6 vs 16.7 days; P ¼ .065) length of stay. They were less likely to develop a geriatric syndrome (24.2% vs 36.0%; P ¼ .048), including less functional decline (14.5% vs 24.3%; P ¼ .056), delirium (14.5% vs 21.4%; P ¼ .16) and hospital acquired pressure injury (4.0% vs 11.6%, P ¼ .03). Conclusions: A multidisciplinary, multicomponent intervention significantly reduced length of stay and geriatric syndromes in older vascular patients.
VA006 Procedural Benefits of Three-Dimensional Image Fusion Angiography During EVAR Are Associated With Improved Postoperative Outcomes Lina Hua, Koah Doan, Nicholas Bajic, Robert Fitridge, Joseph Dawson. University of Adelaide Discipline of Surgery, Adelaide, SA, Australia Objective: Three-dimensional image fusion (3D-IF) angiography during endovascular aneurysm repair (EVAR) allows the amalgamation of preoperative computerized tomography images with live fluoroscopy, resulting in a three-dimensional (3D) volume-rendered angiogram that can be used as a virtual roadmap during EVAR. We previously demonstrated