Anil Hingorani

A systematic review and meta-analysis of adjunctive therapies in diabetic foot ulcers

BACKGROUND Multiple adjunctive therapies have been proposed to accelerate wound healing in patients with diabetes and foot ulcers. The aim of this systematic review is to summarize the best available evidence supporting the use of hyperbaric oxygen therapy (HBOT), arterial pump devices, and pharmacologic agents (pentoxifylline, cilostazol, and iloprost) in this setting. METHODS We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus through October 2011. Pairs of independent reviewers selected studies and extracted data. Predefined outcomes of interest were complete wound healing and amputation. RESULTS We identified 18 interventional studies; of which 9 were randomized, enrolling 1526 patients. The risk of bias in the included studies was moderate. In multiple randomized trials, the addition of HBOT to conventional therapy (wound care and offloading) was associated with increased healing rate (Peto odds ratio, 14.25; 95% confidence interval, 7.08-28.68) and reduced major amputation rate (odds ratio, 0.30; 95% confidence interval, 0.10-0.89), compared with conventional therapy alone. In one small trial, arterial pump devices had a favorable effect on complete healing compared with HBOT and in another small trial compared with placebo devices. Neither iloprost nor pentoxifylline had a significant effect on amputation rate compared with conventional therapy. No comparative studies were identified for cilostazol in diabetic foot ulcers. CONCLUSIONS There is low- to moderate-quality evidence supporting the use of HBOT as an adjunctive therapy to enhance diabetic foot ulcer healing and potentially prevent amputation. However, there are only sparse data regarding the efficacy of arterial pump devices and pharmacologic interventions.

Clinical Experience With Office-Based Duplex-Guided Balloon-Assisted Maturation of Arteriovenous Fistulas for Hemodialysis

BACKGROUND To examine the effect of office-based duplex-guided balloon-assisted maturation (DG-BAM) on arteriovenous fistula (AVF), we retrospectively analyzed our experience. METHODS Over the past 10 months, we performed 185 DG-BAMs (range, 1-8 procedures; mean, 3.7) in 45 patients (29 male, 16 female; mean age, 68.2 ± 12.8 years) with 31 radial-cephalic, 7 brachial-cephalic, and 7 brachial-basilic AVFs. Balloon sizes (3-10 mm) were chosen based on duplex measurements (1-2 mm larger than minimal vein diameter). Forearm AVFs were dilated to 8 mm, and arm AVFs were dilated to 10 mm. RESULTS All cases but one (99.5%) were successfully dilated. This exception was a large AVF rupture that required surgical repair. AVFs failed to mature in seven of the remaining 44 patients (16%) despite DG-BAM because of proximal vein stenoses (PVS). Four patients had cephalic arch stenoses, and three had proximal subclavian vein stenoses. Arm AVFs were more commonly associated with PVS (6 of 14 patients, 43%) as compared with the ones placed in the forearm (1 of 30 patients, 3.3%), with a P value of 0.0024. All these seven AVFs subsequently matured after successful balloon angioplasty of the venous outflow. CONCLUSIONS These data suggest that office-based DG-BAM of AVFs is feasible, safe, and averts nephrotoxic contrast and radiation. PVS appear to be the most common cause of failure for AVFs subjected to BAM. Because arm AVFs are at increased risk of PVS, we suggest that a careful duplex evaluation of the outflow be performed in these cases and in all AVFs that fail to mature.

Effects of anesthesia versus regional nerve block on major leg amputation mortality rate.

There are greater than 120,000 above-knee amputations (AKA) and below-knee amputations (BKA) performed in the USA each year. Traditionally, general anesthesia (GA) was the preferred modality of anesthesia. The use of regional nerve blocks has recently gained popularity, however, without the supporting evidence of any mortality benefits. Our objective was to evaluate whether regional nerve blocks yield significant mortality reduction in major lower-extremity amputations. Retrospective data of both AKA and BKA procedures at the Maimonides Medical Center from 2005 to 2009 were analyzed. Patients received either general sedation, spinal or ultrasound-guided regional nerve blocks as per decision of the attending anesthesiologist. Regional nerve blocks for major lower-extremity amputations consisted of femoral, sciatic, saphenous and popliteal nerve blocks. A retrospective inquiry of 30-day mortality was performed with reference to the Social Security Death Index and hospital records. One hundred and fifty-eight patients were included in the study (82 men and 86 women with mean age of 74.5 years ± 12.9 SD, range of 33-98 years) of which 46 patients had regional nerve blocks and 112 had GA or spinal blocks. Patients who received both regional blocks and GA/spinal blocks within 30 days were excluded. The overall 30-day mortality was 17.1% (27 patients) consisting of 15.2% for regional nerve analgesia versus 17.9% for GA/spinal blocks (P = 0.867). Age did not affect mortality outcome in either groups of anesthesia modality. Our analysis did not reveal any mortality benefit of utilizing regional nerve block over GA or spinal blocks.

Acute Complications after Balloon-assisted Maturation

BACKGROUND Balloon-assisted maturation (BAM) of arteriovenous fistula (AVF) is a fairly new procedure used to accelerate the process of maturation. As with any procedure, complications do arise. In this retrospective analysis of 336 office-based BAM procedures, 5 major complications were analyzed. These were categorized as formation of wall hematoma, extravasation or rupture, spasm, thrombosis, and formation of puncture-site hematoma. METHODS Prospective data were collected from May 14, 2009 to March 3, 2011 on 336 office-based duplex-guided BAM procedures. Access site puncture, vessel cannulation, wire placement, and balloon advancement and insufflation were duplex guided. Balloon calibers were chosen based on duplex vein measurements and surgeon preference (approximately 1-2 mm larger than minimal vein diameter). Vascular injuries were classified based on postprocedural duplex assessment. All patients had follow-up duplex scans within a week after BAM. RESULTS Of the 336 procedures, the most common injury was formation of wall hematoma (136, 40.5%) followed by extravasation or rupture (32, 9.5%), spasm (26, 7.7%), formation of puncture-site hematoma (13, 3.9%), and thrombosis (5, 1.5%). The injuries were further compared based on balloon size, ranging from small balloon group (3-6 mm) to large balloon group (7-12 mm); entry position, retrograde (n=177) versus antegrade (n=159); and type of fistula; radial-cephalic (n=232), brachial-cephalic (n=64), brachial-basilic (n=34), brachial-brachial (n=4), and ulnar-cephalic (n=2). A significant increase in complications was noted in BAM procedures performed in forearm AVF versus upper arm AVF (67% vs 54%, P=0.02) and in the large balloon group versus small balloon group (72% vs 52%, P<0.001). CONCLUSIONS The data suggest that office-based BAM procedures are safe. Fortunately, major complications are not seen at an alarming rate. While increased complications are seen in BAM procedures performed in the forearm and with larger balloons, except for wall hematoma formation (40.19%), each complication occurs in <10% of the procedures. Further studies to help clarify the nature of these complications and their relationship to fistula maturation are warranted.

Treatment of upper extremity venous aneurysms with a polytetrafluoroethylene-covered stent

Background Venous aneurysms of the upper torso are uncommon in contrast to the abdomen and lower extremities. Mostly silent, they can cause significant morbidity. Large or symptomatic venous aneurysms are generally treated with open resection. To our knowledge, there are no documented cases of head and neck venous aneurysms treated by a hybrid endovascular and open approach. Case Presentation A 56-year-old female presented with the complaint of pain and increasing size of a supraclavicular mass. Imaging revealed a large saccular aneurysm of the subclavian vein with the presence of a large intramural thrombus on computed tomography scan with contrast. A covered stent was deployed in order to exclude the aneurysm from circulation. Three weeks later, the symptoms continued, and an aneurysmorrhaphy was performed to excise the stent and aneurysm resection. Discussion A combined endovascular and open approach to resection of symptomatic subclavian vein aneurysms is a viable method with minimal morbidity.

A rare complication of a retained wire during endovascular abdominal aortic aneurysm repair.

We present a case of a high-risk 76-year-old man who was electively admitted for repair of a large infrarenal abdominal aortic aneurysm. After placement of the main body of the bifurcated graft, the contralateral guidewire became entrapped at the level of suprarenal fixation. Multiple endovascular maneuvers were attempted to remove this wire from the femoral approach, but all were unsuccessful. The wire was then transected at the level of the common femoral artery and anchored to the arterial wall with 1 small monofilament suture. A short bare stent was also used to secure this wire to the inner wall of the external iliac artery. However, the proximal end of the wire that extended freely up to the mid-descending aorta was left undisturbed. On postoperative day 2, an attempt at snaring the proximal end of the wire via a brachial approach also failed to displace the trapped wire. At 1-year of follow-up, the patient has been asymptomatic with no obvious sequelae, such as thromboembolism or aortic dissection, and there is no evidence of damage to the aorta or graft on computed tomographic imaging. To our knowledge, this complication has not been previously reported.

IP255. The Role of Intravenous Sedation in Postoperative Back Pain After Iliac Vein Stenting for Nonthrombotic Iliac Vein Lesions

Objective: Lymphedema (LED) affects an estimated 35 million patients in the United States and a staggering 140,200 million people worldwide, yet LED is the forgotten disease of the vascular system. Whereas the diagnosis and treatment of arterial and venous diseases have been strengthened by the development of clinical care guidelines (CCGs), few CCGs appear available for LED. Moreover, for CCGs to have their greatest impact, they should be both of high quality and developed using the most rigorous evidence-based methods. We performed a systematic review of the available CCGs for LED, which were assessed for breadth of content and methodologic strength. Methods: A literature search was conducted from National Guideline Clearinghouse (www.guidelines.gov), BMJ Clinical Evidence (http:// clinicalevidence.bmj.com), andNational Institute forHealth andCareExcellence (http://www.nice.org.uk) as well as MEDLINE and Google, which identified 10CCGs for LED. Thesewere analyzed for inclusion of key elements for diagnosis andtreatmentaswell as for theprocessofguidelinedevelopment and reporting as assessed by the Appraisal of Guidelines for Research and Evaluation II method (based on a 7-point Likert scale for each of the six domains), with focus on the rigor of development and scope domain and expressed in percentage (0%minimum-100%maximum). Results: Ten documents were selected, of which six claimed to be CCGs; but two were limited in scope (rehabilitation or compression only), two were consensus statements, one was a position statement, and one was a systematic review, which yielded four CCGs. Only one of four CCGs was based on contemporary systematic reviews (2016 end date), whereas the remainder had older systematic review end dates (2005, 2007, 2007). The Appraisal of Guidelines for Research and Evaluation II analysis of the four CCGs showed low scores in the rigor of development and scope domain, the key domain influencing overall CCG quality (A, 26%; B, 28%; C, 45%; D, 50%). Conclusions: This systematic review of available LED CCGs shows a paucity of studies largely based on outdated data and with weak overall study quality. Therefore, it is imperative for our vascular societies to develop contemporary high-quality evidence-based CCGs for LED as they have for other vascular diseases.

VESS16. Iliac Vein Stent Placement and the Iliocaval Confluence

CAD, Coronary artery disease; CHF, congestive heart failure; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; ESRD, end-stage renal disease; HTN, hypertension; IQR, interquartile range; MI, myocardial infarction. to identify the burden of ICU utilization after elective infrainguinal lower extremity bypass (LEB) in patients with intermittent claudication (IC). Methods: We queried the Premier Healthcare Database for all adult patients undergoing first-recorded inpatient elective LEB from 2009 to 2015. ICU utilization on postoperative day 0 (POD0) was identified for each patient using Premier-provided room and board chargemaster codes. Baseline patient and hospital characteristics as well as crude postoperative outcomes are reported. A bivariate logistic regression with postestimation C statistics calculation was performed to identify predictors of ICU admission on POD0 (vs ward). Results: Of the 7493 patients who met the selection criteria, 3237 (45.3%) were admitted to the ward, 1138 (15.9%) to a stepdown unit, and 2772 (38.8%) to an ICU on POD0. Patient-level factors (demographics and comorbidities) contributed to minor differences of those who were admitted to ICU vs ward, whereas major differences were found in hospital characteristics. Specifically, ICU patients were more likely to be admitted in rural, nonteaching, small hospitals and hospitals in the South Atlantic division (all P < .001; Table). We found that patients who were admitted to the ICU on POD0 were more likely to be admitted to hospitals with median (interquartile range) total ward admissions after infrainguinal LEB for IC of 10.7% (3.4%-29.7%) vs 90.6% (64.0%-98.3%) for patients admitted to wards on POD0. Patient-level factors poorly predicted admission to ICU on POD0, with C statistics ranging from 0.50 to 0.53; hospital-level factors had higher C statistics ranging from 0.51 to 0.66. There was no difference in the risk of wound complications, major adverse limb events, or major adverse cardiac events of patients admitted to ICU vs wards on POD0 (all P > .05). However, the median total hospital cost was

Lower Extremity Arterial Mapping: Duplex Ultrasound as an Alternative to Arteriography Prior to Femoral, Popliteal, and Infrapopliteal Reconstructions

2340 higher for ICU vs ward (

In Patients with New Arteriovenous Fistulas, Are There Effective Strategies to Enhance AVF Maturation and Durability Beyond Waiting?

13,273 [