Naomi Eisenberg

Efficacy of a Guideline-Recommended Risk-Reduction Program to Improve Cardiovascular and Limb Outcomes in Patients With Peripheral Arterial Disease

IMPORTANCE Patients with peripheral arterial disease (PAD) are at a high risk for cardiovascular events, yet, to our knowledge, no studies have examined the effect of a comprehensive risk-reduction program on long-term outcomes for patients with PAD. OBJECTIVE To investigative whether a program that focuses on 8 major guideline-recommended risk-management therapies reduces cardiovascular and limb events in patients with PAD. DESIGN, SETTING AND PARTICIPANTS An observational cohort study with up to 7 years of follow-up was conducted using data from administrative databases from Ontario, Canada, between July 1, 2004, and March 31, 2013. Patients with symptomatic PAD who were enrolled in the Systematic Assessment of Vascular Risk (SAVR) program at a single tertiary vascular center in Ontario between July 2004 and April 2007 were matched with up to 2 (control) patients with PAD from other Ontario tertiary vascular centers not enrolled in the program using propensity score methods. Cox proportional hazards regression analysis was used to compare outcomes. EXPOSURES Program that promoted antiplatelet agents, statins, angiotensin-converting enzyme inhibitors, blood pressure control, lipid control, diabetic glycemic control, smoking cessation, and target body mass index by engaging vascular surgeons, family physicians, and patients with PAD. MAIN OUTCOMES AND MEASURES The primary outcome was a composite risk ratio of death, acute myocardial infarction, or ischemic stroke. Secondary outcomes included rates of lower limb amputations, bypass surgical procedures, and peripheral angioplasties with and without a stent. RESULTS A total of 791 patients were studied after propensity score matching; the mean (SD) age of patients in the SAVR group (n = 290) was 67.9 (10.4) years and 68.2 (11.2) years in the control group (n = 501). During follow-up, the SAVR group experienced the primary outcome at a significantly lower rate than the control group (adjusted hazard ratio [HR], 0.63; 95% CI, 0.52-0.77). Patients in the SAVR group were also less likely to have major amputation (adjusted HR, 0.47; 95% CI, 0.29-0.77), minor amputation (adjusted HR, 0.26; 95% CI, 0.13-0.54), bypass surgery (adjusted HR, 0.47; 95% CI, 0.30-0.73), or hospitalization due to heart failure (adjusted HR, 0.73; 95% CI, 0.53-1.00). The rate of peripheral angioplasty with or without a stent was higher among the SAVR group (adjusted HR, 2.97; 95% CI, 2.15-4.10). CONCLUSIONS AND RELEVANCE A guideline-recommended risk-reduction program targeted at patients with PAD was associated with fewer cardiovascular and limb events over the long-term. This finding emphasizes the need for well-designed prospective studies to develop and examine the effect of such programs on reducing PAD-related morbidity, mortality, and health care costs.

Post-structural conceptualizations of power relationships in physiotherapy

This paper uses a post-structuralist lens to explore the nature of power relationships within the patient–physical therapist relationship. To ground the discussion, I begin with an overview of the salient aspects of the traditional evolution of Western medicine. I then draw from the philosophy/history of Foucault to challenge traditional thinking and consider the applications to physiotherapy. The analysis reveals that the application of a Foucauldian frame of reference has the potential of modifying the therapeutic relationship to one that is more equitable as opposed to the hierarchical one. I conclude with a discussion of the implications for the development and education of physiotherapists.

Vascular quality of care pilot study: how admission to a vascular surgery service affects evidence-based pharmacologic risk factor modification in patients with lower extremity peripheral arterial disease

Background Peripheral arterial disease (PAD) guidelines recommend aggressive risk factor modification to improve cardiovascular outcomes. Recommended pharmacologic therapies include antiplatelets, angiotensin converting enzyme (ACE) inhibitors, and HMG-CoA-reductase inhibitors (statins). Purpose We studied the degree to which patient admission to a vascular surgery service increased the use of these therapies. Patients and methods The authors conducted a retrospective chart review of 150 patients with PAD admitted to the vascular surgery service at a large Canadian tertiary care hospital. The use of recommended pharmacologic therapies at the time of admission and discharge were compared. A multidisciplinary clinical team established criteria by which patients were deemed ineligible to receive any of the recommended therapies. Angiotensin receptor blockers (ARBs) were considered an alternative to ACE inhibitors. Results Prior to hospital admission, 64% of patients were on antiplatelet therapy, 67% were on an ACE inhibitor or ARB, and 71% were on a statin. At the time of discharge, 91% of patients were on an antiplatelet (or not, with an acceptable reason), 77% were on an ACE inhibitor or an ARB (or not, with an acceptable reason), and 85% were on a statin (or not, with an acceptable reason). While new prescriptions were largely responsible for improved guideline adherence with antiplatelets and statins, most of the apparent improvement in ACE inhibitor and ARB use was the result of identifying an acceptable reason for not having them prescribed. Conclusion This hypothesis generating pilot study supports the findings of others that there is suboptimal prescription of pharmacologic risk reduction therapies in the PAD population. Admission to a vascular service increases these rates. Nevertheless, some patients are still not receiving evidence-based treatment at discharge even after consideration of acceptable reasons. Strategies are needed to improve PAD guideline adherence in both the community at large and the vascular surgery service.

Analysis of Iliac Artery Geometric Properties in Fenestrated Aortic Stent Graft Rotation

Introduction: A complication of fenestrated endovascular aneurysm repair is the potential for stent graft rotation during deployment causing fenestration misalignment and branch artery occlusion. The objective of this study is to demonstrate that this rotation is caused by a buildup of rotational energy as the device is delivered through the iliac arteries and to quantify iliac artery geometric properties associated with device rotation. Methods: A retrospective clinical study was undertaken in which iliac artery geometric properties were assessed from preoperative imaging for 42 cases divided into 2 groups: 27 in the nonrotation group and 15 in the rotation group. Preoperative computed tomography scans were segmented, and the iliac artery centerlines were determined. Iliac artery tortuosity, curvature, torsion, and diameter were calculated from the centerline and the segmented vessel geometry. Results: The total iliac artery net torsion was found to be higher in the rotation group compared to the nonrotation group (23.5 ± 14.7 vs 14.6 ± 12.8 mm−1; P = .05). No statistically significant differences were found for the mean values of tortuosity, curvature, torsion, or diameter between the 2 groups. Conclusion: Stent graft rotation occurred in 36% of the cases considered in this study. Cases with high iliac artery total net torsion were found to be more likely to have stent graft rotation upon deployment. This retrospective study provides a framework for prospectively studying the influence of iliac artery geometric properties on fenestrated stent graft rotation.

Public health campaigns and their effect on stroke knowledge in a high-risk urban population: A five-year study

Background The level of knowledge of stroke risk factors and stroke symptoms within a population may determine their ability to recognize and ultimately react to a stroke. Independent agencies have addressed this through extensive awareness campaigns. The aim of this study was to determine the change in baseline knowledge of stroke risk factors, symptoms, and source of stroke knowledge in a high-risk Toronto population between 2010 and 2015. Methods Questionnaires were distributed to adults presenting to cardiovascular clinics at the University of Toronto in Toronto, Canada. In 2010 and 2015, a total of 207 and 818 individuals, respectively, participated in the study. Participants were identified as stroke literate if they identified (1) at least one stroke risk factor and (2) at least one stroke symptom. Results A total of 198 (95.6%) and 791 (96.7%) participants, respectively, completed the questionnaire in 2010 and 2015. The most frequently identified risk factors for stroke in 2010 and 2015 were, respectively, smoking (58.1%) and hypertension (49.0%). The most common stroke symptom identified was trouble speaking (56.6%) in 2010 and weakness, numbness or paralysis (67.1%) in 2015. Approximately equal percentages of respondents were able to identify ≥1 risk factor (80.3% vs. 83.1%, p = 0.34) and ≥1 symptom (90.9% vs. 88.7%, p = 0.38). Overall, the proportion of respondents who were able to correctly list ≥1 stroke risk factors and stroke symptoms was similar in both groups.(76.8% vs. 75.5%, p = 0.70). The most commonly reported stroke information resource was television (61.1% vs. 67.6%, p = 0.09). Conclusion Stroke literacy has remained stable in this selected high-risk population despite large investments in public campaigns over recent years. However, the baseline remains high over the study period. Evaluation of previous campaigns and development of targeted advertisements using more commonly used media sources offer opportunities to enhance education.

Outcomes of minor amputations in patients with peripheral vascular disease over a 10-year period at a tertiary care institution

Objectives Choosing an optimal amputation level requires balance between maximizing limb salvage while minimizing chances of non-healing wounds and re-amputation. Our aim was to assess the long-term outcome for minor amputations in patients with peripheral vascular disease. Methods A retrospective study of minor amputations between January 1, 2005 and December 31, 2015 was performed. Electronic medical records of eligible patients were examined to extract demographics, co morbidities and clinical data. Results Within the study period, 220 patients underwent 296 primary minor amputations in 244 lower extremities. Wound healing was achieved in 18.2% (54 of 296 amputations) and 43.6% (129 of 296 amputations) at 90 days and 365 days, respectively. Rates of progression to major amputation were 16.4% (40 or 244 limbs) and 21.7% (53 of 244 limbs) at 90 days and 365 days, respectively. In the final multivariate model, lower ipsilateral posterior tibial waveforms predicted poor 90-day healing (OR = 2.22, p = 0.01) as well as limb loss (OR = 3.02, p = 0.02) in a dose-response manner. In the final logistic regression model, emergency department admission (OR = 0.20, p < 0.01), ipsilateral posterior tibial waveform (OR = 2.63, p < 0.01), and post-operative infection (OR = 0.30, p < 0.01) were predictors of poor healing status at study endpoint. Conclusion This study shows that a majority of foot amputees require ongoing care for non-healing wounds and a proportion necessitate conversion to major amputation. Adequate vascularization is essential to promote and maintain healing.

IP241. Adherence to Recommended Imaging Surveillance of Acutely Presenting Stanford Type B Aortic Dissections

ureter to tamponade the bleed. Selective arteriography of the left external iliac artery with the balloon temporarily deflated showed dye extravasation into the ureter. An 8-mm by 5-cm covered Viabahn stent (W. L. Gore & Associates, Flagstaff, Ariz) was deployed across the defect, and follow-up arteriography showed no bleeding into the ureter. The patient’s hematuria resolved. Conclusions: The endovascular approach to repair of ureteral-arterial fistulas can reliably produce good outcomes. However, infection remains a major pitfall to endovascular repair. In the setting of infections with previous endovascular repair, it is advisable to remove all prosthetics, to ligate the ipsilateral iliac artery, and to perform a femoral-femoral bypass.

IP005. Preoperative Aneurysmal Thrombus Volume and Patency of Aortic Branch Vessels Are Inversely Correlated in Abdominal Aortic Aneurysm

population. AD mortality trends were evaluated within sex and race strata and compared with aortic aneurysm mortality using linear regression. Differences in county-specific mortality rates were assessed using the Kruskal-Wallis test. Results: Of the 1,014,039 total deaths that occurred during the study period, 2048 were AD related (60% male, 88% white). In 82% of the cases, AD was noted as the underlying COD (Table). The mean AD-related mortality rate was 1.7 6 0.3 deaths/100,000 compared with 6.3 6 1.7 deaths/ 100,000, the aortic aneurysm-related mortality. There was no change in AD-related mortality over time in comparison to a decline in aortic aneurysm-related mortality during the same period (P < .001; Fig). In ADrelated deaths, the mean age at death was 67.8 6 16.0 years and remained stable over time. Whereas there were no differences in ADrelated mortality rates by sex (P 1⁄4 .9), there was a significant increase in mortality rate among individuals who are nonwhite compared with white (an increase of 0.04 vs 0.0006 death/100,000/year, respectively; P 1⁄4 .01). Mortality rates varied significantly across counties (range, 0.02145.9 deaths/100,000; P < .001), and there was no obvious pattern to this variation. An autopsy was completed in 640 (32%) cases, of which 92% reported AD as underlying COD. Among those, 50.2% had an associated COD of aortic rupture. A higher percentage of hypertensive heart disease was noted among those with rupture (70% vs 47%; P < .001). Conclusions: AD-related mortality did not decline in 21 years in Washington state in contrast to a significant drop in aortic aneurysm-related mortality during the same period. Significant racial and geographic variations were noted. These observations are a first step toward regional population assessments that could potentially change care patterns at the state level.

IP041. Acute and Chronic Renal Dysfunction After Open and Endovascular Abdominal Aortic Aneurysm Repair

configurations include 2 with one fenestration, 18 with two fenestrations, 2 with three fenestrations, 5 with a scallop and one fenestration, and 73 with a scallop and two fenestrations. Mean operative time was 224.4 6 72.1 minutes with a blood loss of 508.2 6 561.0 mL. Mean fluoroscopy time was 64.8 6 25.9 minutes with a radiation dose of 966.5 6 652.6 Gy/cm and 116.3 6 41.4 mL iodinated contrast material. There was no difference in operative time, blood loss, or mean fluoroscopy time between the first 50 and last 50 cases. Mean contrast material volume decreased by 14% from 125 mL to 107 mL (P 1⁄4 .02). The 30-day morbidity includes myocardial infarction (2%), arrhythmia (3%), reintubation (2%), gastrointestinal ischemia (3%), and stroke (1%). There were three perioperative deaths due to decompensated cirrhosis, mesenteric ischemia, and cardiopulmonary arrest, respectively. At an average follow-up of 1.0 6 1.0 years, there were no aneurysm-related deaths with four branch stent thromboses (99% patency) and 91% freedom from endoleak. Reintervention was required in 18 patients, most often for branch vessel kinking (4), endoleak (4), mesenteric ischemia (3), access-related complications (3), and stent maldeployment or thrombosis (2). Conclusions: Despite the complexity and associated risks of FEVAR, outcomes at a high-volume center demonstrate acceptable morbidity and freedom from branch occlusion and endoleaks.

Inferior Vena Cava Filter Removal After Extended Implantation Periods

Inferior Vena Cava Filter Removal After Extended Implantation Periods Arash Jaberi, MD, Mary Jiayi Tao, MD, Naomi Eisenberg, MEd, Kongteng Tan, MD, Graham Roche-Nagle, MD, MBA, FRCSI, EBSQVASC. Division of Interventional Radiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Vascular Surgery, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada