Hand-Arm Vibration Syndrome, a Rarely Observed Diagnosis

850

Journal of Vascular Surgery

Abstracts

September 2016 one patients (23.1%) were admitted to the SICU. Of these, 22 (71.0%) were for postoperative hypertension management requiring IV antihypertensive medication. Of the patients admitted to the SICU for postoperative hypertension, 6 patients (27.3%) underwent regional anesthesia compared with 16 patients (72.7%) who had general anesthesia, a statistically significant finding (95% confidence interval, 1.041-8.610). Conclusions: In patients undergoing eCEA, regional anesthesia can be protective against postoperative hypertension with a reduced requirement for IV postoperative antihypertensive medications and SICU admission. Further investigations involving the exact mechanism of this finding and potential cost benefits are warranted. Author Disclosures: F. Jinwala: None; J. Oh: None; V. Dombrovskiy: None; K. Nagarsheth: None; S. Rahimi: None.

Patterns of Inferior Vena Cava Filter Placement Before and After Implementation of a Strict Indication Policy

Fig 1. Computed tomography angiography of the left neck, sagittal view. The left common carotid artery is occluded (arrow), with preserved flow in the left external and internal carotid arteries. There are no signs of atherosclerotic disease in the left common, external, or internal carotid arteries.

Fig 2. Intraoperative image demonstrating left common carotid artery thrombus, with extension of the thrombus into the internal carotid artery (arrow). Author Disclosures: J. Stuhldreher: None; S. Toursavadkohi: None; T. Monahan: None.

R.

Calderon:

None;

Regional Anesthesia is Associated With Decreased Postoperative Hypertension in Patients Undergoing Eversion Carotid Endarterectomy Felecia Jinwala, MD, Justin Oh, MA, Viktor Dombrovskiy, MD, PhD, Khanjan Nagarsheth, MD, and Saum Rahimi, MD. Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ Objective: Eversion carotid endarterectomy (eCEA) has been effective in reducing stroke risk in patients with carotid artery stenosis. Recent literature shows that patients who undergo eCEA are at risk for development of postoperative hypertension requiring intravenous (IV) antihypertensive medication. The purpose of this study was to assess whether the type of anesthesia (regional or general) has an impact on the incidence of postoperative hypertension requiring IV antihypertensive medication in the surgical intensive care unit (SICU) in patients undergoing eCEA. Methods: We performed a retrospective chart review from August 2009 to March 2013 and identified 124 patients who underwent eCEA. Patient characteristics including age, gender, body mass index, smoking status, and preoperative diagnosis of hypertension were collected; operative data including the use of shunt and type of anesthesia were also obtained. Descriptive statistics were used to summarize patient and procedure characteristics. The difference between select groups was tested by c2 analysis with calculation of odds ratio and 95% confidence intervals. Results: A total of 124 patients were analyzed and 134 eCEA were performed. Of these, 59 (44.0%) were performed under cervical plexus block and 75 (56.0%) were performed under general anesthesia. Thirty-

Nicholas Russo, MS, Matthew D’Alessandro, DO, Arthelma Tyson, MD, Saqib Zia, MBBS, Jonathan Schor, MD, Jonathan Deitch, MD, and Kuldeep Singh, MD. Staten Island University Hospital, Staten Island, NY Background: Although commonly placed, inferior vena cava (IVC) filters are not without consequence. In an effort to reduce filter insertion rates, we implemented a strict indication policy. We reviewed the patterns of IVC filter placement before and after implementation of the policy. Methods: Charts of patients receiving an IVC filter from 2010 to 2016 were reviewed. We compared demographics, comorbidities, and indications. Patterns of filter placement were reviewed before and after implementation of a strict indication policy. We compared information during a 3-year period per group. Statistical analysis was performed using the c2 test. Results: There were 782 filters placed between 2010 and 2016. No procedure-related complications were noted. There were 383 women and 399 men; the mean age of the patients was 70.9 years. The average length of stay was 16.1 days. Before policy implementation, the average number of filters placed was 167 per year; the average number placed after the policy was 100 per year, a 41% reduction (P ¼ .02). Before the policy, 55% (277) of the filters were placed for absolute indications, 30% (150) were placed for relative indications, and 10% (50) were prophylactic. After implementation of the policy, 74% (209) were placed for absolute indications, 19% (54) were placed for relative indications, and 6% (18) were prophylactic. Vascular surgeons placed filters for absolute indications 66% (217) of the time and for relative/prophylactic indications 34% (182) of the time before the policy. After the policy, vascular surgeons placed 84% (182) of the filters for absolute indications and 16% (38) for relative/prophylactic indications. Nonvascular surgeons placed filters 39% (61) of the time for absolute indications and 61% (93) of the time for relative/prophylactic indications before the policy. After the policy, nonvascular surgeons placed 46% (27) of the filters for absolute indications and 54% (34) for relative/prophylactic indications. Filters were placed by vascular surgeons before the policy only 63% of the time; after implementation of the policy, vascular surgeons placed >84% of filters (P ¼ .09). Filter types included 16% nonretrievable and 84% (631) retrievable. Although a strong trend was noted toward removable filter placement, only 8% were actually retrieved. Conclusions: Implementation of a strict indication policy significantly reduced the number of unnecessary IVC filters. In addition, vascular surgeons placed significantly more filters for absolute indications compared with nonvascular surgeons. It remains the duty of the physician to carefully select patients who are appropriate for such a procedure to reduce the number of unnecessary filters. Author Disclosures: N. Russo: None; M. D’Alessandro: None; A. Tyson: None; S. Zia: None; J. Schor: None; J. Deitch: None; K. Singh: None.

Hand-Arm Vibration Syndrome, a Rarely Observed Diagnosis Rebecca Campbell, MS, and Robert I. Hacker, MD. MetroHealth Hospital, Cleveland, Ohio Background: Hand-arm vibration syndrome (HAVS) is a collection of sensory, vascular, and musculoskeletal symptoms caused by repetitive trauma

Journal of Vascular Surgery

Abstracts

851

Volume 64, Number 3 from vibration and is a significant health hazard to workers in any occupation that relies on the use of vibrating tools. HAVS presents similarly to both hypothenar hammer syndrome and thenar hammer syndrome, which include symptoms such as numbness, tingling, pain, and digital ischemia. Unlike HAVS, these syndromes have different mechanisms of injury and, as a result, different management strategies. The aim of this case report is to demonstrate how HAVS can be distinguished from hypothenar hammer syndrome and thenar hammer syndrome on the basis of history, physical examination, and vascular imaging and its treatment options. Case Report: Our patient was a previously healthy plumber who presented to the clinic in December 2015 after experiencing 5 months of numbness, tingling, and pain in his right hand. He sustained multiple small injuries to the tips of his right thumb and third finger that had not healed after several months. His occupational history included significant use of vibrating power tools, including jackhammers, drills, sanders, and power saws, on a daily basis. Computed tomography angiography and noninvasive vascular studies demonstrated patent ulnar and radial arteries to the level of the wrist. Right upper extremity arteriography revealed occlusions of his ulnar, radial, superficial palmar, deep palmar, and multiple digital arteries with formation of collaterals. Based on his history of prolonged exposure to vibratory tools and the pattern of disease in his imaging studies, we concluded that he had HAVS and advised limited vibration exposure, topical vasodilators, and systemic vasodilators. After several weeks of topical therapy and abstention from use of vibratory tools, the wounds on his right hand healed. Conclusions: This case illustrates the clinical manifestations of HAVS, a debilitating condition affecting people who work with vibratory tools. Vascular damage from HAVS is usually irreversible, and thus a high clinical suspicion and rapid diagnosis are critical. Early diagnosis can be achieved with a good history, physical examination, basic noninvasive studies, and confirmatory endovascular imaging of the affected extremity. Treatments include cessation of vibration exposure, topical vasodilators, and physical therapy.

with pHTN were younger (P ¼ .01) and were less likely to have congestive heart failure (P ¼ .032), peripheral vascular disease (P ¼ .044), or history of a percutaneous coronary intervention (P ¼ .018). Patients with pHTN were more likely to have obstructive sleep apnea (P ¼ .023). Survival was not affected by pHTN status (P ¼ .16). The overall fistula maturation rate (defined as successful two-needle cannulation for 4 weeks) was 78.9%. An upper arm arteriovenous fistula (P ¼ .46), an infraclavicular nonautologous graft of any diameter (P ¼ .38), a two-stage surgery (P ¼ .14), the history of a prior dialysis catheter (P ¼ .56), and pharmacomechanical thrombectomy (P ¼ .98) were not associated with the development pHTN. Patients who underwent cleaner thrombectomy (P ¼ .048) or a subsequent 4- to 7-mm chest wall graft (P ¼ .031) after the index fistula failed were more likely to have pHTN. Only one patient had the fistula ligated for worsening heart failure. Patients who experienced the onset of pHTN after DVA (DVA-pHTN; n ¼ 34 [48.6%]) were compared with patients who had pHTN before DVA (pHTN-DVA; n ¼ 36 [51.4%]). pHTN-DVA patients were less likely to have a history of a myocardial infarction (P ¼ .029). There is no difference in the mean change in right ventricular systolic function after arteriovenous fistula creation in comparing patients with pHTN with patients without pHTN (P ¼ .067) and comparing DVApHTN with pHTN-DVA (P ¼ .77). Conclusions: DVA surgery does lead to pHTN, and patients should be monitored for the development of clinically significant symptoms that merit intervention. In general, it is safe to create DVA and to perform the necessary maintenance interventions regardless of the presence or severity of pHTN. Direct central venous outflow may pose a higher risk for severe pHTN warranting DVA ligation. Author Disclosures: R. Miler: None; J. Bena: None; L. Kirksey: None.

Treatment and 5-Year Follow-Up of a 3-Year-Old Boy With Transection of Femoral Artery and Vein Patrick Bonasso, MD, Alexandre d’Audiffret, MD, Richard Vaughan, MD, and Lakshmikumar Pillai, MD. West Virginia University, Morgantown, WV Objective: The purpose of this study was to present the treatment of a 3-year-old boy with transection of his right femoral artery and vein due to dog bite.

Fig. Right upper extremity arteriogram demonstrating patency of two small areas of the superficial and palmar arches with absence of blood supply to the thumb and diminished blood supply to 2nd-5th digits. Author Disclosures: R. Campbell: None; R. I. Hacker: None.

Pulmonary Hypertension and Hemodialysis Access Roy Miler, MD, James Bena, and Lee Kirksey, MD, MBA. Cleveland Clinic, Cleveland, Ohio Objective: The purpose of this project was to identify the patient’s features and the technical factors related to an increased risk of heart failure with the creation of dialysis vascular access (DVA). Methods: The study included 269 patients with chronic kidney disease who had a baseline and postoperative echocardiogram within 6 months of fistula creation at a single institution between January 2000 and March 2015. There were 37 patients with a1-antitrypsin disease, pulmonary fibrosis or sarcoidosis, and a heart or lung transplant who were excluded, leaving 232 patients in the final cohort. Results: Patients with pulmonary hypertension (pHTN; n ¼ 70 [30.2%]) were compared with patients without pHTN (n ¼ 162 [69.8%]). Patients

Fig 1. Complete avulsion of the right common femoral artery and vein without active bleeding and obvious abdominal wall evisceration.