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PC158 Long-Term Outcomes After Endovascular Stent Placement for Symptomatic, Long-Segment Superficial Femoral Artery Lesions
182S
Journal of Vascular Surgery
Abstracts
June Supplement 2017
PC156. Variation in Emergency Department Treatment of Patients With Critical Limb Ischemia Julia Glaser, Paul J. Foley, Grace J. Wang, Benjamin M. Jackson, Ronald M. Fairman, Scott M. Damrauer. University of Pennsylvania Health System, Philadelphia, Pennsylvania Objectives: Regional variation has been shown to exist in the treatment of lower extremity disease. Additionally, lower socioeconomic status is associated with later presentation and worse outcomes in vascular surgery. The decision to admit or discharge a patient with critical limb ischemia (CLI) from the emergency department (ED) depends on many factors. This study examined patient and hospital characteristics associated with disposition from the ED. Methods: Data from the Nationwide Emergency Department Sample, a stratified sample of 20% of EDs nationwide, was used. Patients presenting with rest pain, ischemic ulceration, or ischemic gangrene were selected. Patient and hospital characteristics associated with admission or discharge were calculated. Weighted logistic regression was used to determine predictors of admission to the hospital. Results: A total of 59,005 patients presented to the ED with CLI: 13.2% (n ¼ 7772) with rest pain, 32.0% (n ¼ 18,903) with ulceration, and 54.8% (n ¼ 32,330) with gangrene. Patients were an average age of 69.7 years, and 42.3% (n ¼ 24,942) were female. The overall admission rate was 96.2% (n ¼ 56,788). The rate of admission was significantly higher for gangrene (98.9% [n ¼ 31,640]) than for ulceration (95.0% [n ¼ 17,498]) and rest pain (92.7% [n ¼ 7201]; P < .01). Uninsured patients had the lowest rate of admission (91.0% [n ¼ 1749]); 96.5% (n ¼ 41,782) of Medicare, 95.7% (n ¼ 6014), and 96.4% (n ¼ 5807) of privately insured patients were admitted (P < .01). Admission rates were not significantly different between patients in the highest (96.1% [n ¼ 18,448]) and lowest (96.5% [n ¼ 11,536]) zip code income quartiles (P ¼ .88). Admission rates varied significantly by region (98.1%, Northeast; 95.6%, Northwest; 96.4%, South; 94.1%, West; P < .01). Urban hospitals were more likely to admit (96.7%) than micropolitan or rural EDs (90.5%; P < .01). On multivariate analysis, ulceration (odds ratio [OR], 1.47; confidence interval [CI], 1.08-2.00; P ¼ .01) and gangrene (OR, 3.69; CI, 2.515.44; P < .01) were predictive of admission (referent to rest pain). Lack of insurance (OR, 0.39; CI, 0.24-0.62; P < .01), region (Northwest: OR, 0.51; CI, 0.28-0.91; P ¼ .024; South: OR, 0.53; CI, 0.29-0.97; P ¼ .04; West: OR, 0.27; CI, 0.13-0.55; P < .01; referent to Northeast), and metropolitan teaching hospital (OR, 0.62; CI, 0.41-0.94; P ¼ .24) or nonmetropolitan (OR, 0.21; CI, 0.11-0.42; P < .01; referent to metropolitan nonteaching hospital) were associated with a decreased likelihood of admission. Conclusions: The majority of patients who present to the ED with CLI are admitted to the hospital from the ED. Admission rates are lower for uninsured patients, possibly reflecting a disparity in care. Author Disclosures: S. M. Damrauer: Nothing to disclose; R. M. Fairman: Nothing to disclose; P. J. Foley: Nothing to disclose; J. Glaser: Nothing to disclose; B. M. Jackson: Nothing to disclose; G. J. Wang: Nothing to disclose.
PC158. Long-Term Outcomes After Endovascular Stent Placement for Symptomatic, Long-Segment Superficial Femoral Artery Lesions Nader Zamani, Sherene Sharath, Rocky Browder, Neal R. Barshes, Houssam Younes, Jonathan Braun, Panos Kougias. Baylor College of Medicine, Houston, Tex Objectives: Endovascular intervention is commonly pursued for the treatment of symptomatic, long-segment superficial femoral artery (SFA) disease. The relative effectiveness and comparative long-term outcomes among bare-metal stents (BMS), covered stents (CS), and drug-eluting (DES) stents for long-segment SFA lesions remain uncertain.
Fig 1.
Fig 2. Methods: A retrospective cohort study identified consecutive patients with symptomatic SFA occlusions measuring at least 15 cm who received an endovascular stent (BMS, CS, or DES). The primary outcome of interest was patency, while secondary outcomes included postoperative presentation with acute limb ischemia (ALI), number of reoperations, and limb salvage. Patency rates were compared using time-to-event analysis and log-rank tests. Results: From 186 patients that were identified, a total of 215 procedures were analyzed (BMS: 113 [52%]; CS: 75 [35%]; DES: 27 [13%]) with a median follow-up time of 56 months (although the follow-up for DES was less: median, 10 months; P < .001). There were no significant differences among the groups with respect to mean age, diabetes status, renal dysfunction, and lower extremity runoff (mean 2.0 6 0.7 vessels). The mean length of the SFA lesion being treated in this series was 27 6 8 cm (also similar across all groups, P ¼ .165). Although primary and secondary patency rates were not significantly different among the stent types, DES is associated with an improved short-term primary-assisted patency, with 6-, 12-, and 24-month rates of 92%, 92%, and 83%, respectively. This is compared to 80%, 57%, and 47% for BMS, and 80%, 49%, and 41% for CS, respectively (log-rank test: P ¼ .009; Fig 1). In comparing only BMS with CS, 5- and 8-year primary-assisted patency rates are also higher among BMS: 60% and 60% vs 33% and 33% for CS, respectively (P ¼ .011; Fig 2). Zero DES patients have presented postoperatively with ALI compared to 3% of BMS patients and 13% of CS patients (P ¼ .004). Similarly, the CS group had a higher rate of subsequent open revascularization (32%) compared with BMS (24%) and DES (7%; P ¼ .038). Conclusions: Although long-term primary-assisted patency is greater in BMS as compared to CS, primary and secondary patency rates among all
Journal of Vascular Surgery
Abstracts
183S
Volume 65, Number 6S stent types are similar. CSs are associated with an increased risk of postoperative acute limb ischemia and subsequent open revascularization. Author Disclosures: N. R. Barshes: Nothing to disclose; J. Braun: Nothing to disclose; R. Browder: Nothing to disclose; P. Kougias: Nothing to disclose; S. Sharath: Nothing to disclose; H. Younes: Nothing to disclose; N. Zamani: Nothing to disclose.
PC160. Common Femoral Artery Endarterectomy: Contemporary Results Using Eversion Endarterectomy vs Standard Endarterectomy With Patch Alexander H. Nguyen, Francisco Albuquerque Jr, Robert Larson, Luke G. Wolfe, Mark Levy. Virginia Commonwealth University, Richmond, Va Objectives: For over 50 years, standard endarterectomy with patch (SEP) of the common femoral artery (CFA) has been well described with durable results. Eversion endarterectomy (EE) uses a complete CFA transection above its bifurcation and subsequent end-to-end anastomosis. EE is potentially advantageous over SEP by avoiding prosthetic patch infection and easing future transfemoral access. With subjectively more focal femoral artery lesions encountered during the endovascular era, we reviewed our SEP and EE outcomes to see whether there were any differences between the two methods. Methods: We retrospectively identified all patients undergoing CFA endarterectomy by a single surgeon who adopted preferential EE at a single institution between 2007 and 2015. Patient demographics and surgical details were captured from the electronic medical record, including endarterectomy type and the performance of concurrent endovascular and/or bypass surgery. Complications and adverse events were recorded. Statistical comparison of means was performed using the t-test, and categoric variables were evaluated using the Fisher exact test. Results: Eighty-nine sequentially encountered patients underwent 97 endarterectomies of the CFA (68 SEP and 29 EE). More SEP than EE cases were performed concomitant with either bypass or stenting (62% vs 34%). Most patients were smokers (80% of SEP vs 93% of EE). Patients undergoing EE were older (67 vs 62 years; P ¼ .01), with less hypertension (59% vs 79%; P ¼ .04), and less chronic kidney disease (4% vs 27%; P ¼ .01). The observed frequencies of diabetes, dyslipidemia, coronary artery disease, stroke, coagulopathy, and cancer were not significantly different among EE and SEP patients. The average follow-up duration was 28 months, longer among SEPs patients than EE patients (32 vs 20 months; P ¼ .02). We observed favorable primary patency with EE (Table). There were no statistically significant differences observed among adverse events associated with SEP and EE patients (Fig): CFA restenoses (10% vs 3.4%), CFA thromboses (12% vs 0%), and wound infections (10% vs 7%). Conclusions: EE and SEP both offer reasonably durable outcomes for the treatment of focal femoral arterial occlusive disease. EE may offer an attractive alternative to SEP, potentially decreasing the risk of significant wound complications associated with prosthetic patch infections.
Fig. Adverse event-free survival.
Author Disclosures: F. Albuquerque: Nothing to disclose; R. Larson: Nothing to disclose; M. Levy: Nothing to disclose; A. H. Nguyen: Nothing to disclose; L. G. Wolfe: Nothing to disclose.
PC162. Exploring Associations Between Sleep Disturbance and Walking Activity Among Patients With Symptomatic Peripheral Artery Disease: Results From the Project VOICE Pilot Study Matthew A. Corriere,1 Timothy Craven,2 Donna Keith,2 Justin Hurie,2 Gabriela Velazquez-Ramirez,2 Randolph Geary,2 Matthew Edwards2. 1University of Michigan, Ann Arbor, Mich; 2Wake Forest School of Medicine, Winston-Salem, NC Objectives: Sleep disturbance is an important determinant of both physical and mental health plus quality of life (QOL). Sleep disturbance associated with subclinical cardiovascular disease has been described, but associations with symptomatic peripheral artery disease (PAD) are unknown. We prospectively studied sleep disturbance among patients with symptomatic PAD over 30 days using wearable devices. Methods: Claudicant patients with an ankle-brachial index <.9 were recruited and received walking exercise instructions, a wearable device to track walking and sleep, and access to a PAD-specific digital health platform with educational materials, online communities, and surveys. Participants set walking goals, received weekly phone follow-up, and completed pre/post QOL instruments (Walking Impairment Questionnaire and VascuQol-6). Associations between sleep interruption, walking, patient characteristics, and survey responses were evaluated using Poisson regression.
Table. Primary patency Duration in months No.
6 % (n/N)
12 % (n/N)
All
29
100 (17/17)
100 (16/16)
100 (15/15)
100 (12/12)
100 (9/9)
100 (7/7)
100 (5/5)
Alone
19
100 (10/10)
100 (9/9)
100 (8/8)
100 (6/6)
100 (4/4)
100 (4/4)
100 (1/1)
Procedure
18 % (n/N)
24 % (n/N)
30 % (n/N)
36 % (n/N)
42 % (n/N)
EE
SEP All
68
Alone
26
86 (49/57) 85.7 (18/21)
77.6 (38/49) 81 (12/16)
76 (34/45) 78.6 (11/14)
74 (32/43) 78.6 (11/14)
67.6 (23/34)
60.7 (17/28)
70 (7/10)
57 (4/7)
All, All cases; Alone, cases without concurrent operations; EE, eversion endarterectomy; SEP, standard endarterectomy with patch.
52 (12/23) 57 (4/7)
Journal of Vascular Surgery
Abstracts
June Supplement 2017
PC156. Variation in Emergency Department Treatment of Patients With Critical Limb Ischemia Julia Glaser, Paul J. Foley, Grace J. Wang, Benjamin M. Jackson, Ronald M. Fairman, Scott M. Damrauer. University of Pennsylvania Health System, Philadelphia, Pennsylvania Objectives: Regional variation has been shown to exist in the treatment of lower extremity disease. Additionally, lower socioeconomic status is associated with later presentation and worse outcomes in vascular surgery. The decision to admit or discharge a patient with critical limb ischemia (CLI) from the emergency department (ED) depends on many factors. This study examined patient and hospital characteristics associated with disposition from the ED. Methods: Data from the Nationwide Emergency Department Sample, a stratified sample of 20% of EDs nationwide, was used. Patients presenting with rest pain, ischemic ulceration, or ischemic gangrene were selected. Patient and hospital characteristics associated with admission or discharge were calculated. Weighted logistic regression was used to determine predictors of admission to the hospital. Results: A total of 59,005 patients presented to the ED with CLI: 13.2% (n ¼ 7772) with rest pain, 32.0% (n ¼ 18,903) with ulceration, and 54.8% (n ¼ 32,330) with gangrene. Patients were an average age of 69.7 years, and 42.3% (n ¼ 24,942) were female. The overall admission rate was 96.2% (n ¼ 56,788). The rate of admission was significantly higher for gangrene (98.9% [n ¼ 31,640]) than for ulceration (95.0% [n ¼ 17,498]) and rest pain (92.7% [n ¼ 7201]; P < .01). Uninsured patients had the lowest rate of admission (91.0% [n ¼ 1749]); 96.5% (n ¼ 41,782) of Medicare, 95.7% (n ¼ 6014), and 96.4% (n ¼ 5807) of privately insured patients were admitted (P < .01). Admission rates were not significantly different between patients in the highest (96.1% [n ¼ 18,448]) and lowest (96.5% [n ¼ 11,536]) zip code income quartiles (P ¼ .88). Admission rates varied significantly by region (98.1%, Northeast; 95.6%, Northwest; 96.4%, South; 94.1%, West; P < .01). Urban hospitals were more likely to admit (96.7%) than micropolitan or rural EDs (90.5%; P < .01). On multivariate analysis, ulceration (odds ratio [OR], 1.47; confidence interval [CI], 1.08-2.00; P ¼ .01) and gangrene (OR, 3.69; CI, 2.515.44; P < .01) were predictive of admission (referent to rest pain). Lack of insurance (OR, 0.39; CI, 0.24-0.62; P < .01), region (Northwest: OR, 0.51; CI, 0.28-0.91; P ¼ .024; South: OR, 0.53; CI, 0.29-0.97; P ¼ .04; West: OR, 0.27; CI, 0.13-0.55; P < .01; referent to Northeast), and metropolitan teaching hospital (OR, 0.62; CI, 0.41-0.94; P ¼ .24) or nonmetropolitan (OR, 0.21; CI, 0.11-0.42; P < .01; referent to metropolitan nonteaching hospital) were associated with a decreased likelihood of admission. Conclusions: The majority of patients who present to the ED with CLI are admitted to the hospital from the ED. Admission rates are lower for uninsured patients, possibly reflecting a disparity in care. Author Disclosures: S. M. Damrauer: Nothing to disclose; R. M. Fairman: Nothing to disclose; P. J. Foley: Nothing to disclose; J. Glaser: Nothing to disclose; B. M. Jackson: Nothing to disclose; G. J. Wang: Nothing to disclose.
PC158. Long-Term Outcomes After Endovascular Stent Placement for Symptomatic, Long-Segment Superficial Femoral Artery Lesions Nader Zamani, Sherene Sharath, Rocky Browder, Neal R. Barshes, Houssam Younes, Jonathan Braun, Panos Kougias. Baylor College of Medicine, Houston, Tex Objectives: Endovascular intervention is commonly pursued for the treatment of symptomatic, long-segment superficial femoral artery (SFA) disease. The relative effectiveness and comparative long-term outcomes among bare-metal stents (BMS), covered stents (CS), and drug-eluting (DES) stents for long-segment SFA lesions remain uncertain.
Fig 1.
Fig 2. Methods: A retrospective cohort study identified consecutive patients with symptomatic SFA occlusions measuring at least 15 cm who received an endovascular stent (BMS, CS, or DES). The primary outcome of interest was patency, while secondary outcomes included postoperative presentation with acute limb ischemia (ALI), number of reoperations, and limb salvage. Patency rates were compared using time-to-event analysis and log-rank tests. Results: From 186 patients that were identified, a total of 215 procedures were analyzed (BMS: 113 [52%]; CS: 75 [35%]; DES: 27 [13%]) with a median follow-up time of 56 months (although the follow-up for DES was less: median, 10 months; P < .001). There were no significant differences among the groups with respect to mean age, diabetes status, renal dysfunction, and lower extremity runoff (mean 2.0 6 0.7 vessels). The mean length of the SFA lesion being treated in this series was 27 6 8 cm (also similar across all groups, P ¼ .165). Although primary and secondary patency rates were not significantly different among the stent types, DES is associated with an improved short-term primary-assisted patency, with 6-, 12-, and 24-month rates of 92%, 92%, and 83%, respectively. This is compared to 80%, 57%, and 47% for BMS, and 80%, 49%, and 41% for CS, respectively (log-rank test: P ¼ .009; Fig 1). In comparing only BMS with CS, 5- and 8-year primary-assisted patency rates are also higher among BMS: 60% and 60% vs 33% and 33% for CS, respectively (P ¼ .011; Fig 2). Zero DES patients have presented postoperatively with ALI compared to 3% of BMS patients and 13% of CS patients (P ¼ .004). Similarly, the CS group had a higher rate of subsequent open revascularization (32%) compared with BMS (24%) and DES (7%; P ¼ .038). Conclusions: Although long-term primary-assisted patency is greater in BMS as compared to CS, primary and secondary patency rates among all
Journal of Vascular Surgery
Abstracts
183S
Volume 65, Number 6S stent types are similar. CSs are associated with an increased risk of postoperative acute limb ischemia and subsequent open revascularization. Author Disclosures: N. R. Barshes: Nothing to disclose; J. Braun: Nothing to disclose; R. Browder: Nothing to disclose; P. Kougias: Nothing to disclose; S. Sharath: Nothing to disclose; H. Younes: Nothing to disclose; N. Zamani: Nothing to disclose.
PC160. Common Femoral Artery Endarterectomy: Contemporary Results Using Eversion Endarterectomy vs Standard Endarterectomy With Patch Alexander H. Nguyen, Francisco Albuquerque Jr, Robert Larson, Luke G. Wolfe, Mark Levy. Virginia Commonwealth University, Richmond, Va Objectives: For over 50 years, standard endarterectomy with patch (SEP) of the common femoral artery (CFA) has been well described with durable results. Eversion endarterectomy (EE) uses a complete CFA transection above its bifurcation and subsequent end-to-end anastomosis. EE is potentially advantageous over SEP by avoiding prosthetic patch infection and easing future transfemoral access. With subjectively more focal femoral artery lesions encountered during the endovascular era, we reviewed our SEP and EE outcomes to see whether there were any differences between the two methods. Methods: We retrospectively identified all patients undergoing CFA endarterectomy by a single surgeon who adopted preferential EE at a single institution between 2007 and 2015. Patient demographics and surgical details were captured from the electronic medical record, including endarterectomy type and the performance of concurrent endovascular and/or bypass surgery. Complications and adverse events were recorded. Statistical comparison of means was performed using the t-test, and categoric variables were evaluated using the Fisher exact test. Results: Eighty-nine sequentially encountered patients underwent 97 endarterectomies of the CFA (68 SEP and 29 EE). More SEP than EE cases were performed concomitant with either bypass or stenting (62% vs 34%). Most patients were smokers (80% of SEP vs 93% of EE). Patients undergoing EE were older (67 vs 62 years; P ¼ .01), with less hypertension (59% vs 79%; P ¼ .04), and less chronic kidney disease (4% vs 27%; P ¼ .01). The observed frequencies of diabetes, dyslipidemia, coronary artery disease, stroke, coagulopathy, and cancer were not significantly different among EE and SEP patients. The average follow-up duration was 28 months, longer among SEPs patients than EE patients (32 vs 20 months; P ¼ .02). We observed favorable primary patency with EE (Table). There were no statistically significant differences observed among adverse events associated with SEP and EE patients (Fig): CFA restenoses (10% vs 3.4%), CFA thromboses (12% vs 0%), and wound infections (10% vs 7%). Conclusions: EE and SEP both offer reasonably durable outcomes for the treatment of focal femoral arterial occlusive disease. EE may offer an attractive alternative to SEP, potentially decreasing the risk of significant wound complications associated with prosthetic patch infections.
Fig. Adverse event-free survival.
Author Disclosures: F. Albuquerque: Nothing to disclose; R. Larson: Nothing to disclose; M. Levy: Nothing to disclose; A. H. Nguyen: Nothing to disclose; L. G. Wolfe: Nothing to disclose.
PC162. Exploring Associations Between Sleep Disturbance and Walking Activity Among Patients With Symptomatic Peripheral Artery Disease: Results From the Project VOICE Pilot Study Matthew A. Corriere,1 Timothy Craven,2 Donna Keith,2 Justin Hurie,2 Gabriela Velazquez-Ramirez,2 Randolph Geary,2 Matthew Edwards2. 1University of Michigan, Ann Arbor, Mich; 2Wake Forest School of Medicine, Winston-Salem, NC Objectives: Sleep disturbance is an important determinant of both physical and mental health plus quality of life (QOL). Sleep disturbance associated with subclinical cardiovascular disease has been described, but associations with symptomatic peripheral artery disease (PAD) are unknown. We prospectively studied sleep disturbance among patients with symptomatic PAD over 30 days using wearable devices. Methods: Claudicant patients with an ankle-brachial index <.9 were recruited and received walking exercise instructions, a wearable device to track walking and sleep, and access to a PAD-specific digital health platform with educational materials, online communities, and surveys. Participants set walking goals, received weekly phone follow-up, and completed pre/post QOL instruments (Walking Impairment Questionnaire and VascuQol-6). Associations between sleep interruption, walking, patient characteristics, and survey responses were evaluated using Poisson regression.
Table. Primary patency Duration in months No.
6 % (n/N)
12 % (n/N)
All
29
100 (17/17)
100 (16/16)
100 (15/15)
100 (12/12)
100 (9/9)
100 (7/7)
100 (5/5)
Alone
19
100 (10/10)
100 (9/9)
100 (8/8)
100 (6/6)
100 (4/4)
100 (4/4)
100 (1/1)
Procedure
18 % (n/N)
24 % (n/N)
30 % (n/N)
36 % (n/N)
42 % (n/N)
EE
SEP All
68
Alone
26
86 (49/57) 85.7 (18/21)
77.6 (38/49) 81 (12/16)
76 (34/45) 78.6 (11/14)
74 (32/43) 78.6 (11/14)
67.6 (23/34)
60.7 (17/28)
70 (7/10)
57 (4/7)
All, All cases; Alone, cases without concurrent operations; EE, eversion endarterectomy; SEP, standard endarterectomy with patch.
52 (12/23) 57 (4/7)