Adam Tanious

Prevalence of Migraine Headaches in Patients With Congenital Heart Disease

The prevalence of migraine headaches (MH) is 12% in the general population and increases to 40% in patients with patent foramen ovale. This study evaluated the prevalence of MH in patients with congenital heart disease (CHD). Of 466 patients contacted from the UCLA Adult Congenital Heart Disease Center, 395 (85%) completed a questionnaire to determine the prevalence of MH. Patients were stratified by diagnosis of right-to-left, left-to-right, or no shunt. A group of 252 sex-matched patients with acquired cardiovascular disease served as controls. The prevalence of MH was 45% in adults with CHD compared to 11% in the controls (p<0.001). Of the 179 patients with MH, 143 (80%) had migraines with aura and 36 (20%) had migraines without aura versus 36% and 64% observed in the controls (p<0.001). The frequency of MH was 52% in the right-to-left shunt group, 44% in the left-to-right, and 38% in the no shunt group (p=NS). In patients with a right-to-left shunt who underwent surgical repair, 47% had complete resolution of MH, whereas 76% experienced >50% reduction in headache days per month. In conclusion, the prevalence of MH in all groups of adults with CHD is 3 to 4 times more than a sex-matched control population, with increasing prevalence of MH in patients with no shunt, left-to-right, and right-to-left shunt. The higher than expected frequency of MH in patients with CHD without an intracardiac shunt, suggests additional mechanisms to explain the significant association with MH.

Snorkel endovascular abdominal aortic aneurysm repair versus fenestrated endovascular aneurysm repair: is it a competition?

The endovascular treatment of juxtarenal abdominal aortic aneurysm (AAA) can be performed by either a standard endovascular stent graft with additional snorkle grafts to aorta branches (snorkel endovascular aneurysm repair) or implantation of a fenestrated stent graft (fenestrated endovascular aneurysm repair). While many vascular surgeons consider snorkel endovascular aneurysm repair and fenestrated endovascular aneurysm repair to be competing techniques or alternate strategies, published procedural outcomes suggest more complementary roles. In this clinical review, the advantages and disadvantages of these two approaches are debated, as much can be learned from both strategies. Because the indications and circumstances for juxtarenal AAA repair vary based on patient-specific comorbidities and anatomy, it is recommended that vascular surgeons have access to, and experience with, both treatment strategies. Based on published outcomes, patient outcomes, stent-graft patency, and re-intervention rates are generally similar and acceptable compared with open AAA repair. We conclude that there is a time and a place for both snorkel endovascular aneurysm repair and fenestrated endovascular aneurysm repair for the endovascular management of juxtarenal and pararenal AAA anatomy.

IF01. Carotid Revascularization Within One Month After the Index Stroke Has a Higher Procedural Risk After Carotid Stenting Than After Carotid Endarterectomy

and of these, 22 patients had thrombosis within 30 days after the procedure. On the other hand, 501 patients had the iliac vein stent without crossing the iliocaval confluence, and of these, 16 patients had thrombosis within 30 days of the procedure. There was no difference between these two groups in regard to sex (P 1⁄4 .1) or age (P 1⁄4 .2). Comparing these two groups in regard to 30-day thrombosis as a complication was not statically significant (P 1⁄4 .9). Conclusions: These results question the need for routine iliac vein stent extension into the IVC. We were not able to demonstrate a significant risk of thrombosis with just placing the stent to cover the lesion only with short-term follow-up. This approach may simplify the procedure and result in significant cost savings.

PC160. Risk Score for Non-Home Discharge After Lower Extremity Bypass

Objectives: The ideal result of infrainguinal bypass (IBP) with in-line flow to the foot should be a normal hemodynamic result indicated by a palpable pulse/normal ankle-brachial index (ABI). The results of intervention can vary depending on inflow and outflow of the bypass and the quality and type of conduit chosen. The object of this study is to identify outcome depending on the hemodynamic result after IBP. Methods: National Vascular Quality Initiative (VQI) data from 2003 to 2017 were queried to identify patients with CLI and claudication treated with IBP with primary patency at 1 year. The outcome of interest was maintenance of ABI between 0.9 and 1.3 (normal ABI) at 1 year. Exclusions included patients with noncompressible tibial vessels, those without postoperative ABI and 1 year follow-up, and those with prior ipsilateral infrainguinal endovascular intervention or IBP. Of a total of 37,970 patients, 1519 met our selection criteria. Cohorts perfusion grade were: ABIs 0 to 0.5, (n 1⁄4 206), ABIs 0.5 to 0.9 (n 1⁄4 665), and ABIs 0.9 to 1.3 (n 1⁄4 648; Table I). Demographics and procedural factors were evaluated for predictors of failure to maintain unassisted normal ABI at 1 year using multivariable logistic regression. Stepwise regression was used for variables with P < .2 from c or t test analysis. Results: Of the 648 patients with a normal ABI at discharge, 79.6% maintained a normal ABI at one year follow-up, and 2 patients underwent major amputation. When discharged with an ABI of <0.9, 54.7% had a subsequent ABI measured at >0.9 at the 1-year follow-up and a total of six major amputations occurred. In patients with a normal ABI at discharge, multivariable analysis demonstrated that any history of nonindex limb peripheral vascular intervention, coronary artery disease, concomitant endarterectomy, diabetes, pedal bypass target, postoperative congestive heart failure, or sequential graft were predictive of a drop in ABI at 1 year to <0.9. (Table II). The discharge ABI 0.5 to 0.9 cohort multivariable analysis showed that hypertension, female gender, postoperative myocardial infarction, and nonwhite race were predictive of poor hemodynamic result; use of vein conduit and preop ABI grade were protective of a maintained ABI at the 1-year follow-up (Table II). Conclusions: These results suggest that patients with a normal ABI immediately after bypass have a high likelihood of maintaining a normal hemodynamic response at one year, irrespective of conduit choice. However, conduit type, among other factors, becomes important when postoperative perfusion results are not optimal. Author Disclosures: A. W. Beck: Nothing to disclose; W. Jackson: Nothing to disclose; Z. Novak: Nothing to disclose; M. A. Passman: Nothing to disclose; M. A. Patterson: Nothing to disclose; B. J. Pearce: Nothing to disclose; E. L. Spangler: Nothing to disclose.

Effective arteriovenous fistula alternative for hemodialysis access

BACKGROUND The use of autologous arteriovenous fistulae (AVF) for hemodialysis (HD) is the gold standard; however, for many patients at tertiary referral centers, this is not an option. METHODS We conducted a four year retrospective cohort study to evaluate HD access outcomes with AVF, bovine carotid artery (BCA), and polytetrafluoroethylene arteriovenous graft (PTFE). RESULTS The study contained 416 AVF, 175 BCA, and 58 PTFE, N = 649. There was statistical difference between rates of infection (AVF 3.4%, BCA 2.9%, PTFE 11.9%), P = 0.02. Maturation failed in 7.5% of AVF but in none of the BCA or PTFE (P = 0.001). Accesses were abandoned with AVF (1.9%), BCA (1.5%), and PTFE (9.5%), P = 0.01. CONCLUSION Bovine carotid artery can be an effective alternative form of HD access with lower infection, abandonment, and failure to maturation rates when autologous arteriovenous fistula is not an option.

Intraoperative Gutter Leaks That Merit Our Attention

Introduction: The natural history and potential morbidity of gutter endoleaks are unclear. We present our experience with intraoperative gutter endoleaks and strategies to determine which of these require intervention. Methods: This is a retrospective review of all patients treated with parallel stent grafts from January 2010 to September 2015. We reviewed all operative records and intraoperative angiograms as well as all postoperative imaging and secondary interventions. All gutter leaks were classified as low-flow/nonsac-enhancing gutter endoleaks or high-flow/sac-enhancing gutter endoleaks. Adjunctive interventions to manage the gutter leaks were noted, as were all subsequent interventions for gutter leak and endoleak management. Results: Seventy-eight patients had 144 parallel stents placed over a 5-year period with an average of 1.8 stents per patient. Twenty-eight patients (36%) had gutter endoleaks diagnosed intraoperatively. Seventeen patients had adjunctive procedures to reduce gutter leaks prior to leaving the operating room (OR). Patients selected for treatment had gutters filling early during completion angiography and/or contrast enhancement of the aneurysm sac. Twenty-two patients (28%) left the OR with low-flow/delayed/nonsac-enhancing gutter endoleaks. At 30 days, a total of 6 persistent gutter endoleaks were diagnosed on computed tomographic angiography. This gives a 73% rate of resolution for low-flow/nonaneurysm sac-enhancing endoleaks. There were 2 de novo endoleaks not detected at the index procedure diagnosed at 6-month follow-up. Of the 8 total postoperative endoleaks, 5 required additional intervention with a 100% success rate. Multivariate analysis revealed that the only significant predictor of having a postoperative endoleak is leaving the OR with an endoleak. Conclusions: Intraoperative treatment of gutter endoleaks has an acceptable rate of resolution. It does have a high rate of converting high-flow endoleaks to low-flow endoleaks. Low-flow/nonsac-enhancing gutter endoleaks have a high rate of spontaneous resolution. Intraoperative gutter endoleaks are not predictive of future aneurysm sac growth.

IP005. Who Should Fix the Bowel

administrative data set would demonstrate disparities based on race with respect to access to this latest technology and the associated outcomes following EVAR. Methods: Using deidentified data from the Florida State Agency for Health Care Administration, we identified patients based on International Classification of Diseases-Ninth Revision procedure codes who underwent EVAR between the years 2000 and 2014. We then assigned these procedures with the specialty of the operating physician and then analyzed outcomes based on the race of the patient defined within the following groups: non-Hispanic white, non-Hispanic black, Hispanic, Asian, and other. We also analyzed differences in insurance/payer data. We then stratified patients and patient outcomes based on the classification of the practitioner performing the surgery. Results: We identified 36,601 EVAR procedures during the study period. The average age of the total sample was 73.38 6 9.87 years, with 81.2% (n 1⁄4 29,034) of the cohort being male. Breakdown of patients within each race category was as follows: 17,056 non-Hispanic whites (47.7%), 1630 non-Hispanic African Americans (4.6%), 16,431 Hispanics(46.0%), and 632 patients (1.8%) identified as “other.” An analysis of the differences between racial groups in demographic/background data showed significant differences between age at presentation, sex of patient, and comorbidity score of patients at presentation. There were significant differences in outcomes based on race with respect to total hospital charges, length of stay, and disposition. The Table shows the breakdown of the above analysis with associated significance values. Significant differences were also found in the payer status based of each racial group. There were 1786 practitioners who completed 35,749 EVARs where both practitioner and race data were available. Stratifying by type of practitioner treating, we also found significant differences in the type of practitioner treating the various racial groups as well as the academic status of the practitioner. Conclusions: Racial disparities were discovered with respect to EVAR treatment. African Americans present at younger ages, have the highest percentage of females requiring intervention, have the longest hospital stays, have the highest Medicaid payer source, and have the highest in-hospital total charges of any racial group. Hispanics present with the highest comorbidity scores as compared to their counterparts.

Comparison of the integrated vascular surgery resident operative experience and the traditional vascular surgery fellowship

Objective: After almost 10 years since its approval, residents in integrated vascular surgery training programs now outnumber traditional vascular fellows. We examined the Accreditation Council for Graduate Medical Education (ACGME) case log data to assess whether there is a difference in operative experience between the graduating integrated residents and vascular fellows. Methods: We analyzed the total clinical experience of vascular surgery trainees during the academic years between 2012 and 2014 for the 30 graduated integrated vascular surgery residents (VSRs) and the 243 graduated vascular surgery fellows (VSFs). Data were compared on the basis of reported categories defined by the ACGME operation reporting system. VSR case totals were calculated by combining “surgeon chief,” “surgeon junior,” and “secondary procedures” categories. VSF “surgeon fellow” and “secondary procedures” case totals were combined with all vascular cases done in general surgery residency (using averages of general surgery resident ACGME case log data from the same years) to reflect their total vascular experience. Results: The average total vascular experience reported by VSRs was 1446.0 compared with 1421.8 for VSFs (P = .2086). VSRs performed 694.7 major vascular procedures on average compared with 616.3 major cases for VSFs (P = .0106). Highlighted comparisons include the following: open aortic aneurysm cases, VSRs 20.6 and VSFs 22.2 (P = .320); endovascular aortic aneurysm cases, VSRs 80.0 and VSFs 80.6 (P = .945); cerebrovascular cases, VSRs 78.8 and VSFs 85.0 (P = .1132); and peripheral obstructive cases, VSRs 343.6 and VSFs 293.4 (P = .0032). Conclusions: Integrated VSRs and traditional VSFs graduate with comparable overall vascular surgery clinical experience. VSRs reported, on average, a significantly higher number of major vascular procedures during their tenure as trainees as well as a significantly increased number of cases in six of the other ACGME categories.

Configuration affects parallel stent grafting results

Objective: A number of adjunctive “off‐the‐shelf” procedures have been described to treat complex aortic diseases. Our goal was to evaluate parallel stent graft configurations and to determine an optimal formula for these procedures. Methods: This is a retrospective review of all patients at a single medical center treated with parallel stent grafts from January 2010 to September 2015. Outcomes were evaluated on the basis of parallel graft orientation, type, and main body device. Primary end points included parallel stent graft compromise and overall endovascular aneurysm repair (EVAR) compromise. Results: There were 78 patients treated with a total of 144 parallel stents for a variety of pathologic processes. There was a significant correlation between main body oversizing and snorkel compromise (P = .0195) and overall procedural complication (P = .0019) but not with endoleak rates. Patients were organized into the following oversizing groups for further analysis: 0% to 10%, 10% to 20%, and >20%. Those oversized into the 0% to 10% group had the highest rate of overall EVAR complication (73%; P = .0003). There were no significant correlations between any one particular configuration and overall procedural complication. There was also no significant correlation between total number of parallel stents employed and overall complication. Composite EVAR configuration had no significant correlation with individual snorkel compromise, endoleak, or overall EVAR or procedural complication. The configuration most prone to individual snorkel compromise and overall EVAR complication was a four‐stent configuration with two stents in an antegrade position and two stents in a retrograde position (60% complication rate). The configuration most prone to endoleak was one or two stents in retrograde position (33% endoleak rate), followed by three stents in an all‐antegrade position (25%). There was a significant correlation between individual stent configuration and stent compromise (P = .0385), with 31.25% of retrograde stents having any complication. Conclusions: Parallel stent grafting offers an off‐the‐shelf option to treat a variety of aortic diseases. There is an increased risk of parallel stent and overall EVAR compromise with <10% main body oversizing. Thirty‐day mortality is increased when more than one parallel stent is placed. Antegrade configurations are preferred to any retrograde configuration, with optimal oversizing >20%.

Trends in open abdominal exposure among vascular surgery trainees

Background: This retrospective study evaluates the trends in open abdominal surgery cases among integrated vascular surgery residents compared with their 5 + 2 counterparts. Methods: The Accreditation Council for Graduate Medical Education (ACGME) case logs between 2007 and 2016 were collected from a pool of 9861 residents and fellows from 371 institutions. Trainees were grouped into three categories: general surgery residency (GSR), integrated vascular surgery residency (IVSR), and vascular surgery fellowship in the United States. Inclusion criteria were specific to open abdominal cases of or including the anatomy adjacent to the aorta performed by the surgeon chief. Results: The 5 + 2 graduates have obtained significantly more open vascular surgery training experience than their IVSR graduate counterparts (P < .01). GSR chief residents performed significantly more open abdomen cases than IVSR chief residents (P < .01). IVSR chiefs performed significantly more open vascular procedures than GSR chiefs (P < .01). On the completion of vascular surgery fellowship, 5 + 2 graduates had significantly more open abdominal aortic aneurysm (AAA) exposure during training than IVSR graduates did (P < .01); however, IVSR trainees had performed significantly more open AAA procedures than their GSR counterparts (P < .01). Conclusions: Up to 2016, graduates of the 5 + 2 vascular training pathway had significantly higher open abdominal exposure than those of the IVSR track. However, graduates of the IVSR track had significantly higher open AAA exposure than GSR graduates.