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PC180 Endovascular Stent Repair of Traumatic Superficial Femoral and Popliteal Artery Injuries: An Analysis of the National Trauma Data Bank
188S
Journal of Vascular Surgery
Abstracts
June Supplement 2017 Table. Age (years) Total (n ¼ 7482) (%)
0-1 (n ¼ 145) (%)
2-12 (n ¼ 1488) (%)
13-18 (n ¼ 5849) (%)
Cerebrovascular
31.20
51.70
34.30
29.30
Thoracic
14.00
8.30
8.70
15.50
.097
Abdominal
22.90
20.00
23.40
22.90
<.001
Variable
P value
Injury type
Overall aortic Extremity
<.001
3.90
4.10
3.10
4.10
.308
31.60
18.60
31.50
31.90
<.001
VTE
4.30
7.60
3.30
4.50
.045
Initial mortality
5.10
8.30
4.90
5.00
<.001
10.90
21.40
9.50
11.00
<.001
Overall mortality
VTE, venous thromboembolism.
PC180. Endovascular Stent Repair of Traumatic Superficial Femoral and Popliteal Artery Injuries: An Analysis of the National Trauma Data Bank Daniel B. Alfson, Kenji Inaba, Fred A. Weaver, Vincent L. Rowe. University of Southern California, Los Angeles, Calif Objectives: Despite increasing use of endovascular stent repair of traumatic arterial injuries, such repair of superficial femoral artery (SFA) and popliteal artery (PA) injuries remains uncommon and poorly studied. We describe characteristics and outcomes of trauma patients with SFA and PA injuries repaired using endovascular stenting. Methods: This was a retrospective National Trauma Data Bank analysis of trauma patients with a vascular injury isolated to the SFA and PA who underwent endovascular stent repair from 2007 to 2014. Results: The prevalence of SFA and PA injuries was 0.2%, with an increasing trend in the annual use of endovascular stent repair ranging from 1.3% to 3.1% across the study period (P ¼ .004) despite stable injury burdens (Fig 1). Included were 137 patients (81.5% males) with a median age of 31 years (interquartile range [IQR], 22-45 years). The most common comorbidity was smoking (23.4%), and none had pre-existing peripheral vascular disease. Mechanism of injury (MOI) was 57.4% penetrating. On presentation, 5.1% were hypotensive (systolic blood pressure <90 mm Hg), 9.5% were tachycardic (heart rate >120 beats/min), and 4.5% had Glasgow Coma Scale of <9. Median Injury Severity Score was 10 (IQR, 9-17). SFA injury was more common (65.0%) and associated with penetrating MOI (P < .001). PA injury was associated with blunt MOI (P < .001) and with fasciotomy both alone (P ¼ .015) and with concomitant SFA injury (P ¼ .035). Femur fracture and associated vein injury occurred in 35.8% and 7.3% patients, respectively. Median time to stent repair was 5 hours (IQR, 3-11 hours). Fasciotomy was performed in 21.2% patients after a median of 4 hours (IQR, 3-8 hours). The most common in-hospital complication was deep vein thrombosis (11.1%). Overall mortality was 5.8%. Age $65 years (P ¼ .025) and Glasgow Coma Scale <9 (P ¼ .045) were associated with mortality on univariate analysis, but only age $65 years was independently predictive (odds ratio, 7.5; 95% confidence interval, 1.5-36.4; P ¼ .013). Amputation was performed in 5.1% patients, equally distributed between SFA and PA injury, after a median of 10 days (IQR, 4-32 days). Fasciotomy was significant on both univariate (P ¼ .005) and multivariate analysis (odds ratio, 14.2; 95% confidence interval, 2.3-88.5; P ¼ .005) of amputation, yet time to initial fasciotomy was not associated with amputation (4 vs 3.5 hours; P ¼ .869, Fig 2). Conclusions: Endovascular stent repair of SFA and PA injuries is performed in stable trauma patients with low injury burdens. Death and amputation are infrequent, but age $65 years and fasciotomy are significant risk factors, respectively. Despite increasing annual trends,
Fig 1. Yearly trend in stent repair and Injury Severity Score (ISS).
Fig 2. Risk factors for (A) overall mortality and (B) amputation. CI, Confidence interval; GCS, Glasgow Coma Scale; ISS, Injury Severity Score; OR, odds ratio.
Journal of Vascular Surgery
Abstracts
189S
Volume 65, Number 6S prospective studies are necessary to elucidate the proper algorithm for patient selection in the endovascular management of this patient population. Author Disclosures: D. B. Alfson: Nothing to disclose; K. Inaba: Nothing to disclose; V. L. Rowe: Nothing to disclose; F. A. Weaver: Nothing to disclose.
PC182. The Impact of Different Treatment Modalities on Recalcitrant Venous Ulcer Healing Peter Lawrence,1 Eric Hager,2 Michael P. Harlander-Locke,3 Lowell Kabnick,4 Naveed Saqib,5 Kristofer M. Charlton-Ouw,5 Misaki Kiguchi,6 The Vascular Low-Frequency Disease Consortium. 1University of California Los Angeles School of Medicine, Los Angeles, Calif; 2University of Pittsburgh Medical Center, Pittsburgh, Pa; 3Lake Erie College of Osteopathic Medicine, Erie, Pa; 4New York University Langone Medical Center, New York, NY; 5University of Texas Health Science Center, Austin, Tex; 6MedStar Heart and Vascular Institute, Washington, D.C. Objectives: Refractory venous ulcers are a national health issue, despite advances in wound care and compression therapy. We examined the impact of compression, correction of incompetent superficial and perforator veins, and dilatation of iliac stenosis/occlusion. Methods: All patients with venous ulcers from eight institutions, treated between January 2013 and January 2016, were retrospectively evaluated for the impact of different treatment modalities. Results: A total of 406 patients with venous ulcers, accompanied by reflux in lower extremity deep veins (30%), superficial veins (92%), perforator veins (80%), and with iliac venous stenosis (4%) were treated, and 105 patients (26%) were managed conservatively with compression, for a mean of 3.8 months until ulcer healing. The remaining 301 patients (74%) underwent wound care for a mean of 9 months prior to surgical treatment. There were 276 patients (68%) who underwent ablation of an incompetent great saphenous vein 6.4 months after ulcer onset, 83 patients (20%) underwent ablation of an incompetent small saphenous vein after 11 months, and 288 patients (71%) underwent ablation of an incompetent perforator vein after 21 months. Patients undergoing perforator ablation had a mean of 1.7 perforator veins closed. Ulcer size at beginning of conservative treatment was smaller in those that healed with compression and wound care alone (7 vs 22 cm2, respectively; P < .05). Patients with concomitant deep venous reflux required more vein ablations (3.1 vs 1.4 veins, respectively; P < .05) to achieve ulcer healing. Time from onset to ulcer healing for patients requiring only superficial vein ablation was 9.1 months but was 13.8 months for patients requiring both superficial and perforator vein ablation (P < .05). Patients with deep vein incompetence took the longest time to heal, with a mean of 21 months. Stenosis >75% in the femoral or popliteal vein was a significant barrier to ulcer healing (P < .05). In patients with prior superficial vein ablation and iliac vein stenosis >50%, ulcer healing was achieved following iliac vein stenting in 76%. Absolute ulcer healing was achieved during the study period in 336 patients (83%). There were 35 ulcer recurrences (10%) during the study; new incompetent perforator veins were identified in 13 patients (37%). Conclusions: Patients with multilevel venous disease involving the deep system are at highest risk for developing venous ulcers that are refractory to compression therapy alone. Venous ulcer healing time and rate is improved with ablation of incompetent superficial and perforator veins. Correction of iliac venous stenosis/occlusion also facilitates ulcer healing. Author Disclosures: K. M. Charlton-Ouw: Medtronic and W. L. Gore and Associates Inc: consulting fees (eg, advisory boards); E. Hager: Nothing to disclose; M. P. Harlander-Locke: Nothing to disclose; L. Kabnick: Nothing to disclose; M. Kiguchi: Nothing to disclose; P. Lawrence: Nothing to disclose; The Vascular Low-Frequency Disease Consortium: Nothing to disclose; N. Saqib: Nothing to disclose.
PC184. Delayed Conversion to Kissing Stent Configuration in the Setting of Unilateral Iliac Vein Stenting Chien Yi M. Png, Jacob Lurie, Sida Chen, Sneha Subramaniam, Rami O. Tadros, Peter Faries, Michael Marin, Windsor Ting. Icahn School of Medicine at Mount Sinai, New York, NY Objectives: Iliac vein stents are being increasingly used to treat chronic proximal venous outflow obstruction. Among patients with unilateral stenting in the proximal common iliac vein with extension into the inferior vena cava (IVC), a small number of patients presented with venous symptoms related to outflow obstruction of the contralateral common iliac vein. While the incidence of this complication of iliac vein stenting is unknown, this abstract presents one technical approach to this complication. Methods: We present 11 patients with outflow obstructive symptoms in the contralateral iliac vein after a prior IVC common iliac vein stent placement. Postanesthesia, ultrasound guidance is used to obtain access to the common femoral vein bilaterally. Inferior vena cavograms and venograms of the iliac veins are undertaken using contrast in digital subtraction mode. Intravascular ultrasound (IVUS) using a Volcano Visions PV .035 Digital IVUS catheter (Volcano Corporation, San Diego, Calif) is then used to evaluate the iliac veins and assess the degree of stenosis in each vein segment. The use of IVUS is critical to locate the narrow channel present between the contralateral stent and wall of the IVC, assist passage of the guidewire through this narrow channel, and ensure that the guidewire does not pass through the interstices of the stent (Fig 1). Balloon angioplasty is seldom necessary. The initial guidewire is then exchanged for a stiff 0.35-inch 180-cm guidewire. Next, a 16-mm or 18-mm stent is positioned alongside the existing stent in a kissing iliac stents configuration. After the newly placed stent is deployed, both stents are simultaneously dilated with either 16-mm or 18-mm balloons (Fig 2). Finally, a completion venogram and IVUS confirm fully expanded stents. Results: This procedure was performed in 11 patients (6 males, 5 females), with three performed on the right iliac vein and eight on the left iliac vein. The mean time to development of contralateral occlusive symptoms was 626 days from the initial stenting. Average follow-up time from the second stenting was 167 days, with no postoperative complications. Eight patients reported significant symptomatic improvement in their newly treated limb at 30 days postoperatively, while 10 patients
Fig 1.
Journal of Vascular Surgery
Abstracts
June Supplement 2017 Table. Age (years) Total (n ¼ 7482) (%)
0-1 (n ¼ 145) (%)
2-12 (n ¼ 1488) (%)
13-18 (n ¼ 5849) (%)
Cerebrovascular
31.20
51.70
34.30
29.30
Thoracic
14.00
8.30
8.70
15.50
.097
Abdominal
22.90
20.00
23.40
22.90
<.001
Variable
P value
Injury type
Overall aortic Extremity
<.001
3.90
4.10
3.10
4.10
.308
31.60
18.60
31.50
31.90
<.001
VTE
4.30
7.60
3.30
4.50
.045
Initial mortality
5.10
8.30
4.90
5.00
<.001
10.90
21.40
9.50
11.00
<.001
Overall mortality
VTE, venous thromboembolism.
PC180. Endovascular Stent Repair of Traumatic Superficial Femoral and Popliteal Artery Injuries: An Analysis of the National Trauma Data Bank Daniel B. Alfson, Kenji Inaba, Fred A. Weaver, Vincent L. Rowe. University of Southern California, Los Angeles, Calif Objectives: Despite increasing use of endovascular stent repair of traumatic arterial injuries, such repair of superficial femoral artery (SFA) and popliteal artery (PA) injuries remains uncommon and poorly studied. We describe characteristics and outcomes of trauma patients with SFA and PA injuries repaired using endovascular stenting. Methods: This was a retrospective National Trauma Data Bank analysis of trauma patients with a vascular injury isolated to the SFA and PA who underwent endovascular stent repair from 2007 to 2014. Results: The prevalence of SFA and PA injuries was 0.2%, with an increasing trend in the annual use of endovascular stent repair ranging from 1.3% to 3.1% across the study period (P ¼ .004) despite stable injury burdens (Fig 1). Included were 137 patients (81.5% males) with a median age of 31 years (interquartile range [IQR], 22-45 years). The most common comorbidity was smoking (23.4%), and none had pre-existing peripheral vascular disease. Mechanism of injury (MOI) was 57.4% penetrating. On presentation, 5.1% were hypotensive (systolic blood pressure <90 mm Hg), 9.5% were tachycardic (heart rate >120 beats/min), and 4.5% had Glasgow Coma Scale of <9. Median Injury Severity Score was 10 (IQR, 9-17). SFA injury was more common (65.0%) and associated with penetrating MOI (P < .001). PA injury was associated with blunt MOI (P < .001) and with fasciotomy both alone (P ¼ .015) and with concomitant SFA injury (P ¼ .035). Femur fracture and associated vein injury occurred in 35.8% and 7.3% patients, respectively. Median time to stent repair was 5 hours (IQR, 3-11 hours). Fasciotomy was performed in 21.2% patients after a median of 4 hours (IQR, 3-8 hours). The most common in-hospital complication was deep vein thrombosis (11.1%). Overall mortality was 5.8%. Age $65 years (P ¼ .025) and Glasgow Coma Scale <9 (P ¼ .045) were associated with mortality on univariate analysis, but only age $65 years was independently predictive (odds ratio, 7.5; 95% confidence interval, 1.5-36.4; P ¼ .013). Amputation was performed in 5.1% patients, equally distributed between SFA and PA injury, after a median of 10 days (IQR, 4-32 days). Fasciotomy was significant on both univariate (P ¼ .005) and multivariate analysis (odds ratio, 14.2; 95% confidence interval, 2.3-88.5; P ¼ .005) of amputation, yet time to initial fasciotomy was not associated with amputation (4 vs 3.5 hours; P ¼ .869, Fig 2). Conclusions: Endovascular stent repair of SFA and PA injuries is performed in stable trauma patients with low injury burdens. Death and amputation are infrequent, but age $65 years and fasciotomy are significant risk factors, respectively. Despite increasing annual trends,
Fig 1. Yearly trend in stent repair and Injury Severity Score (ISS).
Fig 2. Risk factors for (A) overall mortality and (B) amputation. CI, Confidence interval; GCS, Glasgow Coma Scale; ISS, Injury Severity Score; OR, odds ratio.
Journal of Vascular Surgery
Abstracts
189S
Volume 65, Number 6S prospective studies are necessary to elucidate the proper algorithm for patient selection in the endovascular management of this patient population. Author Disclosures: D. B. Alfson: Nothing to disclose; K. Inaba: Nothing to disclose; V. L. Rowe: Nothing to disclose; F. A. Weaver: Nothing to disclose.
PC182. The Impact of Different Treatment Modalities on Recalcitrant Venous Ulcer Healing Peter Lawrence,1 Eric Hager,2 Michael P. Harlander-Locke,3 Lowell Kabnick,4 Naveed Saqib,5 Kristofer M. Charlton-Ouw,5 Misaki Kiguchi,6 The Vascular Low-Frequency Disease Consortium. 1University of California Los Angeles School of Medicine, Los Angeles, Calif; 2University of Pittsburgh Medical Center, Pittsburgh, Pa; 3Lake Erie College of Osteopathic Medicine, Erie, Pa; 4New York University Langone Medical Center, New York, NY; 5University of Texas Health Science Center, Austin, Tex; 6MedStar Heart and Vascular Institute, Washington, D.C. Objectives: Refractory venous ulcers are a national health issue, despite advances in wound care and compression therapy. We examined the impact of compression, correction of incompetent superficial and perforator veins, and dilatation of iliac stenosis/occlusion. Methods: All patients with venous ulcers from eight institutions, treated between January 2013 and January 2016, were retrospectively evaluated for the impact of different treatment modalities. Results: A total of 406 patients with venous ulcers, accompanied by reflux in lower extremity deep veins (30%), superficial veins (92%), perforator veins (80%), and with iliac venous stenosis (4%) were treated, and 105 patients (26%) were managed conservatively with compression, for a mean of 3.8 months until ulcer healing. The remaining 301 patients (74%) underwent wound care for a mean of 9 months prior to surgical treatment. There were 276 patients (68%) who underwent ablation of an incompetent great saphenous vein 6.4 months after ulcer onset, 83 patients (20%) underwent ablation of an incompetent small saphenous vein after 11 months, and 288 patients (71%) underwent ablation of an incompetent perforator vein after 21 months. Patients undergoing perforator ablation had a mean of 1.7 perforator veins closed. Ulcer size at beginning of conservative treatment was smaller in those that healed with compression and wound care alone (7 vs 22 cm2, respectively; P < .05). Patients with concomitant deep venous reflux required more vein ablations (3.1 vs 1.4 veins, respectively; P < .05) to achieve ulcer healing. Time from onset to ulcer healing for patients requiring only superficial vein ablation was 9.1 months but was 13.8 months for patients requiring both superficial and perforator vein ablation (P < .05). Patients with deep vein incompetence took the longest time to heal, with a mean of 21 months. Stenosis >75% in the femoral or popliteal vein was a significant barrier to ulcer healing (P < .05). In patients with prior superficial vein ablation and iliac vein stenosis >50%, ulcer healing was achieved following iliac vein stenting in 76%. Absolute ulcer healing was achieved during the study period in 336 patients (83%). There were 35 ulcer recurrences (10%) during the study; new incompetent perforator veins were identified in 13 patients (37%). Conclusions: Patients with multilevel venous disease involving the deep system are at highest risk for developing venous ulcers that are refractory to compression therapy alone. Venous ulcer healing time and rate is improved with ablation of incompetent superficial and perforator veins. Correction of iliac venous stenosis/occlusion also facilitates ulcer healing. Author Disclosures: K. M. Charlton-Ouw: Medtronic and W. L. Gore and Associates Inc: consulting fees (eg, advisory boards); E. Hager: Nothing to disclose; M. P. Harlander-Locke: Nothing to disclose; L. Kabnick: Nothing to disclose; M. Kiguchi: Nothing to disclose; P. Lawrence: Nothing to disclose; The Vascular Low-Frequency Disease Consortium: Nothing to disclose; N. Saqib: Nothing to disclose.
PC184. Delayed Conversion to Kissing Stent Configuration in the Setting of Unilateral Iliac Vein Stenting Chien Yi M. Png, Jacob Lurie, Sida Chen, Sneha Subramaniam, Rami O. Tadros, Peter Faries, Michael Marin, Windsor Ting. Icahn School of Medicine at Mount Sinai, New York, NY Objectives: Iliac vein stents are being increasingly used to treat chronic proximal venous outflow obstruction. Among patients with unilateral stenting in the proximal common iliac vein with extension into the inferior vena cava (IVC), a small number of patients presented with venous symptoms related to outflow obstruction of the contralateral common iliac vein. While the incidence of this complication of iliac vein stenting is unknown, this abstract presents one technical approach to this complication. Methods: We present 11 patients with outflow obstructive symptoms in the contralateral iliac vein after a prior IVC common iliac vein stent placement. Postanesthesia, ultrasound guidance is used to obtain access to the common femoral vein bilaterally. Inferior vena cavograms and venograms of the iliac veins are undertaken using contrast in digital subtraction mode. Intravascular ultrasound (IVUS) using a Volcano Visions PV .035 Digital IVUS catheter (Volcano Corporation, San Diego, Calif) is then used to evaluate the iliac veins and assess the degree of stenosis in each vein segment. The use of IVUS is critical to locate the narrow channel present between the contralateral stent and wall of the IVC, assist passage of the guidewire through this narrow channel, and ensure that the guidewire does not pass through the interstices of the stent (Fig 1). Balloon angioplasty is seldom necessary. The initial guidewire is then exchanged for a stiff 0.35-inch 180-cm guidewire. Next, a 16-mm or 18-mm stent is positioned alongside the existing stent in a kissing iliac stents configuration. After the newly placed stent is deployed, both stents are simultaneously dilated with either 16-mm or 18-mm balloons (Fig 2). Finally, a completion venogram and IVUS confirm fully expanded stents. Results: This procedure was performed in 11 patients (6 males, 5 females), with three performed on the right iliac vein and eight on the left iliac vein. The mean time to development of contralateral occlusive symptoms was 626 days from the initial stenting. Average follow-up time from the second stenting was 167 days, with no postoperative complications. Eight patients reported significant symptomatic improvement in their newly treated limb at 30 days postoperatively, while 10 patients
Fig 1.