Rami O. Tadros

Comparing the embolic potential of open and closed cell stents during carotid angioplasty and stenting

OBJECTIVE We sought to determine the effects of open (O) and closed (C) cell stents on the size and number of embolic particles generated during carotid artery stenting (CAS) and assess the impact on outcome. METHODS Embolic debris from carotid filters after CAS was analyzed using photomicroscopy and imaging software. Patient comorbidities, preoperative cerebrovascular symptoms, stent type, and outcomes (perioperative major adverse events) were examined. RESULTS Carotid filters from 173 consecutive CAS procedures (O, 125 and C, 48) were reviewed. The mean age was 70.9 ± 9.2 years; 58% were men. Mean stenosis was 88.2% ± 8.1%; 36.6% had neurological symptoms preprocedurally. There was no difference in preoperative symptoms between the two groups (O, 38.7% vs C, 31.3%; P = not significant [NS]). However, closed cell stent use was associated with higher degree of stenosis (O, 87.2% ± 8.0% vs C, 90.6% ± 7.8%; P = .01), an older age (O, 70.0 ± 8.6 years vs C, 73.4 ± 10.2 years; P = .03), and peripheral arterial disease (21.1% vs 43.5%; P = .01). A larger mean particle size was observed in patients treated with open cell stents compared to closed cell stents (O, 416.5 ± 335.7 μm vs C, 301.1 ± 251.3 μm; P = .03). There was no significant difference in the total number of particles (O, 13.8 ± 21.5 vs C, 17.6 ± 19.9; P = NS), periprocedural stroke (P = NS), and major adverse events between the two groups (P = NS). CONCLUSIONS Open cell stents are associated with a larger mean particle size compared to closed cell stents. No impact on procedural outcomes based on stent type was observed.

The effect of a hospitalist comanagement service on vascular surgery inpatients

OBJECTIVE Vascular surgery patients have increased medical comorbidities that amplify the complexity of their care. We assessed the effect of a hospitalist comanagement service on inpatient vascular surgery outcomes. METHODS We divided 1059 patients into two cohorts for comparison: 515 between January 2012 and December 2012, before the implementation of a hospitalist comanagement service, and 544 between January 2013 and October 2013, after the initiation of a hospitalist comanagement service. Nine vascular surgeons and 10 hospitalists participated in the hospitalist comanagement service. End points measured were in-hospital mortality, length of stay (LOS), 30-day readmission rates, visual analog scale pain scores (0-10), inpatient adult safety assessments using the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators, and resident perceptions assessed by survey. RESULTS The in-hospital mortality rate decreased from 1.75% to 0.37% after the implementation of the hospitalist comanagement service (P = .016), with a decrease in the observed-to-expected ratio from 0.89 to 0.22. The risk-adjusted in-hospital mortality decreased from 1.56% to 0.0008% (P = .003). Mean LOS was lower in the base period, at 5.1 days vs 5.5 days (P < .001), with an observed-to-expected ratio of 0.83 and 0.78, respectively. The risk-adjusted LOS increased from 4.2 days to 4.3 days (P < .001). The overall 30-day readmission rate was unchanged, at 23.1% compared with 22.8% (P = .6). The related 30-day readmission rate was also similar, at 11.5% compared with 11.4% (P = .5). Patients reporting no pain during hospitalization increased from 72.8% before the hospitalist comanagement service to 77.8% after (P = .04). Reports of moderate pain decreased from 14% to 9.6% (P = .016). Mild and severe pain scores were similar between the two groups. Adult safety measured by AHRQ demonstrated a decrease from three to zero patients in the number of deaths among surgical patients with treatable complications (P = .04). Most house staff reported that the comanagement program had a positive effect on patient care and education. CONCLUSIONS The hospitalist comanagement service has resulted in a significant decrease in in-hospital mortality rates, patient safety, as measured by AHRQ, and improved pain scores. Resident surveys demonstrated perceived improvement in patient care and education. Continued observation will be necessary to assess the long-term effect of the hospitalist comanagement service on quality metrics.

Vascular surgeon-hospitalist comanagement improves in-hospital mortality at the expense of increased in-hospital cost

Objective: We have shown that vascular surgeon‐ hospitalist co management resulted in improved in‐hospital mortality rates. We now aim to assess the impact of the hospitalist co management service (HCS) on healthcare cost. Methods: A total of 1558 patients were divided into three cohorts and compared: 516 in 2012, 525 in 2013, and 517 in 2014. The HCS began in January 2013. Data were standardized for six vascular surgeons that were present 2012–2014. New attendings were excluded. Ten hospitalists participated. Case mix index (CMI), contribution margin, total hospital charges (THCs), length of stay (LOS), actual direct costs (ADCs), and actual variable indirect costs (AVICs) were compared. Analysis of variance with post‐hoc tests, t‐tests, and linear regressions were performed. Results: THC rose by a mean difference of

A novel approach to the management of a recurrent lymphocele following a femoral-femoral bypass

14,578.31 between 2012 and 2014 (P < .001) with a significant difference found between all groups during the study period (P = .0004). ADC increased more than AVIC; however, both significantly increased over time (P = .0002 and P = .014, respectively). A mean

Preoperative inflammatory status as a predictor of primary patency after femoropopliteal stent implantation

3326.63 increase in ADC was observed from 2012 to 2014 (P < .0001). AVIC only increased by an average

Surgical Versus Percutaneous Therapy of Carotid Artery Disease: An Evidence-Based Outcomes Analysis

392.86 during the study period (P = .01). This increased cost was observed in the context of a higher CMI and longer LOS. CMI increased from 2.25 in 2012 to 2.53 in 2014 (P = .006). LOS increased by a mean 1.02 days between 2012 and 2014 (P = .016), and significantly during the study period overall (P = .018). After adjusting for CMI, LOS increases by only 0.61 days between 2012 and 2014 (P = .07). In a final regression model, THC is independently predicted by comanagement, CMI, and LOS. After adjusting for CMI and LOS, the increase in THC because of comanagement (2012 vs 2014) accounts for only

Bilateral May-Thurner syndrome refractory to iliac aneurysm repair

4073.08 of the total increase (P < .001). During this time, 30‐day readmission rates decreased by ˜7% (P = .005), while related 30‐day readmission rates decreased by ˜2% (P = .32). Physician contribution margin remained unchanged over the 3‐year period (P = .76). The most prevalent diagnosis‐related group was consistent across all years. Variation in the principal diagnosis code was observed with the prevalence of circulatory disorders because of type II diabetes replacing atherosclerosis with gangrene as the most prevalent diagnosis in 2013 and 2014 compared with 2012. Conclusions: In‐hospital cost is significantly higher since the start of the HCS. This surge may relate to increased CMI, LOS, and improved coding. This increase in cost may be justified as we have observed sustained reduction in in‐hospital mortality and slightly improved readmission rates.

PC010. Use of a Novel Flexible Covered Stent (GORE VIABAHN VBX) in Fenestrated and Parallel Grafts During Endovascular Treatment of Complex Perivisceral Aortic Aneurysms: Acute Results

An 86-year-old man presented with a recurrent groin lymphocele following endovascular abdominal aortic aneurysm repair using an aorto-uni-iliac reconstruction with polytetrafluoroethylene femoral-femoral crossover. Following this procedure, the patient developed a groin lymphocele. This fluid collection was treated with multiple aspirations and subsequent groin exploration with lymphatic ligation. Despite ligation, the fluid collection returned. Given these recurrences, replacement of the polytetrafluoroethylene graft with Dacron was performed. After graft replacement, the lymphocele recurred. A lymphangiogram was then performed by directly injecting the lymphocele, identifying the culprit lymphatic channels allowing N-butyl cyanoacrylate injection to seal the source of lymphatic drainage. No reappearance of the lymphocele was observed.

IP079. Duplex Ultrasound Can Successfully Identify Endoleaks and Renovisceral Stent Patency in Patients Undergoing Complex Endovascular Aneurysm Repair

Objective: The purpose of this study was to evaluate the impact of preoperative inflammatory status, as determined by complete blood count test parameters, on 12‐ and 24‐month patency of femoropopliteal stenting for peripheral arterial disease. Methods: We retrospectively analyzed baseline clinical and angiographic data among 138 patients (median age, 73 years; 46% female) from 2005 to 2014 at our institution with preoperative complete blood count test values and information of patency for at least 12 months after first‐time femoropopliteal stenting. Patients were stratified into tertiles on the basis of preoperative blood counts to evaluate associations with in‐stent restenosis (ISR) leading to loss of primary patency, defined by a Doppler velocity ratio ≥2.5:1, computed tomography angiography demonstrating ≥50% luminal narrowing within the stent, or reintervention. Results: Univariate analysis determined that the 81 patients (59%) who experienced ISR within 12 months had significantly higher preoperative white blood cell (WBC), platelet, neutrophil, and lymphocyte counts than the 57 patients (41%) whose stents remained patent for longer than 12 months (8.7 vs 6.7 [P < .001], 246 vs 184 [P < .001], 5.7 vs 4.7 [P = .001], and 1.8 vs 1.2 [P = .004], respectively). Compared with patients in the lower WBC tertile (n = 45) who had a median patency of 19.4 months, those in the upper WBC tertile (n = 44) had a median patency of only 7.0 months and a 3.3‐fold increased risk for ISR after adjusting for age, sex, lesion type, TransAtlantic Inter‐Society Consensus II score, tibial vessel runoff, antiplatelet therapy, presence of diabetes, critical limb ischemia, adjunct procedures, hyperlipidemia, and end‐stage renal disease in multivariate analysis (P < .001). Compared with patients in the lower platelet tertile (n = 45) who had a median patency of 16.9 months, those in the upper platelet tertile (n = 47) had a median patency of 7.1 months and a 2.7‐fold increased adjusted risk (P = .001). Compared with patients in the lower neutrophil tertile (n = 33) who had a median patency of 14.3 months, those in the upper neutrophil tertile (n = 33) had a median patency of 6.2 months and a 3.2‐fold increased adjusted risk (P = .001). After adjusting for covariates, patients divided into tertiles by lymphocyte counts exhibited no significant differences for ISR. Conclusions: Routine preoperative tests that determine baseline inflammatory status may provide strong clinical utility in assessing potential risk stratification of patients for ISR after femoropopliteal stenting. Circulating WBCs, platelets, and neutrophils may be important inflammatory mediators of ISR.

Outcomes of using endovascular aneurysm repair with active fixation in complex aneurysm morphology

From the Departments of *Anesthesiology and †Surgery, Icahn School of Medicine at Mount Sinai, New York, New York; ‡Division of Cardiovascular Diseases, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; §Department of Anesthesiology, Cleveland Clinic Florida, Weston, Florida; ¶Department of Cardiovascular Diseases Mayo Clinic, Phoenix, Arizona; ‖Department of Anesthesiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; and #Department of Anesthesiology, Mayo Clinic, Phoenix, Arizona. Address reprint requests to Harish Ramakrishna, MD, FASE, FACC, Department of Anesthesiology, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054. E-mail: Ramakrishna.harish@mayo.edu