Midwestern Vascular Society: Midwestern Vascular 2012

MILWAUKEE – The obesity epidemic in the United States is bringing Americans to their knees, literally.

A growing number of obese patients are presenting to the emergency department with low-energy (LE) knee dislocations (KDs) caused by slips and falls simply from standing or from a single step.

Despite the isolated nature of their injuries, this new cohort of LE patients stayed in the hospital just as long as multisystem trauma patients with KDs resulting from high-energy injuries like car or motorcycle collisions and more than twice as long as nonobese patients with traditional low-energy knee dislocations from sports injuries.

The reason?

Patrice Wendling/IMNG Medical Media

Obese patients with low-energy KDs are more likely to have vascular and nerve injuries and to require open arterial procedures than are patients with high-energy trauma or nonobese patients with LE knee dislocations, Dr. Andrew Georgiadis explained at the annual meeting of the Midwestern Vascular Surgical Society.

He noted that knee dislocation involves progressive hyperextension of the knee, and that, at 30 degrees of hyperextension, the posterior knee capsule is rent, and at 50 degrees, the popliteal artery actually fails.

Dr. Georgiadis and his surgical colleagues have been studying this phenomenon at Detroit’s Henry Ford Hospital, where, over a 17-year period, the proportion of low-energy KDs in the obese has risen from 17% in 1995-2000 to 33% in 2001-2006 and now represents the majority (53%) of all KDs in the hospital.

Among 53 KD patients treated between January 1995 and April 2012, 28 had high-energy injuries and 25 had low-energy injuries, of which 18 were obese and 7 nonobese. Five of the obese patients had a BMI of at least 30 kg/m² or less than 40 kg/m², while the remaining 13 had a BMI of more than 40 kg/m².

When compared with the high-energy and LE non-obese patients, LE obese patients were significantly more likely to have a vascular injury (33% vs. 9%), vascular repair (28% vs. 6%), and nerve injury (50% vs. 6%), said Dr. Georgiadis, an orthopedic surgery resident at Henry Ford.

These rates were even higher in the morbidly obese (BMI over 40 kg/m²) at 39%, 39%, and 54%.

Although there were only seven arterial repairs in the entire series, five of these patients had "massive BMIs" between 42-69 kg/m² and "they all had seemingly innocuous trauma, they all had transected arteries, they all had a vein graft bypass, and all of them had some early complication related to their procedure," he said.

Those complications included wound breakdown, early return to the operating room for a fasciotomy, graft occlusion requiring early thrombectomy/revision, and rhabdomyolysis/limb loss in a patient with a prolonged diagnosis.

When asked by the audience why the grafts thrombosed early, Dr. Georgiadis replied, "I think technical difficulty is really at the heart of all these things. And remember, these are patients who are probably being diagnosed later than someone who is crushed between two buses, so there are a lot of factors combining in these cases."

LE obese patients stayed in the hospital for an average of 8.1 days, which was comparable with the 11.4 days in the high-energy KD patients, of whom only 43% had isolated injuries, and significantly longer than the 3.7 days for non-obese LE patients, he said.

Given the increasing prevalence of obese low-energy KD patients, "we should probably have heightened awareness of this injury, especially at tertiary care centers, to avoid the morbidity of neurovascular injury and the consequences of delayed recognition," Dr. Georgiadis said.

A quick glimpse at the literature suggests that the ever-expanding American is not the only one at risk of obesity-related KDs.

Four cases of knee dislocation were recently reported by Morriston Hospital in Swansea, Wales – all in morbidly obese women (BMI range of 35-41) who experienced a simple mechanical fall from standing. The four cases occurred over the course of 1 year, and all had multiple knee ligament rupture on MRI. One case also had peroneal nerve palsy, according to the article, entitled "Dislocation of the Knee: An Epidemic in Waiting?"

Dr. Georgiadis reported no conflicts of interest.

MILWAUKEE – The obesity epidemic in the United States is bringing Americans to their knees, literally.

A growing number of obese patients are presenting to the emergency department with low-energy (LE) knee dislocations (KDs) caused by slips and falls simply from standing or from a single step.

Despite the isolated nature of their injuries, this new cohort of LE patients stayed in the hospital just as long as multisystem trauma patients with KDs resulting from high-energy injuries like car or motorcycle collisions and more than twice as long as nonobese patients with traditional low-energy knee dislocations from sports injuries.

The reason?

Patrice Wendling/IMNG Medical Media

Obese patients with low-energy KDs are more likely to have vascular and nerve injuries and to require open arterial procedures than are patients with high-energy trauma or nonobese patients with LE knee dislocations, Dr. Andrew Georgiadis explained at the annual meeting of the Midwestern Vascular Surgical Society.

He noted that knee dislocation involves progressive hyperextension of the knee, and that, at 30 degrees of hyperextension, the posterior knee capsule is rent, and at 50 degrees, the popliteal artery actually fails.

Dr. Georgiadis and his surgical colleagues have been studying this phenomenon at Detroit’s Henry Ford Hospital, where, over a 17-year period, the proportion of low-energy KDs in the obese has risen from 17% in 1995-2000 to 33% in 2001-2006 and now represents the majority (53%) of all KDs in the hospital.

Among 53 KD patients treated between January 1995 and April 2012, 28 had high-energy injuries and 25 had low-energy injuries, of which 18 were obese and 7 nonobese. Five of the obese patients had a BMI of at least 30 kg/m² or less than 40 kg/m², while the remaining 13 had a BMI of more than 40 kg/m².

When compared with the high-energy and LE non-obese patients, LE obese patients were significantly more likely to have a vascular injury (33% vs. 9%), vascular repair (28% vs. 6%), and nerve injury (50% vs. 6%), said Dr. Georgiadis, an orthopedic surgery resident at Henry Ford.

These rates were even higher in the morbidly obese (BMI over 40 kg/m²) at 39%, 39%, and 54%.

Although there were only seven arterial repairs in the entire series, five of these patients had "massive BMIs" between 42-69 kg/m² and "they all had seemingly innocuous trauma, they all had transected arteries, they all had a vein graft bypass, and all of them had some early complication related to their procedure," he said.

Those complications included wound breakdown, early return to the operating room for a fasciotomy, graft occlusion requiring early thrombectomy/revision, and rhabdomyolysis/limb loss in a patient with a prolonged diagnosis.

When asked by the audience why the grafts thrombosed early, Dr. Georgiadis replied, "I think technical difficulty is really at the heart of all these things. And remember, these are patients who are probably being diagnosed later than someone who is crushed between two buses, so there are a lot of factors combining in these cases."

LE obese patients stayed in the hospital for an average of 8.1 days, which was comparable with the 11.4 days in the high-energy KD patients, of whom only 43% had isolated injuries, and significantly longer than the 3.7 days for non-obese LE patients, he said.

Given the increasing prevalence of obese low-energy KD patients, "we should probably have heightened awareness of this injury, especially at tertiary care centers, to avoid the morbidity of neurovascular injury and the consequences of delayed recognition," Dr. Georgiadis said.

A quick glimpse at the literature suggests that the ever-expanding American is not the only one at risk of obesity-related KDs.

Four cases of knee dislocation were recently reported by Morriston Hospital in Swansea, Wales – all in morbidly obese women (BMI range of 35-41) who experienced a simple mechanical fall from standing. The four cases occurred over the course of 1 year, and all had multiple knee ligament rupture on MRI. One case also had peroneal nerve palsy, according to the article, entitled "Dislocation of the Knee: An Epidemic in Waiting?"

Dr. Georgiadis reported no conflicts of interest.

MILWAUKEE – The obesity epidemic in the United States is bringing Americans to their knees, literally.

A growing number of obese patients are presenting to the emergency department with low-energy (LE) knee dislocations (KDs) caused by slips and falls simply from standing or from a single step.

Despite the isolated nature of their injuries, this new cohort of LE patients stayed in the hospital just as long as multisystem trauma patients with KDs resulting from high-energy injuries like car or motorcycle collisions and more than twice as long as nonobese patients with traditional low-energy knee dislocations from sports injuries.

The reason?

Patrice Wendling/IMNG Medical Media

Obese patients with low-energy KDs are more likely to have vascular and nerve injuries and to require open arterial procedures than are patients with high-energy trauma or nonobese patients with LE knee dislocations, Dr. Andrew Georgiadis explained at the annual meeting of the Midwestern Vascular Surgical Society.

He noted that knee dislocation involves progressive hyperextension of the knee, and that, at 30 degrees of hyperextension, the posterior knee capsule is rent, and at 50 degrees, the popliteal artery actually fails.

Dr. Georgiadis and his surgical colleagues have been studying this phenomenon at Detroit’s Henry Ford Hospital, where, over a 17-year period, the proportion of low-energy KDs in the obese has risen from 17% in 1995-2000 to 33% in 2001-2006 and now represents the majority (53%) of all KDs in the hospital.

Among 53 KD patients treated between January 1995 and April 2012, 28 had high-energy injuries and 25 had low-energy injuries, of which 18 were obese and 7 nonobese. Five of the obese patients had a BMI of at least 30 kg/m² or less than 40 kg/m², while the remaining 13 had a BMI of more than 40 kg/m².

When compared with the high-energy and LE non-obese patients, LE obese patients were significantly more likely to have a vascular injury (33% vs. 9%), vascular repair (28% vs. 6%), and nerve injury (50% vs. 6%), said Dr. Georgiadis, an orthopedic surgery resident at Henry Ford.

These rates were even higher in the morbidly obese (BMI over 40 kg/m²) at 39%, 39%, and 54%.

Although there were only seven arterial repairs in the entire series, five of these patients had "massive BMIs" between 42-69 kg/m² and "they all had seemingly innocuous trauma, they all had transected arteries, they all had a vein graft bypass, and all of them had some early complication related to their procedure," he said.

Those complications included wound breakdown, early return to the operating room for a fasciotomy, graft occlusion requiring early thrombectomy/revision, and rhabdomyolysis/limb loss in a patient with a prolonged diagnosis.

When asked by the audience why the grafts thrombosed early, Dr. Georgiadis replied, "I think technical difficulty is really at the heart of all these things. And remember, these are patients who are probably being diagnosed later than someone who is crushed between two buses, so there are a lot of factors combining in these cases."

LE obese patients stayed in the hospital for an average of 8.1 days, which was comparable with the 11.4 days in the high-energy KD patients, of whom only 43% had isolated injuries, and significantly longer than the 3.7 days for non-obese LE patients, he said.

Given the increasing prevalence of obese low-energy KD patients, "we should probably have heightened awareness of this injury, especially at tertiary care centers, to avoid the morbidity of neurovascular injury and the consequences of delayed recognition," Dr. Georgiadis said.

A quick glimpse at the literature suggests that the ever-expanding American is not the only one at risk of obesity-related KDs.

Four cases of knee dislocation were recently reported by Morriston Hospital in Swansea, Wales – all in morbidly obese women (BMI range of 35-41) who experienced a simple mechanical fall from standing. The four cases occurred over the course of 1 year, and all had multiple knee ligament rupture on MRI. One case also had peroneal nerve palsy, according to the article, entitled "Dislocation of the Knee: An Epidemic in Waiting?"

Dr. Georgiadis reported no conflicts of interest.

MILWAUKEE – Although female gender is associated with a higher rate of complications, women did not have significantly lower long-term survival after endovascular abdominal aortic aneurysm repair in a review of the Mayo Clinic AAA Registry.

At 30 days, 24% of women experienced complications after EVAR, compared with 15% of men (P value = .003).

Patrice Wendling/IMNG Medical Media

On the other hand, death at 30 days was similar (2.5% vs. 1.5%; P = .41), as was combined early or late death (hazard ratio 1.1 vs. 1.0; P = .36), Dr. Peter Gloviczki reported at the meeting.

He highlighted a recent prospective analysis from Albany (N.Y.) Medical College showing that women had significantly higher mortality than did men (3.2% vs. 0.96%, P less than .005) and more frequent colon ischemia, native arterial rupture, and type 1 endoleaks after elective EVAR. There were no gender differences, however, for any of these outcomes following elective open repair or emergency EVAR or surgery (Vasc. Surg. 2012;55:906-13. Epub 2012 Feb. 8).

In the Mayo Clinic analysis, urgent presentation, age over 70 years, and high comorbidity scores were all significantly associated with complications and higher mortality, said Dr. Gloviczki, president of the Society for Vascular Surgery (SVS) and chair emeritus vascular and endovascular surgery, Mayo Clinic, Rochester, Minn.

The retrospective analysis included 1,002 consecutive patients with abdominal aortic aneurysm (AAA) treated with EVAR at Mayo Clinic from January 1997 to June 30, 2011. Of these, 871 were male (87%) and 131 female (13%). The majority (919) of cases were elective (92%), 43 symptomatic (4%), and 40 ruptured AAA (4%). Patients’ average age was 76 years (range 51-99 years).

Thirty-day mortality was 1% in the elective group, compared with 2.3% in the symptomatic AAA group and 12.5% in the ruptured AAA group (both P less than .0001), he said.

In contrast to the Albany analysis, early mortality after elective repair was similar between men and women (0.75% vs. 2.61%; P = .09). This was further confirmed by multivariate analysis (hazard ratio for all-cause death 1.16; P = .40), despite an increased risk in women for complications (HR 1.67; P = .001) and reinterventions (HR 1.96; P = .002), Dr. Gloviczki said.

High-risk patients, defined by an SVS comorbidity score of more than 10, however, had significantly higher 30-day mortality after elective EVAR than did low-risk patients (2.33% vs. 0.18%; P = .004).

This was driven by a significantly higher rate of early complications in the high-risk group (19.3% vs. 11.4%), particularly myocardial infarction (1.6% vs. 0.18%) and acute renal failure requiring temporary dialysis (3.26% vs. 1.09%; P less than .05 for all), Dr. Gloviczki observed.

At an average follow-up of 3.2 years, overall survival was significantly higher in patients undergoing elective EVAR vs. symptomatic or ruptured repair (64% vs. 50% and 56%; P less than .001), and in low-risk vs. high-risk elective patients (72% vs. 51%; P less than .001).

Both 30-day mortality and complications significantly increased with age after elective repair, he said.

Overall, there were five late ruptures and nine late conversions, for a complication-free 5-year survival of 64% in the elective group.

Dr. Gloviczki noted that access-related difficulties are driving the higher early complication rate in women, but that other factors like age and comorbidities may be at play.

He noted that Mayo Clinic performed its first EVAR in 1996, and that today, 63% of patients with an aneurysm undergo endovascular repair.

When asked what’s changed in his patient selection and aneurysm size cutoff, Dr. Gloviczki said that in younger patients, surgeons may want to intervene earlier if the aneurysm appears likely to increase in size and is suitable for an endograft, but that overall, age alone should not drive patient selection.

"What this study showed me is that characterizing patients as high risk vs. low risk is important, in addition to age," he said. "As you could see, there was an increased mortality in age, but when we looked at high-risk and low-risk criteria, we only lost one patient in the low-risk group. So age alone does not put you into a high-risk category, it is your additional cardiac, pulmonary and renal disease that does."

Dr. Gloviczki and his coauthors reported no relevant conflicts of interest.

MILWAUKEE – Although female gender is associated with a higher rate of complications, women did not have significantly lower long-term survival after endovascular abdominal aortic aneurysm repair in a review of the Mayo Clinic AAA Registry.

At 30 days, 24% of women experienced complications after EVAR, compared with 15% of men (P value = .003).

Patrice Wendling/IMNG Medical Media

On the other hand, death at 30 days was similar (2.5% vs. 1.5%; P = .41), as was combined early or late death (hazard ratio 1.1 vs. 1.0; P = .36), Dr. Peter Gloviczki reported at the meeting.

He highlighted a recent prospective analysis from Albany (N.Y.) Medical College showing that women had significantly higher mortality than did men (3.2% vs. 0.96%, P less than .005) and more frequent colon ischemia, native arterial rupture, and type 1 endoleaks after elective EVAR. There were no gender differences, however, for any of these outcomes following elective open repair or emergency EVAR or surgery (Vasc. Surg. 2012;55:906-13. Epub 2012 Feb. 8).

In the Mayo Clinic analysis, urgent presentation, age over 70 years, and high comorbidity scores were all significantly associated with complications and higher mortality, said Dr. Gloviczki, president of the Society for Vascular Surgery (SVS) and chair emeritus vascular and endovascular surgery, Mayo Clinic, Rochester, Minn.

The retrospective analysis included 1,002 consecutive patients with abdominal aortic aneurysm (AAA) treated with EVAR at Mayo Clinic from January 1997 to June 30, 2011. Of these, 871 were male (87%) and 131 female (13%). The majority (919) of cases were elective (92%), 43 symptomatic (4%), and 40 ruptured AAA (4%). Patients’ average age was 76 years (range 51-99 years).

Thirty-day mortality was 1% in the elective group, compared with 2.3% in the symptomatic AAA group and 12.5% in the ruptured AAA group (both P less than .0001), he said.

In contrast to the Albany analysis, early mortality after elective repair was similar between men and women (0.75% vs. 2.61%; P = .09). This was further confirmed by multivariate analysis (hazard ratio for all-cause death 1.16; P = .40), despite an increased risk in women for complications (HR 1.67; P = .001) and reinterventions (HR 1.96; P = .002), Dr. Gloviczki said.

High-risk patients, defined by an SVS comorbidity score of more than 10, however, had significantly higher 30-day mortality after elective EVAR than did low-risk patients (2.33% vs. 0.18%; P = .004).

This was driven by a significantly higher rate of early complications in the high-risk group (19.3% vs. 11.4%), particularly myocardial infarction (1.6% vs. 0.18%) and acute renal failure requiring temporary dialysis (3.26% vs. 1.09%; P less than .05 for all), Dr. Gloviczki observed.

At an average follow-up of 3.2 years, overall survival was significantly higher in patients undergoing elective EVAR vs. symptomatic or ruptured repair (64% vs. 50% and 56%; P less than .001), and in low-risk vs. high-risk elective patients (72% vs. 51%; P less than .001).

Both 30-day mortality and complications significantly increased with age after elective repair, he said.

Overall, there were five late ruptures and nine late conversions, for a complication-free 5-year survival of 64% in the elective group.

Dr. Gloviczki noted that access-related difficulties are driving the higher early complication rate in women, but that other factors like age and comorbidities may be at play.

He noted that Mayo Clinic performed its first EVAR in 1996, and that today, 63% of patients with an aneurysm undergo endovascular repair.

When asked what’s changed in his patient selection and aneurysm size cutoff, Dr. Gloviczki said that in younger patients, surgeons may want to intervene earlier if the aneurysm appears likely to increase in size and is suitable for an endograft, but that overall, age alone should not drive patient selection.

"What this study showed me is that characterizing patients as high risk vs. low risk is important, in addition to age," he said. "As you could see, there was an increased mortality in age, but when we looked at high-risk and low-risk criteria, we only lost one patient in the low-risk group. So age alone does not put you into a high-risk category, it is your additional cardiac, pulmonary and renal disease that does."

Dr. Gloviczki and his coauthors reported no relevant conflicts of interest.

MILWAUKEE – Although female gender is associated with a higher rate of complications, women did not have significantly lower long-term survival after endovascular abdominal aortic aneurysm repair in a review of the Mayo Clinic AAA Registry.

At 30 days, 24% of women experienced complications after EVAR, compared with 15% of men (P value = .003).

Patrice Wendling/IMNG Medical Media

On the other hand, death at 30 days was similar (2.5% vs. 1.5%; P = .41), as was combined early or late death (hazard ratio 1.1 vs. 1.0; P = .36), Dr. Peter Gloviczki reported at the meeting.

He highlighted a recent prospective analysis from Albany (N.Y.) Medical College showing that women had significantly higher mortality than did men (3.2% vs. 0.96%, P less than .005) and more frequent colon ischemia, native arterial rupture, and type 1 endoleaks after elective EVAR. There were no gender differences, however, for any of these outcomes following elective open repair or emergency EVAR or surgery (Vasc. Surg. 2012;55:906-13. Epub 2012 Feb. 8).

In the Mayo Clinic analysis, urgent presentation, age over 70 years, and high comorbidity scores were all significantly associated with complications and higher mortality, said Dr. Gloviczki, president of the Society for Vascular Surgery (SVS) and chair emeritus vascular and endovascular surgery, Mayo Clinic, Rochester, Minn.

The retrospective analysis included 1,002 consecutive patients with abdominal aortic aneurysm (AAA) treated with EVAR at Mayo Clinic from January 1997 to June 30, 2011. Of these, 871 were male (87%) and 131 female (13%). The majority (919) of cases were elective (92%), 43 symptomatic (4%), and 40 ruptured AAA (4%). Patients’ average age was 76 years (range 51-99 years).

Thirty-day mortality was 1% in the elective group, compared with 2.3% in the symptomatic AAA group and 12.5% in the ruptured AAA group (both P less than .0001), he said.

In contrast to the Albany analysis, early mortality after elective repair was similar between men and women (0.75% vs. 2.61%; P = .09). This was further confirmed by multivariate analysis (hazard ratio for all-cause death 1.16; P = .40), despite an increased risk in women for complications (HR 1.67; P = .001) and reinterventions (HR 1.96; P = .002), Dr. Gloviczki said.

High-risk patients, defined by an SVS comorbidity score of more than 10, however, had significantly higher 30-day mortality after elective EVAR than did low-risk patients (2.33% vs. 0.18%; P = .004).

This was driven by a significantly higher rate of early complications in the high-risk group (19.3% vs. 11.4%), particularly myocardial infarction (1.6% vs. 0.18%) and acute renal failure requiring temporary dialysis (3.26% vs. 1.09%; P less than .05 for all), Dr. Gloviczki observed.

At an average follow-up of 3.2 years, overall survival was significantly higher in patients undergoing elective EVAR vs. symptomatic or ruptured repair (64% vs. 50% and 56%; P less than .001), and in low-risk vs. high-risk elective patients (72% vs. 51%; P less than .001).

Both 30-day mortality and complications significantly increased with age after elective repair, he said.

Overall, there were five late ruptures and nine late conversions, for a complication-free 5-year survival of 64% in the elective group.

Dr. Gloviczki noted that access-related difficulties are driving the higher early complication rate in women, but that other factors like age and comorbidities may be at play.

He noted that Mayo Clinic performed its first EVAR in 1996, and that today, 63% of patients with an aneurysm undergo endovascular repair.

When asked what’s changed in his patient selection and aneurysm size cutoff, Dr. Gloviczki said that in younger patients, surgeons may want to intervene earlier if the aneurysm appears likely to increase in size and is suitable for an endograft, but that overall, age alone should not drive patient selection.

"What this study showed me is that characterizing patients as high risk vs. low risk is important, in addition to age," he said. "As you could see, there was an increased mortality in age, but when we looked at high-risk and low-risk criteria, we only lost one patient in the low-risk group. So age alone does not put you into a high-risk category, it is your additional cardiac, pulmonary and renal disease that does."

Dr. Gloviczki and his coauthors reported no relevant conflicts of interest.

MILWAUKEE – General surgery residents in a community-based residency program experienced a significant 49% decline in open aortic surgeries over the last decade, an analysis showed.

In 2000-2001, residents were exposed to 20-25 open aortic cases per year, but now get in on 8-15 cases per year, said Dr. Adam Rothermel, a third-year general surgery resident at Mount Carmel Hospital in Columbus, Ohio, where the analysis was conducted.

Patrice Wendling/IMNG Medical Media

"Open aortic cases are difficult to find, and our residents, as a whole, would agree that we’re not coming out with good enough experience with these cases," he said at the annual meeting of the Midwestern Vascular Surgical Society.

The results reflect the exponential shift from open vascular surgery to endovascular procedures over the last decade, as well as the more recent implementation of the 80-hour resident work week.

The total number of carotid endarterectomy, infrainguinal bypass, and open aortic cases for the entire hospital decreased by 55%, 30%, and 71%, respectively, over the study period of 2000 to 2011.

Total resident cases over the same period were unchanged for carotid endarterectomy (77 vs. 84 cases), trended downward for infrainguinal bypass (62 vs. 52 cases), and were significantly lower for open aortic cases (43 vs. 8 cases) according to a review of resident case logs, Dr. Rothermel said.

He pointed out that a significant portion of vascular surgery in the United States is still performed by general surgeons, citing surveys showing that general surgeons performed 59% of the vascular procedures in the United States in 1985 (J. Vasc. Surg. 1987;6:611-21) and 49% in 1992 (J. Vasc. Surg. 1996:23:172-81).

Session moderator Dr. Jean E. Starr, medical director of endovascular services at Ohio State University Medical Center in Columbus, said the current results parallel what’s found nationally. She went on to ask what the findings imply for general surgery residents when they’ve finished training, and how this will reflect on patient practice in light of general surgeons performing half of vascular surgeries in the United States.

"When you get out of your general surgery training from a community based program and are expected then, going into say a rural center, to perform these operations, you have to give pause," Dr. Rothermel replied. "I don’t think I have a good way to fix the problem at this point, but I think we need to be aware of the trend."

Audience member Dr. Joseph Giglia, principal investigator for the laparoscopic aortic surgery program at the University of Cincinnati Medical Center, countered by asking whether the findings really matter given that open aortic cases are decreasing significantly across the country. He pointed out that the latest survey data were 20 years old, and submitted that general surgeons no longer perform 50% of vascular surgeries in the United States.

"I think these cases are important for our primary vascular residents to participate in," Dr. Giglia said. "I think there has to be a sea change, a real shift in the paradigm about who’s doing these cases and what we’re going to do in the future."

Dr. Rothermel agreed that another survey should be conducted to better reflect current practice trends.

If vascular surgeons are to pick up the bulk of the caseload, however, efforts to recruit medical students to the specialty may need to be enhanced. A recent survey of 338 medical students showed that 236 first- and second-year students had no clinical exposure to vascular surgery, while only 38 of the 102 third-year students had been exposed to vascular surgery after completing a general surgery rotation (Ann. Vasc. Surg. 2012 July 25 [doi:10.1016/j.avsg.2012.02.012]). Nearly half (49%) of first- and second-year students said that they would consider vascular surgery, however, with another 19% willing to do so if the length of training were reduced.

Dr. Rothermel and Dr. Starr reported no conflicts of interest.

MILWAUKEE – General surgery residents in a community-based residency program experienced a significant 49% decline in open aortic surgeries over the last decade, an analysis showed.

In 2000-2001, residents were exposed to 20-25 open aortic cases per year, but now get in on 8-15 cases per year, said Dr. Adam Rothermel, a third-year general surgery resident at Mount Carmel Hospital in Columbus, Ohio, where the analysis was conducted.

Patrice Wendling/IMNG Medical Media

"Open aortic cases are difficult to find, and our residents, as a whole, would agree that we’re not coming out with good enough experience with these cases," he said at the annual meeting of the Midwestern Vascular Surgical Society.

The results reflect the exponential shift from open vascular surgery to endovascular procedures over the last decade, as well as the more recent implementation of the 80-hour resident work week.

The total number of carotid endarterectomy, infrainguinal bypass, and open aortic cases for the entire hospital decreased by 55%, 30%, and 71%, respectively, over the study period of 2000 to 2011.

Total resident cases over the same period were unchanged for carotid endarterectomy (77 vs. 84 cases), trended downward for infrainguinal bypass (62 vs. 52 cases), and were significantly lower for open aortic cases (43 vs. 8 cases) according to a review of resident case logs, Dr. Rothermel said.

He pointed out that a significant portion of vascular surgery in the United States is still performed by general surgeons, citing surveys showing that general surgeons performed 59% of the vascular procedures in the United States in 1985 (J. Vasc. Surg. 1987;6:611-21) and 49% in 1992 (J. Vasc. Surg. 1996:23:172-81).

Session moderator Dr. Jean E. Starr, medical director of endovascular services at Ohio State University Medical Center in Columbus, said the current results parallel what’s found nationally. She went on to ask what the findings imply for general surgery residents when they’ve finished training, and how this will reflect on patient practice in light of general surgeons performing half of vascular surgeries in the United States.

"When you get out of your general surgery training from a community based program and are expected then, going into say a rural center, to perform these operations, you have to give pause," Dr. Rothermel replied. "I don’t think I have a good way to fix the problem at this point, but I think we need to be aware of the trend."

Audience member Dr. Joseph Giglia, principal investigator for the laparoscopic aortic surgery program at the University of Cincinnati Medical Center, countered by asking whether the findings really matter given that open aortic cases are decreasing significantly across the country. He pointed out that the latest survey data were 20 years old, and submitted that general surgeons no longer perform 50% of vascular surgeries in the United States.

"I think these cases are important for our primary vascular residents to participate in," Dr. Giglia said. "I think there has to be a sea change, a real shift in the paradigm about who’s doing these cases and what we’re going to do in the future."

Dr. Rothermel agreed that another survey should be conducted to better reflect current practice trends.

If vascular surgeons are to pick up the bulk of the caseload, however, efforts to recruit medical students to the specialty may need to be enhanced. A recent survey of 338 medical students showed that 236 first- and second-year students had no clinical exposure to vascular surgery, while only 38 of the 102 third-year students had been exposed to vascular surgery after completing a general surgery rotation (Ann. Vasc. Surg. 2012 July 25 [doi:10.1016/j.avsg.2012.02.012]). Nearly half (49%) of first- and second-year students said that they would consider vascular surgery, however, with another 19% willing to do so if the length of training were reduced.

Dr. Rothermel and Dr. Starr reported no conflicts of interest.

MILWAUKEE – General surgery residents in a community-based residency program experienced a significant 49% decline in open aortic surgeries over the last decade, an analysis showed.

In 2000-2001, residents were exposed to 20-25 open aortic cases per year, but now get in on 8-15 cases per year, said Dr. Adam Rothermel, a third-year general surgery resident at Mount Carmel Hospital in Columbus, Ohio, where the analysis was conducted.

Patrice Wendling/IMNG Medical Media

"Open aortic cases are difficult to find, and our residents, as a whole, would agree that we’re not coming out with good enough experience with these cases," he said at the annual meeting of the Midwestern Vascular Surgical Society.

The results reflect the exponential shift from open vascular surgery to endovascular procedures over the last decade, as well as the more recent implementation of the 80-hour resident work week.

The total number of carotid endarterectomy, infrainguinal bypass, and open aortic cases for the entire hospital decreased by 55%, 30%, and 71%, respectively, over the study period of 2000 to 2011.

Total resident cases over the same period were unchanged for carotid endarterectomy (77 vs. 84 cases), trended downward for infrainguinal bypass (62 vs. 52 cases), and were significantly lower for open aortic cases (43 vs. 8 cases) according to a review of resident case logs, Dr. Rothermel said.

He pointed out that a significant portion of vascular surgery in the United States is still performed by general surgeons, citing surveys showing that general surgeons performed 59% of the vascular procedures in the United States in 1985 (J. Vasc. Surg. 1987;6:611-21) and 49% in 1992 (J. Vasc. Surg. 1996:23:172-81).

Session moderator Dr. Jean E. Starr, medical director of endovascular services at Ohio State University Medical Center in Columbus, said the current results parallel what’s found nationally. She went on to ask what the findings imply for general surgery residents when they’ve finished training, and how this will reflect on patient practice in light of general surgeons performing half of vascular surgeries in the United States.

"When you get out of your general surgery training from a community based program and are expected then, going into say a rural center, to perform these operations, you have to give pause," Dr. Rothermel replied. "I don’t think I have a good way to fix the problem at this point, but I think we need to be aware of the trend."

Audience member Dr. Joseph Giglia, principal investigator for the laparoscopic aortic surgery program at the University of Cincinnati Medical Center, countered by asking whether the findings really matter given that open aortic cases are decreasing significantly across the country. He pointed out that the latest survey data were 20 years old, and submitted that general surgeons no longer perform 50% of vascular surgeries in the United States.

"I think these cases are important for our primary vascular residents to participate in," Dr. Giglia said. "I think there has to be a sea change, a real shift in the paradigm about who’s doing these cases and what we’re going to do in the future."

Dr. Rothermel agreed that another survey should be conducted to better reflect current practice trends.

If vascular surgeons are to pick up the bulk of the caseload, however, efforts to recruit medical students to the specialty may need to be enhanced. A recent survey of 338 medical students showed that 236 first- and second-year students had no clinical exposure to vascular surgery, while only 38 of the 102 third-year students had been exposed to vascular surgery after completing a general surgery rotation (Ann. Vasc. Surg. 2012 July 25 [doi:10.1016/j.avsg.2012.02.012]). Nearly half (49%) of first- and second-year students said that they would consider vascular surgery, however, with another 19% willing to do so if the length of training were reduced.

Dr. Rothermel and Dr. Starr reported no conflicts of interest.

MILWAUKEE – Less invasive lower-extremity endovascular interventions do not reduce hospital readmissions among patients with peripheral artery disease, according to an analysis of the Cerner Health Facts database.

The 30-day readmission rate was 13.9% for patients who underwent open surgery and 15.3% for those who had an endovascular procedure.

Lead author Dr. Todd Vogel expressed surprise that the two approaches were relatively equal, adding that, "I thought with endo, we’re doing less, they’d come back more."

Patrice Wendling/IMNG Medical Media

The common practice of staging lower-limb endovascular interventions is creating concerns that use of hospital readmissions as a quality outcome measure for reimbursement may not accurately identify planned readmissions or quality of care.

Session moderator Dr. Patrick Geraghty said in an interview that lower-extremity intervention outcomes "are probably the most complex and difficult to define outcomes issue for all of vascular surgery," as compared with carotid and aortic aneurysms, and that this is already reflected in efforts proposed by the National Surgical Quality Improvement Program (NSQIP) and the Centers for Medicare and Medicaid Services (CMS).

"Lower-extremity readmission is going to be a real hot-button discussion because we already know it’s substantial," he said. "If I do a stent graft for someone with leg ischemia and the flow improves and they go home on post-op day 1, and I bring them back 10 days later for a planned debridement of a toe ulcer that we’d been looking at, was that bad? Was that poor care, something I should be penalized for?

"Or was it just good care, but it didn’t fit into CMS’s box of everything should be done within one admission and that any readmission is therefore bad?"

The current analysis is unique in that utilizes electronic medical record (EMR) data to provide real-world outcomes for lower-limb interventions, said Dr. Geraghty, a vascular surgeon with Barnes-Jewish Hospital in St. Louis.

"I think we’re seeing here maybe the first fruits of good EMR design, and it’s a prod for surgeons to look into EMR design and ask whether we can design EMR notes for vascular follow-up in the ER such that we pull good EMR data over great numbers of patients," he said at the annual meeting of the Midwestern Vascular Surgical Society.

Dr. Vogel said that the Cerner database is not as population based as Medicare, capturing observational patient EMR data on more than 84 million admissions and ambulatory visits at roughly 187 participating hospitals, albeit primarily urban. Cerner is the second largest EMR in the United States after Epic.

The analysis encompassed 1,458 elective first admissions with a diagnosis of peripheral artery disease (PAD) undergoing a lower-extremity procedure from October 2008 to December 2010. Of these, 777 had open surgery and 681 an endovascular procedure.

Intermittent claudication was the most common indication for any procedure, present in 56.2% of open and 43.8% of endovascular patients.

The overall readmission rate at 30 days was surprisingly high at 14.5%, and was also unexpectedly high for for those with claudication, at 10.2% in the open and 11.3% in the endovascular group, said Dr. Vogel, chief of vascular surgery at the University of Missouri Hospitals and Clinics, Columbia.

"The frightening number to think about is that, in the claudicant group, we have a 10% readmission rate within 30 days," he said, noting that rates were very similar between groups. "So that’s a number we should all begin to think about."

As expected, readmission rates in the open and endovascular groups increased with disease severity. Rates for rest pain and gangrene were 14% vs. 18.2%, and 22% vs. 24%, respectively.

In bivariate analysis, blacks were significantly more likely to be readmitted 30 days after discharge (odds ratio, 1.56), as were patients discharged to a skilled nursing facility or nursing home (OR, 2.59), he said.

There was a nonsignificant trend toward higher readmissions at teaching hospitals (OR, 1.20), while a hospital stay of more than 7 days was a strong, significant predictor of 30-day readmission (OR, 2.54).

Readmissions also were increased in patients with a Charlson Comorbidity Index score of 3-5 (OR, 1.56) or score of 6-10 (OR, 1.90), diabetes (OR, 1.41), or sepsis (OR, 2.99), he said.

The risk of 30-day readmission was increased more than fivefold among patients with poor liver function, as indicated by total bilirubin levels greater than 2 mg/dL (OR, 5.15) or AST over 100 U/L (OR, 5.56). Risk was also more than twofold higher among patients with renal disease, as indicated by hemoglobin (nadir) less than 8 g/dL (OR, 2.17) and serum creatinine of at least 2 mg/dL (OR, 2.07), as well as those dispensed a staggering 30 medications or more (OR, 2.63), Dr. Vogel reported.

Notably, patients with cardiac troponin levels above 0.2 mg/dL were not at significantly higher risk of readmission (OR, 1.75), although those with a white blood cell count greater than 15,000/mcL were (OR, 2.1), which goes along with the finding of sepsis, he said.

In multivariate logistic regression analysis adjusting for age, disease severity, and race, PAD severity dropped out but male gender (OR, 1.39), Charlson Comorbidity Index (OR 1.12), length of stay (OR, 1.25), AST (OR 2.89), and more than 30 dispensed medications (OR, 1.84) remained significant.

"I think these are the things we’re going to have to look at if we’re going to really address readmissions," Dr. Vogel said.

He highlighted a new algorithm created at the Dartmouth-Hitchcock Medical Center that describes strategies for both predicting and preventing readmissions in vascular surgery (J. Vasc. Surg. 2012 56:556-62).

"It’s fun to describe all this, but the next step is to create change," he added.

During a discussion of the study, Dr. Vogel said that it was possible to calculate specialty-specific readmission rates but that such an analysis had not been performed yet.

Patrice Wendling/IMNG Medical Media

Society for Vascular Surgery (SVS) President Peter Gloviczki then rose from the audience to say that such an analysis is very important in light of a recent Medicare database analysis reporting that endovascular lower-extremity revascularization performed by vascular specialists results in higher costs, longer hospital stays, and more repeat revascularization procedures and amputations than the same procedure performed by interventional radiologists (J. Vasc. Interv. Radiol. 2012:23:3-9).

He went on to say that the controversial paper, which was sharply rebuked by past SVS President Richard Cambria, failed to define indications for the interventions or major vs. minor amputations.

"I think if your data show, not necessarily the outcome, but the case mix of the specialties and what we believe is the severity of disease that vascular surgeons take care of compared to radiologists, that would be very good because that is a way to answer with data, and not with rhetoric," Dr. Gloviczki said.

Dr. Vogel agreed that vascular surgeons, as a rule, treat sicker patients with heavier disease burden, subsequently leading to these various secondary outcomes, and that the Medicare analysis failed to adequately process the data.

"It was a very jaded view," he said.

Session comoderator Dr. Melina Kibbe, a vascular surgeon with Northwestern Memorial Hospital in Chicago, said that the current analysis is the first to use the Cerner database and "that this could be why we’re seeing different outcomes than what other people have reported because this is a more real-world database."

She went on to say that using lower-extremity readmissions as a quality measure is highly problematic because care of these patients, much like that for those with cancer, is often staged and extends for years.

Those thoughts were echoed by the newly elected president of the Midwestern Vascular Surgical Society, Dr. Timothy Kresowik. In an interview, he said, "I’d stay away from lower extremity to begin with. I think it’s just a terrible area to try to do performance measures, especially short-term performance measures, because the important thing to remember about lower-extremity bypass is the real issues are long term."

Dr. Vogel, Dr. Geraghty, Dr. Gloviczki, Dr. Kibbe, and Dr. Kresowik reported having no relevant conflicts of interest.

MILWAUKEE – Less invasive lower-extremity endovascular interventions do not reduce hospital readmissions among patients with peripheral artery disease, according to an analysis of the Cerner Health Facts database.

The 30-day readmission rate was 13.9% for patients who underwent open surgery and 15.3% for those who had an endovascular procedure.

Lead author Dr. Todd Vogel expressed surprise that the two approaches were relatively equal, adding that, "I thought with endo, we’re doing less, they’d come back more."

Patrice Wendling/IMNG Medical Media

The common practice of staging lower-limb endovascular interventions is creating concerns that use of hospital readmissions as a quality outcome measure for reimbursement may not accurately identify planned readmissions or quality of care.

Session moderator Dr. Patrick Geraghty said in an interview that lower-extremity intervention outcomes "are probably the most complex and difficult to define outcomes issue for all of vascular surgery," as compared with carotid and aortic aneurysms, and that this is already reflected in efforts proposed by the National Surgical Quality Improvement Program (NSQIP) and the Centers for Medicare and Medicaid Services (CMS).

"Lower-extremity readmission is going to be a real hot-button discussion because we already know it’s substantial," he said. "If I do a stent graft for someone with leg ischemia and the flow improves and they go home on post-op day 1, and I bring them back 10 days later for a planned debridement of a toe ulcer that we’d been looking at, was that bad? Was that poor care, something I should be penalized for?

"Or was it just good care, but it didn’t fit into CMS’s box of everything should be done within one admission and that any readmission is therefore bad?"

The current analysis is unique in that utilizes electronic medical record (EMR) data to provide real-world outcomes for lower-limb interventions, said Dr. Geraghty, a vascular surgeon with Barnes-Jewish Hospital in St. Louis.

"I think we’re seeing here maybe the first fruits of good EMR design, and it’s a prod for surgeons to look into EMR design and ask whether we can design EMR notes for vascular follow-up in the ER such that we pull good EMR data over great numbers of patients," he said at the annual meeting of the Midwestern Vascular Surgical Society.

Dr. Vogel said that the Cerner database is not as population based as Medicare, capturing observational patient EMR data on more than 84 million admissions and ambulatory visits at roughly 187 participating hospitals, albeit primarily urban. Cerner is the second largest EMR in the United States after Epic.

The analysis encompassed 1,458 elective first admissions with a diagnosis of peripheral artery disease (PAD) undergoing a lower-extremity procedure from October 2008 to December 2010. Of these, 777 had open surgery and 681 an endovascular procedure.

Intermittent claudication was the most common indication for any procedure, present in 56.2% of open and 43.8% of endovascular patients.

The overall readmission rate at 30 days was surprisingly high at 14.5%, and was also unexpectedly high for for those with claudication, at 10.2% in the open and 11.3% in the endovascular group, said Dr. Vogel, chief of vascular surgery at the University of Missouri Hospitals and Clinics, Columbia.

"The frightening number to think about is that, in the claudicant group, we have a 10% readmission rate within 30 days," he said, noting that rates were very similar between groups. "So that’s a number we should all begin to think about."

As expected, readmission rates in the open and endovascular groups increased with disease severity. Rates for rest pain and gangrene were 14% vs. 18.2%, and 22% vs. 24%, respectively.

In bivariate analysis, blacks were significantly more likely to be readmitted 30 days after discharge (odds ratio, 1.56), as were patients discharged to a skilled nursing facility or nursing home (OR, 2.59), he said.

There was a nonsignificant trend toward higher readmissions at teaching hospitals (OR, 1.20), while a hospital stay of more than 7 days was a strong, significant predictor of 30-day readmission (OR, 2.54).

Readmissions also were increased in patients with a Charlson Comorbidity Index score of 3-5 (OR, 1.56) or score of 6-10 (OR, 1.90), diabetes (OR, 1.41), or sepsis (OR, 2.99), he said.

The risk of 30-day readmission was increased more than fivefold among patients with poor liver function, as indicated by total bilirubin levels greater than 2 mg/dL (OR, 5.15) or AST over 100 U/L (OR, 5.56). Risk was also more than twofold higher among patients with renal disease, as indicated by hemoglobin (nadir) less than 8 g/dL (OR, 2.17) and serum creatinine of at least 2 mg/dL (OR, 2.07), as well as those dispensed a staggering 30 medications or more (OR, 2.63), Dr. Vogel reported.

Notably, patients with cardiac troponin levels above 0.2 mg/dL were not at significantly higher risk of readmission (OR, 1.75), although those with a white blood cell count greater than 15,000/mcL were (OR, 2.1), which goes along with the finding of sepsis, he said.

In multivariate logistic regression analysis adjusting for age, disease severity, and race, PAD severity dropped out but male gender (OR, 1.39), Charlson Comorbidity Index (OR 1.12), length of stay (OR, 1.25), AST (OR 2.89), and more than 30 dispensed medications (OR, 1.84) remained significant.

"I think these are the things we’re going to have to look at if we’re going to really address readmissions," Dr. Vogel said.

He highlighted a new algorithm created at the Dartmouth-Hitchcock Medical Center that describes strategies for both predicting and preventing readmissions in vascular surgery (J. Vasc. Surg. 2012 56:556-62).

"It’s fun to describe all this, but the next step is to create change," he added.

During a discussion of the study, Dr. Vogel said that it was possible to calculate specialty-specific readmission rates but that such an analysis had not been performed yet.

Patrice Wendling/IMNG Medical Media

Society for Vascular Surgery (SVS) President Peter Gloviczki then rose from the audience to say that such an analysis is very important in light of a recent Medicare database analysis reporting that endovascular lower-extremity revascularization performed by vascular specialists results in higher costs, longer hospital stays, and more repeat revascularization procedures and amputations than the same procedure performed by interventional radiologists (J. Vasc. Interv. Radiol. 2012:23:3-9).

He went on to say that the controversial paper, which was sharply rebuked by past SVS President Richard Cambria, failed to define indications for the interventions or major vs. minor amputations.

"I think if your data show, not necessarily the outcome, but the case mix of the specialties and what we believe is the severity of disease that vascular surgeons take care of compared to radiologists, that would be very good because that is a way to answer with data, and not with rhetoric," Dr. Gloviczki said.

Dr. Vogel agreed that vascular surgeons, as a rule, treat sicker patients with heavier disease burden, subsequently leading to these various secondary outcomes, and that the Medicare analysis failed to adequately process the data.

"It was a very jaded view," he said.

Session comoderator Dr. Melina Kibbe, a vascular surgeon with Northwestern Memorial Hospital in Chicago, said that the current analysis is the first to use the Cerner database and "that this could be why we’re seeing different outcomes than what other people have reported because this is a more real-world database."

She went on to say that using lower-extremity readmissions as a quality measure is highly problematic because care of these patients, much like that for those with cancer, is often staged and extends for years.

Those thoughts were echoed by the newly elected president of the Midwestern Vascular Surgical Society, Dr. Timothy Kresowik. In an interview, he said, "I’d stay away from lower extremity to begin with. I think it’s just a terrible area to try to do performance measures, especially short-term performance measures, because the important thing to remember about lower-extremity bypass is the real issues are long term."

Dr. Vogel, Dr. Geraghty, Dr. Gloviczki, Dr. Kibbe, and Dr. Kresowik reported having no relevant conflicts of interest.

MILWAUKEE – Less invasive lower-extremity endovascular interventions do not reduce hospital readmissions among patients with peripheral artery disease, according to an analysis of the Cerner Health Facts database.

The 30-day readmission rate was 13.9% for patients who underwent open surgery and 15.3% for those who had an endovascular procedure.

Lead author Dr. Todd Vogel expressed surprise that the two approaches were relatively equal, adding that, "I thought with endo, we’re doing less, they’d come back more."

Patrice Wendling/IMNG Medical Media

The common practice of staging lower-limb endovascular interventions is creating concerns that use of hospital readmissions as a quality outcome measure for reimbursement may not accurately identify planned readmissions or quality of care.

Session moderator Dr. Patrick Geraghty said in an interview that lower-extremity intervention outcomes "are probably the most complex and difficult to define outcomes issue for all of vascular surgery," as compared with carotid and aortic aneurysms, and that this is already reflected in efforts proposed by the National Surgical Quality Improvement Program (NSQIP) and the Centers for Medicare and Medicaid Services (CMS).

"Lower-extremity readmission is going to be a real hot-button discussion because we already know it’s substantial," he said. "If I do a stent graft for someone with leg ischemia and the flow improves and they go home on post-op day 1, and I bring them back 10 days later for a planned debridement of a toe ulcer that we’d been looking at, was that bad? Was that poor care, something I should be penalized for?

"Or was it just good care, but it didn’t fit into CMS’s box of everything should be done within one admission and that any readmission is therefore bad?"

The current analysis is unique in that utilizes electronic medical record (EMR) data to provide real-world outcomes for lower-limb interventions, said Dr. Geraghty, a vascular surgeon with Barnes-Jewish Hospital in St. Louis.

"I think we’re seeing here maybe the first fruits of good EMR design, and it’s a prod for surgeons to look into EMR design and ask whether we can design EMR notes for vascular follow-up in the ER such that we pull good EMR data over great numbers of patients," he said at the annual meeting of the Midwestern Vascular Surgical Society.

Dr. Vogel said that the Cerner database is not as population based as Medicare, capturing observational patient EMR data on more than 84 million admissions and ambulatory visits at roughly 187 participating hospitals, albeit primarily urban. Cerner is the second largest EMR in the United States after Epic.

The analysis encompassed 1,458 elective first admissions with a diagnosis of peripheral artery disease (PAD) undergoing a lower-extremity procedure from October 2008 to December 2010. Of these, 777 had open surgery and 681 an endovascular procedure.

Intermittent claudication was the most common indication for any procedure, present in 56.2% of open and 43.8% of endovascular patients.

The overall readmission rate at 30 days was surprisingly high at 14.5%, and was also unexpectedly high for for those with claudication, at 10.2% in the open and 11.3% in the endovascular group, said Dr. Vogel, chief of vascular surgery at the University of Missouri Hospitals and Clinics, Columbia.

"The frightening number to think about is that, in the claudicant group, we have a 10% readmission rate within 30 days," he said, noting that rates were very similar between groups. "So that’s a number we should all begin to think about."

As expected, readmission rates in the open and endovascular groups increased with disease severity. Rates for rest pain and gangrene were 14% vs. 18.2%, and 22% vs. 24%, respectively.

In bivariate analysis, blacks were significantly more likely to be readmitted 30 days after discharge (odds ratio, 1.56), as were patients discharged to a skilled nursing facility or nursing home (OR, 2.59), he said.

There was a nonsignificant trend toward higher readmissions at teaching hospitals (OR, 1.20), while a hospital stay of more than 7 days was a strong, significant predictor of 30-day readmission (OR, 2.54).

Readmissions also were increased in patients with a Charlson Comorbidity Index score of 3-5 (OR, 1.56) or score of 6-10 (OR, 1.90), diabetes (OR, 1.41), or sepsis (OR, 2.99), he said.

The risk of 30-day readmission was increased more than fivefold among patients with poor liver function, as indicated by total bilirubin levels greater than 2 mg/dL (OR, 5.15) or AST over 100 U/L (OR, 5.56). Risk was also more than twofold higher among patients with renal disease, as indicated by hemoglobin (nadir) less than 8 g/dL (OR, 2.17) and serum creatinine of at least 2 mg/dL (OR, 2.07), as well as those dispensed a staggering 30 medications or more (OR, 2.63), Dr. Vogel reported.

Notably, patients with cardiac troponin levels above 0.2 mg/dL were not at significantly higher risk of readmission (OR, 1.75), although those with a white blood cell count greater than 15,000/mcL were (OR, 2.1), which goes along with the finding of sepsis, he said.

In multivariate logistic regression analysis adjusting for age, disease severity, and race, PAD severity dropped out but male gender (OR, 1.39), Charlson Comorbidity Index (OR 1.12), length of stay (OR, 1.25), AST (OR 2.89), and more than 30 dispensed medications (OR, 1.84) remained significant.

"I think these are the things we’re going to have to look at if we’re going to really address readmissions," Dr. Vogel said.

He highlighted a new algorithm created at the Dartmouth-Hitchcock Medical Center that describes strategies for both predicting and preventing readmissions in vascular surgery (J. Vasc. Surg. 2012 56:556-62).

"It’s fun to describe all this, but the next step is to create change," he added.

During a discussion of the study, Dr. Vogel said that it was possible to calculate specialty-specific readmission rates but that such an analysis had not been performed yet.

Patrice Wendling/IMNG Medical Media

Society for Vascular Surgery (SVS) President Peter Gloviczki then rose from the audience to say that such an analysis is very important in light of a recent Medicare database analysis reporting that endovascular lower-extremity revascularization performed by vascular specialists results in higher costs, longer hospital stays, and more repeat revascularization procedures and amputations than the same procedure performed by interventional radiologists (J. Vasc. Interv. Radiol. 2012:23:3-9).

He went on to say that the controversial paper, which was sharply rebuked by past SVS President Richard Cambria, failed to define indications for the interventions or major vs. minor amputations.

"I think if your data show, not necessarily the outcome, but the case mix of the specialties and what we believe is the severity of disease that vascular surgeons take care of compared to radiologists, that would be very good because that is a way to answer with data, and not with rhetoric," Dr. Gloviczki said.

Dr. Vogel agreed that vascular surgeons, as a rule, treat sicker patients with heavier disease burden, subsequently leading to these various secondary outcomes, and that the Medicare analysis failed to adequately process the data.

"It was a very jaded view," he said.

Session comoderator Dr. Melina Kibbe, a vascular surgeon with Northwestern Memorial Hospital in Chicago, said that the current analysis is the first to use the Cerner database and "that this could be why we’re seeing different outcomes than what other people have reported because this is a more real-world database."

She went on to say that using lower-extremity readmissions as a quality measure is highly problematic because care of these patients, much like that for those with cancer, is often staged and extends for years.

Those thoughts were echoed by the newly elected president of the Midwestern Vascular Surgical Society, Dr. Timothy Kresowik. In an interview, he said, "I’d stay away from lower extremity to begin with. I think it’s just a terrible area to try to do performance measures, especially short-term performance measures, because the important thing to remember about lower-extremity bypass is the real issues are long term."

Dr. Vogel, Dr. Geraghty, Dr. Gloviczki, Dr. Kibbe, and Dr. Kresowik reported having no relevant conflicts of interest.

MILWAUKEE – The risk for worse outcomes following carotid-artery stenting may extend to even younger Medicare-age patients than previously reported by such pivotal trials as CREST, a provocative population study suggests.

The rate of the composite primary end point of death, stroke, or cardiac complications was 5.2% for carotid angioplasty and stenting (CAS) and 3.6% for carotid endarterectomy (CEA) among patients younger than age 65 years, and was 6.3% vs. 4.5% among patients aged 65 years or older, who comprised 76% of the study cohort (both P values less than .0001).

Patrice Wendling/IMNG Medical Media

Rates of the primary end point were similar between the carotid stenting and endarterectomy groups among asymptomatic patients aged 65 years or older (4.1% vs. 3.8%; P = .25), but were significantly higher in symptomatic patients age 65 years or older who received stenting (22.5% vs. 12.5%; P less than .0001).

This finding was driven by significantly higher rates of all three individual components of the primary end point: death (5.1% vs. 2.2%), stroke (12.5% vs. 7.6%), and cardiac complications (7.5% v s. 4.2%), "which is a little bit different than what we thought, compared with the CREST trial," lead author Dr. Jeffrey Jim said at the annual Midwestern Vascular Surgical Society meeting.

In the lead-in phase of CREST (Carotid Revascularization Endarterectomy vs. Stent Trial), octogenarians were found to be at higher risk of in-hospital death and stroke post CAS, but not myocardial infarction (J. Vasc. Surg. 2004;40:1106-11).

Subsequent CREST analyses have identified an interaction between age and carotid stenting efficacy, with the crossover at an age of approximately 70 years (N. Engl. J. Med. 2010;363:11-23).

The current results appear to move that threshold to an even younger age, just as the Centers for Medicare and Medicaid Services starts reconsidering the national coverage decision for carotid-artery stenting. Although he did not present the data, Dr. Jim noted that hospital costs also were higher for stenting patients.

Patrice Wendling/IMNG Medical Media

"Our results show that carotid angioplasty and stenting was associated with a higher rate of adverse outcomes and increased charges among patients of Medicare age, and really don’t support the widespread use of carotid stenting over CEA in this general population," Dr. Jim said.

Session moderator Dr. Patrick Geraghty, a vascular surgeon with Barnes–Jewish Health in St. Louis, said the difference in MI rates between arms "basically turns the CREST findings on their head," and asked whether cardiac troponin levels were tracked equally in both arms.

Dr. Jim responded that such tracking wasn’t possible with the Nationwide Inpatient Sample (NIS) database used for the analysis, and that it’s unknown whether one hospital called a troponin level of 0.15 ng/mL a troponin leak, while another coded that as an MI. Anatomic information and operative details also were not available.

The analysis was based on 678,081 hospitalizations for CEA and CAS from 2005 to 2009, the latest available data in the NIS, a comprehensive, inpatient database developed as part of the Healthcare Cost and Utilization Project and designed to approximate a 20% sample of U.S. hospitals.

The 595,813 CEA patients were more likely to be asymptomatic, whereas the 82,268 CAS patients were more likely to be male, medically high risk, treated at a teaching hospital, and an emergent/urgent admission.

The average age was 71 years in the CEA group and 70 years in the CAS group. Three-fourths of both groups had Medicare insurance coverage.

In the entire study cohort, the composite primary end point occurred in 6% of the carotid stenting group and 4.3% of the endarterectomy group (P less than .0001), said Dr. Jim, a vascular specialist at Washington University School of Medicine, St. Louis.

Patients who underwent carotid stenting experienced significantly higher rates of each individual component of the primary end point: death (1.1% vs. 0.5%), stroke (2% vs. 1%) and cardiac complications (3.6% vs. 3.1%).

Independent predictors of the primary end point were CAS, symptomatic stenosis, and medical high risk, defined as a patient age 80 years or older, or a patient who had renal failure, severe chronic lung disease, recent MI, coronary bypass/valve surgery within 30 days, unstable angina, or class III/IV heart failure.

Dr. Jim and Dr. Geraghty reported having no relevant conflicts of interest.

MILWAUKEE – The risk for worse outcomes following carotid-artery stenting may extend to even younger Medicare-age patients than previously reported by such pivotal trials as CREST, a provocative population study suggests.

The rate of the composite primary end point of death, stroke, or cardiac complications was 5.2% for carotid angioplasty and stenting (CAS) and 3.6% for carotid endarterectomy (CEA) among patients younger than age 65 years, and was 6.3% vs. 4.5% among patients aged 65 years or older, who comprised 76% of the study cohort (both P values less than .0001).

Patrice Wendling/IMNG Medical Media

Rates of the primary end point were similar between the carotid stenting and endarterectomy groups among asymptomatic patients aged 65 years or older (4.1% vs. 3.8%; P = .25), but were significantly higher in symptomatic patients age 65 years or older who received stenting (22.5% vs. 12.5%; P less than .0001).

This finding was driven by significantly higher rates of all three individual components of the primary end point: death (5.1% vs. 2.2%), stroke (12.5% vs. 7.6%), and cardiac complications (7.5% v s. 4.2%), "which is a little bit different than what we thought, compared with the CREST trial," lead author Dr. Jeffrey Jim said at the annual Midwestern Vascular Surgical Society meeting.

In the lead-in phase of CREST (Carotid Revascularization Endarterectomy vs. Stent Trial), octogenarians were found to be at higher risk of in-hospital death and stroke post CAS, but not myocardial infarction (J. Vasc. Surg. 2004;40:1106-11).

Subsequent CREST analyses have identified an interaction between age and carotid stenting efficacy, with the crossover at an age of approximately 70 years (N. Engl. J. Med. 2010;363:11-23).

The current results appear to move that threshold to an even younger age, just as the Centers for Medicare and Medicaid Services starts reconsidering the national coverage decision for carotid-artery stenting. Although he did not present the data, Dr. Jim noted that hospital costs also were higher for stenting patients.

Patrice Wendling/IMNG Medical Media

"Our results show that carotid angioplasty and stenting was associated with a higher rate of adverse outcomes and increased charges among patients of Medicare age, and really don’t support the widespread use of carotid stenting over CEA in this general population," Dr. Jim said.

Session moderator Dr. Patrick Geraghty, a vascular surgeon with Barnes–Jewish Health in St. Louis, said the difference in MI rates between arms "basically turns the CREST findings on their head," and asked whether cardiac troponin levels were tracked equally in both arms.

Dr. Jim responded that such tracking wasn’t possible with the Nationwide Inpatient Sample (NIS) database used for the analysis, and that it’s unknown whether one hospital called a troponin level of 0.15 ng/mL a troponin leak, while another coded that as an MI. Anatomic information and operative details also were not available.

The analysis was based on 678,081 hospitalizations for CEA and CAS from 2005 to 2009, the latest available data in the NIS, a comprehensive, inpatient database developed as part of the Healthcare Cost and Utilization Project and designed to approximate a 20% sample of U.S. hospitals.

The 595,813 CEA patients were more likely to be asymptomatic, whereas the 82,268 CAS patients were more likely to be male, medically high risk, treated at a teaching hospital, and an emergent/urgent admission.

The average age was 71 years in the CEA group and 70 years in the CAS group. Three-fourths of both groups had Medicare insurance coverage.

In the entire study cohort, the composite primary end point occurred in 6% of the carotid stenting group and 4.3% of the endarterectomy group (P less than .0001), said Dr. Jim, a vascular specialist at Washington University School of Medicine, St. Louis.

Patients who underwent carotid stenting experienced significantly higher rates of each individual component of the primary end point: death (1.1% vs. 0.5%), stroke (2% vs. 1%) and cardiac complications (3.6% vs. 3.1%).

Independent predictors of the primary end point were CAS, symptomatic stenosis, and medical high risk, defined as a patient age 80 years or older, or a patient who had renal failure, severe chronic lung disease, recent MI, coronary bypass/valve surgery within 30 days, unstable angina, or class III/IV heart failure.

Dr. Jim and Dr. Geraghty reported having no relevant conflicts of interest.

MILWAUKEE – The risk for worse outcomes following carotid-artery stenting may extend to even younger Medicare-age patients than previously reported by such pivotal trials as CREST, a provocative population study suggests.

The rate of the composite primary end point of death, stroke, or cardiac complications was 5.2% for carotid angioplasty and stenting (CAS) and 3.6% for carotid endarterectomy (CEA) among patients younger than age 65 years, and was 6.3% vs. 4.5% among patients aged 65 years or older, who comprised 76% of the study cohort (both P values less than .0001).

Patrice Wendling/IMNG Medical Media

Rates of the primary end point were similar between the carotid stenting and endarterectomy groups among asymptomatic patients aged 65 years or older (4.1% vs. 3.8%; P = .25), but were significantly higher in symptomatic patients age 65 years or older who received stenting (22.5% vs. 12.5%; P less than .0001).

This finding was driven by significantly higher rates of all three individual components of the primary end point: death (5.1% vs. 2.2%), stroke (12.5% vs. 7.6%), and cardiac complications (7.5% v s. 4.2%), "which is a little bit different than what we thought, compared with the CREST trial," lead author Dr. Jeffrey Jim said at the annual Midwestern Vascular Surgical Society meeting.

In the lead-in phase of CREST (Carotid Revascularization Endarterectomy vs. Stent Trial), octogenarians were found to be at higher risk of in-hospital death and stroke post CAS, but not myocardial infarction (J. Vasc. Surg. 2004;40:1106-11).

Subsequent CREST analyses have identified an interaction between age and carotid stenting efficacy, with the crossover at an age of approximately 70 years (N. Engl. J. Med. 2010;363:11-23).

The current results appear to move that threshold to an even younger age, just as the Centers for Medicare and Medicaid Services starts reconsidering the national coverage decision for carotid-artery stenting. Although he did not present the data, Dr. Jim noted that hospital costs also were higher for stenting patients.

Patrice Wendling/IMNG Medical Media

"Our results show that carotid angioplasty and stenting was associated with a higher rate of adverse outcomes and increased charges among patients of Medicare age, and really don’t support the widespread use of carotid stenting over CEA in this general population," Dr. Jim said.

Session moderator Dr. Patrick Geraghty, a vascular surgeon with Barnes–Jewish Health in St. Louis, said the difference in MI rates between arms "basically turns the CREST findings on their head," and asked whether cardiac troponin levels were tracked equally in both arms.

Dr. Jim responded that such tracking wasn’t possible with the Nationwide Inpatient Sample (NIS) database used for the analysis, and that it’s unknown whether one hospital called a troponin level of 0.15 ng/mL a troponin leak, while another coded that as an MI. Anatomic information and operative details also were not available.

The analysis was based on 678,081 hospitalizations for CEA and CAS from 2005 to 2009, the latest available data in the NIS, a comprehensive, inpatient database developed as part of the Healthcare Cost and Utilization Project and designed to approximate a 20% sample of U.S. hospitals.

The 595,813 CEA patients were more likely to be asymptomatic, whereas the 82,268 CAS patients were more likely to be male, medically high risk, treated at a teaching hospital, and an emergent/urgent admission.

The average age was 71 years in the CEA group and 70 years in the CAS group. Three-fourths of both groups had Medicare insurance coverage.

In the entire study cohort, the composite primary end point occurred in 6% of the carotid stenting group and 4.3% of the endarterectomy group (P less than .0001), said Dr. Jim, a vascular specialist at Washington University School of Medicine, St. Louis.

Patients who underwent carotid stenting experienced significantly higher rates of each individual component of the primary end point: death (1.1% vs. 0.5%), stroke (2% vs. 1%) and cardiac complications (3.6% vs. 3.1%).

Independent predictors of the primary end point were CAS, symptomatic stenosis, and medical high risk, defined as a patient age 80 years or older, or a patient who had renal failure, severe chronic lung disease, recent MI, coronary bypass/valve surgery within 30 days, unstable angina, or class III/IV heart failure.

Dr. Jim and Dr. Geraghty reported having no relevant conflicts of interest.