Vascular

SAN FRANCISCO – The introduction of endovascular aneurysm repair, or EVAR, has improved outcomes for the repair of intact and ruptured aortic abdominal aneurysms, particularly among those aged 80 years and older, based on a review of more than 400,000 Medicare beneficiaries.

Among patients in this age group, there was an increase in the number of intact abdominal aortic aneurysm (AAA) repairs, coupled with declines in rupture deaths. In those younger than 75 years, intact repair rates decreased about 10%. Those aged 75-79 years had an increase of about 10%. However, those aged 80 years and older had a more dramatic increase of more than 50%. In addition, operative mortality for intact repair has decreased over time for all age groups, although the decline becomes greater with increasing age.

"The greatest benefit [of EVAR] has been seen in those over 80, who had the largest increase in intact repair rates, the largest decline in intact repair mortality, and the largest decline in rupture deaths," Dr. Marc L. Schermerhorn said at the annual meeting of the American Surgical Association.

The researchers used a 100% sample of Medicare data between 1995 and 2008. They identified patients with intact AAAs undergoing repair – by either EVAR or open surgical repair – as well as patients with ruptured AAAs (with and without repair). They determined the 30-day or in-hospital mortality, then standardized the rates (per 100,000 beneficiaries), adjusting for changes in age, sex, and population size over time.

They identified 338,278 intact repairs and 69,653 ruptures (with 47,524 repairs). EVAR use rapidly increased after Food and Drug Administration approval of the procedure in 1999; as of 2008, EVAR was used for 77% of all intact aneurysm repairs.

"There was a more delayed response but an increase nonetheless in the use of EVAR for ruptured aneurysms, to the point where [in 2008] 31% of all ruptured aneurysms are treated with EVAR," said Dr. Schermerhorn. During this time period, the average age of those undergoing repair increased from 73.7 to 75.5 years.

Operative mortality during open intact repair remained steady, at roughly 5%. EVAR mortality dropped from about 2% in 1995 to 1.4% in 2008. The total operative mortality for intact repair (open and EVAR) fell from roughly 5% to 2.4%, despite the fact that there were more repairs in 2008 and the average age of these patients increased.

"As we increase our utilization of EVAR, this is driving down the total mortality of intact aneurysm repair, so that it’s half of what it was at the beginning of that time period," said Dr. Schermerhorn, chief of vascular and endovascular surgery at Beth Israel Deaconess Medical Center in Boston.

The researchers also found that the annual number of ruptures decreased from 6,535 in 1995 to 3,298 in 2008. The greatest decrease in ruptures (repaired or not) was seen in older patients – those 75 years and older – but there was also a decline among patients younger than 75 years. The mortality with open rupture repair remained largely unchanged during the time period (approximately 45%). However, EVAR rupture repair declined from about 45% to 28%. The rate of all rupture repairs also has decreased from about 45% to 36%.

"Rather than suggesting that we’re simply taking the hemodynamically stable patients for EVAR, the best evidence to say that there’s actually a true reduction in mortality is the fact that for the first time in 3 decades, the overall mortality for ruptured aneurysm repair is now well below 40%," Dr. Schermerhorn said. The mortality for all ruptures (repaired or not) has gone down the most dramatically in those aged 80 years and older, although there were declines in the other age groups as well.

Invited discussant Dr. Philip B. Paty noted that reduced rates of intact aneurysm repair and rupture in patients aged 65-74 years may be attributed to a change in the natural history or a decline in the incidence of aneurysms.

"Did you evaluate the age-specific incidence of comorbidities or medical risk over the period of study to see if we are, in fact, dealing with different patient populations? Alternatively, is it possible that repair in recent years was deferred until a larger sac size was present?" he asked.

"We did look at comorbidities over time, and there have been increases in all of the various comorbidities that you would typically associate with aortic aneurysm patients. Coronary artery disease, peripheral arterial disease, hypertension, and [heart failure] all increased. We did not have access to data about rates of cigarette smoking or medication," Dr. Schermerhorn said.

Other studies have shown that the rate of smoking has gone down with time and the use of statins has gone up. There may be better control of hypertension as well. "We think that it’s possible that for those reasons, there may be a decreasing incidence of aortic aneurysm in the United States." Data from the United Kingdom, Sweden, and Australia suggest that there may be a decline in those countries, he added.

Dr. Paty, vice chair of clinical research in the department of surgery at Memorial Sloan-Kettering Cancer Center in New York, also questioned whether the data reflect a change in practice to observing smaller aneurysms, delaying repair.

This may be the case, according to Dr. Schermerhorn. "Are we deferring aneurysms? I would agree completely." Studies have shown "that it’s safe for us to wait until the aneurysms are up in the 5.5-cm range. So I think that a lot of that redistribution of those [younger than 75 years to those just older than 75] may represent that. That should, however, decrease the rate of aneurysm repair that we do, and some patients will die of competitive causes during that observation period. So that should not be reflected in the increased rate of repair that we detected." In addition, the increased use of advanced abdominal imaging has led to the identification of more aneurysms.

The complete manuscript of this presentation is anticipated to be published in the Annals of Surgery pending editorial review.

The authors reported that they have no relevant conflicts of interest.

SAN FRANCISCO – The introduction of endovascular aneurysm repair, or EVAR, has improved outcomes for the repair of intact and ruptured aortic abdominal aneurysms, particularly among those aged 80 years and older, based on a review of more than 400,000 Medicare beneficiaries.

Among patients in this age group, there was an increase in the number of intact abdominal aortic aneurysm (AAA) repairs, coupled with declines in rupture deaths. In those younger than 75 years, intact repair rates decreased about 10%. Those aged 75-79 years had an increase of about 10%. However, those aged 80 years and older had a more dramatic increase of more than 50%. In addition, operative mortality for intact repair has decreased over time for all age groups, although the decline becomes greater with increasing age.

"The greatest benefit [of EVAR] has been seen in those over 80, who had the largest increase in intact repair rates, the largest decline in intact repair mortality, and the largest decline in rupture deaths," Dr. Marc L. Schermerhorn said at the annual meeting of the American Surgical Association.

The researchers used a 100% sample of Medicare data between 1995 and 2008. They identified patients with intact AAAs undergoing repair – by either EVAR or open surgical repair – as well as patients with ruptured AAAs (with and without repair). They determined the 30-day or in-hospital mortality, then standardized the rates (per 100,000 beneficiaries), adjusting for changes in age, sex, and population size over time.

They identified 338,278 intact repairs and 69,653 ruptures (with 47,524 repairs). EVAR use rapidly increased after Food and Drug Administration approval of the procedure in 1999; as of 2008, EVAR was used for 77% of all intact aneurysm repairs.

"There was a more delayed response but an increase nonetheless in the use of EVAR for ruptured aneurysms, to the point where [in 2008] 31% of all ruptured aneurysms are treated with EVAR," said Dr. Schermerhorn. During this time period, the average age of those undergoing repair increased from 73.7 to 75.5 years.

Operative mortality during open intact repair remained steady, at roughly 5%. EVAR mortality dropped from about 2% in 1995 to 1.4% in 2008. The total operative mortality for intact repair (open and EVAR) fell from roughly 5% to 2.4%, despite the fact that there were more repairs in 2008 and the average age of these patients increased.

"As we increase our utilization of EVAR, this is driving down the total mortality of intact aneurysm repair, so that it’s half of what it was at the beginning of that time period," said Dr. Schermerhorn, chief of vascular and endovascular surgery at Beth Israel Deaconess Medical Center in Boston.

The researchers also found that the annual number of ruptures decreased from 6,535 in 1995 to 3,298 in 2008. The greatest decrease in ruptures (repaired or not) was seen in older patients – those 75 years and older – but there was also a decline among patients younger than 75 years. The mortality with open rupture repair remained largely unchanged during the time period (approximately 45%). However, EVAR rupture repair declined from about 45% to 28%. The rate of all rupture repairs also has decreased from about 45% to 36%.

"Rather than suggesting that we’re simply taking the hemodynamically stable patients for EVAR, the best evidence to say that there’s actually a true reduction in mortality is the fact that for the first time in 3 decades, the overall mortality for ruptured aneurysm repair is now well below 40%," Dr. Schermerhorn said. The mortality for all ruptures (repaired or not) has gone down the most dramatically in those aged 80 years and older, although there were declines in the other age groups as well.

Invited discussant Dr. Philip B. Paty noted that reduced rates of intact aneurysm repair and rupture in patients aged 65-74 years may be attributed to a change in the natural history or a decline in the incidence of aneurysms.

"Did you evaluate the age-specific incidence of comorbidities or medical risk over the period of study to see if we are, in fact, dealing with different patient populations? Alternatively, is it possible that repair in recent years was deferred until a larger sac size was present?" he asked.

"We did look at comorbidities over time, and there have been increases in all of the various comorbidities that you would typically associate with aortic aneurysm patients. Coronary artery disease, peripheral arterial disease, hypertension, and [heart failure] all increased. We did not have access to data about rates of cigarette smoking or medication," Dr. Schermerhorn said.

Other studies have shown that the rate of smoking has gone down with time and the use of statins has gone up. There may be better control of hypertension as well. "We think that it’s possible that for those reasons, there may be a decreasing incidence of aortic aneurysm in the United States." Data from the United Kingdom, Sweden, and Australia suggest that there may be a decline in those countries, he added.

Dr. Paty, vice chair of clinical research in the department of surgery at Memorial Sloan-Kettering Cancer Center in New York, also questioned whether the data reflect a change in practice to observing smaller aneurysms, delaying repair.

This may be the case, according to Dr. Schermerhorn. "Are we deferring aneurysms? I would agree completely." Studies have shown "that it’s safe for us to wait until the aneurysms are up in the 5.5-cm range. So I think that a lot of that redistribution of those [younger than 75 years to those just older than 75] may represent that. That should, however, decrease the rate of aneurysm repair that we do, and some patients will die of competitive causes during that observation period. So that should not be reflected in the increased rate of repair that we detected." In addition, the increased use of advanced abdominal imaging has led to the identification of more aneurysms.

The complete manuscript of this presentation is anticipated to be published in the Annals of Surgery pending editorial review.

The authors reported that they have no relevant conflicts of interest.

SAN FRANCISCO – The introduction of endovascular aneurysm repair, or EVAR, has improved outcomes for the repair of intact and ruptured aortic abdominal aneurysms, particularly among those aged 80 years and older, based on a review of more than 400,000 Medicare beneficiaries.

Among patients in this age group, there was an increase in the number of intact abdominal aortic aneurysm (AAA) repairs, coupled with declines in rupture deaths. In those younger than 75 years, intact repair rates decreased about 10%. Those aged 75-79 years had an increase of about 10%. However, those aged 80 years and older had a more dramatic increase of more than 50%. In addition, operative mortality for intact repair has decreased over time for all age groups, although the decline becomes greater with increasing age.

"The greatest benefit [of EVAR] has been seen in those over 80, who had the largest increase in intact repair rates, the largest decline in intact repair mortality, and the largest decline in rupture deaths," Dr. Marc L. Schermerhorn said at the annual meeting of the American Surgical Association.

The researchers used a 100% sample of Medicare data between 1995 and 2008. They identified patients with intact AAAs undergoing repair – by either EVAR or open surgical repair – as well as patients with ruptured AAAs (with and without repair). They determined the 30-day or in-hospital mortality, then standardized the rates (per 100,000 beneficiaries), adjusting for changes in age, sex, and population size over time.

They identified 338,278 intact repairs and 69,653 ruptures (with 47,524 repairs). EVAR use rapidly increased after Food and Drug Administration approval of the procedure in 1999; as of 2008, EVAR was used for 77% of all intact aneurysm repairs.

"There was a more delayed response but an increase nonetheless in the use of EVAR for ruptured aneurysms, to the point where [in 2008] 31% of all ruptured aneurysms are treated with EVAR," said Dr. Schermerhorn. During this time period, the average age of those undergoing repair increased from 73.7 to 75.5 years.

Operative mortality during open intact repair remained steady, at roughly 5%. EVAR mortality dropped from about 2% in 1995 to 1.4% in 2008. The total operative mortality for intact repair (open and EVAR) fell from roughly 5% to 2.4%, despite the fact that there were more repairs in 2008 and the average age of these patients increased.

"As we increase our utilization of EVAR, this is driving down the total mortality of intact aneurysm repair, so that it’s half of what it was at the beginning of that time period," said Dr. Schermerhorn, chief of vascular and endovascular surgery at Beth Israel Deaconess Medical Center in Boston.

The researchers also found that the annual number of ruptures decreased from 6,535 in 1995 to 3,298 in 2008. The greatest decrease in ruptures (repaired or not) was seen in older patients – those 75 years and older – but there was also a decline among patients younger than 75 years. The mortality with open rupture repair remained largely unchanged during the time period (approximately 45%). However, EVAR rupture repair declined from about 45% to 28%. The rate of all rupture repairs also has decreased from about 45% to 36%.

"Rather than suggesting that we’re simply taking the hemodynamically stable patients for EVAR, the best evidence to say that there’s actually a true reduction in mortality is the fact that for the first time in 3 decades, the overall mortality for ruptured aneurysm repair is now well below 40%," Dr. Schermerhorn said. The mortality for all ruptures (repaired or not) has gone down the most dramatically in those aged 80 years and older, although there were declines in the other age groups as well.

Invited discussant Dr. Philip B. Paty noted that reduced rates of intact aneurysm repair and rupture in patients aged 65-74 years may be attributed to a change in the natural history or a decline in the incidence of aneurysms.

"Did you evaluate the age-specific incidence of comorbidities or medical risk over the period of study to see if we are, in fact, dealing with different patient populations? Alternatively, is it possible that repair in recent years was deferred until a larger sac size was present?" he asked.

"We did look at comorbidities over time, and there have been increases in all of the various comorbidities that you would typically associate with aortic aneurysm patients. Coronary artery disease, peripheral arterial disease, hypertension, and [heart failure] all increased. We did not have access to data about rates of cigarette smoking or medication," Dr. Schermerhorn said.

Other studies have shown that the rate of smoking has gone down with time and the use of statins has gone up. There may be better control of hypertension as well. "We think that it’s possible that for those reasons, there may be a decreasing incidence of aortic aneurysm in the United States." Data from the United Kingdom, Sweden, and Australia suggest that there may be a decline in those countries, he added.

Dr. Paty, vice chair of clinical research in the department of surgery at Memorial Sloan-Kettering Cancer Center in New York, also questioned whether the data reflect a change in practice to observing smaller aneurysms, delaying repair.

This may be the case, according to Dr. Schermerhorn. "Are we deferring aneurysms? I would agree completely." Studies have shown "that it’s safe for us to wait until the aneurysms are up in the 5.5-cm range. So I think that a lot of that redistribution of those [younger than 75 years to those just older than 75] may represent that. That should, however, decrease the rate of aneurysm repair that we do, and some patients will die of competitive causes during that observation period. So that should not be reflected in the increased rate of repair that we detected." In addition, the increased use of advanced abdominal imaging has led to the identification of more aneurysms.

The complete manuscript of this presentation is anticipated to be published in the Annals of Surgery pending editorial review.

The authors reported that they have no relevant conflicts of interest.

NATIONAL HARBOR, MD. – Lower-extremity revascularization can be effective in preventing amputation in peripheral arterial disease, but in some regions of the United States, the amount and intensity of vascular care is inversely related to the amputation rate, a large study of Medicare patients indicates.

To examine the relationship between intensity of vascular care and the risk of amputation, Dr. Philip P. Goodney and his colleagues at Dartmouth-Hitchcock Medical Center and the Dartmouth Institute for Health Policy in Lebanon, N.H., studied all open and endovascular revascularizations provided to 20,464 Medicare patients in the year prior to vascular amputation. They examined associations among patient characteristics, the regional rates of revascularization, and the regional amputation rate among the 307 hospital referral regions, as described in the Dartmouth Atlas of Health Care.

Population-based amputation rates varied across regions, from fewer than 1 to more than 44 amputations per 10,000 Medicare patients. Amputation rates were highest in rural regions of the southern and Appalachian United States, Dr. Goodney said at the Vascular Annual Meeting.

Patients in regions with high amputation rates were more commonly African American than were patients in regions with low amputation rates (50% vs. 12%). Furthermore, those in regions with high amputation rates had lower per-capita income, compared with those in regions with low amputation rates ($17,980 vs. $19,545).

Less vascular care was provided to patients who lived where amputation rates were highest. Those patients had 57% fewer therapeutic revascularization procedures (such as bypass surgery or stent placement) than did patients in regions with low amputation rates (2.2 vs. 4.8 revascularizations per amputation). Even the number of diagnostic angiograms was significantly lower in high amputation regions than in low amputation regions (2.4 vs. 5.0 angiograms per amputation).

"Medicare patients living in regions with the highest amputation rate are commonly poor and African American, and they receive less than half as much vascular care as those in regions with lower burdens of vascular disease," said Dr. Goodney. "In these regions, we believe patients commonly present late in their disease process, with ‘unsalvageable’ limbs. Because of wet gangrene or massive tissue loss, it is often too late for vascular care to matter, and surgeons are forced to simply perform an amputation rather than have the opportunity to revascularize and try to save a patient’s leg. However, we hope that our study will help to limit amputations in the future," Dr. Goodney said.

"Our work provides a ‘blueprint’ for improvement, by targeting the regions of the [United States] where early, integrated efforts to prevent amputation – medical, podiatric, and vascular – have the biggest potential to make a difference," he added.

Dr. Goodney reported no relevant disclosures.

NATIONAL HARBOR, MD. – Lower-extremity revascularization can be effective in preventing amputation in peripheral arterial disease, but in some regions of the United States, the amount and intensity of vascular care is inversely related to the amputation rate, a large study of Medicare patients indicates.

To examine the relationship between intensity of vascular care and the risk of amputation, Dr. Philip P. Goodney and his colleagues at Dartmouth-Hitchcock Medical Center and the Dartmouth Institute for Health Policy in Lebanon, N.H., studied all open and endovascular revascularizations provided to 20,464 Medicare patients in the year prior to vascular amputation. They examined associations among patient characteristics, the regional rates of revascularization, and the regional amputation rate among the 307 hospital referral regions, as described in the Dartmouth Atlas of Health Care.

Population-based amputation rates varied across regions, from fewer than 1 to more than 44 amputations per 10,000 Medicare patients. Amputation rates were highest in rural regions of the southern and Appalachian United States, Dr. Goodney said at the Vascular Annual Meeting.

Patients in regions with high amputation rates were more commonly African American than were patients in regions with low amputation rates (50% vs. 12%). Furthermore, those in regions with high amputation rates had lower per-capita income, compared with those in regions with low amputation rates ($17,980 vs. $19,545).

Less vascular care was provided to patients who lived where amputation rates were highest. Those patients had 57% fewer therapeutic revascularization procedures (such as bypass surgery or stent placement) than did patients in regions with low amputation rates (2.2 vs. 4.8 revascularizations per amputation). Even the number of diagnostic angiograms was significantly lower in high amputation regions than in low amputation regions (2.4 vs. 5.0 angiograms per amputation).

"Medicare patients living in regions with the highest amputation rate are commonly poor and African American, and they receive less than half as much vascular care as those in regions with lower burdens of vascular disease," said Dr. Goodney. "In these regions, we believe patients commonly present late in their disease process, with ‘unsalvageable’ limbs. Because of wet gangrene or massive tissue loss, it is often too late for vascular care to matter, and surgeons are forced to simply perform an amputation rather than have the opportunity to revascularize and try to save a patient’s leg. However, we hope that our study will help to limit amputations in the future," Dr. Goodney said.

"Our work provides a ‘blueprint’ for improvement, by targeting the regions of the [United States] where early, integrated efforts to prevent amputation – medical, podiatric, and vascular – have the biggest potential to make a difference," he added.

Dr. Goodney reported no relevant disclosures.

NATIONAL HARBOR, MD. – Lower-extremity revascularization can be effective in preventing amputation in peripheral arterial disease, but in some regions of the United States, the amount and intensity of vascular care is inversely related to the amputation rate, a large study of Medicare patients indicates.

To examine the relationship between intensity of vascular care and the risk of amputation, Dr. Philip P. Goodney and his colleagues at Dartmouth-Hitchcock Medical Center and the Dartmouth Institute for Health Policy in Lebanon, N.H., studied all open and endovascular revascularizations provided to 20,464 Medicare patients in the year prior to vascular amputation. They examined associations among patient characteristics, the regional rates of revascularization, and the regional amputation rate among the 307 hospital referral regions, as described in the Dartmouth Atlas of Health Care.

Population-based amputation rates varied across regions, from fewer than 1 to more than 44 amputations per 10,000 Medicare patients. Amputation rates were highest in rural regions of the southern and Appalachian United States, Dr. Goodney said at the Vascular Annual Meeting.

Patients in regions with high amputation rates were more commonly African American than were patients in regions with low amputation rates (50% vs. 12%). Furthermore, those in regions with high amputation rates had lower per-capita income, compared with those in regions with low amputation rates ($17,980 vs. $19,545).

Less vascular care was provided to patients who lived where amputation rates were highest. Those patients had 57% fewer therapeutic revascularization procedures (such as bypass surgery or stent placement) than did patients in regions with low amputation rates (2.2 vs. 4.8 revascularizations per amputation). Even the number of diagnostic angiograms was significantly lower in high amputation regions than in low amputation regions (2.4 vs. 5.0 angiograms per amputation).

"Medicare patients living in regions with the highest amputation rate are commonly poor and African American, and they receive less than half as much vascular care as those in regions with lower burdens of vascular disease," said Dr. Goodney. "In these regions, we believe patients commonly present late in their disease process, with ‘unsalvageable’ limbs. Because of wet gangrene or massive tissue loss, it is often too late for vascular care to matter, and surgeons are forced to simply perform an amputation rather than have the opportunity to revascularize and try to save a patient’s leg. However, we hope that our study will help to limit amputations in the future," Dr. Goodney said.

"Our work provides a ‘blueprint’ for improvement, by targeting the regions of the [United States] where early, integrated efforts to prevent amputation – medical, podiatric, and vascular – have the biggest potential to make a difference," he added.

Dr. Goodney reported no relevant disclosures.

The high mortality rate among elderly patients who develop ischemic colitis after hybrid endovascular repair of complex aortic aneurysms suggests that a different approach may be warranted, judging by operative outcomes in more than 200 patients.

Patient survival at 1 year was significantly decreased among patients who had ischemic colitis, compared with those who did not have this complication (51% vs. 79%), Dr. Carlos H. Timaran reported at the Vascular Annual Meeting in National Harbor, Md.

Dr. Timaran and his colleagues at the University of Texas Southwestern Medical Center, Dallas, studied the frequency, predictors, and outcomes of ischemic colitis after abdominal debranching combined with aortic stent grafts (ADSG), which was the approach used to treat pararenal and thoracoabdominal aortic aneurysms (TAAs).

They reviewed clinical data in the North American Complex Abdominal Aortic Debranching (NACAAD) Registry of 208 patients treated by ADSG in 13 North American academic centers between 1999 and 2010. Ischemic colitis was identified by colonoscopy and/or operative findings. End points included the need for colon resection, morbidity, and mortality.

The researchers used univariate and multivariate logistic regression analysis to identify predictive factors for ischemic colitis.

Of the 208 patients, 118 men and 90 women (mean age, 72 ± 10 years) were treated for 45 pararenal aneurysms and 163 TAAs.

ADSG required reconstruction of 468 vessels (2.8 per patient), done in a single stage in 92 patients (44%). Ischemic colitis occurred in 13 patients (6%), and four patients (2%) developed transmural necrosis that required colon resection.

The 30-day mortality was 14% for the entire cohort. According to the investigators, this rate was significantly higher among patients who had ischemic colitis (46% vs. 12%; P less than .05), including those who required colon resection (50%).

Univariate analysis found that significantly higher rates of ischemic colitis were associated with age, Society for Vascular Surgery comorbidity score, chronic kidney disease, ruptured or symptomatic aneurysm, and whether patients had undergone a single-stage operation.

Independent predictors for ischemic colitis included age (odds ratio, 1.12), Society for Vascular Surgery comorbidity score (OR, 1.02), and single-stage operation (OR, 1.3).

"In elderly sicker patients, it appears that a staged approach or another treatment strategy, such as fenestrated or branched endovascular repair, may be better alternatives," Dr. Timaran concluded.

Dr. Timaran disclosed that he has received consulting fees or other remuneration from W.L. Gore & Associates.

The high mortality rate among elderly patients who develop ischemic colitis after hybrid endovascular repair of complex aortic aneurysms suggests that a different approach may be warranted, judging by operative outcomes in more than 200 patients.

Patient survival at 1 year was significantly decreased among patients who had ischemic colitis, compared with those who did not have this complication (51% vs. 79%), Dr. Carlos H. Timaran reported at the Vascular Annual Meeting in National Harbor, Md.

Dr. Timaran and his colleagues at the University of Texas Southwestern Medical Center, Dallas, studied the frequency, predictors, and outcomes of ischemic colitis after abdominal debranching combined with aortic stent grafts (ADSG), which was the approach used to treat pararenal and thoracoabdominal aortic aneurysms (TAAs).

They reviewed clinical data in the North American Complex Abdominal Aortic Debranching (NACAAD) Registry of 208 patients treated by ADSG in 13 North American academic centers between 1999 and 2010. Ischemic colitis was identified by colonoscopy and/or operative findings. End points included the need for colon resection, morbidity, and mortality.

The researchers used univariate and multivariate logistic regression analysis to identify predictive factors for ischemic colitis.

Of the 208 patients, 118 men and 90 women (mean age, 72 ± 10 years) were treated for 45 pararenal aneurysms and 163 TAAs.

ADSG required reconstruction of 468 vessels (2.8 per patient), done in a single stage in 92 patients (44%). Ischemic colitis occurred in 13 patients (6%), and four patients (2%) developed transmural necrosis that required colon resection.

The 30-day mortality was 14% for the entire cohort. According to the investigators, this rate was significantly higher among patients who had ischemic colitis (46% vs. 12%; P less than .05), including those who required colon resection (50%).

Univariate analysis found that significantly higher rates of ischemic colitis were associated with age, Society for Vascular Surgery comorbidity score, chronic kidney disease, ruptured or symptomatic aneurysm, and whether patients had undergone a single-stage operation.

Independent predictors for ischemic colitis included age (odds ratio, 1.12), Society for Vascular Surgery comorbidity score (OR, 1.02), and single-stage operation (OR, 1.3).

"In elderly sicker patients, it appears that a staged approach or another treatment strategy, such as fenestrated or branched endovascular repair, may be better alternatives," Dr. Timaran concluded.

Dr. Timaran disclosed that he has received consulting fees or other remuneration from W.L. Gore & Associates.

The high mortality rate among elderly patients who develop ischemic colitis after hybrid endovascular repair of complex aortic aneurysms suggests that a different approach may be warranted, judging by operative outcomes in more than 200 patients.

Patient survival at 1 year was significantly decreased among patients who had ischemic colitis, compared with those who did not have this complication (51% vs. 79%), Dr. Carlos H. Timaran reported at the Vascular Annual Meeting in National Harbor, Md.

Dr. Timaran and his colleagues at the University of Texas Southwestern Medical Center, Dallas, studied the frequency, predictors, and outcomes of ischemic colitis after abdominal debranching combined with aortic stent grafts (ADSG), which was the approach used to treat pararenal and thoracoabdominal aortic aneurysms (TAAs).

They reviewed clinical data in the North American Complex Abdominal Aortic Debranching (NACAAD) Registry of 208 patients treated by ADSG in 13 North American academic centers between 1999 and 2010. Ischemic colitis was identified by colonoscopy and/or operative findings. End points included the need for colon resection, morbidity, and mortality.

The researchers used univariate and multivariate logistic regression analysis to identify predictive factors for ischemic colitis.

Of the 208 patients, 118 men and 90 women (mean age, 72 ± 10 years) were treated for 45 pararenal aneurysms and 163 TAAs.

ADSG required reconstruction of 468 vessels (2.8 per patient), done in a single stage in 92 patients (44%). Ischemic colitis occurred in 13 patients (6%), and four patients (2%) developed transmural necrosis that required colon resection.

The 30-day mortality was 14% for the entire cohort. According to the investigators, this rate was significantly higher among patients who had ischemic colitis (46% vs. 12%; P less than .05), including those who required colon resection (50%).

Univariate analysis found that significantly higher rates of ischemic colitis were associated with age, Society for Vascular Surgery comorbidity score, chronic kidney disease, ruptured or symptomatic aneurysm, and whether patients had undergone a single-stage operation.

Independent predictors for ischemic colitis included age (odds ratio, 1.12), Society for Vascular Surgery comorbidity score (OR, 1.02), and single-stage operation (OR, 1.3).

"In elderly sicker patients, it appears that a staged approach or another treatment strategy, such as fenestrated or branched endovascular repair, may be better alternatives," Dr. Timaran concluded.

Dr. Timaran disclosed that he has received consulting fees or other remuneration from W.L. Gore & Associates.

CHICAGO – Leg and foot amputations for elderly U.S. patients with peripheral artery disease dropped by more than half during the period 2000-2008 for unknown reasons, based on a review of Medicare data.

During the 9-year period studied, the rate of lower-extremity amputations among U.S. Medicare beneficiaries fell from 9,650/100,000 beneficiaries with peripheral artery disease (PAD) to 4,274/100,000, Dr. W. Schuyler Jones and his associates reported in a poster at the meeting.

Their analysis of the 2000-2008 Medicare data also showed significant regional variations in lower-extremity amputation rates in PAD patients, with the highest rate in New England and the lowest rate in the East North Central region (Illinois, Indiana, Michigan, Ohio, and Wisconsin). Again, no clear explanation exists for this pattern, said Dr. Jones, an interventional cardiologist at Duke University in Durham, N.C., and his associates.

Their analysis of data from the Centers for Medicare & Medicaid Services included 3,354,264 diagnosed with PAD during 2000-2008, of whom 249,310 (7%) underwent amputation of a foot or leg, either below or above the knee. The average age of all PAD patients was 77 years old among both those who underwent amputations and those who did not have this surgery. The analysis identified four factors that were significant, independent predictors of having an amputation: male sex, African American race, and the presence of renal disease or diabetes.

During the 9-year period, the annual incidence of patients newly diagnosed with PAD remained relatively steady, with 398,000 diagnosed in 2000 and 397,000 diagnosed in 2008. The rates showed some year-to-year fluctuation, ranging from a low of 304,000 in 2003 to a high of 517,000 in 2006.

In contrast, the annual incidence of lower-extremity amputations showed a clear downward trajectory, with a sharp drop starting in 2005. During 2000-2004, the annual amputation rate hovered at about 10,000 cases/100,000 patients with PAD, but then fell to 7,455/100,000 in 2005, and fell further to 4,261/100,000 in 2006. During the subsequent 2 years the rate remained at about the same low level first reached in 2006. Roughly similar patterns existed for the subgroups of patients who underwent above-the-knee amputations, below-the-knee amputations, or foot amputations.

The authors of the report performed an analysis of amputation rates by U.S. Census geographic regions for the entire period of 2000-2008 that they adjusted by regional differences in patients’ age, sex, race, comorbidities, and year of amputation. They set the amputation rate in the South Atlantic region as their reference level, and found four regions with significantly higher rates of amputations: New England ran 16% higher, the West South Central region (Arkansas, Louisiana, Oklahoma, and Texas) ran 12% higher, Mid Atlantic (Connecticut, New Jersey, New York, and Pennsylvania) was 8% higher, and the Pacific region (Alaska, California, Hawaii, Oregon, and Washington) was 3% above the reference level. Three other U.S. regions had amputations rates below the reference level, headed by the East North Central which ran 11% below the South Atlantic region, followed by the Mountain region at 10% lower, and the West North Central region (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota) which was 5% below the reference level.

Dr. Jones said that he had no disclosures.

CHICAGO – Leg and foot amputations for elderly U.S. patients with peripheral artery disease dropped by more than half during the period 2000-2008 for unknown reasons, based on a review of Medicare data.

During the 9-year period studied, the rate of lower-extremity amputations among U.S. Medicare beneficiaries fell from 9,650/100,000 beneficiaries with peripheral artery disease (PAD) to 4,274/100,000, Dr. W. Schuyler Jones and his associates reported in a poster at the meeting.

Their analysis of the 2000-2008 Medicare data also showed significant regional variations in lower-extremity amputation rates in PAD patients, with the highest rate in New England and the lowest rate in the East North Central region (Illinois, Indiana, Michigan, Ohio, and Wisconsin). Again, no clear explanation exists for this pattern, said Dr. Jones, an interventional cardiologist at Duke University in Durham, N.C., and his associates.

Their analysis of data from the Centers for Medicare & Medicaid Services included 3,354,264 diagnosed with PAD during 2000-2008, of whom 249,310 (7%) underwent amputation of a foot or leg, either below or above the knee. The average age of all PAD patients was 77 years old among both those who underwent amputations and those who did not have this surgery. The analysis identified four factors that were significant, independent predictors of having an amputation: male sex, African American race, and the presence of renal disease or diabetes.

During the 9-year period, the annual incidence of patients newly diagnosed with PAD remained relatively steady, with 398,000 diagnosed in 2000 and 397,000 diagnosed in 2008. The rates showed some year-to-year fluctuation, ranging from a low of 304,000 in 2003 to a high of 517,000 in 2006.

In contrast, the annual incidence of lower-extremity amputations showed a clear downward trajectory, with a sharp drop starting in 2005. During 2000-2004, the annual amputation rate hovered at about 10,000 cases/100,000 patients with PAD, but then fell to 7,455/100,000 in 2005, and fell further to 4,261/100,000 in 2006. During the subsequent 2 years the rate remained at about the same low level first reached in 2006. Roughly similar patterns existed for the subgroups of patients who underwent above-the-knee amputations, below-the-knee amputations, or foot amputations.

The authors of the report performed an analysis of amputation rates by U.S. Census geographic regions for the entire period of 2000-2008 that they adjusted by regional differences in patients’ age, sex, race, comorbidities, and year of amputation. They set the amputation rate in the South Atlantic region as their reference level, and found four regions with significantly higher rates of amputations: New England ran 16% higher, the West South Central region (Arkansas, Louisiana, Oklahoma, and Texas) ran 12% higher, Mid Atlantic (Connecticut, New Jersey, New York, and Pennsylvania) was 8% higher, and the Pacific region (Alaska, California, Hawaii, Oregon, and Washington) was 3% above the reference level. Three other U.S. regions had amputations rates below the reference level, headed by the East North Central which ran 11% below the South Atlantic region, followed by the Mountain region at 10% lower, and the West North Central region (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota) which was 5% below the reference level.

Dr. Jones said that he had no disclosures.

CHICAGO – Leg and foot amputations for elderly U.S. patients with peripheral artery disease dropped by more than half during the period 2000-2008 for unknown reasons, based on a review of Medicare data.

During the 9-year period studied, the rate of lower-extremity amputations among U.S. Medicare beneficiaries fell from 9,650/100,000 beneficiaries with peripheral artery disease (PAD) to 4,274/100,000, Dr. W. Schuyler Jones and his associates reported in a poster at the meeting.

Their analysis of the 2000-2008 Medicare data also showed significant regional variations in lower-extremity amputation rates in PAD patients, with the highest rate in New England and the lowest rate in the East North Central region (Illinois, Indiana, Michigan, Ohio, and Wisconsin). Again, no clear explanation exists for this pattern, said Dr. Jones, an interventional cardiologist at Duke University in Durham, N.C., and his associates.

Their analysis of data from the Centers for Medicare & Medicaid Services included 3,354,264 diagnosed with PAD during 2000-2008, of whom 249,310 (7%) underwent amputation of a foot or leg, either below or above the knee. The average age of all PAD patients was 77 years old among both those who underwent amputations and those who did not have this surgery. The analysis identified four factors that were significant, independent predictors of having an amputation: male sex, African American race, and the presence of renal disease or diabetes.

During the 9-year period, the annual incidence of patients newly diagnosed with PAD remained relatively steady, with 398,000 diagnosed in 2000 and 397,000 diagnosed in 2008. The rates showed some year-to-year fluctuation, ranging from a low of 304,000 in 2003 to a high of 517,000 in 2006.

In contrast, the annual incidence of lower-extremity amputations showed a clear downward trajectory, with a sharp drop starting in 2005. During 2000-2004, the annual amputation rate hovered at about 10,000 cases/100,000 patients with PAD, but then fell to 7,455/100,000 in 2005, and fell further to 4,261/100,000 in 2006. During the subsequent 2 years the rate remained at about the same low level first reached in 2006. Roughly similar patterns existed for the subgroups of patients who underwent above-the-knee amputations, below-the-knee amputations, or foot amputations.

The authors of the report performed an analysis of amputation rates by U.S. Census geographic regions for the entire period of 2000-2008 that they adjusted by regional differences in patients’ age, sex, race, comorbidities, and year of amputation. They set the amputation rate in the South Atlantic region as their reference level, and found four regions with significantly higher rates of amputations: New England ran 16% higher, the West South Central region (Arkansas, Louisiana, Oklahoma, and Texas) ran 12% higher, Mid Atlantic (Connecticut, New Jersey, New York, and Pennsylvania) was 8% higher, and the Pacific region (Alaska, California, Hawaii, Oregon, and Washington) was 3% above the reference level. Three other U.S. regions had amputations rates below the reference level, headed by the East North Central which ran 11% below the South Atlantic region, followed by the Mountain region at 10% lower, and the West North Central region (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota) which was 5% below the reference level.

Dr. Jones said that he had no disclosures.

With the advantage of around-the-clock hospitalist services, one community hospital has been able to offer catheter-directed thrombolytic therapy – a procedure typically available only at tertiary-care hospitals.

Dr. Brian A. Carpenter, medical director of the adult hospitalist service at Shady Grove Adventist Hospital in Rockville, Md., said that at least 12 patients with massive or submassive pulmonary embolisms have undergone catheter-directed thrombolysis at the hospital. Many others have undergone the procedure for deep vein thrombosis in a lower extremity with vascular extension into the larger vessels of the pelvis.

Before the service was introduced, patients with massive or submassive pulmonary embolism were sent to a tertiary-care hospital if they were stable enough for transfer. Otherwise, they were monitored in the ICU, managed medically with systemic anticoagulation, and transferred later if they still needed further treatment.

Systemic anticoagulation is the mainstay of treatment for pulmonary embolism, but the American Heart Association and the American College of Chest Physicians recommend a more aggressive approach for massive and submassive PE. Up to 60% of patients with massive PE die, data suggest, with two-thirds of the deaths occurring in the first hour after the embolus forms. Within 30 days after submassive PE, 15%-20% of patients die secondary to pulmonary hypertension and subsequent cor pulmonale, according to a data presented at the annual meeting of the Southern Association for Vascular Surgery.

The catheter-directed thrombolytic therapy at Shady Grove Adventist largely owes its success to a vascular surgeon who took the lead in establishing protocols and training support staff, with hospitalists as a key part of the team.

The vascular surgeon, Dr. Jeffrey Y. Wang, reported on the outcomes of the first 12 patients, in whom the procedures were all technically successful. One patient developed hemodynamically significant bradycardia, but all patients were off supplemental oxygen within 24 hours of the procedure. There were no bleeding complications.

One patient died 14 hours after the procedure, most likely because of a paradoxical embolus to the intestine. The 11 surviving patients were discharged to home within 48 hours of the intervention, according to Dr. Wang of Horizon Vascular Specialists. The group contracts to provide vascular surgical care at Shady Grove Adventist and two other hospitals in Maryland.

Catheter-directed thrombolytic therapy can shorten stays in the ICU and the hospital, reduce or eliminate the need for home oxygen therapy, and help restore right heart function in patients with massive or submassive pulmonary embolism, Dr. Wang said. Patients with massive or submassive PE are offered catheter-directed thrombolytic therapy if they are hemodynamically unstable; if they have right heart dysfunction, elevated troponin, or pulmonary artery pressures greater than 70 mmHg; or if they are not weaning off intubation for oxygen within 5 days, Dr. Wang said. He excludes patients who are actively bleeding or who are not able to tolerate any systemic anticoagulation.

Recent surgery was not a disqualifying factor in his case series. "Typically, those patients were orthopedic in nature, with a hip or knee replacement," Dr. Wang said. The patient would develop a big pulmonary embolus, and the orthopedist would give a green light for aggressive treatment.

But most of the patients who have received catheter-directed thrombolytic procedures presented to the emergency department with lower extremity swelling, and were found on sonography to have a thrombus extending into the large pelvic vessels. Dr. Carpenter’s service admits approximately 90% of adult inpatients, so the hospitalists usually are the ones to determine which patients should be considered for the interventional approach and which ones get medical therapy.

Dr. Wang emphasized that the protocols are as important as technical expertise in catheter-directed thrombolysis. Protocols are in place for the ED, the ICU, and the hospitalist team for the early detection of DVT and pulmonary emboli, notification of the appropriate staff, and posttreatment care of patients. Dr. Wang also took the lead on the anticoagulation aspect of computerized physician order entry.

"In our institution, we use the same protocols for call-in and transport to the cath lab as for ST-elevation myocardial infarction, which allows us to get the patient up and into the fluoroscopy suite within 30 minutes," Dr. Wang said. The fluoroscopy suite must be available on an emergency basis.

"It’s amazing to see such a dramatic improvement in patient symptoms almost immediately post procedure," said Dr. Carpenter.

Patients who undergo catheter-directed thrombolysis require close postoperative monitoring, said Dr. Carpenter, who is with Inpatient Specialists, a group that contracts with hospitals to provide hospitalist services. The main risks are bleeding, low blood pressure, or respiratory distress. "The bleeding might not necessarily be obvious," as the antithrombotic agent is given locally and bleeding can be local as well.

Community hospitals that offer catheter-directed thrombolysis need sufficient commitment from vascular surgeons and robust postprocedure support, Dr. Carpenter said. The vascular surgery group should be able to offer the procedure to all patients who need it.

Around-the-clock hospitalist availability is a good idea, especially if the surgeon is not on the in-house staff. "Don’t do [this procedure] if the hospitalist is providing triage services at night," he advised.

With 23 full-time positions (translating into 40 full-time or part-time physicians), the adult hospitalist service at Shady Grove Adventist, a 339-bed hospital, typically provides 10 hospitalists during weekdays (including one medical-psychiatric physician) and 8 on weekend days.

Besides the adult hospitalist group, the hospital has a pediatric hospitalist service, 24-hour in-house ICU hospitalist coverage, and a surgical hospitalist group. "Not many hospitals have surgical hospitalists," Dr. Carpenter noted. Laborists also are available 24 hours a day for in-house ob.gyn. consultations.

Dr. Carpenter, who has been a hospitalist since 2006, said that this "is how hospital-based medicine is progressing. "Shady Grove has been an early adopter" of expanded hospitalist services.

Dr. Carpenter and Dr. Wang reported having no financial disclosures.

With the advantage of around-the-clock hospitalist services, one community hospital has been able to offer catheter-directed thrombolytic therapy – a procedure typically available only at tertiary-care hospitals.

Dr. Brian A. Carpenter, medical director of the adult hospitalist service at Shady Grove Adventist Hospital in Rockville, Md., said that at least 12 patients with massive or submassive pulmonary embolisms have undergone catheter-directed thrombolysis at the hospital. Many others have undergone the procedure for deep vein thrombosis in a lower extremity with vascular extension into the larger vessels of the pelvis.

Before the service was introduced, patients with massive or submassive pulmonary embolism were sent to a tertiary-care hospital if they were stable enough for transfer. Otherwise, they were monitored in the ICU, managed medically with systemic anticoagulation, and transferred later if they still needed further treatment.

Systemic anticoagulation is the mainstay of treatment for pulmonary embolism, but the American Heart Association and the American College of Chest Physicians recommend a more aggressive approach for massive and submassive PE. Up to 60% of patients with massive PE die, data suggest, with two-thirds of the deaths occurring in the first hour after the embolus forms. Within 30 days after submassive PE, 15%-20% of patients die secondary to pulmonary hypertension and subsequent cor pulmonale, according to a data presented at the annual meeting of the Southern Association for Vascular Surgery.

The catheter-directed thrombolytic therapy at Shady Grove Adventist largely owes its success to a vascular surgeon who took the lead in establishing protocols and training support staff, with hospitalists as a key part of the team.

The vascular surgeon, Dr. Jeffrey Y. Wang, reported on the outcomes of the first 12 patients, in whom the procedures were all technically successful. One patient developed hemodynamically significant bradycardia, but all patients were off supplemental oxygen within 24 hours of the procedure. There were no bleeding complications.

One patient died 14 hours after the procedure, most likely because of a paradoxical embolus to the intestine. The 11 surviving patients were discharged to home within 48 hours of the intervention, according to Dr. Wang of Horizon Vascular Specialists. The group contracts to provide vascular surgical care at Shady Grove Adventist and two other hospitals in Maryland.

Catheter-directed thrombolytic therapy can shorten stays in the ICU and the hospital, reduce or eliminate the need for home oxygen therapy, and help restore right heart function in patients with massive or submassive pulmonary embolism, Dr. Wang said. Patients with massive or submassive PE are offered catheter-directed thrombolytic therapy if they are hemodynamically unstable; if they have right heart dysfunction, elevated troponin, or pulmonary artery pressures greater than 70 mmHg; or if they are not weaning off intubation for oxygen within 5 days, Dr. Wang said. He excludes patients who are actively bleeding or who are not able to tolerate any systemic anticoagulation.

Recent surgery was not a disqualifying factor in his case series. "Typically, those patients were orthopedic in nature, with a hip or knee replacement," Dr. Wang said. The patient would develop a big pulmonary embolus, and the orthopedist would give a green light for aggressive treatment.

But most of the patients who have received catheter-directed thrombolytic procedures presented to the emergency department with lower extremity swelling, and were found on sonography to have a thrombus extending into the large pelvic vessels. Dr. Carpenter’s service admits approximately 90% of adult inpatients, so the hospitalists usually are the ones to determine which patients should be considered for the interventional approach and which ones get medical therapy.

Dr. Wang emphasized that the protocols are as important as technical expertise in catheter-directed thrombolysis. Protocols are in place for the ED, the ICU, and the hospitalist team for the early detection of DVT and pulmonary emboli, notification of the appropriate staff, and posttreatment care of patients. Dr. Wang also took the lead on the anticoagulation aspect of computerized physician order entry.

"In our institution, we use the same protocols for call-in and transport to the cath lab as for ST-elevation myocardial infarction, which allows us to get the patient up and into the fluoroscopy suite within 30 minutes," Dr. Wang said. The fluoroscopy suite must be available on an emergency basis.

"It’s amazing to see such a dramatic improvement in patient symptoms almost immediately post procedure," said Dr. Carpenter.

Patients who undergo catheter-directed thrombolysis require close postoperative monitoring, said Dr. Carpenter, who is with Inpatient Specialists, a group that contracts with hospitals to provide hospitalist services. The main risks are bleeding, low blood pressure, or respiratory distress. "The bleeding might not necessarily be obvious," as the antithrombotic agent is given locally and bleeding can be local as well.

Community hospitals that offer catheter-directed thrombolysis need sufficient commitment from vascular surgeons and robust postprocedure support, Dr. Carpenter said. The vascular surgery group should be able to offer the procedure to all patients who need it.

Around-the-clock hospitalist availability is a good idea, especially if the surgeon is not on the in-house staff. "Don’t do [this procedure] if the hospitalist is providing triage services at night," he advised.

With 23 full-time positions (translating into 40 full-time or part-time physicians), the adult hospitalist service at Shady Grove Adventist, a 339-bed hospital, typically provides 10 hospitalists during weekdays (including one medical-psychiatric physician) and 8 on weekend days.

Besides the adult hospitalist group, the hospital has a pediatric hospitalist service, 24-hour in-house ICU hospitalist coverage, and a surgical hospitalist group. "Not many hospitals have surgical hospitalists," Dr. Carpenter noted. Laborists also are available 24 hours a day for in-house ob.gyn. consultations.

Dr. Carpenter, who has been a hospitalist since 2006, said that this "is how hospital-based medicine is progressing. "Shady Grove has been an early adopter" of expanded hospitalist services.

Dr. Carpenter and Dr. Wang reported having no financial disclosures.

With the advantage of around-the-clock hospitalist services, one community hospital has been able to offer catheter-directed thrombolytic therapy – a procedure typically available only at tertiary-care hospitals.

Dr. Brian A. Carpenter, medical director of the adult hospitalist service at Shady Grove Adventist Hospital in Rockville, Md., said that at least 12 patients with massive or submassive pulmonary embolisms have undergone catheter-directed thrombolysis at the hospital. Many others have undergone the procedure for deep vein thrombosis in a lower extremity with vascular extension into the larger vessels of the pelvis.

Before the service was introduced, patients with massive or submassive pulmonary embolism were sent to a tertiary-care hospital if they were stable enough for transfer. Otherwise, they were monitored in the ICU, managed medically with systemic anticoagulation, and transferred later if they still needed further treatment.

Systemic anticoagulation is the mainstay of treatment for pulmonary embolism, but the American Heart Association and the American College of Chest Physicians recommend a more aggressive approach for massive and submassive PE. Up to 60% of patients with massive PE die, data suggest, with two-thirds of the deaths occurring in the first hour after the embolus forms. Within 30 days after submassive PE, 15%-20% of patients die secondary to pulmonary hypertension and subsequent cor pulmonale, according to a data presented at the annual meeting of the Southern Association for Vascular Surgery.

The catheter-directed thrombolytic therapy at Shady Grove Adventist largely owes its success to a vascular surgeon who took the lead in establishing protocols and training support staff, with hospitalists as a key part of the team.

The vascular surgeon, Dr. Jeffrey Y. Wang, reported on the outcomes of the first 12 patients, in whom the procedures were all technically successful. One patient developed hemodynamically significant bradycardia, but all patients were off supplemental oxygen within 24 hours of the procedure. There were no bleeding complications.

One patient died 14 hours after the procedure, most likely because of a paradoxical embolus to the intestine. The 11 surviving patients were discharged to home within 48 hours of the intervention, according to Dr. Wang of Horizon Vascular Specialists. The group contracts to provide vascular surgical care at Shady Grove Adventist and two other hospitals in Maryland.

Catheter-directed thrombolytic therapy can shorten stays in the ICU and the hospital, reduce or eliminate the need for home oxygen therapy, and help restore right heart function in patients with massive or submassive pulmonary embolism, Dr. Wang said. Patients with massive or submassive PE are offered catheter-directed thrombolytic therapy if they are hemodynamically unstable; if they have right heart dysfunction, elevated troponin, or pulmonary artery pressures greater than 70 mmHg; or if they are not weaning off intubation for oxygen within 5 days, Dr. Wang said. He excludes patients who are actively bleeding or who are not able to tolerate any systemic anticoagulation.

Recent surgery was not a disqualifying factor in his case series. "Typically, those patients were orthopedic in nature, with a hip or knee replacement," Dr. Wang said. The patient would develop a big pulmonary embolus, and the orthopedist would give a green light for aggressive treatment.

But most of the patients who have received catheter-directed thrombolytic procedures presented to the emergency department with lower extremity swelling, and were found on sonography to have a thrombus extending into the large pelvic vessels. Dr. Carpenter’s service admits approximately 90% of adult inpatients, so the hospitalists usually are the ones to determine which patients should be considered for the interventional approach and which ones get medical therapy.

Dr. Wang emphasized that the protocols are as important as technical expertise in catheter-directed thrombolysis. Protocols are in place for the ED, the ICU, and the hospitalist team for the early detection of DVT and pulmonary emboli, notification of the appropriate staff, and posttreatment care of patients. Dr. Wang also took the lead on the anticoagulation aspect of computerized physician order entry.

"In our institution, we use the same protocols for call-in and transport to the cath lab as for ST-elevation myocardial infarction, which allows us to get the patient up and into the fluoroscopy suite within 30 minutes," Dr. Wang said. The fluoroscopy suite must be available on an emergency basis.

"It’s amazing to see such a dramatic improvement in patient symptoms almost immediately post procedure," said Dr. Carpenter.

Patients who undergo catheter-directed thrombolysis require close postoperative monitoring, said Dr. Carpenter, who is with Inpatient Specialists, a group that contracts with hospitals to provide hospitalist services. The main risks are bleeding, low blood pressure, or respiratory distress. "The bleeding might not necessarily be obvious," as the antithrombotic agent is given locally and bleeding can be local as well.

Community hospitals that offer catheter-directed thrombolysis need sufficient commitment from vascular surgeons and robust postprocedure support, Dr. Carpenter said. The vascular surgery group should be able to offer the procedure to all patients who need it.

Around-the-clock hospitalist availability is a good idea, especially if the surgeon is not on the in-house staff. "Don’t do [this procedure] if the hospitalist is providing triage services at night," he advised.

With 23 full-time positions (translating into 40 full-time or part-time physicians), the adult hospitalist service at Shady Grove Adventist, a 339-bed hospital, typically provides 10 hospitalists during weekdays (including one medical-psychiatric physician) and 8 on weekend days.

Besides the adult hospitalist group, the hospital has a pediatric hospitalist service, 24-hour in-house ICU hospitalist coverage, and a surgical hospitalist group. "Not many hospitals have surgical hospitalists," Dr. Carpenter noted. Laborists also are available 24 hours a day for in-house ob.gyn. consultations.

Dr. Carpenter, who has been a hospitalist since 2006, said that this "is how hospital-based medicine is progressing. "Shady Grove has been an early adopter" of expanded hospitalist services.

Dr. Carpenter and Dr. Wang reported having no financial disclosures.

SCOTTSDALE, ARIZ. – Inflammatory abdominal aortic aneurysms can be treated safely and effectively by endovascular aneurysm repair, though patients with significant hydronephrosis may have worse outcomes, a retrospective study suggests.

The study included 69 patients who underwent either endovascular repair (10 patients) or open surgical repair (59 patients) at the surgeon’s discretion at Mayo Clinics in Minnesota, Florida, or Arizona between 1999 and 2011.

Previous case series and meta-analyses have reported mixed results with endovascular aneurysm repair (EVAR), but the current study suggests that EVAR is appropriate management for inflammatory abdominal aortic aneurysms (AAAs), Dr. William M. Stone said at the annual meeting of the Southern Association for Vascular Surgery.

In the study’s EVAR group, eight patients presented with symptoms (80%), including one with rupture. In the open-repair group, 31 patients (52%) presented with symptoms, including 3 with rupture (5%).

Ureteral involvement was seen in 23 patients: 2 patients in the EVAR group (20%) and 21 in the open group (34%). Of these 23 patients, 21 underwent preoperative ureteral stent placement (91%). Thirty-six patients in the open-repair group had suprarenal aortic cross clamps (61%).

All of the EVAR procedures were technically successful, and patients were followed for an average of 34 months. The mean aneurysm size in the EVAR group decreased from 5.94 cm preoperatively to 4.73 cm after EVAR, an average change of nearly 18%, reported Dr. Stone of the Mayo Clinic in Phoenix.

Aneurysm size decreased in seven patients (70%), and did not change in two patients (20%) after EVAR. One EVAR patient was lost to follow-up. Preoperative hydronephrosis in one patient (10%) before EVAR did not change after EVAR, and one patient developed new hydronephrosis after EVAR. No patients in the EVAR group died, developed endoleaks, or needed steroids. Two patients developed atrial fibrillation after EVAR and were treated for it.

The inflammatory rind measured 5.4 cm before EVAR and 2.7 cm afterward on average, a mean change of 50%, he said.

In the open-repair group, surgeons used midline incisions in 52 patients (88%), a left flank approach in 6 patients (10%), and a bilateral subcostal approach in 1 (2%) to repair aneurysms with a mean size of 6.3 cm.

One patient in the open-repair group died postoperatively of a ruptured suprarenal inflammatory aneurysm. Major complications were seen in 22 patients (38%), including renal complications in 5 (8%), ischemic colitis in 2 (3%), and ureteral obstruction that required intervention in 3 (5%). A late anastomotic rupture in one patient in the open-surgery group was repaired by EVAR.

During a mean follow-up of 43 months, 17 patients in the open-repair group were lost to follow-up (28%). All of the remaining patients had resolution of their aneurysm sac. Four patients (7%) received steroids, not to treat the aneurysm but for comorbidities.

Among 12 patients in the open-repair group with preoperative hydronephrosis (20%), the hydronephrosis resolved in 7 of the 12 (58%), remained stable in 4 patients (33%), and worsened in 1 patient (8%). The patient with worsening hydronephrosis underwent ureterolysis. Two patients developed renal atrophy.

Although the retrospective study was small, it appeared to show a trend toward less severe complications in the EVAR group, "which is what we intuitively would have guessed," Dr. Stone said.

Previous data from the EUROSTAR (European Collaborators on Stent-Graft Techniques for Abdominal Aortic Aneurysm Repair) registry suggested that inflammatory AAA size decreased by 87% after EVAR, he noted (Semin. Interv. Cardiol. 2000;5:29-33). Aneurysm wall thickness averaged 21 mm preoperatively, 17 mm at intermediate follow-up, and 13 mm with long-term follow-up, which is "consistent with our review," he said.

Patients in the EUROSTAR database had problems with graft limb stenosis that were not seen in the current series, Dr. Stone noted. A ureteral stent and/or ureterolysis were required in 18% of the EUROSTAR patients who underwent EVAR. The rate of ureteral "entrapment" (inflammation around the ureters) improved from 45% to 27% after EVAR.

Courtesy of Dr. William M. Stone

In a previous meta-analysis of data on 46 patients in 14 studies, EVAR decreased aneurysm size in most patients, with a median decrease of 11 mm. Periaortic fibrosis decreased in 52%, was unchanged in 42%, and progressed in 7% (J. Endovasc. Ther. 2005;12:560-7).

A separate meta-analysis of 56 studies with 1,120 patients compared EVAR with open repair of AAA, and found 1-year all-cause mortality rates of 2% with EVAR and 14% with open repair (Eur. J. Vasc. Endovasc. Surg. 2009;38:291-7). Periaortic fibrosis decreased in 65% of the EVAR group and in 73% of the open-repair group. Hydronephrosis regressed in 38% of the EVAR group and in 69% of the open-repair group.

In the current study, the two groups did not differ significantly in mean age, preoperative aneurysm size, or length of follow-up. In the EVAR group, patients averaged 72 years of age, and eight patients (80%) were male. In the open-repair group, patients averaged 66 years of age, and 45 (77%) were male.

Patients were excluded from endovascular treatment if they had infected aneurysms or aneurysms with inflammation that were not deemed to be true inflammatory aneurysms. The diagnosis of inflammatory aortic aneurysm was confirmed preoperatively by CT scan in the EVAR group or at the time of surgery in the open-repair group.

Dr. Stone reported having no financial disclosures.

SCOTTSDALE, ARIZ. – Inflammatory abdominal aortic aneurysms can be treated safely and effectively by endovascular aneurysm repair, though patients with significant hydronephrosis may have worse outcomes, a retrospective study suggests.

The study included 69 patients who underwent either endovascular repair (10 patients) or open surgical repair (59 patients) at the surgeon’s discretion at Mayo Clinics in Minnesota, Florida, or Arizona between 1999 and 2011.

Previous case series and meta-analyses have reported mixed results with endovascular aneurysm repair (EVAR), but the current study suggests that EVAR is appropriate management for inflammatory abdominal aortic aneurysms (AAAs), Dr. William M. Stone said at the annual meeting of the Southern Association for Vascular Surgery.

In the study’s EVAR group, eight patients presented with symptoms (80%), including one with rupture. In the open-repair group, 31 patients (52%) presented with symptoms, including 3 with rupture (5%).

Ureteral involvement was seen in 23 patients: 2 patients in the EVAR group (20%) and 21 in the open group (34%). Of these 23 patients, 21 underwent preoperative ureteral stent placement (91%). Thirty-six patients in the open-repair group had suprarenal aortic cross clamps (61%).

All of the EVAR procedures were technically successful, and patients were followed for an average of 34 months. The mean aneurysm size in the EVAR group decreased from 5.94 cm preoperatively to 4.73 cm after EVAR, an average change of nearly 18%, reported Dr. Stone of the Mayo Clinic in Phoenix.

Aneurysm size decreased in seven patients (70%), and did not change in two patients (20%) after EVAR. One EVAR patient was lost to follow-up. Preoperative hydronephrosis in one patient (10%) before EVAR did not change after EVAR, and one patient developed new hydronephrosis after EVAR. No patients in the EVAR group died, developed endoleaks, or needed steroids. Two patients developed atrial fibrillation after EVAR and were treated for it.

The inflammatory rind measured 5.4 cm before EVAR and 2.7 cm afterward on average, a mean change of 50%, he said.

In the open-repair group, surgeons used midline incisions in 52 patients (88%), a left flank approach in 6 patients (10%), and a bilateral subcostal approach in 1 (2%) to repair aneurysms with a mean size of 6.3 cm.

One patient in the open-repair group died postoperatively of a ruptured suprarenal inflammatory aneurysm. Major complications were seen in 22 patients (38%), including renal complications in 5 (8%), ischemic colitis in 2 (3%), and ureteral obstruction that required intervention in 3 (5%). A late anastomotic rupture in one patient in the open-surgery group was repaired by EVAR.

During a mean follow-up of 43 months, 17 patients in the open-repair group were lost to follow-up (28%). All of the remaining patients had resolution of their aneurysm sac. Four patients (7%) received steroids, not to treat the aneurysm but for comorbidities.

Among 12 patients in the open-repair group with preoperative hydronephrosis (20%), the hydronephrosis resolved in 7 of the 12 (58%), remained stable in 4 patients (33%), and worsened in 1 patient (8%). The patient with worsening hydronephrosis underwent ureterolysis. Two patients developed renal atrophy.

Although the retrospective study was small, it appeared to show a trend toward less severe complications in the EVAR group, "which is what we intuitively would have guessed," Dr. Stone said.

Previous data from the EUROSTAR (European Collaborators on Stent-Graft Techniques for Abdominal Aortic Aneurysm Repair) registry suggested that inflammatory AAA size decreased by 87% after EVAR, he noted (Semin. Interv. Cardiol. 2000;5:29-33). Aneurysm wall thickness averaged 21 mm preoperatively, 17 mm at intermediate follow-up, and 13 mm with long-term follow-up, which is "consistent with our review," he said.

Patients in the EUROSTAR database had problems with graft limb stenosis that were not seen in the current series, Dr. Stone noted. A ureteral stent and/or ureterolysis were required in 18% of the EUROSTAR patients who underwent EVAR. The rate of ureteral "entrapment" (inflammation around the ureters) improved from 45% to 27% after EVAR.

Courtesy of Dr. William M. Stone

In a previous meta-analysis of data on 46 patients in 14 studies, EVAR decreased aneurysm size in most patients, with a median decrease of 11 mm. Periaortic fibrosis decreased in 52%, was unchanged in 42%, and progressed in 7% (J. Endovasc. Ther. 2005;12:560-7).

A separate meta-analysis of 56 studies with 1,120 patients compared EVAR with open repair of AAA, and found 1-year all-cause mortality rates of 2% with EVAR and 14% with open repair (Eur. J. Vasc. Endovasc. Surg. 2009;38:291-7). Periaortic fibrosis decreased in 65% of the EVAR group and in 73% of the open-repair group. Hydronephrosis regressed in 38% of the EVAR group and in 69% of the open-repair group.

In the current study, the two groups did not differ significantly in mean age, preoperative aneurysm size, or length of follow-up. In the EVAR group, patients averaged 72 years of age, and eight patients (80%) were male. In the open-repair group, patients averaged 66 years of age, and 45 (77%) were male.

Patients were excluded from endovascular treatment if they had infected aneurysms or aneurysms with inflammation that were not deemed to be true inflammatory aneurysms. The diagnosis of inflammatory aortic aneurysm was confirmed preoperatively by CT scan in the EVAR group or at the time of surgery in the open-repair group.

Dr. Stone reported having no financial disclosures.

SCOTTSDALE, ARIZ. – Inflammatory abdominal aortic aneurysms can be treated safely and effectively by endovascular aneurysm repair, though patients with significant hydronephrosis may have worse outcomes, a retrospective study suggests.

The study included 69 patients who underwent either endovascular repair (10 patients) or open surgical repair (59 patients) at the surgeon’s discretion at Mayo Clinics in Minnesota, Florida, or Arizona between 1999 and 2011.

Previous case series and meta-analyses have reported mixed results with endovascular aneurysm repair (EVAR), but the current study suggests that EVAR is appropriate management for inflammatory abdominal aortic aneurysms (AAAs), Dr. William M. Stone said at the annual meeting of the Southern Association for Vascular Surgery.

In the study’s EVAR group, eight patients presented with symptoms (80%), including one with rupture. In the open-repair group, 31 patients (52%) presented with symptoms, including 3 with rupture (5%).

Ureteral involvement was seen in 23 patients: 2 patients in the EVAR group (20%) and 21 in the open group (34%). Of these 23 patients, 21 underwent preoperative ureteral stent placement (91%). Thirty-six patients in the open-repair group had suprarenal aortic cross clamps (61%).

All of the EVAR procedures were technically successful, and patients were followed for an average of 34 months. The mean aneurysm size in the EVAR group decreased from 5.94 cm preoperatively to 4.73 cm after EVAR, an average change of nearly 18%, reported Dr. Stone of the Mayo Clinic in Phoenix.

Aneurysm size decreased in seven patients (70%), and did not change in two patients (20%) after EVAR. One EVAR patient was lost to follow-up. Preoperative hydronephrosis in one patient (10%) before EVAR did not change after EVAR, and one patient developed new hydronephrosis after EVAR. No patients in the EVAR group died, developed endoleaks, or needed steroids. Two patients developed atrial fibrillation after EVAR and were treated for it.

The inflammatory rind measured 5.4 cm before EVAR and 2.7 cm afterward on average, a mean change of 50%, he said.

In the open-repair group, surgeons used midline incisions in 52 patients (88%), a left flank approach in 6 patients (10%), and a bilateral subcostal approach in 1 (2%) to repair aneurysms with a mean size of 6.3 cm.

One patient in the open-repair group died postoperatively of a ruptured suprarenal inflammatory aneurysm. Major complications were seen in 22 patients (38%), including renal complications in 5 (8%), ischemic colitis in 2 (3%), and ureteral obstruction that required intervention in 3 (5%). A late anastomotic rupture in one patient in the open-surgery group was repaired by EVAR.

During a mean follow-up of 43 months, 17 patients in the open-repair group were lost to follow-up (28%). All of the remaining patients had resolution of their aneurysm sac. Four patients (7%) received steroids, not to treat the aneurysm but for comorbidities.

Among 12 patients in the open-repair group with preoperative hydronephrosis (20%), the hydronephrosis resolved in 7 of the 12 (58%), remained stable in 4 patients (33%), and worsened in 1 patient (8%). The patient with worsening hydronephrosis underwent ureterolysis. Two patients developed renal atrophy.

Although the retrospective study was small, it appeared to show a trend toward less severe complications in the EVAR group, "which is what we intuitively would have guessed," Dr. Stone said.

Previous data from the EUROSTAR (European Collaborators on Stent-Graft Techniques for Abdominal Aortic Aneurysm Repair) registry suggested that inflammatory AAA size decreased by 87% after EVAR, he noted (Semin. Interv. Cardiol. 2000;5:29-33). Aneurysm wall thickness averaged 21 mm preoperatively, 17 mm at intermediate follow-up, and 13 mm with long-term follow-up, which is "consistent with our review," he said.

Patients in the EUROSTAR database had problems with graft limb stenosis that were not seen in the current series, Dr. Stone noted. A ureteral stent and/or ureterolysis were required in 18% of the EUROSTAR patients who underwent EVAR. The rate of ureteral "entrapment" (inflammation around the ureters) improved from 45% to 27% after EVAR.

Courtesy of Dr. William M. Stone

In a previous meta-analysis of data on 46 patients in 14 studies, EVAR decreased aneurysm size in most patients, with a median decrease of 11 mm. Periaortic fibrosis decreased in 52%, was unchanged in 42%, and progressed in 7% (J. Endovasc. Ther. 2005;12:560-7).

A separate meta-analysis of 56 studies with 1,120 patients compared EVAR with open repair of AAA, and found 1-year all-cause mortality rates of 2% with EVAR and 14% with open repair (Eur. J. Vasc. Endovasc. Surg. 2009;38:291-7). Periaortic fibrosis decreased in 65% of the EVAR group and in 73% of the open-repair group. Hydronephrosis regressed in 38% of the EVAR group and in 69% of the open-repair group.

In the current study, the two groups did not differ significantly in mean age, preoperative aneurysm size, or length of follow-up. In the EVAR group, patients averaged 72 years of age, and eight patients (80%) were male. In the open-repair group, patients averaged 66 years of age, and 45 (77%) were male.

Patients were excluded from endovascular treatment if they had infected aneurysms or aneurysms with inflammation that were not deemed to be true inflammatory aneurysms. The diagnosis of inflammatory aortic aneurysm was confirmed preoperatively by CT scan in the EVAR group or at the time of surgery in the open-repair group.

Dr. Stone reported having no financial disclosures.

Physicians and patients heading into the operating room have to hope that the surgeon or proceduralist does the job right the first time. Generally, needing a do-over is not a good thing.

Soon, however, vascular and cardiac surgeons at Cleveland Clinic will be able to take several consequences-free do-overs that should lower risk for the patient. Some of the latest advances in imaging and technology are being incorporated into new simulation rooms built adjacent to a few new ORs. In these rooms physicians can rehearse the procedure they’re about to do on a three-dimensional simulation of the patient, who is being prepared for surgery next door.

Courtesy DR. ROY K. GREENBERG 

For example, “fusion” imaging can help in the repair of aortic aneurysms. The results of an angiogram taken at the time of the procedure are superimposed on a preoperative CT scan of the patient to create three-dimensional imaging studies “telling us where all the arteries are without using any contrast,” Dr. Roy K. Greenberg said at the annual meeting of the Southern Association for Vascular Surgery. Not having to use catheters and wires to figure that out makes the procedure much easier, said Dr. Greenberg of the Cleveland Clinic Foundation.

His talk on “Aortic Care for the 21^st Century” at the meeting was the first Jesse E. Thompson, M.D. Distinguished Guest Lecture.

“The imaging can be loaded in patient-specific simulators, providing a means to ‘test’ the procedures in virtual reality, train the team, and problem-solve `off-line’ ” with less risk to the patient, he said.

The Cleveland Clinic is no slouch when it comes to simulation. Their doctors-in-training practice on mannequins, robots, and other virtual stand-ins for patients. There is an Anesthesia Simulation Lab. The Clinic is even building an entire Center for Multidisciplinary Simulation.

The two new ORs that Dr. Greenberg described take simulation to the next level. The simulators are not in a remote room, they’re not in a separate building, and they’re not at a course that physicians go to for two or three days before the surgery. “I think they have to be integrated into the actual work flow and case,” he said.

The ORs should be finished in the fourth quarter of 2012, and will feature a control room behind each OR. Behind each control room will be a simulator room.

Dr. Greenberg described the work flow for a fenestrated endovascular aneurysm repair as something like this: The preoperative CT scan is used for patient selection and device design, and is imported into the OR and the simulator before the patient arrives. The CT scan and fluoroscopic imaging studies are used in fusion imaging in the OR, minimizing the use of contrast agents and radiation.

Standard clinic procedures required team sign-ins when the patient is on the table. Each team members signs in, introduces themselves, and makes sure they're operating on the correct anatomic part. Then “we have that obligatory 2.5 hours while anesthesia gets everything else ready,” during which the operative team goes to the simulator room. Residents, fellows, and the rest of the team get to practice the procedure using the repair device on a simulation of that particular patient.

“So there’s no question about what steps are next” during the live surgery, he said. If something doesn’t seem right during rehearsal, “you can say, `Why not?’ Is that a problem with the simulator, or is it going to be a problem with the procedure?”

Dr. Greenberg said he doesn’t know of any other institutions doing patient-specific simulations like this, but “I hope they will.”

Dr. Greenberg disclosed receiving royalties for intellectual property licensed to Cook, Inc. and funds for research and travel from Cook.

Physicians and patients heading into the operating room have to hope that the surgeon or proceduralist does the job right the first time. Generally, needing a do-over is not a good thing.

Soon, however, vascular and cardiac surgeons at Cleveland Clinic will be able to take several consequences-free do-overs that should lower risk for the patient. Some of the latest advances in imaging and technology are being incorporated into new simulation rooms built adjacent to a few new ORs. In these rooms physicians can rehearse the procedure they’re about to do on a three-dimensional simulation of the patient, who is being prepared for surgery next door.

Courtesy DR. ROY K. GREENBERG 

For example, “fusion” imaging can help in the repair of aortic aneurysms. The results of an angiogram taken at the time of the procedure are superimposed on a preoperative CT scan of the patient to create three-dimensional imaging studies “telling us where all the arteries are without using any contrast,” Dr. Roy K. Greenberg said at the annual meeting of the Southern Association for Vascular Surgery. Not having to use catheters and wires to figure that out makes the procedure much easier, said Dr. Greenberg of the Cleveland Clinic Foundation.

His talk on “Aortic Care for the 21^st Century” at the meeting was the first Jesse E. Thompson, M.D. Distinguished Guest Lecture.

“The imaging can be loaded in patient-specific simulators, providing a means to ‘test’ the procedures in virtual reality, train the team, and problem-solve `off-line’ ” with less risk to the patient, he said.

The Cleveland Clinic is no slouch when it comes to simulation. Their doctors-in-training practice on mannequins, robots, and other virtual stand-ins for patients. There is an Anesthesia Simulation Lab. The Clinic is even building an entire Center for Multidisciplinary Simulation.

The two new ORs that Dr. Greenberg described take simulation to the next level. The simulators are not in a remote room, they’re not in a separate building, and they’re not at a course that physicians go to for two or three days before the surgery. “I think they have to be integrated into the actual work flow and case,” he said.

The ORs should be finished in the fourth quarter of 2012, and will feature a control room behind each OR. Behind each control room will be a simulator room.

Dr. Greenberg described the work flow for a fenestrated endovascular aneurysm repair as something like this: The preoperative CT scan is used for patient selection and device design, and is imported into the OR and the simulator before the patient arrives. The CT scan and fluoroscopic imaging studies are used in fusion imaging in the OR, minimizing the use of contrast agents and radiation.

Standard clinic procedures required team sign-ins when the patient is on the table. Each team members signs in, introduces themselves, and makes sure they're operating on the correct anatomic part. Then “we have that obligatory 2.5 hours while anesthesia gets everything else ready,” during which the operative team goes to the simulator room. Residents, fellows, and the rest of the team get to practice the procedure using the repair device on a simulation of that particular patient.

“So there’s no question about what steps are next” during the live surgery, he said. If something doesn’t seem right during rehearsal, “you can say, `Why not?’ Is that a problem with the simulator, or is it going to be a problem with the procedure?”

Dr. Greenberg said he doesn’t know of any other institutions doing patient-specific simulations like this, but “I hope they will.”

Dr. Greenberg disclosed receiving royalties for intellectual property licensed to Cook, Inc. and funds for research and travel from Cook.

Physicians and patients heading into the operating room have to hope that the surgeon or proceduralist does the job right the first time. Generally, needing a do-over is not a good thing.

Soon, however, vascular and cardiac surgeons at Cleveland Clinic will be able to take several consequences-free do-overs that should lower risk for the patient. Some of the latest advances in imaging and technology are being incorporated into new simulation rooms built adjacent to a few new ORs. In these rooms physicians can rehearse the procedure they’re about to do on a three-dimensional simulation of the patient, who is being prepared for surgery next door.

Courtesy DR. ROY K. GREENBERG 

For example, “fusion” imaging can help in the repair of aortic aneurysms. The results of an angiogram taken at the time of the procedure are superimposed on a preoperative CT scan of the patient to create three-dimensional imaging studies “telling us where all the arteries are without using any contrast,” Dr. Roy K. Greenberg said at the annual meeting of the Southern Association for Vascular Surgery. Not having to use catheters and wires to figure that out makes the procedure much easier, said Dr. Greenberg of the Cleveland Clinic Foundation.

His talk on “Aortic Care for the 21^st Century” at the meeting was the first Jesse E. Thompson, M.D. Distinguished Guest Lecture.

“The imaging can be loaded in patient-specific simulators, providing a means to ‘test’ the procedures in virtual reality, train the team, and problem-solve `off-line’ ” with less risk to the patient, he said.

The Cleveland Clinic is no slouch when it comes to simulation. Their doctors-in-training practice on mannequins, robots, and other virtual stand-ins for patients. There is an Anesthesia Simulation Lab. The Clinic is even building an entire Center for Multidisciplinary Simulation.

The two new ORs that Dr. Greenberg described take simulation to the next level. The simulators are not in a remote room, they’re not in a separate building, and they’re not at a course that physicians go to for two or three days before the surgery. “I think they have to be integrated into the actual work flow and case,” he said.

The ORs should be finished in the fourth quarter of 2012, and will feature a control room behind each OR. Behind each control room will be a simulator room.

Dr. Greenberg described the work flow for a fenestrated endovascular aneurysm repair as something like this: The preoperative CT scan is used for patient selection and device design, and is imported into the OR and the simulator before the patient arrives. The CT scan and fluoroscopic imaging studies are used in fusion imaging in the OR, minimizing the use of contrast agents and radiation.

Standard clinic procedures required team sign-ins when the patient is on the table. Each team members signs in, introduces themselves, and makes sure they're operating on the correct anatomic part. Then “we have that obligatory 2.5 hours while anesthesia gets everything else ready,” during which the operative team goes to the simulator room. Residents, fellows, and the rest of the team get to practice the procedure using the repair device on a simulation of that particular patient.

“So there’s no question about what steps are next” during the live surgery, he said. If something doesn’t seem right during rehearsal, “you can say, `Why not?’ Is that a problem with the simulator, or is it going to be a problem with the procedure?”

Dr. Greenberg said he doesn’t know of any other institutions doing patient-specific simulations like this, but “I hope they will.”

Dr. Greenberg disclosed receiving royalties for intellectual property licensed to Cook, Inc. and funds for research and travel from Cook.

MIAMI BEACH – Local or regional anesthesia is a better option than is general anesthesia for patients undergoing endovascular repair of an abdominal aortic aneurysm, based on findings from a registry with nearly 1,200 patients.

Both local anesthesia and regional anesthesia each surpassed general anesthesia in two periprocedural measures: significantly reducing procedure time, and significantly reducing postoperative hospitalization, Dr. Rutger A. Stokmans said at ISET 2012, an international symposium on endovascular therapy.

In addition, both local and regional anesthesia led to trends in reduced rates of major adverse events during the 30 days following surgery, although these differences did not reach statistical significance. All three anesthesia types linked with similar rates of both technical and clinical success of the aneurysm repairs. Regional anesthesia also led to a significantly lower rate of ICU admission, compared with both general and local anesthesia; local anesthesia showed no significant difference for this measure, compared with general anesthesia.

Based on these findings, local or regional anesthesia should be preferred when performing endovascular aneurysm repair (EVAR), whereas general anesthesia should usually be avoided, said Dr. Stokmans, a vascular surgeon at Catharina Hospital in Eindhoven, the Netherlands.

These findings support the most recent anesthesia recommendations of the European Society for Vascular Surgery, which in 2011 guidelines for managing abdominal aortic aneurysms (AAA) cited local anesthesia as preferred for EVAR, with regional or general anesthesia reserved for patients with contraindications for local anesthesia, he said (Euro. J. Vasc. Endovasc. Surg .2011;41[suppl. 1]:S1-S58). The most recent guidelines for AAA management from the Society for Vascular Surgery suggested using local or regional anesthesia over general anesthesia, he added (J. Vasc. Surg. 2009[suppl.]:50:S2-S49).

But despite these recommendations, the most commonly used anesthesia type worldwide for EVAR repair of AAA has been general anesthesia, followed by regional anesthesia, with local treatment used least often, according to the registry data reported by Dr. Stokmans. Among the 1,199 patients enrolled in ENGAGE (Endurant Stent Graft Natural Selection Global Postmarketing Registry) during March 2009 to December 2010 in 30 countries on five continents, 749 (62%) underwent their EVAR with general anesthesia, 325 (27%) with regional, and 125 (10%) with local anesthesia. (Percentages do not add up to 100% because of rounding.)

The registry data also showed striking regional variations in anesthesia use, with general anesthesia used on about 90% of patients in Canada, Australia, and New Zealand, and on about 70% of patients in Scandinavian countries and the United Kingdom. But in Central Europe, regional anesthesia – used on nearly 70% of EVAR patients – dominated. The only region favoring local anesthesia was South America (Argentina, Columbia, and Uruguay), where about 50% of patients received local, but more than 40% received general anesthesia, he said. The registry contained no U.S. patients, although the Endurant AAA stent graft system is marketed in the United States.

The average age of the EVAR patients in the registry was about 73 years. Those patients who underwent general anesthesia were significantly older, by an average of about 18 months, compared with those who received local or regional anesthesia.

The proportions of patients undergoing general, regional, or local anesthesia were similar in the subgroups of patients with American Society of Anesthesiologists (ASA) physical status scores of 1, 2, or 3. However, among the highest-risk patients included in the study – those with an ASA score of 4 – a significantly greater proportion of patients received general anesthesia. The multivariate models used in the analysis, therefore, were adjusted for age and for ASA score. About 42% of patients were in ASA class 2, and another 42% in class 3.

All patients were hemodynamically stable at the time of their enrollment. The maximum AAA diameter of registry patients was 6 cm, and about 88% of patients had an AAA diameter greater than 5 cm.

Average procedure times were 106 minutes in the general anesthesia patients, 95 minutes in the regional patients, and 81 minutes in the local anesthesia patients – statistically significant differences among the three groups.

The average postoperative hospitalization was 5.2 days in the general anesthesia patients, 4.3 days in the regional patients, and 3.6 days in the local anesthesia patients, differences that were statistically significant among each of the three groups.

The rate of technical surgical success was 98% in all three subgroups, and the rate of clinical success reached 97%-98% in all three groups.

The rates of major adverse events during the 30 days following surgery were 5.1% in the general anesthesia patients, 3.2% in the local patients, and 2.2% in the regional anesthesia patients. None of these differences reached statistical significance. Major adverse events included death, MI, stroke, renal failure, blood loss greater than 1 L, and bowel ischemia. No patients developed paraplegia or respiratory failure.

Postoperative ICU admission occurred for 27% of the regional anesthesia patients, 35% of the general patients, and 42% of the local anesthesia patients. The rate among the regional patients was significantly less than in the other two groups, but the difference in rates between the general and local anesthesia patients did not reach statistical significance.

The ENGAGE registry was organized and sponsored by Medtronic, which markets the Endurant stent. Dr. Stokmans and his associates received an unrestricted research grant from Medtronic. Dr. Stokmans said that he had no other disclosures.

MIAMI BEACH – Local or regional anesthesia is a better option than is general anesthesia for patients undergoing endovascular repair of an abdominal aortic aneurysm, based on findings from a registry with nearly 1,200 patients.

Both local anesthesia and regional anesthesia each surpassed general anesthesia in two periprocedural measures: significantly reducing procedure time, and significantly reducing postoperative hospitalization, Dr. Rutger A. Stokmans said at ISET 2012, an international symposium on endovascular therapy.

In addition, both local and regional anesthesia led to trends in reduced rates of major adverse events during the 30 days following surgery, although these differences did not reach statistical significance. All three anesthesia types linked with similar rates of both technical and clinical success of the aneurysm repairs. Regional anesthesia also led to a significantly lower rate of ICU admission, compared with both general and local anesthesia; local anesthesia showed no significant difference for this measure, compared with general anesthesia.

Based on these findings, local or regional anesthesia should be preferred when performing endovascular aneurysm repair (EVAR), whereas general anesthesia should usually be avoided, said Dr. Stokmans, a vascular surgeon at Catharina Hospital in Eindhoven, the Netherlands.

These findings support the most recent anesthesia recommendations of the European Society for Vascular Surgery, which in 2011 guidelines for managing abdominal aortic aneurysms (AAA) cited local anesthesia as preferred for EVAR, with regional or general anesthesia reserved for patients with contraindications for local anesthesia, he said (Euro. J. Vasc. Endovasc. Surg .2011;41[suppl. 1]:S1-S58). The most recent guidelines for AAA management from the Society for Vascular Surgery suggested using local or regional anesthesia over general anesthesia, he added (J. Vasc. Surg. 2009[suppl.]:50:S2-S49).

But despite these recommendations, the most commonly used anesthesia type worldwide for EVAR repair of AAA has been general anesthesia, followed by regional anesthesia, with local treatment used least often, according to the registry data reported by Dr. Stokmans. Among the 1,199 patients enrolled in ENGAGE (Endurant Stent Graft Natural Selection Global Postmarketing Registry) during March 2009 to December 2010 in 30 countries on five continents, 749 (62%) underwent their EVAR with general anesthesia, 325 (27%) with regional, and 125 (10%) with local anesthesia. (Percentages do not add up to 100% because of rounding.)

The registry data also showed striking regional variations in anesthesia use, with general anesthesia used on about 90% of patients in Canada, Australia, and New Zealand, and on about 70% of patients in Scandinavian countries and the United Kingdom. But in Central Europe, regional anesthesia – used on nearly 70% of EVAR patients – dominated. The only region favoring local anesthesia was South America (Argentina, Columbia, and Uruguay), where about 50% of patients received local, but more than 40% received general anesthesia, he said. The registry contained no U.S. patients, although the Endurant AAA stent graft system is marketed in the United States.

The average age of the EVAR patients in the registry was about 73 years. Those patients who underwent general anesthesia were significantly older, by an average of about 18 months, compared with those who received local or regional anesthesia.

The proportions of patients undergoing general, regional, or local anesthesia were similar in the subgroups of patients with American Society of Anesthesiologists (ASA) physical status scores of 1, 2, or 3. However, among the highest-risk patients included in the study – those with an ASA score of 4 – a significantly greater proportion of patients received general anesthesia. The multivariate models used in the analysis, therefore, were adjusted for age and for ASA score. About 42% of patients were in ASA class 2, and another 42% in class 3.

All patients were hemodynamically stable at the time of their enrollment. The maximum AAA diameter of registry patients was 6 cm, and about 88% of patients had an AAA diameter greater than 5 cm.

Average procedure times were 106 minutes in the general anesthesia patients, 95 minutes in the regional patients, and 81 minutes in the local anesthesia patients – statistically significant differences among the three groups.

The average postoperative hospitalization was 5.2 days in the general anesthesia patients, 4.3 days in the regional patients, and 3.6 days in the local anesthesia patients, differences that were statistically significant among each of the three groups.

The rate of technical surgical success was 98% in all three subgroups, and the rate of clinical success reached 97%-98% in all three groups.

The rates of major adverse events during the 30 days following surgery were 5.1% in the general anesthesia patients, 3.2% in the local patients, and 2.2% in the regional anesthesia patients. None of these differences reached statistical significance. Major adverse events included death, MI, stroke, renal failure, blood loss greater than 1 L, and bowel ischemia. No patients developed paraplegia or respiratory failure.

Postoperative ICU admission occurred for 27% of the regional anesthesia patients, 35% of the general patients, and 42% of the local anesthesia patients. The rate among the regional patients was significantly less than in the other two groups, but the difference in rates between the general and local anesthesia patients did not reach statistical significance.

The ENGAGE registry was organized and sponsored by Medtronic, which markets the Endurant stent. Dr. Stokmans and his associates received an unrestricted research grant from Medtronic. Dr. Stokmans said that he had no other disclosures.

MIAMI BEACH – Local or regional anesthesia is a better option than is general anesthesia for patients undergoing endovascular repair of an abdominal aortic aneurysm, based on findings from a registry with nearly 1,200 patients.

Both local anesthesia and regional anesthesia each surpassed general anesthesia in two periprocedural measures: significantly reducing procedure time, and significantly reducing postoperative hospitalization, Dr. Rutger A. Stokmans said at ISET 2012, an international symposium on endovascular therapy.

In addition, both local and regional anesthesia led to trends in reduced rates of major adverse events during the 30 days following surgery, although these differences did not reach statistical significance. All three anesthesia types linked with similar rates of both technical and clinical success of the aneurysm repairs. Regional anesthesia also led to a significantly lower rate of ICU admission, compared with both general and local anesthesia; local anesthesia showed no significant difference for this measure, compared with general anesthesia.

Based on these findings, local or regional anesthesia should be preferred when performing endovascular aneurysm repair (EVAR), whereas general anesthesia should usually be avoided, said Dr. Stokmans, a vascular surgeon at Catharina Hospital in Eindhoven, the Netherlands.

These findings support the most recent anesthesia recommendations of the European Society for Vascular Surgery, which in 2011 guidelines for managing abdominal aortic aneurysms (AAA) cited local anesthesia as preferred for EVAR, with regional or general anesthesia reserved for patients with contraindications for local anesthesia, he said (Euro. J. Vasc. Endovasc. Surg .2011;41[suppl. 1]:S1-S58). The most recent guidelines for AAA management from the Society for Vascular Surgery suggested using local or regional anesthesia over general anesthesia, he added (J. Vasc. Surg. 2009[suppl.]:50:S2-S49).

But despite these recommendations, the most commonly used anesthesia type worldwide for EVAR repair of AAA has been general anesthesia, followed by regional anesthesia, with local treatment used least often, according to the registry data reported by Dr. Stokmans. Among the 1,199 patients enrolled in ENGAGE (Endurant Stent Graft Natural Selection Global Postmarketing Registry) during March 2009 to December 2010 in 30 countries on five continents, 749 (62%) underwent their EVAR with general anesthesia, 325 (27%) with regional, and 125 (10%) with local anesthesia. (Percentages do not add up to 100% because of rounding.)

The registry data also showed striking regional variations in anesthesia use, with general anesthesia used on about 90% of patients in Canada, Australia, and New Zealand, and on about 70% of patients in Scandinavian countries and the United Kingdom. But in Central Europe, regional anesthesia – used on nearly 70% of EVAR patients – dominated. The only region favoring local anesthesia was South America (Argentina, Columbia, and Uruguay), where about 50% of patients received local, but more than 40% received general anesthesia, he said. The registry contained no U.S. patients, although the Endurant AAA stent graft system is marketed in the United States.

The average age of the EVAR patients in the registry was about 73 years. Those patients who underwent general anesthesia were significantly older, by an average of about 18 months, compared with those who received local or regional anesthesia.

The proportions of patients undergoing general, regional, or local anesthesia were similar in the subgroups of patients with American Society of Anesthesiologists (ASA) physical status scores of 1, 2, or 3. However, among the highest-risk patients included in the study – those with an ASA score of 4 – a significantly greater proportion of patients received general anesthesia. The multivariate models used in the analysis, therefore, were adjusted for age and for ASA score. About 42% of patients were in ASA class 2, and another 42% in class 3.

All patients were hemodynamically stable at the time of their enrollment. The maximum AAA diameter of registry patients was 6 cm, and about 88% of patients had an AAA diameter greater than 5 cm.

Average procedure times were 106 minutes in the general anesthesia patients, 95 minutes in the regional patients, and 81 minutes in the local anesthesia patients – statistically significant differences among the three groups.

The average postoperative hospitalization was 5.2 days in the general anesthesia patients, 4.3 days in the regional patients, and 3.6 days in the local anesthesia patients, differences that were statistically significant among each of the three groups.

The rate of technical surgical success was 98% in all three subgroups, and the rate of clinical success reached 97%-98% in all three groups.

The rates of major adverse events during the 30 days following surgery were 5.1% in the general anesthesia patients, 3.2% in the local patients, and 2.2% in the regional anesthesia patients. None of these differences reached statistical significance. Major adverse events included death, MI, stroke, renal failure, blood loss greater than 1 L, and bowel ischemia. No patients developed paraplegia or respiratory failure.

Postoperative ICU admission occurred for 27% of the regional anesthesia patients, 35% of the general patients, and 42% of the local anesthesia patients. The rate among the regional patients was significantly less than in the other two groups, but the difference in rates between the general and local anesthesia patients did not reach statistical significance.

The ENGAGE registry was organized and sponsored by Medtronic, which markets the Endurant stent. Dr. Stokmans and his associates received an unrestricted research grant from Medtronic. Dr. Stokmans said that he had no other disclosures.

SAN FRANCISCO – A majority of patients who are rehospitalized after surgery have a postoperative complication, most commonly after colectomy, lower extremity bypass, or carotid endarterectomy.

Reducing postoperative complications could reduce costs associated with readmissions by millions of dollars per year, a retrospective study of data on 90,932 patients from 214 hospitals suggests.

Investigators linked records from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the Medicare Provider Analysis and Review files for patients aged 65 years or older who underwent surgery in 2005-2008.

Within 30 days of surgery, 13% of patients were readmitted. A postoperative complication listed in the ACS-NSQIP registry was seen in 53% of readmitted patients compared with 16% of patients who did not need readmission, Dr. Elise H. Lawson and her associates reported at the annual clinical congress of the American College of Surgeons.

The study looked at 20 postoperative complications, including surgical site infections, wound disruption, pneumonia, unplanned intubation, pulmonary embolism, progressive renal insufficiency, acute renal failure, urinary tract infection, stroke, coma, cardiac arrest requiring CPR, myocardial infarction, bleeding requiring transfusion, deep venous thrombosis, sepsis or septic shock, being on a ventilator for more than 48 hours, and an unplanned return to the OR, among others.

Colectomy was associated with the greatest number of readmissions, followed by lower extremity bypass and carotid endarterectomy. After colectomy, 27% of patients developed a complication, and 13.4% of all colectomy patients were readmitted within 30 days.

Readmission rates after colectomy were 28% for patients who developed postoperative complications and 8% for patients without complications, said Dr. Lawson of the University of California, Los Angeles. She won the College’s 2011 Excellence in Research Award for her study.

Hypothetically, if postoperative complications could be prevented after colectomy, the risk-adjusted probability of readmission within 30 days would be 8%, she said. The study adjusted for the effects of many other factors that influenced the risk of having a postoperative complication, including age, sex, body mass index, functional status, emergency procedures, smoking, renal failure, and diabetes.

Not only did patients with complications have more readmissions, but those readmissions were more expensive. The cost for readmission after colectomy was $13,400 for patients with a complication and $7,500 for those without complications.

It’s unrealistic to think that a hospital could prevent all postoperative complications, Dr. Lawson said. Reducing complications after colectomy by even 10% (to 24%) would lower the overall postcolectomy readmission rate from 13.4% to 12.8%, the investigators estimated. For the 108,820 colectomies performed each year in Medicare beneficiaries aged 65 years or older, a 10% reduction in postoperative complications would reduce costs from readmissions alone by $9.3 million per year, she said.

Reducing complications after colectomy by 30% (to 19%) would lower the postcolectomy readmission rate to 11.7% and save an estimated $28 million per year in readmission costs. Halving the postcolectomy complication rate (to 13.5%) would reduce the readmission rate to 10.6% and save an estimated $46 million per year in readmission costs.

Previous data suggest that 13% of surgical patients and 16% of medical patients are readmitted after discharge from hospitalization, accounting for an estimated $17 billion in Medicare costs. Medicare plans to reduce payments for readmissions starting in 2013.

The reasons that patients are readmitted are not well understood, which was one motivation for the study, Dr. Lawson said. Unplanned readmissions that are related to the initial surgery may be due to postoperative complications or exacerbations of a preoperative comorbidity. Unplanned readmissions also may be for reasons unrelated to the initial surgery, such as for trauma or falls. In other cases, readmission may be planned for chemotherapy or elective procedures. The study excluded patients who died before discharge or who were not discharged from the primary hospitalization.

Dr. Lawson said she has no relevant conflicts of interest.

SAN FRANCISCO – A majority of patients who are rehospitalized after surgery have a postoperative complication, most commonly after colectomy, lower extremity bypass, or carotid endarterectomy.

Reducing postoperative complications could reduce costs associated with readmissions by millions of dollars per year, a retrospective study of data on 90,932 patients from 214 hospitals suggests.

Investigators linked records from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the Medicare Provider Analysis and Review files for patients aged 65 years or older who underwent surgery in 2005-2008.

Within 30 days of surgery, 13% of patients were readmitted. A postoperative complication listed in the ACS-NSQIP registry was seen in 53% of readmitted patients compared with 16% of patients who did not need readmission, Dr. Elise H. Lawson and her associates reported at the annual clinical congress of the American College of Surgeons.

The study looked at 20 postoperative complications, including surgical site infections, wound disruption, pneumonia, unplanned intubation, pulmonary embolism, progressive renal insufficiency, acute renal failure, urinary tract infection, stroke, coma, cardiac arrest requiring CPR, myocardial infarction, bleeding requiring transfusion, deep venous thrombosis, sepsis or septic shock, being on a ventilator for more than 48 hours, and an unplanned return to the OR, among others.

Colectomy was associated with the greatest number of readmissions, followed by lower extremity bypass and carotid endarterectomy. After colectomy, 27% of patients developed a complication, and 13.4% of all colectomy patients were readmitted within 30 days.

Readmission rates after colectomy were 28% for patients who developed postoperative complications and 8% for patients without complications, said Dr. Lawson of the University of California, Los Angeles. She won the College’s 2011 Excellence in Research Award for her study.

Hypothetically, if postoperative complications could be prevented after colectomy, the risk-adjusted probability of readmission within 30 days would be 8%, she said. The study adjusted for the effects of many other factors that influenced the risk of having a postoperative complication, including age, sex, body mass index, functional status, emergency procedures, smoking, renal failure, and diabetes.

Not only did patients with complications have more readmissions, but those readmissions were more expensive. The cost for readmission after colectomy was $13,400 for patients with a complication and $7,500 for those without complications.

It’s unrealistic to think that a hospital could prevent all postoperative complications, Dr. Lawson said. Reducing complications after colectomy by even 10% (to 24%) would lower the overall postcolectomy readmission rate from 13.4% to 12.8%, the investigators estimated. For the 108,820 colectomies performed each year in Medicare beneficiaries aged 65 years or older, a 10% reduction in postoperative complications would reduce costs from readmissions alone by $9.3 million per year, she said.

Reducing complications after colectomy by 30% (to 19%) would lower the postcolectomy readmission rate to 11.7% and save an estimated $28 million per year in readmission costs. Halving the postcolectomy complication rate (to 13.5%) would reduce the readmission rate to 10.6% and save an estimated $46 million per year in readmission costs.

Previous data suggest that 13% of surgical patients and 16% of medical patients are readmitted after discharge from hospitalization, accounting for an estimated $17 billion in Medicare costs. Medicare plans to reduce payments for readmissions starting in 2013.

The reasons that patients are readmitted are not well understood, which was one motivation for the study, Dr. Lawson said. Unplanned readmissions that are related to the initial surgery may be due to postoperative complications or exacerbations of a preoperative comorbidity. Unplanned readmissions also may be for reasons unrelated to the initial surgery, such as for trauma or falls. In other cases, readmission may be planned for chemotherapy or elective procedures. The study excluded patients who died before discharge or who were not discharged from the primary hospitalization.

Dr. Lawson said she has no relevant conflicts of interest.

SAN FRANCISCO – A majority of patients who are rehospitalized after surgery have a postoperative complication, most commonly after colectomy, lower extremity bypass, or carotid endarterectomy.

Reducing postoperative complications could reduce costs associated with readmissions by millions of dollars per year, a retrospective study of data on 90,932 patients from 214 hospitals suggests.

Investigators linked records from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the Medicare Provider Analysis and Review files for patients aged 65 years or older who underwent surgery in 2005-2008.

Within 30 days of surgery, 13% of patients were readmitted. A postoperative complication listed in the ACS-NSQIP registry was seen in 53% of readmitted patients compared with 16% of patients who did not need readmission, Dr. Elise H. Lawson and her associates reported at the annual clinical congress of the American College of Surgeons.

The study looked at 20 postoperative complications, including surgical site infections, wound disruption, pneumonia, unplanned intubation, pulmonary embolism, progressive renal insufficiency, acute renal failure, urinary tract infection, stroke, coma, cardiac arrest requiring CPR, myocardial infarction, bleeding requiring transfusion, deep venous thrombosis, sepsis or septic shock, being on a ventilator for more than 48 hours, and an unplanned return to the OR, among others.

Colectomy was associated with the greatest number of readmissions, followed by lower extremity bypass and carotid endarterectomy. After colectomy, 27% of patients developed a complication, and 13.4% of all colectomy patients were readmitted within 30 days.

Readmission rates after colectomy were 28% for patients who developed postoperative complications and 8% for patients without complications, said Dr. Lawson of the University of California, Los Angeles. She won the College’s 2011 Excellence in Research Award for her study.

Hypothetically, if postoperative complications could be prevented after colectomy, the risk-adjusted probability of readmission within 30 days would be 8%, she said. The study adjusted for the effects of many other factors that influenced the risk of having a postoperative complication, including age, sex, body mass index, functional status, emergency procedures, smoking, renal failure, and diabetes.

Not only did patients with complications have more readmissions, but those readmissions were more expensive. The cost for readmission after colectomy was $13,400 for patients with a complication and $7,500 for those without complications.

It’s unrealistic to think that a hospital could prevent all postoperative complications, Dr. Lawson said. Reducing complications after colectomy by even 10% (to 24%) would lower the overall postcolectomy readmission rate from 13.4% to 12.8%, the investigators estimated. For the 108,820 colectomies performed each year in Medicare beneficiaries aged 65 years or older, a 10% reduction in postoperative complications would reduce costs from readmissions alone by $9.3 million per year, she said.

Reducing complications after colectomy by 30% (to 19%) would lower the postcolectomy readmission rate to 11.7% and save an estimated $28 million per year in readmission costs. Halving the postcolectomy complication rate (to 13.5%) would reduce the readmission rate to 10.6% and save an estimated $46 million per year in readmission costs.

Previous data suggest that 13% of surgical patients and 16% of medical patients are readmitted after discharge from hospitalization, accounting for an estimated $17 billion in Medicare costs. Medicare plans to reduce payments for readmissions starting in 2013.

The reasons that patients are readmitted are not well understood, which was one motivation for the study, Dr. Lawson said. Unplanned readmissions that are related to the initial surgery may be due to postoperative complications or exacerbations of a preoperative comorbidity. Unplanned readmissions also may be for reasons unrelated to the initial surgery, such as for trauma or falls. In other cases, readmission may be planned for chemotherapy or elective procedures. The study excluded patients who died before discharge or who were not discharged from the primary hospitalization.

Dr. Lawson said she has no relevant conflicts of interest.

NATIONAL HARBOR, MD – Local delivery of an antibiotic using impregnated bone-cement beads enabled sterile cultures to be achieved in the majority of infected surgical sites before final repair or graft replacement, according to a small, retrospective study reported by Dr. Dennis F. Bandyk.

This type of nonbiodegradable antibiotic implant is especially useful in cases of infection related to a groin incision, he said at the annual meeting of the Eastern Vascular Society.

"You can make these drug-delivery beads in the operating room in about 10 to 15 minutes.

"After EVAR [endovascular aneurysm repair], we have about a 5% incidence of surgical site infection. Arterial revascularization in the literature has a 10% to 30% infection rate, [and] it’s 18% in lengthy lower limb revascularization at our institution in Tampa. Major amputations generally range from a 15% to 25% infection rate, with 22% for the last 3 years at Tampa. The problem likely exists because of colonization with staph, particularly MRSA [methicillin-resistant Staphylococcus aureus], of injured and ischemic tissue, especially with involvement of the groin," Dr. Bandyk said.

"We have no decent methods of preventing these sorts of surgical site infections," he noted. The approach that his group takes to treat these infections is to use sequential in situ antibiotic treatment.

"I believe that many of the SSIs [surgical site infections] we have follow this theme of a biofilm-mediated infection," he said. Specific pathogenic strains colonize the area; they produce an extracellular matrix that then creates selective antibiotic resistance, since many of the antibiotics don’t penetrate biofilms.

The reported study comprised a 7-year case audit of 78 patients (55% male) who had complex SSI following peripheral arterial repair, treatment of an infected hip, or above- or below-knee lower limb amputation (12 infected stumps).

Antibiotic delivery directly to the wounds was mediated via the use of polymethyl methacrylate (PMMA) bone-cement beads. For gram-positive infection, which occurred in 70% of patients, the beads were impregnated with vancomycin (2 g/40 g PMMA) in the early part of the case series. Daptomycin (1.5 g/40 g PMMA) was found superior to vancomycin during in vitro testing, and became the antibiotic of choice for patients seen later in the case series. Tobramycin (2 g/40 g PMMA) was used for gram-negative infection, seen in 30% of patients. This was coupled to culture-specific parenteral antibiotics for 3-6 weeks. MRSA accounted for at least half of all early and late infections, and thus MRSA must be taken into account when comparing therapy options.

Infected surgical sites were explored and cultured, and based on a Gram stain of pus or a prior culture result, PMMA antibiotic-impregnated beads were implanted into the wound after soft tissue debridement, including the adjunct use of wound irrigants such as the "brown volcano" – a mixture of salt, peroxide, and Betadine – which disrupts biofilms.

Arterial infections underwent an average of 2.3 debridements. Surgical wounds were primarily closed with a planned bead exchange 3-5 days later (often repeated one to three times) to confirm sterilization prior to graft preservation or in situ graft replacement. The main outcomes were rates of wound sterilization (negative culture) based on wound type, procedures for persistent infection, and freedom from arterial repair infection.

In terms of outcomes, there were no cases of limb loss, higher-level amputation, or death at 30 days. The rate of recurrent infection was 7% over a mean follow-up period of 3 years. Sterile wound cultures were achieved in 91% of cases after 1-3 bead exchanges. Daptomycin beads appeared to work the most rapidly, Dr. Bandyk added.

"So you can sterilize the wound with the prosthetic in place," he noted.

Because of this strategy’s success, his group has transitioned to treating almost 58% of their SSIs in this way, said Dr. Bandyk, professor of surgery at the University of South Florida, Tampa.

"You can make these drug-delivery beads in the operating room in about 10 to 15 minutes. Vancomycin is bacteriostatic and does not penetrate biofilms; daptomycin is a bacteriocidal antibiotic that does penetrate biofilms," he explained.

In addition, because the use of antibiotic beads in general "isn’t anything new, you get paid for putting it in and paid for pulling it out."

Discussion after the presentation focused on the expense of daptomycin versus vancomycin and the difficulty of obtaining it in many institutions due to cost and issues of antibiotic stewardship. Dr. Bandyk responded, "I thought we were surgeons. Most surgeons believe that we should use a bactericidal agent that can get to the tissue with a chance of killing the bacteria that are there. I didn’t realize that we were in this sort of price war with the hospital. If you look at what a biofilm infection is, you will understand why vancomycin doesn’t work."

In response to a question as to whether the type of incision was an issue regarding SSI, Dr. Bandyk said: "It’s the patient that’s producing the infection, and certain patient characteristics, so it isn’t necessarily how we’re closing, which way we are putting the incision ... So don’t blame yourself for every surgical site infection. It’s the patient factors that are operative in many of these cases. Of almost all of our infections that occurred, two-thirds came from the MRSA-colonized patient," he said.

Dr. Bandyk reported being on the speakers bureau and having received funding from Cubist Pharmaceuticals, the manufacturer of daptomycin (Cubicin).

NATIONAL HARBOR, MD – Local delivery of an antibiotic using impregnated bone-cement beads enabled sterile cultures to be achieved in the majority of infected surgical sites before final repair or graft replacement, according to a small, retrospective study reported by Dr. Dennis F. Bandyk.

This type of nonbiodegradable antibiotic implant is especially useful in cases of infection related to a groin incision, he said at the annual meeting of the Eastern Vascular Society.

"You can make these drug-delivery beads in the operating room in about 10 to 15 minutes.

"After EVAR [endovascular aneurysm repair], we have about a 5% incidence of surgical site infection. Arterial revascularization in the literature has a 10% to 30% infection rate, [and] it’s 18% in lengthy lower limb revascularization at our institution in Tampa. Major amputations generally range from a 15% to 25% infection rate, with 22% for the last 3 years at Tampa. The problem likely exists because of colonization with staph, particularly MRSA [methicillin-resistant Staphylococcus aureus], of injured and ischemic tissue, especially with involvement of the groin," Dr. Bandyk said.

"We have no decent methods of preventing these sorts of surgical site infections," he noted. The approach that his group takes to treat these infections is to use sequential in situ antibiotic treatment.

"I believe that many of the SSIs [surgical site infections] we have follow this theme of a biofilm-mediated infection," he said. Specific pathogenic strains colonize the area; they produce an extracellular matrix that then creates selective antibiotic resistance, since many of the antibiotics don’t penetrate biofilms.

The reported study comprised a 7-year case audit of 78 patients (55% male) who had complex SSI following peripheral arterial repair, treatment of an infected hip, or above- or below-knee lower limb amputation (12 infected stumps).

Antibiotic delivery directly to the wounds was mediated via the use of polymethyl methacrylate (PMMA) bone-cement beads. For gram-positive infection, which occurred in 70% of patients, the beads were impregnated with vancomycin (2 g/40 g PMMA) in the early part of the case series. Daptomycin (1.5 g/40 g PMMA) was found superior to vancomycin during in vitro testing, and became the antibiotic of choice for patients seen later in the case series. Tobramycin (2 g/40 g PMMA) was used for gram-negative infection, seen in 30% of patients. This was coupled to culture-specific parenteral antibiotics for 3-6 weeks. MRSA accounted for at least half of all early and late infections, and thus MRSA must be taken into account when comparing therapy options.

Infected surgical sites were explored and cultured, and based on a Gram stain of pus or a prior culture result, PMMA antibiotic-impregnated beads were implanted into the wound after soft tissue debridement, including the adjunct use of wound irrigants such as the "brown volcano" – a mixture of salt, peroxide, and Betadine – which disrupts biofilms.

Arterial infections underwent an average of 2.3 debridements. Surgical wounds were primarily closed with a planned bead exchange 3-5 days later (often repeated one to three times) to confirm sterilization prior to graft preservation or in situ graft replacement. The main outcomes were rates of wound sterilization (negative culture) based on wound type, procedures for persistent infection, and freedom from arterial repair infection.

In terms of outcomes, there were no cases of limb loss, higher-level amputation, or death at 30 days. The rate of recurrent infection was 7% over a mean follow-up period of 3 years. Sterile wound cultures were achieved in 91% of cases after 1-3 bead exchanges. Daptomycin beads appeared to work the most rapidly, Dr. Bandyk added.

"So you can sterilize the wound with the prosthetic in place," he noted.

Because of this strategy’s success, his group has transitioned to treating almost 58% of their SSIs in this way, said Dr. Bandyk, professor of surgery at the University of South Florida, Tampa.

"You can make these drug-delivery beads in the operating room in about 10 to 15 minutes. Vancomycin is bacteriostatic and does not penetrate biofilms; daptomycin is a bacteriocidal antibiotic that does penetrate biofilms," he explained.

In addition, because the use of antibiotic beads in general "isn’t anything new, you get paid for putting it in and paid for pulling it out."

Discussion after the presentation focused on the expense of daptomycin versus vancomycin and the difficulty of obtaining it in many institutions due to cost and issues of antibiotic stewardship. Dr. Bandyk responded, "I thought we were surgeons. Most surgeons believe that we should use a bactericidal agent that can get to the tissue with a chance of killing the bacteria that are there. I didn’t realize that we were in this sort of price war with the hospital. If you look at what a biofilm infection is, you will understand why vancomycin doesn’t work."

In response to a question as to whether the type of incision was an issue regarding SSI, Dr. Bandyk said: "It’s the patient that’s producing the infection, and certain patient characteristics, so it isn’t necessarily how we’re closing, which way we are putting the incision ... So don’t blame yourself for every surgical site infection. It’s the patient factors that are operative in many of these cases. Of almost all of our infections that occurred, two-thirds came from the MRSA-colonized patient," he said.

Dr. Bandyk reported being on the speakers bureau and having received funding from Cubist Pharmaceuticals, the manufacturer of daptomycin (Cubicin).

NATIONAL HARBOR, MD – Local delivery of an antibiotic using impregnated bone-cement beads enabled sterile cultures to be achieved in the majority of infected surgical sites before final repair or graft replacement, according to a small, retrospective study reported by Dr. Dennis F. Bandyk.

This type of nonbiodegradable antibiotic implant is especially useful in cases of infection related to a groin incision, he said at the annual meeting of the Eastern Vascular Society.

"You can make these drug-delivery beads in the operating room in about 10 to 15 minutes.

"After EVAR [endovascular aneurysm repair], we have about a 5% incidence of surgical site infection. Arterial revascularization in the literature has a 10% to 30% infection rate, [and] it’s 18% in lengthy lower limb revascularization at our institution in Tampa. Major amputations generally range from a 15% to 25% infection rate, with 22% for the last 3 years at Tampa. The problem likely exists because of colonization with staph, particularly MRSA [methicillin-resistant Staphylococcus aureus], of injured and ischemic tissue, especially with involvement of the groin," Dr. Bandyk said.

"We have no decent methods of preventing these sorts of surgical site infections," he noted. The approach that his group takes to treat these infections is to use sequential in situ antibiotic treatment.

"I believe that many of the SSIs [surgical site infections] we have follow this theme of a biofilm-mediated infection," he said. Specific pathogenic strains colonize the area; they produce an extracellular matrix that then creates selective antibiotic resistance, since many of the antibiotics don’t penetrate biofilms.

The reported study comprised a 7-year case audit of 78 patients (55% male) who had complex SSI following peripheral arterial repair, treatment of an infected hip, or above- or below-knee lower limb amputation (12 infected stumps).

Antibiotic delivery directly to the wounds was mediated via the use of polymethyl methacrylate (PMMA) bone-cement beads. For gram-positive infection, which occurred in 70% of patients, the beads were impregnated with vancomycin (2 g/40 g PMMA) in the early part of the case series. Daptomycin (1.5 g/40 g PMMA) was found superior to vancomycin during in vitro testing, and became the antibiotic of choice for patients seen later in the case series. Tobramycin (2 g/40 g PMMA) was used for gram-negative infection, seen in 30% of patients. This was coupled to culture-specific parenteral antibiotics for 3-6 weeks. MRSA accounted for at least half of all early and late infections, and thus MRSA must be taken into account when comparing therapy options.

Infected surgical sites were explored and cultured, and based on a Gram stain of pus or a prior culture result, PMMA antibiotic-impregnated beads were implanted into the wound after soft tissue debridement, including the adjunct use of wound irrigants such as the "brown volcano" – a mixture of salt, peroxide, and Betadine – which disrupts biofilms.

Arterial infections underwent an average of 2.3 debridements. Surgical wounds were primarily closed with a planned bead exchange 3-5 days later (often repeated one to three times) to confirm sterilization prior to graft preservation or in situ graft replacement. The main outcomes were rates of wound sterilization (negative culture) based on wound type, procedures for persistent infection, and freedom from arterial repair infection.

In terms of outcomes, there were no cases of limb loss, higher-level amputation, or death at 30 days. The rate of recurrent infection was 7% over a mean follow-up period of 3 years. Sterile wound cultures were achieved in 91% of cases after 1-3 bead exchanges. Daptomycin beads appeared to work the most rapidly, Dr. Bandyk added.

"So you can sterilize the wound with the prosthetic in place," he noted.

Because of this strategy’s success, his group has transitioned to treating almost 58% of their SSIs in this way, said Dr. Bandyk, professor of surgery at the University of South Florida, Tampa.

"You can make these drug-delivery beads in the operating room in about 10 to 15 minutes. Vancomycin is bacteriostatic and does not penetrate biofilms; daptomycin is a bacteriocidal antibiotic that does penetrate biofilms," he explained.

In addition, because the use of antibiotic beads in general "isn’t anything new, you get paid for putting it in and paid for pulling it out."

Discussion after the presentation focused on the expense of daptomycin versus vancomycin and the difficulty of obtaining it in many institutions due to cost and issues of antibiotic stewardship. Dr. Bandyk responded, "I thought we were surgeons. Most surgeons believe that we should use a bactericidal agent that can get to the tissue with a chance of killing the bacteria that are there. I didn’t realize that we were in this sort of price war with the hospital. If you look at what a biofilm infection is, you will understand why vancomycin doesn’t work."

In response to a question as to whether the type of incision was an issue regarding SSI, Dr. Bandyk said: "It’s the patient that’s producing the infection, and certain patient characteristics, so it isn’t necessarily how we’re closing, which way we are putting the incision ... So don’t blame yourself for every surgical site infection. It’s the patient factors that are operative in many of these cases. Of almost all of our infections that occurred, two-thirds came from the MRSA-colonized patient," he said.

Dr. Bandyk reported being on the speakers bureau and having received funding from Cubist Pharmaceuticals, the manufacturer of daptomycin (Cubicin).