Mark C. Rummel

Office-based endovascular suite is safe for most procedures.

OBJECTIVE This study was conducted to identify the safety of endovascular procedures in the office endovascular suite and to assess patient satisfaction in this setting. METHODS Between May 22, 2007, and December 31, 2012, 2822 patients underwent 6458 percutaneous procedures in an office-based endovascular suite. Demographics of the patients, complications, hospital transfers, and 30-day mortality were documented in a prospective manner. Follow-up calls were made, and a satisfaction survey was conducted. Almost all dialysis procedures were done under local anesthesia and peripheral arterial procedures under conscious sedation. All patients, except those undergoing catheter removals, received hydrocodone and acetaminophen (5/325 mg), diazepam (5-10 mg), and one dose of an oral antibiotic preprocedure and three doses postprocedure. Patients who required conscious sedation received fentanyl and midazolam. Conscious sedation was used almost exclusively in patients having an arterial procedure. Measurements of blood urea nitrogen, creatinine, international normalized ratio, and partial thromboplastin time were performed before peripheral arteriograms. All other patients had no preoperative laboratory tests. Patients considered high risk (American Society of Anesthesiologists Physical Status Classification 4), those who could not tolerate the procedure with mild to moderate conscious sedation, patients with a previous bad experience, or patients who weighed >400 pounds were not candidates for office based procedures. RESULTS There were 54 total complications (0.8%): venous, 2.2%; aortogram without interventions, 1%; aortogram with interventions, 2.7%; fistulogram, 0.5%; catheters, 0.3%; and venous filter-related, 2%. Twenty-six patients required hospital transfer from the office. Ten patients needed an operative intervention because of a complication. No procedure-related deaths occurred. There were 18 deaths in a 30-day period. Of patients surveyed, 99% indicated that they would come back to the office for needed procedures. CONCLUSIONS When appropriately screened, almost all peripheral interventions can be performed in the office with minimal complications. For dialysis patients, outpatient intervention has a very low complication rate and is the mainstay of treatment to keep the dialysis access patent. Venous insufficiency, when managed in the office setting, also has a low complication rate. Office-based procedural settings should be seriously considered for percutaneous interventions for arterial, venous, and dialysis-related procedures.

Thrombolysis therapy in patients with femoropopliteal synthetic graft occlusions

Background The aim of this study was to evaluate the efficiency of thrombolysis in the presence of an occluded femoropopliteal synthetic graft. Patients and methods Over a 3-year period, 46 occluded femoropopliteal grafts were treated with urokinase and reconstruction. The cases were divided into three groups: group 1 (n = 25), complete thrombolysis followed by reconstruction or angioplasty or both; group 2 (n = 5), complete thrombolysis alone; and group 3 (n = 16), failure of thrombolysis requiring reconstruction or leading to amputation. Patients were closely observed after the treatment for more than 1 year. Results There are no fatal complications among patients with thrombolytic therapy. In group 1, the 3-year patency rates were 12% and the 3-year limb salvage rates were 77%. In group 2, the 3-year patency rates and the limb salvage rates were 20% and 80%, respectively. The group 3 patency rates and the limb salvage rates were 8% and 40%, respectively. The best results were achieved in patients who had thrombolysis followed by reconstruction (group 1) and in those who had thrombolysis alone (group 2). Limb salvage was poor in patients with failure of lytic therapy regardless of the reconstruction ( P Conclusion The use of intra-arterial urokinase followed by secondary vascular reconstructive procedures was studied. The patient with synthetic graft occlusion still has a reasonably favorable prognosis for long-term limb salvage when thrombolysis is successful.

PC190. Improving the Retrieval Rate of Inferior Vena Cava Filters: Impact of Inferior Vena Cava Filter Retrieval in the Office Endovascular Center

AAA, Abdominal aortic aneurysm; CAS, carotid artery stenting; CEA, carotid endarterectomy; EVAR, endovascular aortic repair; IQR, interquartile range; PVI, percutaneous peripheral vascular intervention; VW comorbidity score, Van Walraven comorbidity score. There were <0.001% of cases missing weekend admission data, <0.1% of cases were missing patient age or sex, <0.2% of cases were missing primary payor data, <1.5% of cases were missing elective status, and 19.9% of cases were missing race data. b P values are from Pearson c tests or Wilcoxon rank-sum test, as appropriate Fig. Totals filtered implanted. OEC, Office endovascular center. Journal of Vascular Surgery Abstracts e225 Volume 67, Number 6

Optimizing Your Vascular Practice: How to Communicate With Referring Doctors, Increase Referrals, and Work With Cardiologists and Interventional Radiologists

After the fellowship in vascular surgery is completed there is the daunting task of going into practice and succeeding. There are various tools that one can use to succeed in practice and also work closely with other specialists. The key to success is marketing and innovation. Using the two together any vascular surgeon can succeed. Marketing has multiple facets not to be confused with advertising. Total marketing revolves around the surgeon. It involves personal attributes, running of the office, behavior in the hospital, working with other physicians, and using advertising channels. Innovation is required as the art and science of the specialty continues to evolve. Vascular surgeons need to be on the cutting edge of providing latest technology as well as latest methods of delivering care.

Evaluation of Collagen-Coated Woven Velour Polyester and Expanded Polytetrafluoroethylene Grafts During Early Lytic Therapy in an Animal Model

This study was conducted to determine the relative safety of early urokinase lytic therapy in expanded polytetrafluoroethylene (ePTFE) and collagen-impregnated woven velour polyester (CIWVP) grafts. Twelve mixed-breed dogs were selected and implanted with thin-wall ePTFE and CIWVP grafts in the external iliac artery position. At 3, 4, 6, and 12 weeks, three dogs were selected for lytic therapy. After exposure of the previously implanted grafts, lytic therapy was initiated with a bolus of 100,000 units of urokinase, followed by 4000 units/minute for two hours, then reduced to 2000 units/minute for a subsequent two hours. Hypertension was induced by methoxamine hydrochloride at the conclusion of lytic therapy. Direct observation and angiography were used to assess for bleeding and contrast extravasation hourly until completion. The animals were then sacrificed and the grafts excised and microscopically examined for incorporation, pseudointimal deposition, and accelerated collagen layer degradation. None of the implanted grafts showed evidence of transluminal or suture line bleeding or extravasation of contrast material. Hypertension did not change these results. Analysis demonstrated a thicker pseudointimal, giant cell infiltration, extensive incorporation, and occasional fragmentation of the CIWVP graft when compared with the ePTFE grafts. The systemic fibrinolytic state did not cause collagen layer degradation. No evidence existed of suture line or transluminal bleeding from CIWVP or ePTFE grafts during urokinase lytic therapy conducted at 3, 4, 6, or 12 weeks in a canine model. Microscopic examination demonstrated a difference in pseudointima, graft incorporation, and inflammatory response when the two conduits were compared. Urokinase did not appear to accelerate collagen layer breakdown.

Effect on Thrombolysis and its Complication of Graft Occlusion and Specific Risk Factors

The objective of this study was to correlate the initial outcome of thrombolytic therapy in patients with specific risk factors who presented with an occluded synthetic graft. Seventy-seven angiographically documented occluded synthetic grafts were treated with urokinase. All patients presented within thirty days of occlusion. The cases were investi gated according to specific risk factors: smoking (SM), hypertension (HT), coronary artery disease (CAD), and diabetes mellitus (DM). A high number of occlusions occurred in patients had a history of heavy smoking (84.4%). Complete thrombolysis was achieved in 46 of 77 (59.7%) graft occlusions. Thirty-eight of 65 (58.5%) occlusions in patients who smoked, 29 of 47 (61.7%) occlusions in patients with HT, 22 of 36 (61.1%) occlu sions in patients with CAD, and 18 of 25 (72.0%) occlusions in patients with DM were completely lysed. When comparison was made between the specific risk factors, no signif icant difference was found in complete lysis. Forty-seven complications occurred in 31 (40.3%) of 77 cases. One patient (1.3%) suffered from a fatal intracranial hemorrhage. No significant increase in complications was seen when the various risk factors were compared. In conclusion, no relation was observed between the initial success rate with throm bolytic therapy and multiple risk factors in patients with arterial graft occlusion.

Inguinal Lymphorrhea Following Arterial Puncture and Pseudoaneurysm Resection A Case Report

Lymphorrhea, the abnormal drainage of lymphatic fluid, may lead to a discrete collection of lymph (lymphocele) or to a draining lymphatic fistula, depending on the nature of the injury to the involved lymphatic chain. The authors present a recent case, review the current surgical literature, and make recommendations regarding surgical therapy.