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Large unruptured left sinus of valsalva aneurysm: A rare incidental finding
JOURNAL OF VASCULAR SURGERY Volume 61, Number 6S
Abstracts 87S
P ¼ .01). Women were in minority (67 of 280 [24%]), older (82 vs 78 years, P ¼ .002), and had smaller aortic diameter (73 vs 85 mm, P ¼ .002) compared with men. The 30-day mortality for women and men was similar (37%, P ¼ .86). Women and men had a similar proportion of endovascular aneurysm repair (31% vs 25%, P ¼ .51). In the age-matched analysis, women had smaller aneurysms (73.4 vs 84.7 mm, P ¼ .013), lower body mass index (22.5 vs 26.8 kg/m2, P < .001), and less cardiac disease (28% vs 45%, P ¼ .05) but a similar aortic size index (4.09 vs 4.23, P ¼ .81). Operation rate did not differ between genders (71.6% vs 59.7% in men, P ¼ .146). Conclusions: Almost one-fourth of persons with rAAA admitted to a hospital will not be treated with a vascular intervention. Larger aneurysms and older age rather than gender is associated with not receiving treatment. This discrepancy compared with other reports could possibly depend upon the inclusion of all untreated patients that are older and sicker than the treated cohort. Author Disclosures: R. Hultgren: Nothing to disclose; M. Gambe: Nothing to disclose; S. Zommorodi: Nothing to disclose; J. Roy: Nothing to disclose. Paradoxical Association Between Asymptomatic Carotid Stenosis and Functional Mobility in Patients With Peripheral Arterial Disease Rishi Kundi1, Odessa Addison1, Richa Patel2, Andrew P. Goldberg1, Alice S. Ryan1, Steven J. Prior1, Brajesh K. Lal1. 1University of Maryland School of Medicine, Baltimore, Md; 2University of Maryland, Baltimore, Reisterstown, Md Objectives: The cognitive and intellectual consequences of asymptomatic atherosclerotic carotid stenosis (ACS) are an area of active research, but the impact of ACS on physical and mobility function remains unknown. We tested the hypothesis that ACS is a predictor of mobility function and quality of life in older patients with peripheral arterial disease (PAD). To our knowledge, this is the first investigation of mobility dysfunction associated with ACS in PAD patients. Methods: Patients with clinical Rutherford class I-III PAD and ankle-brachial indices (ABIs) of <0.7 were recruited from the outpatient vascular surgery clinic at the Baltimore Veterans Affairs Medical Center from August to
December 2014. All participants were without open wounds or gangrene, and pertinent medical histories were gathered by self-report and confirmed by record review. Duplex ultrasonography results were obtained from record review and confirmed by direct image interpretation. Health related quality of life was determined using the Medical Outcomes Study Short-Form (SF-36). Self-reported mobility was assessed via the Walking Impairment Questionnaire (WIQ). Objective measures of mobility function included the Short Physical Performance Battery (SPPB), the Modified Physical Performance Test (MPPT), nine-stair ascent time, 6-minute walk distance (6MWD), gait speed, and grip strength. Partial correlations for all mobility and ultrasound measures with ABI as a covariate were analyzed with SPSS Statistics 22.0 (IBM, New York, NY). Results: Twenty-three consecutive patients (all men) were tested. Mean 6 standard error of the mean age was 68.4 6 1.5, BMI was 28.1 6 1.1 kg/m2, and ABI was 0.66 6 0.04. Mean end-diastolic velocity was 33.2 6 3.7 cm/s, corresponding to <50% internal carotid stenosis by both North American Symptomatic Carotid Endarterectomy Trial and Society of Radiologists in Ultrasound criteria. Performance on tests of mobility function was universally below normal values, consistent with patients’ known claudication and PAD (Table). Peak end-diastolic velocity (EDV) within the cervical internal carotid artery directly correlated with self-reported maximal walking distance (r ¼ 0.324, P ¼ .06) and speed (r ¼ 0.52, P ¼ .006) from the WIQ. EDV also correlated with objective assessments of function such as MPPT score (r ¼ 0.341, P ¼ .05), stair ascent time (r ¼ e0.352, P ¼ .05), both usual (r ¼ 0.626, P ¼ .001) and fast (r ¼ 0.662, P < .001) gait speed, and grip strength (r ¼ 0.397, P ¼ .034). There also was a tendency for correlation with 6MW (P ¼ .07), SPPB (P ¼ .08), and SF36 physical and mental measures (P ¼ .073, P ¼ .086; Table). Conclusions: In patients with PAD, a greater degree of ACS, as measured by EDV, is associated with better physical and mobility functionality by both self-reported and objective metrics. This association is notable, given the asymptomatic degree of stenosis, and the paradoxical direction of the association between measures of function and carotid disease. With a greater degree of stenosis, both self-reported and objective measures of physical ability and mobility were better. While this appears counterintuitive, possible mechanisms include hemodynamic
Table. Partial correlation coefficients (r) between internal carotid artery end-diastolic velocity (EDV) and self-reported and objective measures of function WIQ
WIQ
Distance
Speed
6MW
MPPT
SPPB
SA
GS
GS
(Usual)
(Fast)
Gp
SF36
SF36
Phy
Ment
Mean score 34.5 6 5.90 38.0 6 6.08 1076 6 61.30 29 6 1.02 10 6 0.35 6.0 6 0.48 .94 6 0.05 1.2 6 0.06 34.0 6 1.62 37.9 6 2.00 52.9 6 2.13 (n ¼ 23) Correlation 0.324 0.520 0.319 0.341 0.308 e0.352 0.626 0.662 0.397 0.313 0 294 with EDV (r) P .060 .006 .070 .050 .080 .060 .001 .000 .034 .073 .086 6MW, 6-minute walk; EDV, end-diastolic velocity; Gp, grip strength; GS, gait speed; MPPT, Modified Physical Performance Test; SA, stair ascension time; SF36, Short-Form quality of life questionnaire, Physical and Mental batteries; SPPB, Short Physical Performance Battery; WIQ, Walking Impairment Questionnaire.
88S Abstracts
changes, whether cardiac or vasomotor, resulting from carotid bulb disease that oppose or mitigate the mobility deficits associated with peripheral ischemia. Other explanations include invalid surrogacy of velocity criteria for stenosis in the context of PAD. Our findings indicate that a complex relationship exists between carotid stenosis and mobility function in the patient with peripheral arterial disease that warrants further investigation. Author Disclosures: R. Kundi: Nothing to disclose; O. Addison: Nothing to disclose; R. Patel: Nothing to disclose; A. P. Goldberg: Nothing to disclose; A. S. Ryan: Nothing to disclose; S. J. Prior: Nothing to disclose; B. K. Lal: Nothing to disclose. Inferior Vena Cava Filter Use With Musculoskeletal Tumor Resection Lidie Lajoie, Ajay Dhadwal, Joe Huang, Frank Padberg, Michael Curi. Rutgers Division of Vascular Surgery, Newark, NJ Objectives: Patients undergoing resection for musculoskeletal tumors are at high risk for venous thromboembolism due to malignancy, major surgery, and postoperative immobilization. We describe outcomes of inferior vena cava (IVC) filter placement for pulmonary embolism prevention in patients undergoing major resections for musculoskeletal tumors. Methods: A single-center retrospective review of all cases in which IVC filters were placed prior to major musculoskeletal tumor resections was performed for the last 3 years. Results: IVC filters were placed for 72 patients (56% female) during the study period. Patients were a mean age of 61 years. Concurrent vascular mobilization or reconstruction was required in 10% and 6% of cases, respectively. Major plastic reconstruction was required to close defects in 50%. Of the nine patients requiring both vascular mobilization/reconstruction and major plastic reconstruction, eight received enoxaparin for perioperative deep venous thrombosis (DVT) prophylaxis (89%). After a median follow-up of 7 months from IVC filter insertion, 19% of patients developed DVT, and 7% developed pulmonary embolism. There were five deaths, none from pulmonary embolism. Five of the 11 patients (45%) who required vascular mobilization or reconstruction developed postoperative DVT. Compared with patients undergoing musculoskeletal tumor resection alone, patients requiring both vascular mobilization/reconstruction and major plastic reconstruction had significantly higher rates of postoperative DVT: 19% vs 44%, respectively (odds ratio, 4.2; P ¼ .06). Conclusions: Patients undergoing resection and reconstruction for musculoskeletal tumors are at high risk for venous thromboembolism, particularly when major vascular mobilization and plastic reconstruction is required. Prophylactic IVC filter use can prevent potentially fatal pulmonary embolism in these patients and should be considered. Author Disclosures: L. Lajoie: Nothing to disclose; A. Dhadwal: Nothing to disclose; J. Huang: Nothing to disclose; F. Padberg: Nothing to disclose; M. Curi: Nothing to disclose.
JOURNAL OF VASCULAR SURGERY June Supplement 2015
Preliminary Results of a Smoking Cessation Intervention for Patients With Peripheral Vascular Disease (PVD): A Randomized Controlled Study Sareh Rajaee1, Tara A. Holder1, Jeffrey Indes1, Bart E. Muhs2, Timur Sarac3, Bauer Sumpio1, Benjamin Toll4, Cassius I. Ochoa Chaar1. 1Yale New Haven Hospital, New Haven, Conn; 2The Vascular Experts, Middletown, Conn; 3The Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio; 4Yale University School of Medicine, New Haven, Conn Objectives: Cigarette smoking is a significant risk factor for peripheral vascular disease (PVD). The goal of this study is to evaluate the efficacy of a smoking cessation intervention delivered by surgeons to patients with PVD. Methods: This ongoing randomized controlled study is conducted at a tertiary care center. Patients with PVD who present to our outpatient or inpatient vascular service are randomized. Both control and intervention groups receive 2 weeks of free nicotine patches and a referral to the hospital’s outpatient smoking cessation program, which operates on gain-framed messaging focused on the benefits of smoking cessation. The intervention group additionally receives a brief presentation by a surgeon regarding the benefits of smoking cessation, with a focus on PVD-related complications. At enrollment and on follow-up at 1 and 6 months, patients undergo a carbon monoxide breath test and complete a survey on smoking habits. The primary outcome is smoking reduction by at least 50%. Fisher exact test and logistic regression were used to assess the primary outcome among groups. Results: Fifty patients have been enrolled, and 43 have completed 1-month follow-up (control, n ¼ 21; intervention, n ¼ 22). Eighteen patients (42%) have reduced smoking by at least 50%, with 12 patients (28%) having quit completely. There is no significant difference in smoking reduction between the intervention and control groups (43% vs 41%). Patients who undergo open surgery are more likely to reduce smoking than those who undergo endovascular (odds ratio, 7.8; 95% confidence interval, 1.61-48.1; P ¼ .01) or medical management (odds ratio, 6.8; 95% confidence interval, 1.27-45.7; P ¼ .02). Conclusions: At the time of this preliminary analysis, brief smoking cessation counseling by a surgeon does not affect smoking reduction in patients with PVD. Patients who undergo open interventions are more likely to reduce smoking than patients who undergo endovascular interventions or medical management. This may be due to the increased invasiveness and length of hospital stay associated with open interventions. Author Disclosures: S. Rajaee: Nothing to disclose; T. A. Holder: Nothing to disclose; J. Indes: Nothing to disclose; B. E. Muhs: Aptus Endosystems, ownership interest; T. Sarac: Nothing to disclose; B. Sumpio: Pfizer, Janssen, Bristol-Myers Squibb, speakers bureau; B. Toll: Nothing to disclose; C. I. Ochoa Chaar: Nothing to disclose. Long-Term Results After Elective Open Surgical Repair of Abdominal Aortic Aneurysm: A 14-Year Follow-Up Study Daniela Mazzaccaro1, Alberto Settembrini2, Michele Carmo3, Alessandro Fossati4, Simone Salvati3, Raffaello
Abstracts 87S
P ¼ .01). Women were in minority (67 of 280 [24%]), older (82 vs 78 years, P ¼ .002), and had smaller aortic diameter (73 vs 85 mm, P ¼ .002) compared with men. The 30-day mortality for women and men was similar (37%, P ¼ .86). Women and men had a similar proportion of endovascular aneurysm repair (31% vs 25%, P ¼ .51). In the age-matched analysis, women had smaller aneurysms (73.4 vs 84.7 mm, P ¼ .013), lower body mass index (22.5 vs 26.8 kg/m2, P < .001), and less cardiac disease (28% vs 45%, P ¼ .05) but a similar aortic size index (4.09 vs 4.23, P ¼ .81). Operation rate did not differ between genders (71.6% vs 59.7% in men, P ¼ .146). Conclusions: Almost one-fourth of persons with rAAA admitted to a hospital will not be treated with a vascular intervention. Larger aneurysms and older age rather than gender is associated with not receiving treatment. This discrepancy compared with other reports could possibly depend upon the inclusion of all untreated patients that are older and sicker than the treated cohort. Author Disclosures: R. Hultgren: Nothing to disclose; M. Gambe: Nothing to disclose; S. Zommorodi: Nothing to disclose; J. Roy: Nothing to disclose. Paradoxical Association Between Asymptomatic Carotid Stenosis and Functional Mobility in Patients With Peripheral Arterial Disease Rishi Kundi1, Odessa Addison1, Richa Patel2, Andrew P. Goldberg1, Alice S. Ryan1, Steven J. Prior1, Brajesh K. Lal1. 1University of Maryland School of Medicine, Baltimore, Md; 2University of Maryland, Baltimore, Reisterstown, Md Objectives: The cognitive and intellectual consequences of asymptomatic atherosclerotic carotid stenosis (ACS) are an area of active research, but the impact of ACS on physical and mobility function remains unknown. We tested the hypothesis that ACS is a predictor of mobility function and quality of life in older patients with peripheral arterial disease (PAD). To our knowledge, this is the first investigation of mobility dysfunction associated with ACS in PAD patients. Methods: Patients with clinical Rutherford class I-III PAD and ankle-brachial indices (ABIs) of <0.7 were recruited from the outpatient vascular surgery clinic at the Baltimore Veterans Affairs Medical Center from August to
December 2014. All participants were without open wounds or gangrene, and pertinent medical histories were gathered by self-report and confirmed by record review. Duplex ultrasonography results were obtained from record review and confirmed by direct image interpretation. Health related quality of life was determined using the Medical Outcomes Study Short-Form (SF-36). Self-reported mobility was assessed via the Walking Impairment Questionnaire (WIQ). Objective measures of mobility function included the Short Physical Performance Battery (SPPB), the Modified Physical Performance Test (MPPT), nine-stair ascent time, 6-minute walk distance (6MWD), gait speed, and grip strength. Partial correlations for all mobility and ultrasound measures with ABI as a covariate were analyzed with SPSS Statistics 22.0 (IBM, New York, NY). Results: Twenty-three consecutive patients (all men) were tested. Mean 6 standard error of the mean age was 68.4 6 1.5, BMI was 28.1 6 1.1 kg/m2, and ABI was 0.66 6 0.04. Mean end-diastolic velocity was 33.2 6 3.7 cm/s, corresponding to <50% internal carotid stenosis by both North American Symptomatic Carotid Endarterectomy Trial and Society of Radiologists in Ultrasound criteria. Performance on tests of mobility function was universally below normal values, consistent with patients’ known claudication and PAD (Table). Peak end-diastolic velocity (EDV) within the cervical internal carotid artery directly correlated with self-reported maximal walking distance (r ¼ 0.324, P ¼ .06) and speed (r ¼ 0.52, P ¼ .006) from the WIQ. EDV also correlated with objective assessments of function such as MPPT score (r ¼ 0.341, P ¼ .05), stair ascent time (r ¼ e0.352, P ¼ .05), both usual (r ¼ 0.626, P ¼ .001) and fast (r ¼ 0.662, P < .001) gait speed, and grip strength (r ¼ 0.397, P ¼ .034). There also was a tendency for correlation with 6MW (P ¼ .07), SPPB (P ¼ .08), and SF36 physical and mental measures (P ¼ .073, P ¼ .086; Table). Conclusions: In patients with PAD, a greater degree of ACS, as measured by EDV, is associated with better physical and mobility functionality by both self-reported and objective metrics. This association is notable, given the asymptomatic degree of stenosis, and the paradoxical direction of the association between measures of function and carotid disease. With a greater degree of stenosis, both self-reported and objective measures of physical ability and mobility were better. While this appears counterintuitive, possible mechanisms include hemodynamic
Table. Partial correlation coefficients (r) between internal carotid artery end-diastolic velocity (EDV) and self-reported and objective measures of function WIQ
WIQ
Distance
Speed
6MW
MPPT
SPPB
SA
GS
GS
(Usual)
(Fast)
Gp
SF36
SF36
Phy
Ment
Mean score 34.5 6 5.90 38.0 6 6.08 1076 6 61.30 29 6 1.02 10 6 0.35 6.0 6 0.48 .94 6 0.05 1.2 6 0.06 34.0 6 1.62 37.9 6 2.00 52.9 6 2.13 (n ¼ 23) Correlation 0.324 0.520 0.319 0.341 0.308 e0.352 0.626 0.662 0.397 0.313 0 294 with EDV (r) P .060 .006 .070 .050 .080 .060 .001 .000 .034 .073 .086 6MW, 6-minute walk; EDV, end-diastolic velocity; Gp, grip strength; GS, gait speed; MPPT, Modified Physical Performance Test; SA, stair ascension time; SF36, Short-Form quality of life questionnaire, Physical and Mental batteries; SPPB, Short Physical Performance Battery; WIQ, Walking Impairment Questionnaire.
88S Abstracts
changes, whether cardiac or vasomotor, resulting from carotid bulb disease that oppose or mitigate the mobility deficits associated with peripheral ischemia. Other explanations include invalid surrogacy of velocity criteria for stenosis in the context of PAD. Our findings indicate that a complex relationship exists between carotid stenosis and mobility function in the patient with peripheral arterial disease that warrants further investigation. Author Disclosures: R. Kundi: Nothing to disclose; O. Addison: Nothing to disclose; R. Patel: Nothing to disclose; A. P. Goldberg: Nothing to disclose; A. S. Ryan: Nothing to disclose; S. J. Prior: Nothing to disclose; B. K. Lal: Nothing to disclose. Inferior Vena Cava Filter Use With Musculoskeletal Tumor Resection Lidie Lajoie, Ajay Dhadwal, Joe Huang, Frank Padberg, Michael Curi. Rutgers Division of Vascular Surgery, Newark, NJ Objectives: Patients undergoing resection for musculoskeletal tumors are at high risk for venous thromboembolism due to malignancy, major surgery, and postoperative immobilization. We describe outcomes of inferior vena cava (IVC) filter placement for pulmonary embolism prevention in patients undergoing major resections for musculoskeletal tumors. Methods: A single-center retrospective review of all cases in which IVC filters were placed prior to major musculoskeletal tumor resections was performed for the last 3 years. Results: IVC filters were placed for 72 patients (56% female) during the study period. Patients were a mean age of 61 years. Concurrent vascular mobilization or reconstruction was required in 10% and 6% of cases, respectively. Major plastic reconstruction was required to close defects in 50%. Of the nine patients requiring both vascular mobilization/reconstruction and major plastic reconstruction, eight received enoxaparin for perioperative deep venous thrombosis (DVT) prophylaxis (89%). After a median follow-up of 7 months from IVC filter insertion, 19% of patients developed DVT, and 7% developed pulmonary embolism. There were five deaths, none from pulmonary embolism. Five of the 11 patients (45%) who required vascular mobilization or reconstruction developed postoperative DVT. Compared with patients undergoing musculoskeletal tumor resection alone, patients requiring both vascular mobilization/reconstruction and major plastic reconstruction had significantly higher rates of postoperative DVT: 19% vs 44%, respectively (odds ratio, 4.2; P ¼ .06). Conclusions: Patients undergoing resection and reconstruction for musculoskeletal tumors are at high risk for venous thromboembolism, particularly when major vascular mobilization and plastic reconstruction is required. Prophylactic IVC filter use can prevent potentially fatal pulmonary embolism in these patients and should be considered. Author Disclosures: L. Lajoie: Nothing to disclose; A. Dhadwal: Nothing to disclose; J. Huang: Nothing to disclose; F. Padberg: Nothing to disclose; M. Curi: Nothing to disclose.
JOURNAL OF VASCULAR SURGERY June Supplement 2015
Preliminary Results of a Smoking Cessation Intervention for Patients With Peripheral Vascular Disease (PVD): A Randomized Controlled Study Sareh Rajaee1, Tara A. Holder1, Jeffrey Indes1, Bart E. Muhs2, Timur Sarac3, Bauer Sumpio1, Benjamin Toll4, Cassius I. Ochoa Chaar1. 1Yale New Haven Hospital, New Haven, Conn; 2The Vascular Experts, Middletown, Conn; 3The Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio; 4Yale University School of Medicine, New Haven, Conn Objectives: Cigarette smoking is a significant risk factor for peripheral vascular disease (PVD). The goal of this study is to evaluate the efficacy of a smoking cessation intervention delivered by surgeons to patients with PVD. Methods: This ongoing randomized controlled study is conducted at a tertiary care center. Patients with PVD who present to our outpatient or inpatient vascular service are randomized. Both control and intervention groups receive 2 weeks of free nicotine patches and a referral to the hospital’s outpatient smoking cessation program, which operates on gain-framed messaging focused on the benefits of smoking cessation. The intervention group additionally receives a brief presentation by a surgeon regarding the benefits of smoking cessation, with a focus on PVD-related complications. At enrollment and on follow-up at 1 and 6 months, patients undergo a carbon monoxide breath test and complete a survey on smoking habits. The primary outcome is smoking reduction by at least 50%. Fisher exact test and logistic regression were used to assess the primary outcome among groups. Results: Fifty patients have been enrolled, and 43 have completed 1-month follow-up (control, n ¼ 21; intervention, n ¼ 22). Eighteen patients (42%) have reduced smoking by at least 50%, with 12 patients (28%) having quit completely. There is no significant difference in smoking reduction between the intervention and control groups (43% vs 41%). Patients who undergo open surgery are more likely to reduce smoking than those who undergo endovascular (odds ratio, 7.8; 95% confidence interval, 1.61-48.1; P ¼ .01) or medical management (odds ratio, 6.8; 95% confidence interval, 1.27-45.7; P ¼ .02). Conclusions: At the time of this preliminary analysis, brief smoking cessation counseling by a surgeon does not affect smoking reduction in patients with PVD. Patients who undergo open interventions are more likely to reduce smoking than patients who undergo endovascular interventions or medical management. This may be due to the increased invasiveness and length of hospital stay associated with open interventions. Author Disclosures: S. Rajaee: Nothing to disclose; T. A. Holder: Nothing to disclose; J. Indes: Nothing to disclose; B. E. Muhs: Aptus Endosystems, ownership interest; T. Sarac: Nothing to disclose; B. Sumpio: Pfizer, Janssen, Bristol-Myers Squibb, speakers bureau; B. Toll: Nothing to disclose; C. I. Ochoa Chaar: Nothing to disclose. Long-Term Results After Elective Open Surgical Repair of Abdominal Aortic Aneurysm: A 14-Year Follow-Up Study Daniela Mazzaccaro1, Alberto Settembrini2, Michele Carmo3, Alessandro Fossati4, Simone Salvati3, Raffaello