James H. Black

Regional hypothermia with epidural cooling for prevention of spinal cord ischemic complications after thoracoabdominal aortic surgery

Multiple operative adjuncts have been developed and clinically applied to reduce the incidence of spinal cord ischemic complications (SCI) after thoracoabdominal aneurysm (TAA) repair. Hypothermia is known to reduce oxygen requirements in central nervous tissue and has been successfully applied in the arena of central cardioaortic surgery. Based on our experimental and clinical results, we have employed regional hypothermia by epidural cooling to ameliorate SCI during TAA repair in over 300 patients. This review describes the results obtained in our experience using an approach to TAA repair whereupon the spinal cord is protected during surgery by regional hypothermia via epidural cooling.

Individualized Performance Feedback to Surgical Residents Improves Appropriate Venous Thromboembolism Prophylaxis Prescription and Reduces Potentially Preventable VTE: A Prospective Cohort Study.

Objective: To investigate the effect of providing personal clinical effectiveness performance feedback to general surgery residents regarding prescription of appropriate venous thromboembolism (VTE) prophylaxis. Background: Residents are frequently charged with prescribing medications for patients, including VTE prophylaxis, but rarely receive individual performance feedback regarding these practice habits. Methods: This prospective cohort study at the Johns Hopkins Hospital compared outcomes across 3 study periods: (1) baseline, (2) scorecard alone, and (3) scorecard plus coaching. All general surgery residents (nu200a=u200a49) and surgical patients (nu200a=u200a2420) for whom residents wrote admission orders during the first 9 months of the 2013–2014 academic year were included. Outcomes included the proportions of patients prescribed appropriate VTE prophylaxis, patients with preventable VTE, and residents prescribing appropriate VTE prophylaxis for every patient, and results from the Accreditation Council for Graduate Medical Education resident survey. Results: At baseline, 89.4% of patients were prescribed appropriate VTE prophylaxis and only 45% of residents prescribed appropriate prophylaxis for every patient. During the scorecard period, appropriate VTE prophylaxis prescription significantly increased to 95.4% (Pu200a<u200a0.001). For the scorecard plus coaching period, significantly more residents prescribed appropriate prophylaxis for every patient (78% vs 45%, Pu200a=u200a0.0017). Preventable VTE was eliminated in both intervention periods (0% vs 0.35%, Pu200a=u200a0.046). After providing feedback, significantly more residents reported receiving data about practice habits on the Accreditation Council for Graduate Medical Education resident survey (87% vs 38%, Pu200a<u200a0.001). Conclusions: Providing personal clinical effectiveness feedback including data and peer-to-peer coaching improves resident performance, and results in a significant reduction in harm for patients.

Thoracoabdominal aneurysm repair: anesthetic management.

Surgical repair of descending thoracic and thoracoabdominal aortic aneurysms (TAAs) presents one of the greatest challenges for the anesthesiologist. The challenge comes from the fine balance of complex medical issues in the setting of altered physiology that occurs during the perioperative period. Patients presenting for TAA repair usually have multiple preexisting comorbid conditions involving their cardiac, pulmonary, and renal systems; and aneurysm repair poses a direct and immediate threat to these systems in addition to the gastrointestinal and neurologic systems. To preserve proper function of these organ systems, the anesthesiologist must be adept at monitoring and manipulating rapid and extreme hemodynamic changes, maintaining adequate pulmonary function during one lung ventilation, and preserving metabolic and hematologic homeostasis after aortic crossclamping and unclamping in the setting of significant blood loss. In these high-risk patients, distal aortic perfusion, spinal cord preservation through cooling techniques, distal shunting procedures, and the use of motor-evoked potentials have all been used in attempt to decrease the risk of spinal cord and mesenteric ischemia. The recent development of endovascular stent graft repair is changing the practices of many institutions. Thoracoabdominal aneurysms are classified according to the Crawford classification depending on the extent of the aneurysm. Type I aneurysms extend from the left subclavian artery to the diaphragm. Type II aneurysms extend from the left subclavian artery to below the renal arteries. Type III aneurysms extend from the midthoracic descending aorta to below the

Endovascular abdominal aortic aneurysm repair.

Since Parodi’s first report of intraluminal graft implantation for the treatment of an abdominal aortic aneurysm in 1991, repair of abdominal aortic aneurysms (AAAs) through endovascular technology has been used by an increasing number of centers. Where once it was the exclusive domain of major academic medical centers, the procedure has gained widespread acceptance at community hospitals as well. Despite the wellproven and durable technique of open aneurysm repair, the endovascular approach provides a less invasive method of treatment that could reduce risks, provide shorter patient recovery periods, and possibly achieve a cost savings by reduced resource use and decreased length of stay. Although initially developed for use in those deemed unfit for open repair, endovascular exclusion has emerged as a viable option for many patient populations. The intricacies and nuances of endovascular repair present unique issues that the prospective anesthesiologist must address. Although theoretically less invasive, it is still performed on vascular patients who present with significant comorbid issues that the perioperative physician must manage. Most importantly, the multidisciplinary nature of this procedure necessitates a team approach among surgeons, radiology personnel, nurses, and anesthesiologists to ensure optimal patient outcomes.

Differential outcomes of type A dissection with malperfusion according to affected organ system

BACKGROUNDnThe management of malperfusion in patients with acute Stanford type A aortic dissection is controversial. We sought to determine the rate of resolution of malperfusion following primary repair of the dissection and to identify anatomic sites of malperfusion that may require additional management.nnnMETHODSnWe reviewed the hospital records of patients who presented to our institution with acute type A aortic dissection. Patient demographics, operative details and post-operative course were retrospectively extracted from our institutional electronic database. Depending upon the anatomic site, malperfusion was identified by a combination of radiographic and clinical definitions. Data were analyzed using standard univariable and multivariable methods.nnnRESULTSnBetween 1997-2013, 101 patients underwent repair of an acute type A dissection. Thirty-day mortality was 14.9% (15/101); there were five intraoperative deaths. There was no difference in 30-day mortality between patients with or without malperfusion (15.4% vs. 14.7%, P=0.93). Twenty-five patients (24.7%), who survived surgery, presented with 31 sites of malperfusion. Anatomic sites included extremities [14], renal [10], cerebral [5] and intestinal [2]. Of these 31 sites, malperfusion resolved in 18 (58.1%) with primary aortic repair. Renal malperfusion resolved radiographically in 80.0%, with no difference in the incidence of insufficiency (44.0% vs. 35.2%; P=0.44) or dialysis (20.0% vs. 15.5%; P=0.61) between malperfusion and non-malperfusion patients. Extremity malperfusion resolved postoperatively in six out of 14 patients. Of the remaining eight, concomitant revascularization was performed in four, one had an amputation and three required postoperative interventions. Advanced patient age (OR: 1.06, 95% CI: 1.01-1.12, P=0.02) was an independent predictor of 30-day mortality, while preoperative malperfusion was not (OR: 0.77, 95% CI: 0.18-3.31, P=0.73).nnnCONCLUSIONSnMalperfusion complicating acute type A dissection can be managed in many patients by aortic replacement alone with low overall mortality. Most cases of renal and cerebral malperfusion resolved following aortic surgery. Revascularization was frequently necessary in patients with extremity malperfusion. Patients presenting with intestinal ischemia had very poor outcomes. A patient-specific approach is recommended in such complex patients.

Long-Term Outcomes of an Endovascular-First Approach for Diabetic Patients With Predominantly Tibial Disease

Body: Objective(s): Recent studies suggest that lower extremity bypass (LEB) is associated with improved outcomes compared to endovascular peripheral vascular interventions (PVI). The aim of our study was to compare perioperative and long-term outcomes following LEB vs. PVI in diabetic patients treated in a multidisciplinary setting. Methods: All patients presenting to our multidisciplinary diabetic limb preservation service from 6/201212/2017 were enrolled in a prospective database. Patients who underwent lower extremity revascularization with either LEB or PVI for chronic limb-threatening ischemia (CLTI) were included in the analysis. Perioperative (30-day) complications and 4-year patency and limb salvage rates were compared for LEB vs. PVI using chi-square and Kaplan-Meier curve analyses. Results: A total of 179 lower extremity revascularization procedures were performed in 106 patients (mean age 64±1 years, 65% male, 59% black), including 50 (28%) LEB and 130 (72%) PVI. Nearly two-thirds of patients (63%) had multilevel peripheral arterial disease, while 29% had isolated tibial disease and 9% had isolated femoralpopliteal disease. More than half of procedures (53%) were performed for WIfI stage 4 limbs, 26% for stage 3, and 22% for stage 1/2, and this did not differ between the LEB vs. PVI groups (P=0.31). In the LEB group, 57% of targets were infrapopliteal. In the PVI group, 36% of procedures were isolated tibial interventions and 26% were multilevel interventions including the tibial segment. Perioperative complications occurred in 52% of LEB vs. 11% of PVI (P<0.001). At 4 years of follow-up, there was no significant difference in primary patency for LEB vs. PVI (45±1% vs. 29±8%, P=0.86). Secondary patency was better for the LEB group (84±7% vs. 56±8%; P=0.02), but limb salvage rates were similarly excellent (88±6% vs. 92±4%; P=0.35) (Figure). Conclusions: In this cohort of diabetic patients with CLTI undergoing predominantly tibial interventions, LEB was associated with a higher risk of perioperative complications than PVI. While secondary patency rates are better following LEB, our data suggest that an endovascular-first approach results in equivalent long-term limb salvage when patients are treated in a multidisciplinary setting. Figure1. Long-term patency and limb salvage outcomes following lower extremity bypass and peripheral vascular interventions for diabetic foot ulcer patients with chronic limb-threatening ischemia. Author Disclosure Block: C.W. Hicks: None. J.K. Canner: None. Y.W. Lum: None. M.B. Malas: None. J.H. Black: None. C.J. Abularrage: None.

Transfemoral Carotid Artery Stents Should Be Used with Caution in Patients with Asymptomatic Carotid Artery Stenosis

BACKGROUNDnSignificant national variation exists in defining the degree of stenosis that requires intervention in patients with asymptomatic carotid artery stenosis (ACAS). We aimed to evaluate the risk of perioperative and 2-year stroke and death in ACAS patients undergoing carotid endarterectomy (CEA) and carotid artery stenting (CAS) for severe versus very severe stenosis in a contemporary population.nnnMETHODSnAll patients undergoing CEA or transfemoral CAS for ACAS in the Vascular Quality Initiative (2005-2017) were included. Degree of stenosis was defined as the highest recorded on any imaging method. Univariable and multivariate logistic regression analyses were performed to assess risk of stroke, stroke/death, and major adverse cardiac events (MACE) at 30 days; and Cox proportional hazard, life tables, and Kaplan-Meier estimates were implemented to evaluate ipsilateral stroke and stroke/death at 2 years postoperatively in patients undergoing CEA versus CAS for severe (60-79%) and very severe (≥80%) stenosis adjusting for baseline characteristics.nnnRESULTSnA total of 53,337 ACAS patients were examined (severe stenosisxa0=xa017,586; 33.%), of which 11.5% (nxa0=xa06,127) underwent CAS. The crude incidence of 30-day stroke/death was significantly higher for CAS versus CEA in the very severe stenosis group (2.0% vs. 1.2%, Pxa0<xa00.001), but not in the severe stenosis group (1.7% vs. 1.3%, Pxa0=xa00.17). MACE was not significantly different for CAS versus CEA in either group (Pxa0≥xa00.64). On multivariable analysis, CAS was associated with a persistently higher risk of 30-day stroke or death compared to CEAxa0in patients with very severe stenosis (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.26-2.13). The 30-day composite stroke/death risk for patients undergoing CEA was similar for severe versus very severe stenosis (OR 1.07, 95% CI 0.89-1.28), but there was a trend toward higher risk of perioperative stroke in the severe stenosis group (OR 1.23, 95% CI 0.97-1.56). Two-year outcomes were similar; the crude annualized incidence rates of stroke and stroke/death were higher for CAS versus CEA in both the severe (stroke: incidence rate ratio [IRR] 1.62, 95% CI 1.00-2.55; stroke/death: IRR 1.53, 95% CI 1.11-1.64) and very severe stenosis (stroke: IRR 1.97, 95% CI 1.44-2.65; stroke/death: IRR 1.51, 95% CI 1.34-1.68) groups (all, Pxa0≤xa00.04). On multivariable Cox proportional hazards analysis, CAS was associated with a higher risk of stroke or death compared to CEA in patients with both severe (hazard ratio [HR] 1.40, 95% CI 1.15-1.70) and very severe stenosis (HR 1.62, 95% CI 1.37-1.90).nnnCONCLUSIONSnMore than one-third of patients undergoing carotid revascularization for ACAS had 60-79% stenosis. Having lower degree of stenosis is not protective against stroke and death for either CEA or CAS at either 30 days or 2 years postoperatively. We believe that optimal medical management should be the first line in stroke prevention for asymptomatic patients with severe (60-79%) carotid stenosis.

Endovascular Interventions in Acute Mesenteric Ischemia: TheImplication of Lactic Acidosis

Background: nIn the setting of acute mesenteric ischemia (AMI), lactic acidosis has been used as a surrogate for at-risk or necrotic bowel. The role of endovascular therapy in maximizing outcomes in AMI patients remains controversial and there are no set guidelines for using endovascular intervention as an initial treatment strategy. We sought to determine if the endovascular strategy was safe and effective in patients with AMI who develop lactic acidosis. nMethods and Findings: nThe Nationwide Inpatient Sample (NIS) was examined for patients presenting with AMI (557.9) between the years 2005-2009. Patients were included if they presented as urgent/emergent and underwent endovascular therapy. Patients were divided according to the presence of lactic acidosis. The primary outcome measured was in-hospital mortality. 663 patients met inclusion criteria. Of these patients, 74 (11.2%) developed lactic acidosis. Patients with lactic acidosis were found to have an increased mortality compared to patients without lactic acidosis when undergoing endovascular treatment (47.1% vs. 20.8%, p = 0.029). The two groups did not differ in rates of bowel resection (19.8 vs. 12.4%, p = 0.41), TPN administration (23.1% vs. 14.1%, p=0.382) or length of stay (11.4 days vs. 13.6 days, p=0.54). The main limitation of this study was the use of a large database that precluded granular level data regarding patient characteristics and decisions for management strategies. nConclusions: nEndovascular intervention should be considered cautiously as a primary therapeutic strategy in AMI patients with lactic acidosis as it was associated with increased mortality. The presence of lactic acidosis in patients with AMI was not associated with worse bowel related outcomes and thus may not be useful to determine whether open surgery is mandated as an initial approach.