- Email: [email protected]
PC138. Acute Arterial Mesenteric Ischemia: Contemporary Single Center Experience over 15 Years
JOURNAL OF VASCULAR SURGERY June Supplement 2016
194S Abstracts
Results: We evaluated 175 primary AVF placed in our institution, of which 9 were excluded due to lack of data. Mean follow-up was 40 months (range, 0.5-132 months). There were 73 patients in both groups A and B. Our calculations did not include 20 patients who required TDC placement before the AVF matured. Eight patients (11%) developed CVS in group A and 11 (15%) in group B. There was no statistical difference between groups (P ¼ .5). We also did not observe statistical difference in length of time between AVF creation and development of CVS between groups A (mean, 404 days; range, 51-904 days), and B (mean, 376 days; range, 111070; P ¼ .85). In group B, patients that developed CVS had the mean TDC days of 177 (range, 41-646 days) which was not significantly different from those that did not develop CVS (152; range, 13- 434 days; P ¼ .67). Seven patients (9.6%) developed TDC infections that were successfully treated with antibiotics and or catheter exchange or removal. Conclusions: Our study, although small, reveals that even when hemodialysis is required on a more emergency basis, the use of a TDC does not adversely affect autogenous fistula outcomes with respect to the development of CVS. Therefore, we recommend continued support for a fistula first policy in this circumstance.
thrombosis, and dissection of the renal artery, and 33% (5) of the patients had a residual stenosis that was not correctable by initial endovascular efforts. Of the 5 patients with residual stenosis after repair, 80% (4) required an additional intervention, which was statistically higher than 10% (1) of patients without residual stenosis (P ¼ .01). Secondary interventions included 2 patch angioplasties, 1 PTA with stenting, and 2 PTA alone. The overall survival of patients who underwent any intervention was 93% (14) over the course of the study. 40% (6 of 15) of patients returned to dialysis in an average of 7 months (range 0-918 days) after intervention. Conclusions: At our institution the majority of patients with vascular complications after renal transplant can be repaired by endovascular techniques with minimal complications and need for reintervention. The patients with residual stenosis after initial intervention after transplant were at increased risk for a secondary intervention.
Author Disclosures: S. Blackwood: Nothing to disclose; A. Dietzek: Nothing to disclose; D. Gillaspie: Nothing to disclose; I. Kontopidis: Nothing to disclose; E. Krol: Nothing to disclose; J. Louie: Nothing to disclose; Z. Phillips: Nothing to disclose.
Acute Arterial Mesenteric Ischemia: Contemporary Single Center Experience over 15 Years Umer H. Bhatti1, Manju Kalra, MBBS2, Thomas C. Bower, MD2, Gustavo S. Oderich, MD2, Mark Fleming, MD2, Randall R. DeMartino, MD, MS2, Courtney Heins, BS2, Peter Gloviczki, MD2. 1Mayo Clinic, Karachi, Pakistan; 2Mayo Clinic, Rochester, Minn
PC136. PC136 Vascular Interventions Following Renal Transplant Alison O. Flentje, BS, S. Sadie Ahanchi, MD, Jean M. Panneton, MD. Eastern Virginia Medical School, Norfolk, Va Objectives: By renal duplex ultrasound, renal transplant vascular complications (RTVC) occur in <10% of transplanted kidneys but are an important cause of transplant dysfunction. Percutaneous transluminal angioplasty (PTA), with and without stenting, as well as surgical revision, are often used in treatment of RTVC, but not without risk of restenosis. The aim of our study was to describe our experience and investigate the clinical impact of vascular interventions in RTVC. Methods: A retrospective record review was conducted of 327 patients who underwent renal transplant at a single institution from 2008 to 2012. The data collected included demographics, medical comorbidities, procedural factors, and outcomes. Results: Of the 319 included patients, 37 (12%) were identified as having a RTVC by duplex ultrasound, which included 16 transplant renal artery (TRA) stenosis, 10 transplant renal vein (TRV) stenosis/compression, 9 native iliac artery (NIA) stenosis, and 2 NIA dissection. A total of 15 patients (40%) underwent intervention for these lesions, which included 4 PTA alone, 10 PTA w/stenting, and 1 endarterectomy with patch angioplasty. Of the 15 RTVC interventions, 20% (3) of the patients suffered a major complication, which included stent embolization, stent
Author Disclosures: S. Ahanchi: Nothing to disclose; A. O. Flentje: Nothing to disclose; J. M. Panneton: Medtronic: consulting fees (eg, advisory boards), speaker’s bureau, Volcano and W. L. Gore: consulting fees (eg, advisory boards). PC138 PC138.
Objectives: This study evaluated current modes of presentation, referral patterns, and management of acute arterial mesenteric ischemia (AAMI) at a tertiary referral institution. Methods: We retrospectively reviewed medical records consecutive patients who presented with AAMI over a 15-year period (January 2000 to December 2014). Patient demographics, time to presentation, treatment modalities, and outcomes were evaluated. Patients were divided into 3 groups based on etiology and vascular intervention: group 1darterial embolism, group 2darterial thrombosis, group 3dnonsalvageable/no vascular intervention. Outcomes in groups 1 and 2 were compared using a Cox proportional hazards analysis. Results: There were 124 patients with a mean age 70.6 years (range, 22-95); 37 in group, 71 in group 2, and 16 in group 3. Patients had a significantly higher incidence of atrial fibrillation (AF) in group 1, history of chronic mesenteric ischemia (CMI), prior vascular intervention in group 2, and hyperlipidemia, congestive heart failure (CHF) and overall SVS co-morbidity score in group 3 (Table). Surgical interventions included group 1 (open: 95%, endovascular: 5%, laparotomy: 98%) and group 2 (open: 72%, endovascular: 28%, laparotomy: 90%). Group 3 patients underwent only exploratory laparotomy. Bowel resection/second look laparotomy were performed in group 1 (38%/65%) and group 2 (38%/ 59%) respectively. Early mortality (30 days) and median hospital length of stay in groups 1 and 2 were 19%
JOURNAL OF VASCULAR SURGERY Volume 63, Number 6S
Abstracts 195S
Table. Demographic and surgical intervention data and risk factors for early mortality in 124 patients with acute arterial mesenteric ischemia Group 1
Group 2
Group 3
Risk factors: 30-day mortality (group 1 & group 2)
Arterial embolus Arterial thromboses Nonsalvageable (N¼37) (N¼71) (N¼16) P value Age, mean (SD) Male gender, No. (%) OSH transfer, No. (%) TDT, median hours Hyperlipidemia, No. (%) Prior MI, No. (%) CHF, No. (%) Atrial fibrillation, No. (%) CKD (Cr >1.5 mg/dL), No. (%) COPD, No. (%) Hypercoaguable state, No. (%) CMI, No. (%) SVS Score, median Endovascular intervention, No. (%) Bowel resection (first up), No. (%) Thrombolectomy, No. (%) Patch angioplasty, No. (%) Endarterectomy, No. (%) Bypass graft, No. (%) Bypass orientation Antegrade, No. (%) Retrograde, No. (%)
76.0 (16.0) 13 (35.1) 27 (73.0) 23.0 14 (37.8) 7 (18.9) 9 (24.3) 21 (56.8) 6 (16.2) 8 (21.6) 2 (5.6) 0 (0.0) 8.0 2 (5.4) 14 (37.8) 32 (86.5) 6 (16.2) 0 (0.0) 0 (0.0)
66.5 (12.8) 25 (35.2) 46 (64.8) 35.0 41 (57.7) 18 (25.4) 8 (11.3) 8 (11.3) 12 (16.9) 16 (22.5) 5 (7.0) 34 (47.9) 8.0 20 (28.2) 26 (37.7) 22 (31.0) 12 (16. 9) 6 (8.5) 32 (45.1)
76.6 (8.0) 6 (37.5) 10 (62.5) 28.5 13 (81.3) 2 (12.5) 6 (37.5) 6 (37.5) 4 (25.0) 4 (25.0) 0 (0.0) 2 (12.5) 15.0 e 40 (37.7) e e e e
e e
13 (40.6) 19 (59.4)
e e
<.01 .98 .63 .32 .01 .46 .02 <.01 .71 .96 .86 <.01 .02 <.01 .98 <.001 .20 .12 <.001
OR (95% CI) 1.02 2.42 0.79 0.99 2.42 0.86 3.27 2.35 2.09 2.47 0.28 0.74 1.12 1.05 1.40
P value
(0.99-1.00) (0.89-6.62) (0.28-2.21) (0.98-1.01) (0.85-6.95) (0.26-2.89) (1.03-10.39) (0.84-6.62) (0.61-6.78) (0.85-7.21) (0.01-6.19) (0.24-2.25) (1.03-1.21) (0.31-3.56) (0.50-3.91)
.24 .08 .65 .27 .10 .81 .04 .10 .22 .10 .42 .59 <.01a .94 .52
e
CHF, Congestive heart failure; CI, confidence interval; CKD, chronic kidney disease, CMI, chronic mesenteric ischemia; COPD, chronic obstructive pulmonary disease; Cr, creatinine; MI, myocardial infarction; OR, odds ratio; OSH, outside hospital; SD, standard deviation; SVS, Society for Vascular Surgery; TDT, time to definitive treatment. a SVS score analyzed as a continuous variable.
and 17% and 26 and 20 days, respectively. On univariate analysis, factors associated with significantly higher early mortality included CHF and increasing SVS score. On Kaplan-Meier analysis cumulative 1- and 5-year survival rates in groups 1 and 2 were 72% and 45%, 64% and 43%, respectively (P ¼ .628). Conclusions: Despite advances in awareness and imaging capabilities more than one tenth of patients with AAMI presented to a tertiary referral care center too late for salvage. Mortality, predicted mainly by markers of extensive atherosclerosis, remains significant after both arterial embolism and in situ thrombosis despite increasing use of endovascular techniques. Author Disclosures: U. H. Bhatti: Nothing to disclose; T. C. Bower: Nothing to disclose; R. R. DeMartino: Nothing to disclose; M. Fleming: Nothing to disclose; P. Gloviczki: Nothing to disclose; C. Heins: Nothing to disclose; M. Kalra: Nothing to disclose; G .S. Oderich: Nothing to disclose. PC140. PC140 Malignant Vascular Tumors: A Nationwide Analysis Abdul Q. Alarhayem, MD, Mark G. Davies, MD, PhD. University of Texas Medical School, San Antonio, Tex Objectives: Malignant vascular tumors (angiosarcoma and epithelioid hemangioendotheliomas [EHE])
are rare soft tissue tumors that account for <1% of all sarcomas. The purpose of this study was to determine prognostic factors, management strategies, and outcomes of these rare tumors. Methods: Using data from the National Cancer Institute’s Surveillance, Epidemiology, and End Results program from 1973 to 2012, we identified patients with vascular malignancies using the International Classification of Diseases for Oncology (ICD-O-3) codes. Results: The Surveillance, Epidemiology, and End Results program recorded 1394 cases of angiosarcoma, and 221 EHE. There were no significant differences in cancer incidence between males and females. Most patients were white (85%), followed by African Americans (7%). The mean age at the time of diagnosis was 63 years. Grade was recorded in 649 cases (40%): 86 were grade I, 123 were grade II, 208 were grade III, and 232 were grade IV. The 5-year survival rate was 24.5% in patients with angiosarcoma and 41.9% in patients with EHE. Survival rates for both tumors correlated with age at diagnosis and stage of disease. The overall 5-year relative survival rate in patients <50 years was 41.9%, and 18.2% in patients $50 years. Almost 30% of patients with angiosarcoma had more than one primary tumor compared to 16.3% of patients with EHE. About 80% of patients underwent surgical resection. After correcting for grade, surgical resection was associated with improved 5-year survival with higher grades (grade II-IV); however, radiotherapy was not (angiosarcoma: 20.9% vs 22.1%, EHE: 38.5% vs 46.4%; NS).
194S Abstracts
Results: We evaluated 175 primary AVF placed in our institution, of which 9 were excluded due to lack of data. Mean follow-up was 40 months (range, 0.5-132 months). There were 73 patients in both groups A and B. Our calculations did not include 20 patients who required TDC placement before the AVF matured. Eight patients (11%) developed CVS in group A and 11 (15%) in group B. There was no statistical difference between groups (P ¼ .5). We also did not observe statistical difference in length of time between AVF creation and development of CVS between groups A (mean, 404 days; range, 51-904 days), and B (mean, 376 days; range, 111070; P ¼ .85). In group B, patients that developed CVS had the mean TDC days of 177 (range, 41-646 days) which was not significantly different from those that did not develop CVS (152; range, 13- 434 days; P ¼ .67). Seven patients (9.6%) developed TDC infections that were successfully treated with antibiotics and or catheter exchange or removal. Conclusions: Our study, although small, reveals that even when hemodialysis is required on a more emergency basis, the use of a TDC does not adversely affect autogenous fistula outcomes with respect to the development of CVS. Therefore, we recommend continued support for a fistula first policy in this circumstance.
thrombosis, and dissection of the renal artery, and 33% (5) of the patients had a residual stenosis that was not correctable by initial endovascular efforts. Of the 5 patients with residual stenosis after repair, 80% (4) required an additional intervention, which was statistically higher than 10% (1) of patients without residual stenosis (P ¼ .01). Secondary interventions included 2 patch angioplasties, 1 PTA with stenting, and 2 PTA alone. The overall survival of patients who underwent any intervention was 93% (14) over the course of the study. 40% (6 of 15) of patients returned to dialysis in an average of 7 months (range 0-918 days) after intervention. Conclusions: At our institution the majority of patients with vascular complications after renal transplant can be repaired by endovascular techniques with minimal complications and need for reintervention. The patients with residual stenosis after initial intervention after transplant were at increased risk for a secondary intervention.
Author Disclosures: S. Blackwood: Nothing to disclose; A. Dietzek: Nothing to disclose; D. Gillaspie: Nothing to disclose; I. Kontopidis: Nothing to disclose; E. Krol: Nothing to disclose; J. Louie: Nothing to disclose; Z. Phillips: Nothing to disclose.
Acute Arterial Mesenteric Ischemia: Contemporary Single Center Experience over 15 Years Umer H. Bhatti1, Manju Kalra, MBBS2, Thomas C. Bower, MD2, Gustavo S. Oderich, MD2, Mark Fleming, MD2, Randall R. DeMartino, MD, MS2, Courtney Heins, BS2, Peter Gloviczki, MD2. 1Mayo Clinic, Karachi, Pakistan; 2Mayo Clinic, Rochester, Minn
PC136. PC136 Vascular Interventions Following Renal Transplant Alison O. Flentje, BS, S. Sadie Ahanchi, MD, Jean M. Panneton, MD. Eastern Virginia Medical School, Norfolk, Va Objectives: By renal duplex ultrasound, renal transplant vascular complications (RTVC) occur in <10% of transplanted kidneys but are an important cause of transplant dysfunction. Percutaneous transluminal angioplasty (PTA), with and without stenting, as well as surgical revision, are often used in treatment of RTVC, but not without risk of restenosis. The aim of our study was to describe our experience and investigate the clinical impact of vascular interventions in RTVC. Methods: A retrospective record review was conducted of 327 patients who underwent renal transplant at a single institution from 2008 to 2012. The data collected included demographics, medical comorbidities, procedural factors, and outcomes. Results: Of the 319 included patients, 37 (12%) were identified as having a RTVC by duplex ultrasound, which included 16 transplant renal artery (TRA) stenosis, 10 transplant renal vein (TRV) stenosis/compression, 9 native iliac artery (NIA) stenosis, and 2 NIA dissection. A total of 15 patients (40%) underwent intervention for these lesions, which included 4 PTA alone, 10 PTA w/stenting, and 1 endarterectomy with patch angioplasty. Of the 15 RTVC interventions, 20% (3) of the patients suffered a major complication, which included stent embolization, stent
Author Disclosures: S. Ahanchi: Nothing to disclose; A. O. Flentje: Nothing to disclose; J. M. Panneton: Medtronic: consulting fees (eg, advisory boards), speaker’s bureau, Volcano and W. L. Gore: consulting fees (eg, advisory boards). PC138 PC138.
Objectives: This study evaluated current modes of presentation, referral patterns, and management of acute arterial mesenteric ischemia (AAMI) at a tertiary referral institution. Methods: We retrospectively reviewed medical records consecutive patients who presented with AAMI over a 15-year period (January 2000 to December 2014). Patient demographics, time to presentation, treatment modalities, and outcomes were evaluated. Patients were divided into 3 groups based on etiology and vascular intervention: group 1darterial embolism, group 2darterial thrombosis, group 3dnonsalvageable/no vascular intervention. Outcomes in groups 1 and 2 were compared using a Cox proportional hazards analysis. Results: There were 124 patients with a mean age 70.6 years (range, 22-95); 37 in group, 71 in group 2, and 16 in group 3. Patients had a significantly higher incidence of atrial fibrillation (AF) in group 1, history of chronic mesenteric ischemia (CMI), prior vascular intervention in group 2, and hyperlipidemia, congestive heart failure (CHF) and overall SVS co-morbidity score in group 3 (Table). Surgical interventions included group 1 (open: 95%, endovascular: 5%, laparotomy: 98%) and group 2 (open: 72%, endovascular: 28%, laparotomy: 90%). Group 3 patients underwent only exploratory laparotomy. Bowel resection/second look laparotomy were performed in group 1 (38%/65%) and group 2 (38%/ 59%) respectively. Early mortality (30 days) and median hospital length of stay in groups 1 and 2 were 19%
JOURNAL OF VASCULAR SURGERY Volume 63, Number 6S
Abstracts 195S
Table. Demographic and surgical intervention data and risk factors for early mortality in 124 patients with acute arterial mesenteric ischemia Group 1
Group 2
Group 3
Risk factors: 30-day mortality (group 1 & group 2)
Arterial embolus Arterial thromboses Nonsalvageable (N¼37) (N¼71) (N¼16) P value Age, mean (SD) Male gender, No. (%) OSH transfer, No. (%) TDT, median hours Hyperlipidemia, No. (%) Prior MI, No. (%) CHF, No. (%) Atrial fibrillation, No. (%) CKD (Cr >1.5 mg/dL), No. (%) COPD, No. (%) Hypercoaguable state, No. (%) CMI, No. (%) SVS Score, median Endovascular intervention, No. (%) Bowel resection (first up), No. (%) Thrombolectomy, No. (%) Patch angioplasty, No. (%) Endarterectomy, No. (%) Bypass graft, No. (%) Bypass orientation Antegrade, No. (%) Retrograde, No. (%)
76.0 (16.0) 13 (35.1) 27 (73.0) 23.0 14 (37.8) 7 (18.9) 9 (24.3) 21 (56.8) 6 (16.2) 8 (21.6) 2 (5.6) 0 (0.0) 8.0 2 (5.4) 14 (37.8) 32 (86.5) 6 (16.2) 0 (0.0) 0 (0.0)
66.5 (12.8) 25 (35.2) 46 (64.8) 35.0 41 (57.7) 18 (25.4) 8 (11.3) 8 (11.3) 12 (16.9) 16 (22.5) 5 (7.0) 34 (47.9) 8.0 20 (28.2) 26 (37.7) 22 (31.0) 12 (16. 9) 6 (8.5) 32 (45.1)
76.6 (8.0) 6 (37.5) 10 (62.5) 28.5 13 (81.3) 2 (12.5) 6 (37.5) 6 (37.5) 4 (25.0) 4 (25.0) 0 (0.0) 2 (12.5) 15.0 e 40 (37.7) e e e e
e e
13 (40.6) 19 (59.4)
e e
<.01 .98 .63 .32 .01 .46 .02 <.01 .71 .96 .86 <.01 .02 <.01 .98 <.001 .20 .12 <.001
OR (95% CI) 1.02 2.42 0.79 0.99 2.42 0.86 3.27 2.35 2.09 2.47 0.28 0.74 1.12 1.05 1.40
P value
(0.99-1.00) (0.89-6.62) (0.28-2.21) (0.98-1.01) (0.85-6.95) (0.26-2.89) (1.03-10.39) (0.84-6.62) (0.61-6.78) (0.85-7.21) (0.01-6.19) (0.24-2.25) (1.03-1.21) (0.31-3.56) (0.50-3.91)
.24 .08 .65 .27 .10 .81 .04 .10 .22 .10 .42 .59 <.01a .94 .52
e
CHF, Congestive heart failure; CI, confidence interval; CKD, chronic kidney disease, CMI, chronic mesenteric ischemia; COPD, chronic obstructive pulmonary disease; Cr, creatinine; MI, myocardial infarction; OR, odds ratio; OSH, outside hospital; SD, standard deviation; SVS, Society for Vascular Surgery; TDT, time to definitive treatment. a SVS score analyzed as a continuous variable.
and 17% and 26 and 20 days, respectively. On univariate analysis, factors associated with significantly higher early mortality included CHF and increasing SVS score. On Kaplan-Meier analysis cumulative 1- and 5-year survival rates in groups 1 and 2 were 72% and 45%, 64% and 43%, respectively (P ¼ .628). Conclusions: Despite advances in awareness and imaging capabilities more than one tenth of patients with AAMI presented to a tertiary referral care center too late for salvage. Mortality, predicted mainly by markers of extensive atherosclerosis, remains significant after both arterial embolism and in situ thrombosis despite increasing use of endovascular techniques. Author Disclosures: U. H. Bhatti: Nothing to disclose; T. C. Bower: Nothing to disclose; R. R. DeMartino: Nothing to disclose; M. Fleming: Nothing to disclose; P. Gloviczki: Nothing to disclose; C. Heins: Nothing to disclose; M. Kalra: Nothing to disclose; G .S. Oderich: Nothing to disclose. PC140. PC140 Malignant Vascular Tumors: A Nationwide Analysis Abdul Q. Alarhayem, MD, Mark G. Davies, MD, PhD. University of Texas Medical School, San Antonio, Tex Objectives: Malignant vascular tumors (angiosarcoma and epithelioid hemangioendotheliomas [EHE])
are rare soft tissue tumors that account for <1% of all sarcomas. The purpose of this study was to determine prognostic factors, management strategies, and outcomes of these rare tumors. Methods: Using data from the National Cancer Institute’s Surveillance, Epidemiology, and End Results program from 1973 to 2012, we identified patients with vascular malignancies using the International Classification of Diseases for Oncology (ICD-O-3) codes. Results: The Surveillance, Epidemiology, and End Results program recorded 1394 cases of angiosarcoma, and 221 EHE. There were no significant differences in cancer incidence between males and females. Most patients were white (85%), followed by African Americans (7%). The mean age at the time of diagnosis was 63 years. Grade was recorded in 649 cases (40%): 86 were grade I, 123 were grade II, 208 were grade III, and 232 were grade IV. The 5-year survival rate was 24.5% in patients with angiosarcoma and 41.9% in patients with EHE. Survival rates for both tumors correlated with age at diagnosis and stage of disease. The overall 5-year relative survival rate in patients <50 years was 41.9%, and 18.2% in patients $50 years. Almost 30% of patients with angiosarcoma had more than one primary tumor compared to 16.3% of patients with EHE. About 80% of patients underwent surgical resection. After correcting for grade, surgical resection was associated with improved 5-year survival with higher grades (grade II-IV); however, radiotherapy was not (angiosarcoma: 20.9% vs 22.1%, EHE: 38.5% vs 46.4%; NS).