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Management of vascular iatrogenic catheter complications in academic practice
Vol. 219, No. 4S, October 2014
ligation (36.7%, p<0.05). Amputation rates were also higher in CPAPV patients who underwent bypass (8.4%). CONCLUSIONS: CPAPV patients have higher amputation rates when the arterial injury is managed with ligation but remain high despite bypass possibly as a result of the high rates of venous ligation. Superior vena cava reconstruction in patients on hemodialysis Robert W Feldtman, MD, FACS, Pablo V Uceda, MD, Cameron E Kliner, MS, Kaitlyn E Egan, BS, Kenneth R Kollmeyer, MD, FACS, Sam S Ahn, MD, FACS DFW Vascular Group, Dallas, TX INTRODUCTION: In 2012, end stage renal disease climbed to 365.0 per million population in Texas. We hypothesize a potential advantage in aggressively pursuing SVC reconstruction in patients with ESRD on hemodialysis utilizing UE conduits, first by endovenous methods and secondarily by open chest procedures. METHODS: July 2009 to January 2014, eleven patients underwent SVC reconstruction and were retrospectively analyzed. Indications for surgery were SVC syndrome. All had UE conduits for hemodialysis access. In all cases, an endovenous approach to SVC stenting was utilized unless open intervention was required. RESULTS: Mean age was 56.4 15.7. Eight (72.7%) were females. Most common risk factors were hypertension (81.8%), hyperlipidemia (36.4%), history of tobacco use (36.4%), and diabetes mellitus (36.4%). Endovenous approach and open bypass were used in seven (63.6%) and four (36.4%) cases, respectively. Ten patients (90.9%) presented with facial and cervical edema; five (45.5%) with additional UE edema, three (27.3%) with respiratory embarrassment, and two (18.2%) with weakness and headache. In all cases etiology was indwelling hemodialysis access devices. All cases resolved SVC syndrome and facies, and retained UE dialysis conduits. Post-operative complications occurred in two (18.2%) cases. Technical success was 100%, no re-interventions or deaths within 30 days. CONCLUSIONS: SVC reconstruction, by endovenous or open approach, seems to be safe and effective at relieving SVC signs and resolving SVC occlusion in patients on hemodialysis. Although an endovenous approach is preferred, both open and endovenous approaches can be utilized to preserve dialysis access and the use of UE fistulae.
Scientific Poster Presentations: 2014 Clinical Congress
e199
arterial pressure, vessel diameter, and downstream resistance. Given the limited utility of ankle-brachial index (ABI) among diabetic patients, we analyzed the value of PAV in the assessment of LEAI patients. METHODS: We retrospectively identified 233 patients that had undergone simultaneous LE arterial duplex with ABI between Jan. 2010 and Aug. 2013, and analyzed demographics, Rutherford Category (RC), ABI, and PAV, using the t-test, uni- and multivariate regression. RESULTS: There were 140 male (60%), 115 diabetic (49%), 192 hypertensive (82%), 174 dyslipidemia (75%), 136 smoking (58%), and 112 symptomatic patients (48%). Mean patient age was 64 10 years, mean ABI was 0.75 0.30, and mean PAV was 50 29 cm/sec.PAVs were lower among patients with progressively lower ABIs. PAVs correlated with ABI among all patients (R2 0.3413, p<0.001), but correlated best among non-diabetic patients (R2 0.4016, p<0.001). The ability of a PAV<40 to detect an ABI<0.5 was analyzed: Overall sensitivity was 84% (44/52), 92% among non-diabetic patients (24/26), and 90% among patients with RC 4-6 (27/30). The test’s precision was 82% among patients with RC 4-6 (27/33). CONCLUSIONS: PAV significantly correlates with ABI, particularly among non-diabetic patients. A PAV 40 cm/sec detects severe to critical LEAI, best among non-diabetic and RC 4-6 patients. The routine inclusion of PAV may offer adjunctive value in LEAI assessment, particularly when diabetes renders ABI less reliable. Management of vascular iatrogenic catheter complications in academic practice Brandon C Cain, MD, Benjamin J Pearce, MD, Mark A Patterson, MD, FACS, Marc A Passman, MD, FACS, Thomas C Matthews, MD, Zdenek Novak, MD, PhD, William D Jordan, MD University of Alabama at Birmingham, Birmingham, AL INTRODUCTION: Reimbursement under the Affordable Care Act (ACA) will become increasingly affected by several quality performance measures. Of these, inadvertent vascular injury is a major Patient Safety Indicator (PSI) and will be under greater scrutiny at the hospital level. We sought to evaluate the characteristics and outcomes for patients with iatrogenic catheter complications.
Use of peak ankle velocity (PAV) to assess lower extremity arterial insufficiency (LEAI) Hamed Taheri, MD, Michael F Amendola, MD, RPVI, Francisco C Albuquerque, MD, RPVI, Luke G Wolfe, MS, Justin Pfieifer, MS, RVT, Mark M Levy, MD, RPVI, RVT Virginia Commonwealth University, Richmond, VA
METHODS: A prospectively maintained clinical Vascular Database was queried for cases of inadvertent catheter related vascular injury from 2003 to 2013. Injury related to catheters for arterial monitoring, central venous and dialysis access were identified. Descriptive statistics were performed for basic patient demographics, catheter type and purpose, anatomic location, 30-day and overall survival and end organ specific outcome. Multivariate and Cox regression analyses were performed to elucidate potentially significant risk factors.
INTRODUCTION: The PAV is the peak systolic velocity measured among ankle tibial arteries during a duplex exam; it reflects ankle
RESULTS: A total of 116 cases of iatrogenic vascular injury secondary to catheter placement were identified. Specific injured vessel
e200
Scientific Poster Presentations: 2014 Clinical Congress
sites included aortic (0.9%), innominate (0.9%), vertebral (1.8%), radial (10.3%), carotid (12.1%), subclavian (19.8%), and femoral (54.3%). BMI for the entire cohort was 27.9 8.5. Forty-five patients were managed non-operatively (NONOP) vs 71 managed with intervention (INT). Overall survival was 62.2% NONOP and 56.3% INT with 30-day mortality of 28.9% NONOP v. 12.7% INT, (p < .05). End organ failure occurred in 4.2% (2 strokes, 1 amputation) of INT compared to zero in the NONOP group. Neither catheter type, anatomic location nor Body Mass Index predicted an adverse outcome. CONCLUSIONS: Inadvertent vascular injury occurs in gravely ill patients evidenced by the poor overall survival of the entire cohort. Thirty-day mortality improved with operative intervention. Balloon angioplasty for nonthrombotic iliac vein lesions Arkady Ganelin, MD, Anil P Hingorani, MD, FACS, Yuriy Ostrozhynskyy, Enrico Ascher, MD, FACS, Borislav Kheyson, MD, Eleanora Iadgarova, RN, Natalie Marks, MD Vascular Institute of New York, Brooklyn, NY INTRODUCTION: Iliac vein stenting of nonthrombotic iliac vein lesions (NIVL) is an evolving treatment option for venous insufficiency. We examine the effects of balloon angioplasty. METHODS: Over 4 months, we have performed 193 venograms with angioplasties and stenting of the iliac veins. The average age were 65.96 y/o(range 25-93, SD 14.66), with 140 females and 53 males. We used IVUS (intravascular ultrasound) to measure and record the area of involved iliofemoral veins. The measurement of stenosis was compared with the adjacent non-stenotic iliofemoral veins. If more than 50% cross sectional area or diameter reduction was found, it was treated with appropriate balloon size and stent. RESULTS: The average area reduction or diameter of stenotic lesion was 60.92 mm2 (range 12-177, SD 29.41). The postballooning average size of the stenotic area was 59.29 mm2 (range 9-207, SD 30.75) (p¼0.59). 90 patients had an increase of 28.25% (SD 36.88) in cross sectional area an, with pre-angioplasty average of 57.71 mm2 (SD 28.32) and post-angioplasty 72.08 mm2 (SD 33.40). In 97 patients a decrease of 23.41% (SD 18.01) in cross sectional area post-angioplasty was found, with pre-angioplasty average of 64.29 mm2 (SD 30.81) and post-angioplasty 47.53 mm2 (SD 22.69). No statistically significant correlation was found between area reduction in comparison to age, gender, laterality and CEAP scores (2-6). CONCLUSIONS: Our data shows that no statistically significant efficacy was found in utilizing angioplasty to treat the area reduction of NIVL. Updated meta-analysis of femoropopliteal bypass grafts for lower extremity arterial disease Gerhard Hoffmann, MD, FACS Sta¨dtische Klinikum Solingen, Solingen, Germany
J Am Coll Surg
INTRODUCTION: Objective of this updated meta-analysis assesses long-term patency of femoropopliteal bypass grafts classified as above-knee polytetrafluoroethylene (AK-PTFE), above-knee saphenous vein (AK-GSV), or below-knee saphenous vein (BK-GSV). METHODS: 104 articles from studies published from 1986 through 2013 were identified; contributing 1 or more series using survival analysis, assessing femoropopliteal bypasses in one of the foregoing configurations, reported a 1-year graft patency rate including at least 30 bypasses. Series with predominance of claudicant patients were included in meta-analysis C, series with critical ischemia were included in meta-analysis CI. Pooled survival curves of graft patency were constructed. RESULTS: In meta-analysis C, the pooled primary graft patency was 54.3% for AK-PTFE, 72.7% for AK-GSV, and 66.1% for BK-GSV at 5 years; there was a significant difference between AK-grafts at 3, 4, and 5 years (p < .05). The corresponding pooled secondary graft patency was 73.2%, 80.1%, and 79.7%, respectively (p > .05). In meta-analysis CI, the pooled primary graft patency was 48.3% for AK-PTFE, 69.4% for AK-GSV, 68.9% for BK-GSV at 5 years; there was a significant difference between AK-grafts until 4 years (p < .05). The corresponding pooled secondary graft patency was 54.0%, 71.9%, and 77.8%, respectively, with a significant difference between AK-grafts at 2, 3, and 4 years (p < .05). CONCLUSIONS: Femoropopliteal revascularization deserves reevaluation for many reasons. Meta-analysis of uncontrolled surgical series can provide a reliable account of available data because these series are frequent in the literature and often involve a large number of patients. Autogenous conduits are superior to all materials. Surgical co-management by hospitalists after major vascular surgery: is there value? IM Leitman, MD, FACS, Dahlia Rizk, DO, Allison J Capossela, BS, Joanna Mecca, MD, Kevin Narag, MD, Valentina Lavarias, Thomas R Bernik, MD, FACS, Robert Grossi, MD, Christopher B Mills, MD, FACS, Marty S Karpeh Jr, MD, FACS Mount Sinai Health System, New York, NY INTRODUCTION: The co-management relationship between surgeons and hospitalists can be defined as a shared responsibility for the care of the hospitalized surgical patient. The patient’s surgeon manages the surgical issues and the hospitalist manages the patient’s other medical conditions. This relationship involves collaboration, multidisciplinary care, and active participation in medical decision making. The purpose of this Surgery-Hospitalist Co-management program (SHCP) is to promote and improve the quality of care of high-risk surgical patients. METHODS: SHCP was a collaborative effort of the Departments of Surgery and Medicine at an urban, academic medical center. A service agreement was drafted to outline the roles and responsibilities for the participating providers, describe a workflow to provide seamless care, avoid overlap of functions, and develop mechanisms
ligation (36.7%, p<0.05). Amputation rates were also higher in CPAPV patients who underwent bypass (8.4%). CONCLUSIONS: CPAPV patients have higher amputation rates when the arterial injury is managed with ligation but remain high despite bypass possibly as a result of the high rates of venous ligation. Superior vena cava reconstruction in patients on hemodialysis Robert W Feldtman, MD, FACS, Pablo V Uceda, MD, Cameron E Kliner, MS, Kaitlyn E Egan, BS, Kenneth R Kollmeyer, MD, FACS, Sam S Ahn, MD, FACS DFW Vascular Group, Dallas, TX INTRODUCTION: In 2012, end stage renal disease climbed to 365.0 per million population in Texas. We hypothesize a potential advantage in aggressively pursuing SVC reconstruction in patients with ESRD on hemodialysis utilizing UE conduits, first by endovenous methods and secondarily by open chest procedures. METHODS: July 2009 to January 2014, eleven patients underwent SVC reconstruction and were retrospectively analyzed. Indications for surgery were SVC syndrome. All had UE conduits for hemodialysis access. In all cases, an endovenous approach to SVC stenting was utilized unless open intervention was required. RESULTS: Mean age was 56.4 15.7. Eight (72.7%) were females. Most common risk factors were hypertension (81.8%), hyperlipidemia (36.4%), history of tobacco use (36.4%), and diabetes mellitus (36.4%). Endovenous approach and open bypass were used in seven (63.6%) and four (36.4%) cases, respectively. Ten patients (90.9%) presented with facial and cervical edema; five (45.5%) with additional UE edema, three (27.3%) with respiratory embarrassment, and two (18.2%) with weakness and headache. In all cases etiology was indwelling hemodialysis access devices. All cases resolved SVC syndrome and facies, and retained UE dialysis conduits. Post-operative complications occurred in two (18.2%) cases. Technical success was 100%, no re-interventions or deaths within 30 days. CONCLUSIONS: SVC reconstruction, by endovenous or open approach, seems to be safe and effective at relieving SVC signs and resolving SVC occlusion in patients on hemodialysis. Although an endovenous approach is preferred, both open and endovenous approaches can be utilized to preserve dialysis access and the use of UE fistulae.
Scientific Poster Presentations: 2014 Clinical Congress
e199
arterial pressure, vessel diameter, and downstream resistance. Given the limited utility of ankle-brachial index (ABI) among diabetic patients, we analyzed the value of PAV in the assessment of LEAI patients. METHODS: We retrospectively identified 233 patients that had undergone simultaneous LE arterial duplex with ABI between Jan. 2010 and Aug. 2013, and analyzed demographics, Rutherford Category (RC), ABI, and PAV, using the t-test, uni- and multivariate regression. RESULTS: There were 140 male (60%), 115 diabetic (49%), 192 hypertensive (82%), 174 dyslipidemia (75%), 136 smoking (58%), and 112 symptomatic patients (48%). Mean patient age was 64 10 years, mean ABI was 0.75 0.30, and mean PAV was 50 29 cm/sec.PAVs were lower among patients with progressively lower ABIs. PAVs correlated with ABI among all patients (R2 0.3413, p<0.001), but correlated best among non-diabetic patients (R2 0.4016, p<0.001). The ability of a PAV<40 to detect an ABI<0.5 was analyzed: Overall sensitivity was 84% (44/52), 92% among non-diabetic patients (24/26), and 90% among patients with RC 4-6 (27/30). The test’s precision was 82% among patients with RC 4-6 (27/33). CONCLUSIONS: PAV significantly correlates with ABI, particularly among non-diabetic patients. A PAV 40 cm/sec detects severe to critical LEAI, best among non-diabetic and RC 4-6 patients. The routine inclusion of PAV may offer adjunctive value in LEAI assessment, particularly when diabetes renders ABI less reliable. Management of vascular iatrogenic catheter complications in academic practice Brandon C Cain, MD, Benjamin J Pearce, MD, Mark A Patterson, MD, FACS, Marc A Passman, MD, FACS, Thomas C Matthews, MD, Zdenek Novak, MD, PhD, William D Jordan, MD University of Alabama at Birmingham, Birmingham, AL INTRODUCTION: Reimbursement under the Affordable Care Act (ACA) will become increasingly affected by several quality performance measures. Of these, inadvertent vascular injury is a major Patient Safety Indicator (PSI) and will be under greater scrutiny at the hospital level. We sought to evaluate the characteristics and outcomes for patients with iatrogenic catheter complications.
Use of peak ankle velocity (PAV) to assess lower extremity arterial insufficiency (LEAI) Hamed Taheri, MD, Michael F Amendola, MD, RPVI, Francisco C Albuquerque, MD, RPVI, Luke G Wolfe, MS, Justin Pfieifer, MS, RVT, Mark M Levy, MD, RPVI, RVT Virginia Commonwealth University, Richmond, VA
METHODS: A prospectively maintained clinical Vascular Database was queried for cases of inadvertent catheter related vascular injury from 2003 to 2013. Injury related to catheters for arterial monitoring, central venous and dialysis access were identified. Descriptive statistics were performed for basic patient demographics, catheter type and purpose, anatomic location, 30-day and overall survival and end organ specific outcome. Multivariate and Cox regression analyses were performed to elucidate potentially significant risk factors.
INTRODUCTION: The PAV is the peak systolic velocity measured among ankle tibial arteries during a duplex exam; it reflects ankle
RESULTS: A total of 116 cases of iatrogenic vascular injury secondary to catheter placement were identified. Specific injured vessel
e200
Scientific Poster Presentations: 2014 Clinical Congress
sites included aortic (0.9%), innominate (0.9%), vertebral (1.8%), radial (10.3%), carotid (12.1%), subclavian (19.8%), and femoral (54.3%). BMI for the entire cohort was 27.9 8.5. Forty-five patients were managed non-operatively (NONOP) vs 71 managed with intervention (INT). Overall survival was 62.2% NONOP and 56.3% INT with 30-day mortality of 28.9% NONOP v. 12.7% INT, (p < .05). End organ failure occurred in 4.2% (2 strokes, 1 amputation) of INT compared to zero in the NONOP group. Neither catheter type, anatomic location nor Body Mass Index predicted an adverse outcome. CONCLUSIONS: Inadvertent vascular injury occurs in gravely ill patients evidenced by the poor overall survival of the entire cohort. Thirty-day mortality improved with operative intervention. Balloon angioplasty for nonthrombotic iliac vein lesions Arkady Ganelin, MD, Anil P Hingorani, MD, FACS, Yuriy Ostrozhynskyy, Enrico Ascher, MD, FACS, Borislav Kheyson, MD, Eleanora Iadgarova, RN, Natalie Marks, MD Vascular Institute of New York, Brooklyn, NY INTRODUCTION: Iliac vein stenting of nonthrombotic iliac vein lesions (NIVL) is an evolving treatment option for venous insufficiency. We examine the effects of balloon angioplasty. METHODS: Over 4 months, we have performed 193 venograms with angioplasties and stenting of the iliac veins. The average age were 65.96 y/o(range 25-93, SD 14.66), with 140 females and 53 males. We used IVUS (intravascular ultrasound) to measure and record the area of involved iliofemoral veins. The measurement of stenosis was compared with the adjacent non-stenotic iliofemoral veins. If more than 50% cross sectional area or diameter reduction was found, it was treated with appropriate balloon size and stent. RESULTS: The average area reduction or diameter of stenotic lesion was 60.92 mm2 (range 12-177, SD 29.41). The postballooning average size of the stenotic area was 59.29 mm2 (range 9-207, SD 30.75) (p¼0.59). 90 patients had an increase of 28.25% (SD 36.88) in cross sectional area an, with pre-angioplasty average of 57.71 mm2 (SD 28.32) and post-angioplasty 72.08 mm2 (SD 33.40). In 97 patients a decrease of 23.41% (SD 18.01) in cross sectional area post-angioplasty was found, with pre-angioplasty average of 64.29 mm2 (SD 30.81) and post-angioplasty 47.53 mm2 (SD 22.69). No statistically significant correlation was found between area reduction in comparison to age, gender, laterality and CEAP scores (2-6). CONCLUSIONS: Our data shows that no statistically significant efficacy was found in utilizing angioplasty to treat the area reduction of NIVL. Updated meta-analysis of femoropopliteal bypass grafts for lower extremity arterial disease Gerhard Hoffmann, MD, FACS Sta¨dtische Klinikum Solingen, Solingen, Germany
J Am Coll Surg
INTRODUCTION: Objective of this updated meta-analysis assesses long-term patency of femoropopliteal bypass grafts classified as above-knee polytetrafluoroethylene (AK-PTFE), above-knee saphenous vein (AK-GSV), or below-knee saphenous vein (BK-GSV). METHODS: 104 articles from studies published from 1986 through 2013 were identified; contributing 1 or more series using survival analysis, assessing femoropopliteal bypasses in one of the foregoing configurations, reported a 1-year graft patency rate including at least 30 bypasses. Series with predominance of claudicant patients were included in meta-analysis C, series with critical ischemia were included in meta-analysis CI. Pooled survival curves of graft patency were constructed. RESULTS: In meta-analysis C, the pooled primary graft patency was 54.3% for AK-PTFE, 72.7% for AK-GSV, and 66.1% for BK-GSV at 5 years; there was a significant difference between AK-grafts at 3, 4, and 5 years (p < .05). The corresponding pooled secondary graft patency was 73.2%, 80.1%, and 79.7%, respectively (p > .05). In meta-analysis CI, the pooled primary graft patency was 48.3% for AK-PTFE, 69.4% for AK-GSV, 68.9% for BK-GSV at 5 years; there was a significant difference between AK-grafts until 4 years (p < .05). The corresponding pooled secondary graft patency was 54.0%, 71.9%, and 77.8%, respectively, with a significant difference between AK-grafts at 2, 3, and 4 years (p < .05). CONCLUSIONS: Femoropopliteal revascularization deserves reevaluation for many reasons. Meta-analysis of uncontrolled surgical series can provide a reliable account of available data because these series are frequent in the literature and often involve a large number of patients. Autogenous conduits are superior to all materials. Surgical co-management by hospitalists after major vascular surgery: is there value? IM Leitman, MD, FACS, Dahlia Rizk, DO, Allison J Capossela, BS, Joanna Mecca, MD, Kevin Narag, MD, Valentina Lavarias, Thomas R Bernik, MD, FACS, Robert Grossi, MD, Christopher B Mills, MD, FACS, Marty S Karpeh Jr, MD, FACS Mount Sinai Health System, New York, NY INTRODUCTION: The co-management relationship between surgeons and hospitalists can be defined as a shared responsibility for the care of the hospitalized surgical patient. The patient’s surgeon manages the surgical issues and the hospitalist manages the patient’s other medical conditions. This relationship involves collaboration, multidisciplinary care, and active participation in medical decision making. The purpose of this Surgery-Hospitalist Co-management program (SHCP) is to promote and improve the quality of care of high-risk surgical patients. METHODS: SHCP was a collaborative effort of the Departments of Surgery and Medicine at an urban, academic medical center. A service agreement was drafted to outline the roles and responsibilities for the participating providers, describe a workflow to provide seamless care, avoid overlap of functions, and develop mechanisms