Michael F. Amendola

Myelocystocele-cloacal exstrophy in a pedigree with a mitochondrial 12S rRNA mutation, aminoglycoside-induced deafness, pigmentary disturbances, and spinal anomalies

A large Filipino-American family with progressive matrilineal hearing loss, premature graying, depigmented patches, and digital anomalies was ascertained through a survey of a spina bifida clinic for neural crest disorders. Deafness followed a matrilineal pattern of inheritance and was associated with the A1555G mutation in the 12S rRNA gene (MTRNR1) in affected individuals as well as unaffected maternal relatives. Several other malformations were found in carriers of the mutation. The proband had a myelocystocele, Arnold-Chiari type I malformation, cloacal exstrophy, and severe early-onset hearing loss. Several family members had premature graying, white forelock, congenital leukoderma with or without telecanthus, somewhat suggestive of a Waardenburg syndrome variant. In addition to the patient with myelocystocele, two individuals had scoliosis and one had segmentation defects of spinal vertebrae. The syndromic characteristics reported here are novel for the mitochondrial A1555G substitution, and may result from dysfunction of mitochondrial genes during early development. However, the mitochondrial A1555G mutation is only rarely associated with neural tube defects as it was not found in a screen of 218 additional individuals with spina bifida, four of whom had congenital hearing loss.

Central aortic wire confirmation for emergent endovascular procedures: As fast as surgeon-performed ultrasound.

BACKGROUND Uncontrolled hemorrhage is the leading cause of preventable death after trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an evolving technique for controlling noncompressible torso hemorrhage. A challenge limiting REBOA use is the dependence on fluoroscopy for confirmation of intra-aortic positioning of a guide wire, a necessary component for safe and accurate balloon deployment. The current study evaluates using surgeon-performed sonography alone, without fluoroscopy, in identifying the aorta and the presence of an intra-aortic guide wire. We postulate that with the use of the subxiphoid Focused Abdominal Sonography for Trauma (FAST) view, both the aorta and an intra-aortic guide wire can be reliably identified. METHODS One hundred angiography patients underwent femoral arterial cannulation and guide wire advancement to the supraceliac aorta. From the subxiphoid FAST view, the aorta was identified in both sagittal and transverse planes. Intra-aortic wire identification was subsequently recorded. The rate of preferential central aortic wire positioning from unaided guide wire advancement was also observed. RESULTS The mean patient age and body mass index were 61.8 years and 27.0 kg/m2, respectively. Eighty-eight percent of the studies were performed using portable point-of-care ultrasound machines. Identification of the aorta via the subxiphoid FAST was successful in 97 (97%) of 100 patients in the sagittal and 98 (98%) of 100 patients in the transverse orientation. Among visualized aortas, an intra-aortic wire was identifiable in 94 (97%) of 97 patients in the sagittal and 91 (93%) of 98 patients in the transverse orientation. Unaided wire advancement achieved preferential central aortic positioning in 97 (97%) of 100 patients. Fluoroscopy-free ultrasound identification of an advancing intra-aortic guide wire was successful in 56 (98%) of 57 patients. CONCLUSION The subxiphoid FAST view can reliably identify a central aortic guide wire in both transverse and sagittal orientations. Unaided guide wire advancement has a high likelihood of both preferential central aortic positioning and subsequent ultrasound identification. These findings eliminate the need for routine fluoroscopy for this important initial maneuver during emergency endovascular procedures. LEVEL OF EVIDENCE Diagnostic study, level V.

Previous Hemodialysis Access Improves Functional Outcomes of the Proximal Radial Artery Fistula in Males

BACKGROUND The proximal radial artery fistula (PRA) has been established as an early viable surgical option for arteriovenous fistula creation. The overall assisted primary patency reported in the literature approaches 100% at 1 year. We hypothesize that this excellent patency does not represent a functional result when seen in light of successful cannulation and fistula utilization. METHODS We retrospectively queried our Veterans Administration Hospital operative database to identify 284 male patients who had 571 access procedures performed by a senior vascular surgeon attending (R.K.D.) from January 1, 2003, to December 31, 2008. Operative details, patient comorbidities, fistula maturation time (time to first cannulation), functional patency (date of access to abandonment, revision to another fistula type, conversion to a prosthetic graft, thrombosis of the fistula, conversion to peritoneal dialysis, renal transplant, or patient death), and total duration (creation of the fistula to the end of its functional patency) were collected and analyzed. RESULTS A total of 144 PRAs were placed during the study period. In all, 87 patients underwent primary proximal radial artery fistula (P-PRA) placement in a limb without previous access; 57 patients had a secondary proximal radial artery fistula (S-PRA) after a failed previous fistula or graft in the same limb. There were no differences between the 2 groups in terms of age, comorbidities, and operative details. A total of 91 patients (63.2%) were receiving hemodialysis at the time of P-PRA or S-PRA placement. Outcomes of P-PRA and S-PRA populations on hemodialysis were examined. There was increased cannulation success (33% vs. 55%; P = 0.00354, Fishers exact test), functional patency (755.2 ± 661.2 days vs. 405.4 ± 531.9 days; P = 0.0220, Wilcoxon two-sample test), and total duration (859.5 ± 650.7 days vs. 516.8 ± 547.2 days; P = 0.0361, Wilcoxon two-sample test) of S-PRA over P-PRA. There was no difference in endovascular interventions between the 2 groups (1.6 ± 1.0 interventions per access versus 1.1 ± 0.7 interventions per access; P = 0.2109, Wilcoxon two-sample test). Subgroup analysis (analysis of variance) of the S-PRA group indicated that a patent but failing previous access in the same arm was not superior in terms of successful cannulation, functional patency, or total duration when compared with a thrombosed previous access. CONCLUSIONS The PRA remains a viable first access procedure undertaken at our institution. Compared with the reported 12-month assisted primary patency of this fistula type, we found a small percentage of PRAs actually being accessed for successful hemodialysis treatment. The S-PRA appears to have a significantly higher successful cannulation rate, functional patency, and total duration time when compared with the P-PRA in patients receiving hemodialysis treatments. The mechanism of these improved outcomes is not known; considering patency or thrombosis of a previous access in the S-PRA group did not predict future access success in the same extremity.

IP237. Effects of the Digital Footprint in Online Presence of Vein Practice

addition, age and coronary artery disease was associated with MI on univariable analysis. On multivariable analysis for POMI, coronary artery disease (odds ratio [OR], 5.42; 95% confidence interval [CI], 2.09-14.06; P < .001) and postoperative transfusion (OR, 4.9; 95% CI, 1.92-12.49; P < .001) were both significant; however, intraoperative transfusion was not (OR, 1.37; 95% CI, 0.49-3.83; P 1⁄4 .55). On multivariable analysis, postoperative death was associated with increasing age of the patient (OR, 1.08; 95% CI, 1.01-1.15; P 1⁄4 .017), and statin use was highly protective (OR, 0.26; 95% CI, 0.095-0.74; P 1⁄4 .012), but intraoperative or postoperative transfusion was not associated with death after adjustment. Conclusions: In our series with routine postoperative troponin screening, the use of postoperative but not intraoperative pRBC transfusion was associated with POMI. We did not identify an association of transfusion with postoperative death. These data suggest that the perioperative setting of transfusions is important in its impact on postoperative outcomes and needs to be accounted for in evaluating transfusion outcomes and indications.

IP167. To Remove or Not to Remove? Inferior Vena Cava Filter Management Insights From the MAUDE Database

Objective: Permanent inferior vena cava (P-IVC) filters historically have been used to protect patients from life-threatening pulmonary embolism (PE). Removable IVC (R-IVC) filters were introduced to allow physicians the option of retrieving them once the threat of PE was minimized. On August 9, 2010, the Food and Drug Administration (FDA) issued an updated safety communication that stated implanting physicians and clinicians responsible for the ongoing care of patients consider removing the filter as soon as protection from PE is no longer needed. The Manufacturer and User Facility Device Experience (MAUDE) database was established by the FDA to allow voluntarily reporting of adverse outcomes with medical devices. We set forth to examine how P-IVC and R-IVC filter reporting differs in this database. Methods: The MAUDE database was accessed in December 2017. There were two different groups: R-IVC filtersdTulip (Cook Medical, Bloomington, Ind), Celect filters (Cook Medical), OptEase (Cordis Medical, Bridgewater, NJ), and G2 filters (Bard Medical, Murray Hill, NJ); and P-IVC filtersdGreenfield (Boston Scientific, Marlborough, Mass), Simon Nitinol (Bard Medical), VenaTech (B. Braun, Melsungen, Germany), and TrapEase (Cordis Medical). The database was searched for associated mortality, open filter removal, endovascular filter removal, filter removal with replacement, adding a second new filter, and days from index event to report. Results: A total of 1019 entries were examined. Comparing P-IVC entries (n 1⁄4 263 [25.8%]) and R-IVC entries (n 1⁄4 756 [74.2%]), R-IVC filters were more likely to be reported after the FDA warning compared with P-IVC filters (36.6% vs 18.6%; P 1⁄4 .0001). Conclusions: In examining the MAUDE database, we have found there were fewer entries for permanent filters compared with removable filters. Permanent filters had long report time, fewer open and endovascular removals, and removals with filter replacements. Interestingly, mortality rates and new second filter rates were increased compared with retrievable filters. Alarming high rates of open removal were found in the R-IVC group despite a lower mortality. The majority of reports were before the FDA warning in 2010; however, R-IVC filters had more reports compared with P-IVC filters.

IP165. YouTube Carotid Endarterectomy Videos: Are Academic Institutions Keeping Up With the Content?

Objective: Inferior vena cava (IVC) filters have been used to protect patients from life-threatening pulmonary embolism (PE). Removable IVC filters have been introduced, allowing physicians to eliminate them once the threat of PE has been minimized. In 2010, the Food and Drug Administration issued an updated safety communication that stated implanting physicians and clinicians responsible for the ongoing care of patients consider removing the filter as soon as protection from PE is no longer needed. This warning has led to increased interest in the legal community to communicate with patients who have IVC filters. One way to do so has been to post informational videos to YouTube, most of which we hypothesize will examine the complications of filters. Methods: YouTube was searched in November 2017. A keyword search on YouTube for IVC filter was undertaken; the top 99 videos of a medicallegal nature were examined for duration, time in months since posting, total views, sex of the speaker, whether basic anatomy was shown, whether perforation was mentioned, and whether blood clots formed by the IVC were mentioned. The videos were grouped into those that mentioned either open or endovascular removal (removal mentioned)

IP163. What Is the Public Being Told on YouTube About Inferior Vena Cava Filters

Objective: Inferior vena cava (IVC) filters have been used to protect patients from life-threatening pulmonary embolism (PE). Removable IVC filters have been introduced, allowing physicians to eliminate them once the threat of PE has been minimized. In 2010, the Food and Drug Administration issued an updated safety communication that stated implanting physicians and clinicians responsible for the ongoing care of patients consider removing the filter as soon as protection from PE is no longer needed. This warning has led to increased interest in the legal community to communicate with patients who have IVC filters. One way to do so has been to post informational videos to YouTube, most of which we hypothesize will examine the complications of filters. Methods: YouTube was searched in November 2017. A keyword search on YouTube for IVC filter was undertaken; the top 99 videos of a medicallegal nature were examined for duration, time in months since posting, total views, sex of the speaker, whether basic anatomy was shown, whether perforation was mentioned, and whether blood clots formed by the IVC were mentioned. The videos were grouped into those that mentioned either open or endovascular removal (removal mentioned)

PC058 What Is the Real Mode of Failure? Trends in Angio-Seal Adverse Events Reported to the MAUDE Database

obtained. Primary outcomes were loss of independence, complications, and death after discharge. Data were analyzed using c, Student t-test, and multivariable analysis. Results: Elective AAA repair was performed in 16,007 patients. There was more loss of independence in patients who had complications after EVAR (23.7%) and open repair (24.94%) than in patients who did not have complications (P < .01). There was more pneumonia (9.51% vs 1.21%; P < .01), bleeding requiring transfusion (51.03% vs 16.24%; P < .01), prolonged intubation (14.84% vs 0.85%; P < .01), renal failure (5.99% vs .50%; P < .01), and sepsis (3.86% vs .63%; P < .01) in patients who had loss of independence after any abdominal aortic surgery. History of cerebrovascular accident (odds ratio [OR], 3.15; confidence interval [CI], 1.59-6.25), complication after surgery (OR, 3.95; CI, 3.45-4.51), female (OR, 1.79; CI, 1.59-2.03), age

PC066 How to Predict Wound Complications After Endovascular Aortic Aneurysm Repair

75 years (OR, 2.2; CI, 1.95-2.49), emergency surgery (OR, 2.24; CI, 1.82-2.77), and coronary artery disease (OR, 1.59; CI, 1.16-2.18) were associated with increased likelihood of loss of independence. Risk factors for death after discharge included complication (OR, 4.38; CI, 2.65-7.24), coronary artery disease (OR, 3.39; CI, 1.75-6.59), emergency surgery (OR, 3.62; CI, 2.08-6.29), unplanned readmission (OR, 3.19; CI, 1.875.44), and EVAR (OR, 1.87; CI, 1.11-3.14). Conclusions: Preoperative functional status is a strong predictor of postoperative outcomes. There is decreased loss of independence after EVAR than open repair when the procedure is without complications. However the benefits of EVAR compared to open surgery are lost when there is a complication. Loss of independence can be decreased by minimizing these complications.

IP171. Who Is Sending the Message? A Lack of Vascular Surgeon Presence in YouTube Videos Regarding “Endovascular” Procedures

Objectives: Anterior lumbar instrumentation and fusion (ALIF) procedures often involve vascular surgeons to provide the exposure because of the expertise in retroperitoneal dissection and need for iliac vessel mobilization. Exposing the spine from an anterior approach can be very challenging in the obese patient. This study sought to evaluate outcomes of ALIF in obese vs nonobese patients to determine whether vascular surgeons should be more selective regarding which patients they choose to assist with. Methods: Adults with degeneration of lumbosacral disc who were electively hospitalized and underwent ALIF were selected from the National Inpatient Sample data 2012 to 2014 using the appropriate International Classification of Diseases-Ninth Revision-Clinical Modification codes and comorbidity measure for obesity. Differences between groups were evaluated with the c test, multivariable logistic regression analysis for categoric variables, and with the t-test or Wilcoxon rank sum test for numeric variables. Results: There were 31,590 patients evaluated, including 4945 (15.7%) with obesity. Women predominated over men (54.5% vs 45.5%; P < .0001), especially in the obese subgroup (57.9% vs 41.2%). Obesity rates in blacks (22.6%) and Hispanics (17.5%) were greater than in whites (15.3%; P < .0001 and P 1⁄4 .03, respectively). Compared to nonobese patients, those with obesity were more likely to develop postoperative complications, overall (odds ratio [OR], 1.76; 95% confidence interval [CI], 1.65-1.88), including cardiac (OR, 1.80; 95% CI, 1.31-2.49), respiratory (OR, 2.46; 95% CI, 2.01-3.03) and renal complications (OR, 2.64; 95% CI, 2.26-3.09). They were more likely to develop infection (OR, 1.66; 95% CI, 1.40-1.96), such as sepsis (OR, 1.99; 95% CI, 1.35-2.94) and urinary tract infection (OR, 1.70; 95% CI, 1.36-2.13). There were greater rates of postoperative bleeding (16.8% vs 11.4%; P < .0001), and obese patients were more likely to receive a blood transfusion (OR, 1.47; 95% CI, 1.32-1.64). However, hospital mortality did not differ between both subgroups. All of these results were confirmed in the multivariable analysis. Patients with obesity had greater hospital length of stay (3.9 vs 3.2 days) and cost (