Enjae Jung

Patterns of Care in Hospitalized Vascular Surgery Patients at End of Life

Importance There is limited literature reporting circumstances surrounding end-of-life care in vascular surgery patients. Objective To identify factors driving end-of-life decisions in vascular surgery patients. Design, Setting, and Participants In this cohort study, medical records were reviewed for all vascular surgery patients at a tertiary care university hospital who died during their hospitalization from 2005 to 2014. Main Outcomes and Measures Patient, family, and hospitalization variables potentially important to influencing end-of-life decisions. Results Of 111 patients included (67 [60%] male; median age, 75 [range, 24-94] years), 81 (73%) were emergent vs 30 (27%) elective admissions. Only 15 (14%) had an advance directive. Of the 81 (73%) patients placed on comfort care, 31 (38%) had care withheld or withdrawn despite available medical options, 15 (19%) had an advance directive, and 28 (25%) had a palliative care consultation. The median time from palliative care consultation to death was 10 hours (interquartile range, 3.36-66 hours). Comparing the 31 patients placed on comfort care despite available medical options with an admission diagnosis–matched cohort, we found that more than 5 days admitted to the intensive care unit (odds ratio [OR], 4.11; 95% CI, 1.59-10.68; P < .001), more than 5 days requiring ventilator support (OR, 9.45; 95% CI, 3.41-26.18; P < .001), new renal failure necessitating dialysis (OR, 14.48; 95% CI, 3.69-56.86; P < .001), and new respiratory failure necessitating tracheostomy (OR, 23.92; 95% CI, 2.80-204; P < .001) correlated with transition to comfort care. Conclusions and Relevance Palliative care consultations may be underused at the end of life. A large percentage of patients were transitioned to comfort measures despite available treatment, yet few presented with advance directives. In high-risk patients, discussions regarding extended stays in the intensive care unit, prolonged ventilator management, and possible dialysis and tracheostomy should be communicated with patients and families at time of hospitalization and advance directives solicited.

Ambulation and functional outcome after major lower extremity amputation

Objective: Major lower extremity amputations (MLEAs) remain a significant source of disability. It is unknown whether postamputation functional outcomes and outcome predictability have changed with a population of increasingly aging and obese patients. Accordingly, we sought to evaluate contemporary trends. Methods: A retrospective chart review was performed to identify patients undergoing MLEA using Current Procedural Terminology codes in a university hospital. Demographics, comorbidities, perioperative variables, and outcomes were obtained. Descriptive statistics, t‐tests, and χ2 and multivariate logistic regression modeling were used where appropriate. Survival analyses were performed with the Kaplan‐Meier method. Results: From October 2005 to November 2016, 206 patients (147 male; mean age, 63 ± 13.5 years) underwent 256 MLEAs (90.9% below‐knee amputations, 1.3% through‐knee amputations, and 7.8% above‐knee amputations [AKAs]) related to acute and critical limb ischemia, infection, or other causes. Mean follow‐up was 178.7 ± 266.9 days. Conversion from below‐knee amputation to AKA was 3.5%. Estimated 1‐year survival was 83%, and it was 15% lower in nonambulatory patients (75% vs 90%; P = .04). Overall 1‐year postamputation ambulatory rate was 46.1%. Nonambulatory patients had a higher body mass index (30.9 ± 8.0 vs 25.6 ± 5.4; P < .001), lower preoperative hematocrit (31.0% ± 7.4% vs 33.3% ± 8.1%; P < .05), higher modified frailty index (mFI; 8.4 ± 1.0 vs 5.4 ± 1.2; P < .0001), higher chronic alcohol use (9% vs 1%; P = .01), dependent preoperative functional status (29% vs 2.1%; P < .01), and lack of family support (66.3% vs 17.9%; P < .01); they were less likely to be married (83.2% vs 35.8%; P < .01) and more likely to have an AKA (20% vs 52.6%; P = .004). There were no patients with dementia, on dialysis, or with bilateral MLEAs who were ambulatory after amputation. Factors predictive of nonambulatory status after MLEA with multivariate logistic regression analysis included increased body mass index (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.81‐0.98; P = .017) and an increased mFI (OR, 0.23; 95% CI, 0.16‐0.34; P < .0001); a higher hemoglobin level was protective (OR, 1.3; 95% CI, 1.03‐1.62; P = .019). Conclusions: Patients should be counseled that <50% of patients receiving MLEAs are ambulatory after amputation. Educating patients about the deleterious effects of obesity on ambulatory status after MLEA may motivate patients to improve their level of fitness to achieve successful ambulation. Patients with an elevated mFI, patients with dementia, and those on dialysis should be considered for AKAs.

PC182. Development of Duplex Ultrasound Criteria for External Carotid Artery Stenosis: Importance of Assessing Both Peak Systolic Velocity and Presence of Color Aliasing

be diagnostic for recurrent stenosis, however, its uniform application and benefit is controversial. With this study we aim to determine whether follow-up with ADSI yielded a better outcome than those with Doppler and ankle-brachial index (ABI) follow-up alone. Methods: We performed a retrospective analysis collecting data of patients undergoing SFA stent implantation for occlusive disease at a tertiary care referral center between 2009 and 2016. Patients with PTA only, those with an in-stent restenosis, and those with no follow-up were excluded. The remaining patients were divided into those with at least one ADSI (ADSI group) and those with clinical/ABI follow-up only (ABI group). Variables analyzed included patients demographics, comorbidities, indication and procedural details. The two groups were compared via univariate analysis with respect to the following variables: patency, proximal/distal (relative to stent) progression and intervention, major adverse limb event, limb loss and mortality. Results: There were 238 patients with SFA stent implantation included in the study, 152 into ADSI and 86 into ABI. There was no difference in demographics and comorbidities between the groups. ADSI and ABI were homogenous regarding clinical presentation (claudication/critical limb ischemia ADSI 39.1%/60.9% vs ABI 37.6%/62.4%; P 1⁄4 .982) and TransAtlantic Inter-Society Consensus classification (P 1⁄4 .546). The 1-year outcome showed a similar primary patency rates for ADSI (63.8%) versus ABI (65.1%; P 1⁄4 .841). Both groups had improvement in assisted patency, however, ADSI had a higher assisted patency compared with ABI (81.6% vs 69.8%; P 1⁄4 .037). Secondary patency was also higher for ADSI (88.1%) vs ABI (72.9%; P 1⁄4 .003). Despite similar clinical presentations, ABI patients were more likely to undergo a major amputation (ABI 14.7% vs ADSI 3.4%; P 1⁄4 .002) at the 1-year follow-up. Conclusions: In SFA stent implantation, ADSI follow-up shows an advantage in assisted patency and secondary patency, which may contribute to a decreased rate of major amputation. Within the first year of follow-up evaluation of SFA stent implantation, ADSI would seem to be advantageous and consideration should be given to more uniform application of surveillance ADSI.

Tibial artery duplex ultrasound-derived peak systolic velocities may be an objective performance measure after above-knee endovascular therapy for arterial stenosis

Objective: The ankle‐brachial index (ABI) is a well‐established measure of distal perfusion in lower extremity ischemia; however, the ABI is of limited value in patients with noncompressible lower extremity arteries. We sought to demonstrate whether duplex ultrasound‐determined tibial artery velocities can be used as an alternative to ABI as an objective performance measure after endovascular treatment of above‐knee arterial stenosis. Methods: Thirty‐six patients undergoing above‐knee endovascular intervention had preprocedure and postprocedure duplex ultrasound examination within 6 months of intervention. Preprocedure vs postprocedure changes in tibial artery mean peak systolic velocity (PSV; mean of proximal, mid, and distal velocities) were compared with changes in ABI and a reference (control) cohort of 68 patients without peripheral vascular disease. Results: Thirty‐six patients (41 limbs) had an above‐knee endovascular intervention and had preprocedure and postprocedure duplex ultrasound examinations of the ipsilateral extremity including the tibial arteries. Before the procedure, mean tibial artery PSVs in the 36 patients undergoing intervention were outside (below) the 95% confidence intervals for the control patients. In comparing preprocedure and postprocedure PSVs, the mean anterior tibial (P < .01), mean peroneal (P < .01), and mean posterior tibial (P < .01) PSVs all increased and correlated with an increase in ABI (P < .01). After endovascular intervention, duplex ultrasound‐derived mean PSVs fell within or near established reference ranges for patients without peripheral arterial disease. Mean tibial artery PSV increases were similar in patients with and without noncompressible vessels. Conclusions: Tibial artery PSVs increase, correlate with an increase in ABI, and fall within or near confidence intervals for normal controls after above‐knee endovascular interventions. After endovascular intervention, tibial artery PSVs can supplement ABI as an objective performance measure in patients with and in particular without compressible tibial arteries.

Nonatherosclerotic vascular causes of acute abdominal pain

BACKGROUND To examine the epidemiology, treatments, and outcomes of acute symptomatic non-atherosclerotic mesenteric vascular disease. METHODS Subjects were reviewed over a six year period. Categories included embolism (EM), dissection (DI), and aneurysm (AN). Presentation, demographics, treatment and outcomes were compared. RESULTS 46 patients were identified (EM:20, AN:15, DI:11). Age at presentation differed (EM: 66.3, AN 62.4, DI 54.6, p < .05). EM more likely affected the superior mesenteric artery (EM80%, AN20%, DI45%, p = .002), DI hepatic artery (EM20%, AN13%, DI55%, p < .05), and AN mesenteric branches (EM5%, AN47%, DI0%; p = .001). EM more likely had history of arrhythmia (EM40%, AN7%, DI0%, p,0.05) and diarrhea (EM30%, AN7%, DI0%, p < .05). Treatment was most often surgical in EM (EM85%, AN33%, DI9%, p < .001), endovascular in AN (EM5%, AN40%, DI 9%, p < .02), and conservative in DI (EM15%, AN 33%, DI82%, p < .05). In hospital mortality was infrequent (EM10%, AN7%, DI0%, p = ns). Mean hospital length of stay differed by mechanism (EM13.6days, AN9.2, DI2.3, p = .005). Median follow up was 61 months. Survival at 1, 3 and 5 years for emboli was 75%, 70% and 59%, for aneurysms 93%, 86%, and 77%, and for dissections 100% at all time points (p = .043 log rank). CONCLUSIONS Patients with EM, AN, and DI differ in age, anatomic distribution and method of treatment. The etiology significantly affects long term survival.

SS24 Cryopreserved Vein vs Autologous Vein in Portomesenteric Reconstruction During Oncologic Surgery

asymptomatic stenosis (41 [51%]). The perioperative complications were few and similar between groups (bleeding, infection, immediate occlusion, and stroke). Patency rates, as determined by duplex ultrasound imaging, were similar at 1 year (100% VBG vs 99% PBG; P 1⁄4 .434). The 5to 10-year patency was also similar between groups (84% VBG vs 88% PBG; P 1⁄4 .434; Fig). Conclusions: Ipsilateral internal carotid artery bypass performed for a variety of indications using prosthetic and venous conduits have demonstrated excellent short-term results. Both types of conduit in this series have demonstrated continued durability over long-term follow-up.

VESS21. Defining Predictors of Ambulation and Functional Outcome After Major Lower Extremity Amputation: A Contemporary Review

Objectives: Critical hand ischemia caused by below-the-elbow atherosclerotic occlusive disease is increasing. The aim of this study was to examine the patient-centered outcomes of open and endovascular interventions in patients presenting with critical ischemia. Methods: A database of patients undergoing upper extremity symptomatic atherosclerotic disease below the elbow between 2006 and 2016 was retrospectively queried. Patients with critical ischemia (tissue loss and rest pain) were identified. There were three groups: endovascular revascularization, revascularization by bypass, and no revascularization. Patients with acute embolism, active vasculitis, end-stage renal disease, ipsilateral dialysis access complications of steal, and ipsilateral trauma were excluded. Results: A total of 108 patients (56% male; average age, 59 years) presented with symptomatic below-elbow disease: 93% presented with digital ulceration and the remainder with rest pain. Diabetes was present in 81%, and 41% had chronic renal insufficiency (not on dialysis). Fifty-three patients (49%) underwent angiography, had no intervention, and subsequently were committed to wound care. Of these, 26 required no further intervention, 10 had a palmar sympathectomy, 17 underwent a phalanx or digital amputation, and 34 (31%) underwent an endovascular intervention with a median of 1.5 vessels (ulnar, radial, or interosseous) intervened on. Technical success was achieved in 29 patients. Of the five technical failures, 2 went on to bypass, 1 had a focal endarterectomy and patch angioplasty, and 1 was treated conservatively. Ten patients in the endovascular group required a phalanx or digital amputation. A total of 21 patients (19%) underwent a reversed saphenous vein bypass to the radial in 12 and the ulnar in 11 patients. In follow-up, 11 patients underwent open or endovascular intervention to maintain patency. There were nine phalanx or digital amputations in the bypass group. No belowor above-elbow amputations were performed. The wound healing rate without amputation was 65% (70 of 108). The predictors of wound healing were technical success of the revascularization, intact palmar arch, and presence of digital runoff. The presence of an incomplete arch and poor digital runoff were associated with a phalanx or digital amputation. Conclusions: Upper extremity interventions for critical ischemia are associated with a high rate of success. Major amputations are rare, and many can be treated conservatively. In correctly selected patients, both endovascular and open interventions have a high rate of success

Interhospital vascular surgery transfers to a tertiary care hospital

Objective: Interhospital transfers (IHTs) to tertiary care centers are linked to lower operative mortality in vascular surgery patients. However, IHT incurs great health care costs, and some transfers may be unnecessary or futile. In this study, we characterize the patterns of IHT at a tertiary care center to examine appropriateness of transfer for vascular surgery care. Methods: A retrospective review was performed of all IHT requests made to our institution from July 2014 to October 2015. Interhospital physician communication and reasons for not accepting transfers were reviewed. Diagnosis, intervention, referring hospital size, and mortality were examined. Follow‐up for all patients was reviewed. Results: We reviewed 235 IHT requests for vascular surgical care involving 210 patients during 15 months; 33% of requested transfers did not occur, most commonly after communication with the physician resulting in reassurance (35%), clinic referral (30%), or further local workup obviating need for transfer (11%); 67% of requests were accepted. Accepted transfers generally carried life‐ or limb‐threatening diagnoses (70%). Next most common transfer reasons were infection or nonhealing wounds (7%) and nonurgent postoperative complications (7%). Of accepted transfers, 72% resulted in operative or endovascular intervention; 20% were performed <8 hours of arrival, 12% <24 hours of arrival, and 68% during hospital admission (average of 3 days); 28% of accepted patients received no intervention. Small hospitals (<100 beds) were more likely than large hospitals (>300 beds) to transfer patients not requiring intervention (47% vs 18%; P = .005) and for infection or nonhealing wounds (30% vs 10%; P = .013). Based on referring hospital size, there was no difference in IHTs requiring emergent, urgent, or nonurgent operations. There was also no difference in transport time, time from consultation to arrival, or death of patients according to hospital size. Overall patient mortality was 12%. Conclusions: Expectedly, most vascular surgery IHTs are for life‐ or limb‐threatening diagnoses, and most of these patients receive an operation. Transfer efficiency and surgical case urgency are similar across hospital sizes. Nonoperative IHTs are sent more often by small hospitals and may represent a resource disparity that would benefit from regionalizing nonurgent vascular care.